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Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care

Bourgois, Philippe, PhD; Holmes, Seth M., MD, PhD; Sue, Kim, MD, PhD; Quesada, James, PhD

doi: 10.1097/ACM.0000000000001294
Perspectives

The authors propose reinvigorating and extending the traditional social history beyond its narrow range of risk behaviors to enable clinicians to address negative health outcomes imposed by social determinants of health. In this Perspective, they outline a novel, practical medical vulnerability assessment questionnaire that operationalizes for clinical practice the social science concept of “structural vulnerability.” A structural vulnerability assessment tool designed to highlight the pathways through which specific local hierarchies and broader sets of power relationships exacerbate individual patients’ health problems is presented to help clinicians identify patients likely to benefit from additional multidisciplinary health and social services. To illustrate how the tool could be implemented in time- and resource-limited settings (e.g., emergency department), the authors contrast two cases of structurally vulnerable patients with differing outcomes. Operationalizing structural vulnerability in clinical practice and introducing it in medical education can help health care practitioners think more clearly, critically, and practically about the ways social structures make people sick. Use of the assessment tool could promote “structural competency,” a potential new medical education priority, to improve understanding of how social conditions and practical logistics undermine the capacities of patients to access health care, adhere to treatment, and modify lifestyles successfully. Adoption of a structural vulnerability framework in health care could also justify the mobilization of resources inside and outside clinical settings to improve a patient’s immediate access to care and long-term health outcomes. Ultimately, the concept may orient health care providers toward policy leadership to reduce health disparities and foster health equity.

P. Bourgois is professor of anthropology and director, Center for Social Medicine and Humanities, Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, California.

S.M. Holmes is associate professor of medical anthropology and public health, University of California, Berkeley, Berkeley, California, and attending physician, Department of Internal Medicine, Highland Hospital, Oakland, California.

K. Sue is a first-year general internal medicine resident, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.

J. Quesada is professor and chair, Department of Anthropology, San Francisco State University, San Francisco, California.

Funding/Support: Research funded by National Institutes of Health grants DA010164, AA020331, DA037820, AA01759201, John Simon Guggenheim Foundation, American Council on Learned Societies, School for Advanced Research in Santa Fe, National Endowment for the Humanities, Paul and Daisy Soros Foundation, Re: Work Institute of Humboldt University, Berlin.

Other disclosures: None reported.

Ethical approval: Authorization through the San Francisco State University, University of Pennsylvania, and University of California, Los Angeles institutional review boards.

Previous presentations: A preliminary version of this article was presented at the March 2012 Structural Competency Conference at New York University. Other versions have been presented or circulated in clinical settings, conferences, and workshops and in medical education settings.

Correspondence should be addressed to Philippe Bourgois, Department of Psychiatry, David Geffen School of Medicine at UCLA, Suite B7-435, 760 Westwood Plaza, Los Angeles, CA 90095-1759; telephone: (415) 994-9581; e-mail: pbourgois@gmail.com.

Medical students commonly learn—sometimes through the so-called hidden curriculum—that taking a social history involves routinely asking about a narrow set of risk behaviors, including alcohol, tobacco, and illicit drug use, sexual history, intimate partner violence, and depression.1 Although many doctors and health care professionals intuit that “the social” is an arena of great importance in a patient’s ability to adhere to treatment, addressing the structural impediments to health is, nonetheless, generally considered to lie outside the purview of everyday clinical practice. As Srivastava2 (p588) explains, “Social history is often treated as an optional extra, relegated to the social worker in case of real need.”

We propose to reinvigorate the traditional social history and extend it beyond the current narrow range of risk behaviors to enable clinicians to address negative health outcomes imposed by poverty, inequality, and discrimination. In this Perspective, we outline a novel, practical medical vulnerability assessment questionnaire that operationalizes for clinical practice the social science concept of “structural vulnerability”3–6 (see Table 1 for definitions of key terms). The questions are framed around crucial domains of societally imposed risk factors that may exacerbate a patient’s health outcomes. We propose using this tool to facilitate the development of a comprehensive treatment plan that engages a multidisciplinary health care team capable of working in concert with service providers outside the clinic. To convey the clinical utility of the concept of structural vulnerability and to illustrate how our tool could be implemented in time- and resource-limited settings, we contrast two cases of patients who presented to the San Francisco County hospital’s emergency department with wounds from interpersonal violence, trapped in destructive cycles of chronic morbidity, substance abuse, high utilization of emergency care, and frequent hospital admissions.

