EM must address upstream factors driving poor health, inequity, and barriers disrupting patients' lives
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Figure: health, inequality, patients, burnout, crowding, racial groups, ethnic groups, cultural competency, structural competency, residency, curriculum,
Sickness is not addressed by medical care alone. Illness and injury arise from the environment, and nowhere is the burden of social needs more apparent than in the emergency department. (Acad Emerg Med. 2018;25[3]:330; https://bit.ly/3JDHo5W;West J Emerg Med. 2020;21[6]:152; https://bit.ly/3TehPLW.)
Social needs are manifestations of structural conditions and policy decisions that disproportionately oppress certain groups. (Health Affairs Forefront. Jan. 16, 2019; https://bit.ly/3FoXEFr.) In an insidious cycle, these inequities reinforce harmful biases, threatening patient care. (National Equity Project. http://bit.ly/3yACP5Y.) Emergency departments around the country are facing unprecedented levels of crowding, which may exacerbate stereotypes and biases. (EMRA. Oct. 16, 2018; http://bit.ly/3Fo85t3.)
This is especially relevant as disparities run rampant throughout the ED care continuum. (Am J Emerg Med. 2019;37[9]:1770; https://bit.ly/3lfc2co; JAMA Network Open. 2021;4[1]:e2033710; http://bit.ly/3J883GE.) Patients from historically oppressed groups experience substantial discrepancies in care. (Acad Emerg Med. 2021;28[9]:957; https://bit.ly/3ldGbsI; West J Emerg Med. 2020;21[4]:949; https://bit.ly/3FoyjeV.) We must integrate structural competency into residency training to address this problem. Structural competency is a powerful framework that provides physicians with the skills to understand and respond to the social, economic, and political forces affecting our patients, inside and outside the emergency department.
Cultural competency has been added to most residency curricula as we shift to a paradigm of whole person care. (J Emerg Med. 2017;53[3]:391.) It falls short, however, with its excessive focus on individual-level factors, inadvertently reinforcing stereotypes about specific racial and ethnic groups. Cultural competency fails to provide the learner with the necessary context to understand the enormous role that structural factors play in adverse outcomes. (AEM Educ Train. 2019;4[Suppl 1]:S88; https://bit.ly/3ZNn6MT.) The landscape of graduate medical education is changing, however, and there is a growing call for residency programs to ensure their learners have a sound understanding of the social and structural determinants of health. (Acad Med. 2020;95[12]:1817; https://bit.ly/3latJda.)
Effective July 1, the Accreditation Council for Graduate Medical Education will require emergency medicine residents to demonstrate an awareness and responsiveness to the social and structural determinants of health and call on residency programs to design and implement curricula on the structural determinants of health specific to the populations they serve to eliminate health disparities. (ACGME. June 12, 2022; https://bit.ly/3Jjwocq.)
This is formally known as structural competency training. Various examples in the emergency medicine literature demonstrate how this approach has been successfully incorporated into residency programs. Programs should consider a few key steps as this becomes integrated into the residency curriculum. Starting with a needs assessment is a helpful first step. This should focus on determining knowledge gaps related to the social and structural determinants of health of the population served.
The curricula should be longitudinal, integrated into preexisting resident education, focused on the emergency department's specific patient population, have support from key stakeholders, and have a system in place for collecting feedback and evaluations. (AEM Educ Train. 2022;6[Suppl 1]:S13.) Successful examples include utilizing simulation training to teach residents about health equity-related issues, leveraging community partnerships to familiarize residents with outpatient resources, developing a resident retreat focused on systemic racism, and building a resident rotation focused on social emergency medicine. (AEM Educ Train. 2021;5[Suppl 1]:S102; https://bit.ly/3l8a3a3; AEM Educ Train. 2022;6[6]:e10820; West J Emerg Med. 2020;22[1]:41; https://bit.ly/42dCMus; West J Emerg Med. 2022;23[4.1]; http://bit.ly/3FmtmTM.) These useful examples provide residency programs with support in building their own structural competency curricula.
By providing trainees with the skills to intervene on the social and structural determinants of health, we may be able to address a vastly underrecognized cause of resident burnout. (AEM Educ Train. 2017;2[1]:66; https://bit.ly/3hUG4gS.) This is especially relevant given that the majority of emergency medicine residents report symptoms consistent with burnout, a condition partly due to a sense of disempowerment to effect change and a feeling of futility in daily practice. (Ann Emerg Med. 2019;74[5]:682.) A new educational paradigm in emergency medicine residency education emphasizing the core tenets of structural competency is urgently needed.
Given our advances in understanding the root causes of health inequity, it is time to move beyond cultural competency. Emergency departments treat a disproportionate share of patients with social and structural vulnerabilities, so it is critical that residency programs embrace an approach emphasizing the upstream factors driving poor health and inequity. This area is ripe for growth and should be leveraged to create the next generation of physician leaders ready to dismantle the social and structural barriers disrupting our patients' lives.
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Dr. Mahmoud-Werthmannis an emergency physician and social emergency medicine fellow at Stanford School of Medicine. Follow her on Twitter@sallymahmoudMD.
