Structural competency: Theorizing a new medical engagement with stigma and inequality

Introduction

Medical professionals recognize that physicians must learn both the science of medicine and the art of patient communication. Currently, much of the medical field is focused on the concept of “cultural competency” and “cultural humility.” These concepts have pushed medical education to move beyond “colorblindness” and recognize that social factors, such as race, ethnicity, sexual orientation, and class, impact how patients’ symptoms can present. These factors also play a role in patients’ understanding of illness, health, well-being, cultural stigma, and compliance with treatment. Training on cultural competency and humility are essential to understanding the patient as a whole person. Culturally sensitive, non-judgmental communication, diagnosis, and treatment strategies improve health outcomes and reduce health-related stigma.

Medical professionals also recognize the limitations of “cultural competency.” Health is all-encompassing, with the social determinants of health (social, economic, education, political, and physical systems) impacting a patient’s well being long before they arrive for treatment and after they leave. An individualized approach towards healthcare that focuses only on addressing disease’s biological components is limited in its effectiveness because it does not see or treat the whole patient. Metzl and Hansen argue that doctors need to incorporate learnings from public health, social sciences, and critical race studies in a new approach to training medical students that equips them with an understanding of structural analysis. In their view, structural analysis refers to the language to engage with and communicate about structural impacts on health and propose interventions that address structural factors of care.

Jonathan M. Metzl, MD, Ph.D. is the Frederick B. Rentschler II Professor of Sociology and Medicine, Health, and Society; Director of the Center for Medicine, Health, and Society; and Professor of Psychiatry at Vanderbilt University as well as the Research Director of the Safe Tennessee Project. Helena B. Hansen, MD, Ph.D., is an Associate Professor of Psychiatry of Anthropology at New York University. 

Methods and Findings

This paper advances the idea of  “structural competency” and theorizes that structural competency should be incorporated into medical curricula. The authors draw from social science to guide their thinking. 

Metzl and Hansen propose five core competencies that a structural competency curriculum should prepare medical students to achieve. These are:

1. Recognizing the structures that shape clinical interactions: introducing an understanding of the broader socio-political, economic, and physical contexts that influence the healthcare system from the macro-level (e.g., decisions about insurance or drug pricing) to the micro-level (e.g., interpersonal interactions with patients)
2. Developing an extra-clinical language of structure: creating a more interdisciplinary, social science-based curriculum that trains students to understand the impact of social structures on biology and to engage with the complex broader contexts of individual patients and cases.
3. Rearticulating ‘cultural’ formulations in structural terms: connecting the useful pieces of “cultural competency” that inform patient interaction practices to reduce stigma with a structural understanding of the contexts that create and sustain that stigma.
4. Observing and imagining structural interventions: connecting training to the real world and empowering students to learn how they could change the structures influencing health.
5. Developing “structural humility”: training students to embrace humility and recognize that their role is to be continually learning and listening in addition to speaking and leading.

Conclusions

A medical curriculum that incorporates each of these components would prepare future physicians to understand and recognize the structural forces that impact their patients’ health. Further, it would train medical students with the skills they need to use language from across disciplines to communicate and think about the impact of structural forces. At the same time, it would prepare medical students to apply this structural knowledge to design health interventions and to recognize the limits of this approach. In essence, this would allow physicians to engage with the full complexity of health and illness and recognize when they need to bring in additional experts to advise on care. This curriculum also prepares physicians to step into the expanded and increasingly important non-clinical public health role. Finally, by shifting the focus of clinical treatment from individuals to addressing structures, infrastructure, and contexts, structural competency allows medicine to adopt a framework that would enable the field to engage in antiracist practices, both within medicine and in addressing the social determinants of health.