Table 1

Table 1

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The Development of the Concept of Structural Vulnerability

In the United States and globally, health care professionals and social scientists have repeatedly noted the urgency of the challenge to address what public health calls the “social determinants of health.”7–10 In the United States, a history of discrimination and ineffective health care for cultural minority populations—from Native Americans in rural areas to African Americans and Latinos in segregated inner-city neighborhoods to refugees from war-torn countries—has spawned medical and social science critiques of clinical assessments based on stereotypes around race, class, gender, sexuality, or citizenship that contribute to disparate clinical care and outcomes.3 , 6–11 For example, studies show that African Americans and women receive treatment for myocardial infarctions less often than white men, even when they report identical symptoms in emergency departments.12 , 13 A large social science literature has documented the ways in which subtle cultural and normative markers, such as accent, body posture, and etiquette, can interface with demographic categories (race/ethnicity, age, gender, social class) to create hierarchical judgments that promote social inequality and potentially limit an individual’s opportunities for security and achievement in any given society.14 These subtle symbolic demarcations of hierarchies may influence perceptions by clinical and social service providers as well as by the larger society about the type of care considered appropriate for an individual or a social group, creating a potential stigma of differential “health-related deservingness.”15

In response to these challenges, in the late 1970s U.S. health care educators sought to promote “cultural competency” to ameliorate racial and ethnic disparities in health outcomes.16–18 Medical education incorporated the concept of cultural competency to sensitize health care practitioners and systems to the needs of diverse individuals and communities whose beliefs, values, and customary practices often differed from those of the medical professionals serving them. Cultural competency, however, has been critiqued for inadvertently compounding cookie-cutter stereotyping of diverse patients.3 , 17–19 Furthermore, in practice it has tended to focus primarily on cultural barriers to care framed in terms of race and ethnicity, often neglecting the negative health effects of political and economic forces—especially socioeconomic status—that compound discrimination.7–9

In the early 1990s, infectious disease physician and anthropologist Paul Farmer20 warned that concentrating exclusively on “culture” misrecognizes the pathological effects of social inequality. He eloquently brought the political science and human rights concept of “structural violence”21 , 22 to clinical attention by documenting the ways in which policies, market forces, and institutional arrangements disproportionately shorten the lives of the poor. His work reinvigorated the field of global health and enlivened a generation of idealistic health professions students and clinicians to mobilize practically and politically for the transfer of medical resources to resource-poor nations and underserved domestic populations. Importantly, the concept of structural violence has been instrumental in defining access to health care as a human right.9

Because of these efforts, many clinicians have become aware of the negative health effects of political and economic forces outside the clinic. Many, however, feel helpless in the face of these social structural forces and consider them to be beyond the purview of clinical practice. Others interpret nonadherence to treatment protocols and inability to pursue healthy lifestyle modifications to be the willful moral choices of their patients rather than effects of social structural inequalities. As a result, clinicians sometimes become frustrated by their patients or subject to burnout. The social science theorizing and debates on these topics are too complex—and potentially arcane for a clinical audience—to be treated fully here. Nevertheless, the assessment tool we present builds on this critical social science work, as well as on Farmer’s applied engagement with social inequality and global health disparities, to help clinicians articulate and address the effects of detrimental social structures on patient care.3 , 23 , 24 We are responding to the call to promote what physician–social scientists have called “structural competency” in medicine.25

To address this challenge practically, we designed a clinical assessment tool to operationalize the concept of structural vulnerability, by highlighting the pathways through which specific local hierarchies and broader sets of power relations may exacerbate an individual patient’s health problems. Our goal here is to facilitate an applied pragmatic approach to intervening on these forces by identifying obstacles to healthy lifestyles and treatment adherence outside the clinic and facilitating access to care inside the clinic. We begin with the awareness that all individuals live within diverse but identifiable power relationships and hierarchies that can limit access to resources and can shape their decision making and behavior in ways that are sometimes beyond their capacity to control or change without extra support.

