New Medicine for the U.S. Health Care System: Training Physicians for Structural Interventions

Abstract

Structural competency provides a language and theoretical framework to promote institutional-level interventions by clinical practitioners working with community organizations, non-health-sector institutions, and policy makers. The special collection of articles on structural competency in this issue of Academic Medicine addresses the need to move from theory to an appraisal of core educational interventions that operationalize the goals of and foster structural competency. In this Commentary, the authors review the role of clinical practitioners in enhancing population-level health outcomes through collaborations with professionals in fields outside medicine, including the social sciences and law. They describe the core elements of structural competency in preclinical and clinical education, as illustrated by the articles of this special collection: perceiving the structural causes of patients’ disease, envisioning structural interventions, and cultivating alliances with non-health-sector agencies that can implement structural interventions. Finally, the authors argue that preparing trainees to form partnerships will empower them to influence the social determinants of their patients’ health and reduce health inequalities.

The current moment presents an unprecedented opportunity to shift clinical training in the United States from a focus on technological intervention toward provision of more comprehensive health care—care in which students, interns, residents, fellows, and faculty engage with neighborhood organizations, non-health-sector institutions (e.g., schools, corrections, housing), and policy makers to promote patient and community health. The Affordable Care Act of 2010 and state-level Medicaid redesign, informed by the Institute for Health Innovation’s “triple aim” of improving population health and patient satisfaction while reducing cost,¹ have provided a new clinical focus on social and institutional determinants of health. A groundswell of physician advocacy groups, such as Partners in Health,² White Coats for Black Lives,³ and HealthBegins,⁴ are calling for a foregrounding of health disparities in clinical training and practice. In addition, the Robert Wood Johnson Foundation, the nation’s largest private funder focused on health, recently announced “building a culture of health” as its core principle,⁵ signaling its support for multidisciplinary efforts to improve the social conditions, policies, and service infrastructures that drive health inequalities.

At the same time, clinical educators are facing the need to prepare physicians to address social and institutional barriers to health. In a survey of U.S. physicians conducted for the Robert Wood Johnson Foundation, a majority of respondents expressed frustration that they do not have the tools to address the social causes of disease among their patients.⁶ Physicians cite structural factors as sources of professional discontent, such as restrictive insurance policies, lack of time with patients, and unsatisfying relationships with communities.^7,8 They report signs of professional burnout,⁹ and they are leaving clinical practice in record numbers.^10–13 As stated in a recent Commentary in Academic Medicine, clinical leadership is required to shape the implementation of health reform by addressing the institutional roots of health disparities and developing trusting relationships with communities.¹⁴

A special collection of articles in this issue of Academic Medicine takes as its organizing principle a conceptual intervention that we call “structural competency.”^15,16 Structural competency introduces a language and theoretical framework to promote institutional intervention by clinical practitioners to improve patient and community health. The term structural refers to clinical interventions above the level of the individual patient and in collaboration with community organizations, non-health-sector institutions, and policy makers. Structural competency thus draws on the social science, medical humanities, and public health scholarship illustrating the systemic, institutional determinants of health inequalities and therefore indicating that health disparities require institution-level intervention for remediation.

A growing number of publications are theorizing structural competency,^17–19 which began as a theoretical framework for describing a shift in clinical orientation. It has become clear, however, that clinical educators require a pedagogical approach that will foster structural competency. A number of medical schools and teaching hospitals are adopting a structural competency framework in clinical training, following a series of national conferences in 2012 and 2013 on structural competency attended by clinical professionals, social medicine researchers, and community health advocates (see http://structuralcompetency.org) as well as two webinar series in 2014–2016 on structural competency that targeted clinicians in practice (hosted by the American Medical Student Association and by the State University of New York²⁰). There is a need, therefore, to move from theory to an appraisal of core educational interventions and exemplary clinical curricula that operationalize the goals of structural competency.

This collection describes a first level of curricular innovation designed to foster structural competency through preclinical and clinical education. The articles in this collection outline ways that educators can enable students and residents to recognize the social and institutional drivers of their patients’ health. They illustrate the clinical competencies and interdisciplinary sensibilities that prepare trainees to act on those drivers, as well as the alliances with parties outside medicine that must be formed to impart structural change.

