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Letters to the Editor

Beyond Structural Competency: Why Politics Should Be Taught During Medical Education

Goel, Rishi R. MSc; Kavanagh, Nolan M. MPH

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doi: 10.1097/ACM.0000000000003614
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To the Editor:

Medical education emphasizes structural competency.1 While this approach examines many inequities in the health care system, it often overlooks one of the most important influences on health: politics. The political process has produced major structural changes to health care through insurance reform. Politics also affects many structural determinants of health, such as economic opportunity. In many ways, politics is the most powerful tool for improving the health of our communities.

The COVID-19 pandemic has magnified the impact of politics on access to medical care, health policies, and community responses to those policies. Consider recent trends in social distancing. Despite government mandates, not all communities are distancing equally well. Structural competency teaches us that staying home from work is a privilege. Indeed, counties with lower socioeconomic status have struggled to fully participate. But even after adjusting for demographic and socioeconomic characteristics, one variable best predicts how much a community engages in social distancing: political affiliation.2 Therefore, effectively confronting this pandemic requires an understanding of the political structures in which our country operates.

As COVID-19 forces medical schools to modify their curricula, educators should use this opportunity to incorporate the effects of politics on health and health care into medical education. To be clear, we are not advocating for any specific political ideology. Rather, we share Virchow’s belief that “medicine is a social science and politics is nothing else but medicine on a large scale.”3 Understanding politics is critical to understanding medicine.

We propose adding the following objectives to medical education. Physicians should be able to:

  1. Understand the nation’s political institutions, political culture, and political ideologies;
  2. Recognize how the political process shapes health care systems and the structural determinants of health; and
  3. Engage in the political process to develop or advocate for solutions that promote health equity.

We must learn how to practice medicine in an increasingly political society. Formal education in politics is a necessary addition to the structural competency framework. Making this change will ensure that physicians are trained to not only diagnose but also treat structural inequities in health.

References

1. Metzl JM, Hansen H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126–133
2. Kavanagh NM, Goel RR, Venkataramani AS. Association of county-level socioeconomic and political characteristics with engagement in social distancing for COVID-19 [published online ahead of print April 11, 2020]. medRxiv. doi:10.1101/2020.04.06.20055632
3. Mackenbach JP. Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. J Epidemiol Community Health. 2009;63:181–184
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