Our application of the social science concept of structural vulnerability to medicine takes the social determinants of health perspective as a foundation and builds on the wider range of critical social science of medicine and public health theory—highlighted by terms such as “structural violence,” “racial disparities in health,” “eco-social models of health,” “upstream factors in health,” “fundamental social causes of health,” and “social suffering”7 , 8 , 26–31—to expand and define more practically the diversity of forces, both external and internal to the clinical encounter, that can sabotage the health of patients regardless of the conscious intentions of the caregiver or the patient. Structural vulnerability is produced by one’s location in a hierarchical social order that is embedded in diverse networks of power relationships and effects.32 , 33 An earlier conceptualization focusing on the challenges faced by Latino migrant laborers noted that marginalized and pariah populations are important examples of those affected by structural vulnerability, including “the poor, the medically uninsured, the sexually stigmatized … [culturally subordinated] ethnic minorities, the disabled, the formerly incarcerated, the drug addicted, runaways.…”3 (p346) In sum, a patient’s structural vulnerability is the outcome of a combination of socioeconomic and demographic attributes (gender, socioeconomic status, race/ethnicity, sexuality, citizenship status, institutional location), in conjunction with assumed or attributed status (including health-related deservingness, normality, credibility, assumed intelligence, imputed honesty). Policy trends, such as mass incarceration or zero tolerance in law enforcement, can exacerbate these markers and hierarchical ideological classifications to position individuals differentially within specific political, economic, and legally sanctioned institutional sites in ways that limit many aspects of life, including health outcomes.

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A Structural Vulnerability Assessment Tool for the Clinical Encounter

Awareness of structural vulnerability is not enough. Health care practitioners facing time constraints and inadequate access to social service resources often feel overwhelmed by their patient load. In Chart 1, we present an assessment protocol consisting of initial screening questions followed by qualitative assessment probes to help clinicians quickly gauge aspects of a patient’s structural vulnerability. We designed this tool to guide priorities for immediate intervention and follow-up support strategies in order to move beyond simple recognition of problems. We are building on the practice of using validated screening instruments in the clinic to flag problems such as substance abuse, mental health challenges, and intimate partner violence.34–36 Recent applied health services literature suggests that the administration of short procedural checklists at strategic clinical contact points (from outpatient vaccine clinics to intensive care units) can result in more appropriate caregiving.37

Our initial screening questions flag domains representing common social structural and institutional obstacles that can place a patient at risk for recurring negative health outcomes. A treatment plan based on structural vulnerability assessment may include immediate resource allocation and connection to further services and advocacy in addition to further medical tests and prescriptions. Consider a hypothetical example of a patient presenting with chest pain. Instead of simply ruling out myocardial infarction and attributing the pain to cocaine use, medical service providers could identify the patient’s structural vulnerabilities and mobilize resources outside the clinic to address the patient’s ongoing daily triggers for cocaine use, such as the patient’s homelessness in an inner-city environment that is characterized by chronic open-air drug sales and use.

In practice, clinicians will need to adapt the vulnerability assessment protocol to their patient populations, clinical institutional setting (e.g., hospital emergency department, outpatient clinic, inpatient ward), and surrounding community resource base. Health care practitioners, consequently, will retain clinical decision-making authority and use their judgment to apply insights from the assessment to the challenges faced by their individual patients in reference to their locale. Our assessment tool supplies an anchoring qualitative guide for flexible, on-site adaptation with further strategic probes to identify the most crucial practical domains that an individualized treatment plan or patient problem list needs to address. The weight of the relevant domains will differ across nations, regions, and neighborhoods.38 , 39