For example, Metzl and Petty²¹ demonstrate how baccalaureate prehealth education is a critical site for developing the sensibilities and analytic skills that students will need as clinical trainees. They describe an innovative prehealth major at Vanderbilt University that adapts structural competency concepts and skills for undergraduate classrooms. They also discuss the pilot of the Social Foundations of Health evaluation instrument, which was developed to evaluate critical thinking and recognition of relationships among social and structural determinants of health.

Taking these pedagogical concerns into the first year of medical school, Dao and colleagues²² report on a curricular innovation at the Perelman School of Medicine at the University of Pennsylvania. Introduction to Medicine and Society, a required cultural competence course, draws on medicine, social science, and the humanities and on critical pedagogy to foster “critical consciousness” of inequalities and pragmatic action in three domains (internal, interpersonal, and structural). In this classroom-based curriculum, traditional information delivery approaches are replaced by experiential, relational exercises designed to increase students’ communication skills and their ability to foster dialogue across identity and status differences, preparing them for future engagement with community organizations and service agencies.

Moving to clinical strategy, Bourgois and colleagues²³ present a checklist for use by clinical trainees and practitioners to assess the structural vulnerability of patients and to inform social services provision and advocacy for institutional change. This tool is based on decades of work with marginalized, often undocumented immigrants in San Francisco. Checklists are educational constructs already familiar to medical students and trainees, which eases their adoption. Using the structural vulnerability assessment tool profoundly alters the orientation of the patient encounter from a focus on individual symptoms to a focus on the social environmental pathogens that are among the fundamental causes of patients’ symptoms.

Finally, taking a pedagogic orientation into residency training and cross-disciplinary collaboration, Paul and colleagues²⁴ highlight the utility of medical–legal partnerships (MLPs) between lawyers providing pro bono services and clinical practitioners in addressing institutional and legal barriers to care. Their case example illustrates how a psychiatry resident worked with an interdisciplinary team, which included a lawyer, to help a patient whose anxiety symptoms almost led to her eviction. In the process, the resident developed the skills of screening patients for social and legal needs and of interdisciplinary collaboration. Through the MLP, the resident was able to address structural barriers to the patient’s health on multiple levels through in-clinic legal and social services provision and advocacy in the housing court system. In the end, the resident helped achieve structural change through educating the housing court staff about the rights and needs of people with mental illness, leading to more respectful and informed interactions.

Together, the articles in this collection show how pedagogical innovations at many stages of training—from prehealth and preclinical classrooms to student and resident clinical rotations—can prepare trainees to address the pathologies of the institutional systems that drive health outcomes more broadly. However, these articles represent only the first stage in the process of reorienting clinical practice. Structural change that has a lasting impact on population health will require clinical trainees and practitioners to exercise their considerable symbolic capital as physicians and health care professionals in their interaction with community organizations, non-health-sector institutions, and policy makers. Clinical trainees therefore need to learn how to partner with community leaders and professionals from other disciplines—such as lawyers, urban planners, school administrators, and corrections officers—to achieve better health outcomes for their patients.

Interdisciplinary partnerships that have taken clinical training into communities include From Punishment to Public Health, a group formed by mental health providers, public health researchers, and corrections officials that has involved medical students and psychiatry fellows in programs to divert people with psychiatric symptoms from arrest and direct them to mental health care.²⁵ It has also prepared clinical trainees to testify before policy makers in support of legal reform to decrease the incarceration of people with mental illness. Another structural intervention that has brought trainees into communities is a New York University psychiatry residency elective that placed fourth-year residents in Brownsville, Brooklyn, a predominantly African American, low-income neighborhood with the highest density of public housing in the United States and high levels of violence. The psychiatry residents collaborated with the Brownsville Partnership, a community development organization, to conduct a community mental health needs assessment. This collaboration led to trauma-informed bereavement groups in local churches and community centers, as well as to enhanced communication between mental health providers and probation officers, who averted rearrests and hospitalizations through early treatment of their clients’ symptoms.²⁶ Such partnerships represent the end goal of structural competency training.

Ultimately, it is only by preparing clinical trainees to partner with entities outside the clinic that we can empower them to influence the social determinants of their patients’ health and reduce health inequalities. This is new ground for contemporary clinical education, but the articles in this collection begin to shed light on the important ways that medical education can lead the way toward helping medicine address vital, exigent, and all-too-pressing health justice issues.

Acknowledgments: The authors wish to thank Sewit Bereket for her editorial assistance, and the reviewers for the articles in this special collection in Academic Medicine for their thoughtful comments.