Our protocol could also be operationalized quantitatively. In some institutional settings, adapting this assessment tool so that it becomes a numerical checklist could have the advantage of creating a quick index of patient vulnerability—pragmatically equivalent to an objective “structural vulnerability diagnosis”—as a means to advocate for the allocation of limited resources. Elevated vulnerability scores within specific domains, for example, could enable timely triage by clinicians to justify distribution of vouchers for clothing, shelter, food, legal services, rehabilitative therapies, and mental health and substance abuse treatments. Dispensing these extra social services and practical survival resources could become as legitimate and routine to the purview of medical practice as blood draws, pulse taking, medical tests, and medication prescriptions. At the same time, clinicians and administrators must be wary of the danger that the simplicity or rigidity of quantifiable variables could limit the critical and creative thinking necessary for addressing complex social determinants of health in the urgency of a given context. A quantitative screen could become just one more bureaucratic hoop to jump through for health care practitioners. Our qualitative version of the assessment tool (Chart 1) represents, nonetheless, an appropriate starting point. It should be considered a draft for local adaptation.

A secondary but important goal of our proposed clinical encounter tool is to improve the relationship of practitioners to their surrounding communities by increasing awareness of the importance of identifying or developing community-based social service resources in response to patient needs. For example, if clinicians at a given institution see a pattern of high rates of alcohol use disorders in their patient population, they could either refer patients to existing community-based organizations or build programs designed to serve this population’s needs.

Implementation of the structural vulnerability assessment tool requires the formation of interprofessional health care teams and coordination with community stakeholders. Over the longer term, use of the tool should promote collaborative institutional practices emphasizing accessible primary health care, accountable medical leadership, family and community participation, and expanded roles for community health workers or peer advocates/accompagnateurs.24

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“Chronic Acute Care” in the Emergency Department: Two Cases

To illustrate how our structural vulnerability assessment tool could work in practice, we contrast two cases of structurally vulnerable patients who presented to the San Francisco County hospital with wounds from interpersonal violence but had divergent outcomes. The first case highlights lost opportunities for deploying the tool in a clinical setting with limited time and resources. The second case shows how the tool could be implemented through the collaboration of interdisciplinary health care teams.

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Case 1: Deploying the structural vulnerability tool within time and resource constraints

M.T.* is a 44-year-old Mexican undocumented day laborer with a history of hypertension, hyperlipidemia, and osteoarthritis. He presents to the emergency department with a broken nose and a black eye. He smells of alcohol and has a belligerent affect. The first person to see him after the triage nurse is a white female emergency medicine physician who has treated M.T. before for similar complaints related to physical trauma. M.T. is routinely admitted to the county hospital for acute inpatient care and then discharged back to the streets after several days, only to repeat this cycle of emergency department encounters and hospitalizations.

On M.T.’s release from the hospital, the senior author (J.Q.) wrote the following anthropological field note:

[M.T.] comes to the Day Labor Program [a program supporting day laborers in a neighborhood near the hospital] with a bandage on his head and his face is swollen. He was discharged yesterday after two nights of hospitalization with prescriptions for: 1mg/daily Folic Acid; 100mg/daily Thiamine/Vitamin B1. He holds up an unsigned prescription form with the medication Naltrexone scrawled on it and asks me, shrugging quizzically, “They think all these medications are good for my alcoholism?”

He is too agitated to let me answer, telling me that last night he slept on a slab of cardboard in the alcove of [a theater] with an acquaintance. They were rousted in the middle of the night “By a wild crazy man.” Early this morning M.T. learned the man who shared his cardboard was found dead with his throat slit. He is scared the police are trying to find him for questioning and potential deportation. Another day laborer tells M.T. to “shut up.” M.T. shouts back angrily, but then runs away frightened.

The field note highlights M.T.’s immediate everyday survival emergencies (fear of law enforcement, propensity for rage, homelessness, and violence) that prevent him from engaging with the ambiguous and impractical follow-up care noted only semilegibly on his prescription from the hospital.

Health care staff may feel frustrated working with M.T. and other chronic users of the emergency department, sometimes referred to derogatorily as “frequent flyers,”40 as they watch the health of these patients deteriorate between multiple cycles of urgent care visits. If the average cost of an emergency department visit for an uninsured patient is $1,178,41 and the cost of one inpatient night in a California government-funded hospital is $2,590,42 M.T.’s monthly average toll of one to three nights of hospitalizations would cost well over $100,000 annually. Could such expenditures be allocated more effectively if the medical discharge treatment plan were to include housing and food vouchers, more appropriate and robust counseling, and case management along with substance abuse rehabilitation?

In the short time at her disposal, M.T.’s physician could pose our tool’s initial screening questions during the social history intake to rapidly identify the salient parameters of his structural vulnerability that are most proximally propelling him to repeat cycles of homelessness, binge drinking, and violent encounters. In an ideal scenario, the physician might use the qualitative probes to gain a better understanding of M.T.’s typical daily activities in one or more of the tool’s eight domains: his income-generating strategies (financial security); how and where he eats (food access); whether he has helpful or disruptive friends and family (social network); if law enforcement may be pursuing him (legal status, discrimination); where he sleeps and his perception of physical safety (residence, risk environments); and his functional health literacy (education).

By doing so, M.T.’s physician might learn that M.T. has no formal education beyond sixth grade and has been undocumented in the United States for 15 years. She might discover M.T. has a girlfriend—who is alcoholic and generates income through sex work—with whom he moves between homelessness and temporary shelters. She might find out that he has an aunt in a nearby town who occasionally houses him and holds his mail, as well as one adult daughter who lives nearby but has not spoken to him in five years. The physician might recognize that M.T. understands he has high blood pressure but cannot afford his medication co-pays. M.T. might admit he is a recurrent victim of street violence and that he binge drinks, is unable to escape chronic environmental exposure to alcohol and drugs in shelters and on the street, and is unable to manage outbursts of drunken anger. M.T. might describe a history of heavy repetitive manual labor and tell her that he receives no public subsidies and only unstably earns $100 a week through the municipal day laborer cooperative on odd jobs that exacerbate his arthritis pain and inflame his chronic occupational injuries of muscle and joint strain. This information might help M.T.’s physician interpret how his drinking and propensity for rage mask his sense of failure in his expected male role to provide for his girlfriend, who recently filed an order of protection against M.T.

The time constraints faced by emergency department providers would likely oblige the physician to abbreviate her probing. She could, however, within a few minutes screen M.T. as positive on multiple domains of structural vulnerability (financial security, residence, risk environments, social network, legal status, and discrimination) as well as document the more common social history risk variables of alcohol/tobacco dependence and intimate partner violence. Her intervention priorities for his problem list would need to balance M.T.’s overlapping medical and social needs with available resources. If housing instability appears to be the most proximal reason for M.T.’s chronic exposure to street violence and alcohol, she might prioritize access to stable housing followed by anger management counseling and substance abuse treatment or occupa tional therapy, pain management, and outreach to kin. Most immediately and practically, she might ensure that M.T. leaves the hospital with his prescriptions filled and a list of alcohol rehabilitation programs—or at least a pamphlet schedule of local Alcoholics Anonymous meetings. In the longer term, the physician might explore partnerships with the nearby day laborer cooperative to support establish ment of peer-led substance abuse treat ment, anger management counseling, and/or occupational therapy programs as well as potential changes to city policies for housing and services for undocumented immigrants.

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Case 2: Successful engagement with structural vulnerability by multidisciplinary teams

C.W. is a 22-year-old African American man with paraplegia related to a police-inflicted gunshot wound from a gang-related incident. He has been hospitalized repeatedly for debridement and wound repair complications. He has most recently been seen in the emergency department for a new gang-related gunshot wound.

At the time of C.W.’s last emergency department visit and hospitalization, the county hospital was running a high-user case management program in which an interdisciplinary team of health care practitioners coordinated the care of structurally vulnerable patients. While he was hospitalized, C.W. was quickly referred to the high-user team. The team documented that C.W. was living out of his car in his former gang’s territory, with no access to wheelchair-accessible housing. They helped obtain a respite bed prior to his hospital release while they processed a Section 8 housing application for him in a neighborhood distant from gang territory. They also documented how C.W.’s second gunshot wound was complicating his gang-related legal sanctions, and they preemptively liaised with the courts “to find an equitable sentence and probation that allowed him to also attend to his [outpatient] medical issues.”43 (p6) Furthermore, they sought out a primary care physician to coordinate C.W.’s medical follow-up, including plastic surgery and orthopedics, as well as income support services for his daily living needs, paratransit vouchers, and medication delivery.

C.W.’s case provides an example of how clinicians can, through multidisciplinary clinical team engagement with strategic external institutions and services, address complex social challenges outside the clinic that threaten a patient’s health outcomes. C.W.’s case was presented in the high-user program’s 2005 annual report43 as an example of a socioeconomically complex clinical case history that was amenable to improvement in quality of care and outcomes through the county hospital’s initiative for repeatedly hospitalized patients. (See also the discussion in Messac et al.23)

The high-user program began in 2001 to reduce hospital recidivism by addressing the “biopsychosocial needs” of high-use patients through an intensive case management model. Located in the County of San Francisco’s only safety net hospital and level 1 trauma center, the high-user program was designed to serve indigent patients hospitalized three times or more within the past year. In 2004, two-thirds of these patients were homeless or unstably housed, 70% had concomitant mental illness, and 80% had alcohol and substance use problems.23 , 43

The high-user program was justified to administrators as reducing long-term costs by improving patient outcomes through streamlining the coordination of high-tech medical care and social services provision.44 Each patient was assigned an interdisciplinary team (social worker, public health nurse, psychiatrist, primary care physician, and clerk) that met twice weekly to formulate individualized treatment plans. The team’s priority was to connect patients to safe housing, employment or public income subsidies, transportation, and community-based primary care clinical and social services.

The high-user program’s success with C.W.’s case demonstrates the ability of clinicians to engage productively with diverse institutional services outside the hospital to address structural vulnera bility domains. The multidisciplinary clinical team proactively applied for public housing for C.W. in a safe neigh borhood (residence, risk environments) and communicated with the courts to contravene the contradiction between law enforcement and health priorities (legal status, discrimination). Through their efforts, they helped break the destructive cycle of gang violence for C.W., which clinicians taking a narrow medical focus might have considered to be beyond their purview. With this level of support, C.W. adhered to wound care and rehabilitation and transitioned to nonviolent “OG” (original gangster) status in the community.

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The U.S. Policy Environment: Cost–Benefit and Outcome Measures

Bipartisan political concern for reducing health care costs has enabled the devel opment of innovative comprehensive care programs to serve complex high-use patients. Such initiatives exist across the United States, in cities such as Detroit, Michigan; Baltimore, Maryland; Camden, New Jersey; and Allentown, Pennsylvania.45–48 In 2013, the Center for Medicare and Medicaid Innovation funded 24 Health Care Innovation Awards for three-year implementation studies to address care coordination, improve transitions between health care settings, and develop comprehensive multidisciplinary health care teams and innovative practice designs, like patient-centered medical homes, to avoid rehospitalizations or emergency room visits.49 While these initiatives are often justified as cost-saving as well as effective for structurally vulnerable patients, administrative annual budget processes can overlook the benefits of these programs and eliminate them despite their delivery of high-quality care. For example, the high-user program that enabled C.W.’s positive outcome was cut after seven years, during a dot-com bust in the San Francisco Bay Area.50 The program no longer existed at the county hospital when M.T. was hospitalized.

Despite the possibility of contradictions between meeting cost-saving priorities and achieving optimal health care outcomes for structurally vulnerable patients, the practical effect of integrating our assessment tool into clinical practice can be evaluated quantitatively through both standard health indicator outcomes data and interinstitutional monitoring of hospitalization readmissions, outpatient follow-up, and emergency department use to demonstrate cost–benefit outcomes utility. Interviews, surveys, and ethnographic case studies of patient quality of life and health care worker satisfaction could provide greater qualitative context to help interpret the quantitative outcomes. Qualitative data could be especially useful for adapting new programs designed for structurally vulnerable patients to make them more effective and for mitigating cost-accounting reductionism or statistical insensitivity to quality-of-care measures. Such data could also be used to evaluate the sustainability of these initiatives from the health care practitioner’s perspective.

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Integrating Structural Competency Into Medical Education

The immediate goal for our proposed structural vulnerability assessment tool is to provide a quick screening evaluation that will enable health care practitioners to prioritize a comprehensive treatment plan that interfaces with resources outside the clinic. Unlike most assessment instruments commonly used in clinical medicine,34–36 the structural vulnerability assessment tool brings crucial social structural variables—such as poverty, discrimination, legal status, and, more abstractly, inequality, hierarchy, and power relations—into focus for health care practitioners. Our tool is a strategic practical heuristic mechanism designed to promote an understanding of how social conditions and practical logistics can undermine the capacities of patients to access health care, adhere to treatment, and modify lifestyles successfully.

Training in how to adapt and apply the tool to local clinical settings could become a building block for a new, or supplemental, “structural competency” in clinical education and certification. This new competency could be integrated into existing medical school preclinical curricula on professionalism, the doctor–patient relationship, and history taking, as well as into electives on ethics, social medicine, and global health. To this end, locally adapted drafts of our tool, as well as independently initiated programs, have been, or are being, piloted in curricula in medical schools, public health graduate programs, hospital-based residency programs, continuing medical education courses, and community-based and hospital-based clinics. Participants in such initiatives include the University of California, San Francisco; University of California, Berkeley; University of California, Los Angeles; Samuel Merritt University; Highland Hospital (Oakland, California); Santa Rosa Family Medicine Residency (Santa Rosa, California); Oregon Health and Science University; University of Pennsylvania; New York University; New York Medical College, Vanderbilt University’s Center for Medicine, Health, and Society; and the State University of New York at Albany.51–60

The concept of structural vulnerability lends itself to integration into medical education across several of the eight domains of general physician competencies outlined by Englander et al.61 It complements “systems-based practice,” defined as “demonstrat[ing] an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”61 (p1092) It addresses “knowledge for practice” by enhancing clinician awareness of social-behavioral sciences, as described by Englander et al: “Apply[ing] principles of social-behavioral sciences to provision of patient care, including assessment of the impact of psychosocial and cultural influences on health, disease, care seeking, care compliance, and barriers to and attitudes towards care.”61 (p1091) Finally, training in the clinical implementation of our tool has the potential to address competencies in the domains of “personal and professional development,” “professionalism,” and “interpersonal and communication skills.” We hope implementation of our tool in clinical settings will also contribute to the growing national conversations on universal access to quality care initiated by the implementation of the Affordable Care Act.

Our assessment tool’s final domain—discrimination—encourages a shift of the clinical gaze toward critical self-reflection on the stigma of being perceived as not deserving high-quality health care. This is meant to promote an empathetic awareness of the visible markers, as well as the contextual forces, that sometimes frustrate or alienate clinicians and lead them to blame patients for inflicting poor health on themselves. Teaching critical self-awareness and empathy for suffering is a challenging goal for medical education. Ideally, skill with implementing the tool in daily practice may improve the fluidity and effectiveness of the patient encounter, reduce both physician and patient frustration, and improve outcomes.

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In Conclusion

Ultimately, addressing challenges related to social determinants of health requires the mobilization of resources. To this end, the development of a pedagogically and institutionally vetted structural vulnerability tool that has proven itself to be practical in the clinic might justify prescribing and developing social support services despite cost-cutting environments that have been reducing resources for the poor. Over the longer term, a new structural competency curriculum might also expand the vocation and imagination of clinicians toward taking greater political leadership in favor of reducing health disparities and fostering health equity.

Acknowledgments: Comments by anonymous reviewers and editors of Academic Medicine improved the quality and clarity of the article. George Karandinos conducted data analysis; Laurie Hart offered valuable comments; Jeff Ondocsin and Safiqa Khimani helped with editing logistics; and Joshua Neff developed key term definitions. The authors thank their multiple clinical and medical anthropology collaborators who provided feedback on their concept and piloted a diverse set of structural vulnerability assessment initiatives in clinical and medical education settings. They are especially appreciative of the work done by Michelle Schneidermann at San Francisco General Hospital and the Rad Med Critical Social Medicine group at the University of California, Berkeley, and the University of California, San Francisco (http://www.rad-med.com). They are grateful to Helena Hansen and Jonathan Metzl for establishing multiple forums for conceptualizing structural competency.

* Identifying details have been changed in both patient cases.
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