This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to ...forces that influence health outcomes at levels above individual interactions. It reviews existing structural approaches to stigma and health inequalities developed outside of medicine, and proposes changes to U.S. medical education that will infuse clinical training with a structural focus. The approach, termed “structural competency,” consists of training in five core competencies: 1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) rearticulating “cultural” formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility. Examples are provided of structural health scholarship that should be adopted into medical didactic curricula, and of structural interventions that can provide participant-observation opportunities for clinical trainees. The paper ultimately argues that increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes then needs to be better coupled with medical models for structural change.
•Proposes changes to U.S. medical education that will infuse clinical training with structural awareness.•Moves beyond “cultural competency” to address how structures produce health inequalities.•“Structural competency” consists of training in five core competencies.•Provides examples of structural health scholarship and structural interventions.•Ultimately argues for medical models of structural change.
Structural Competency and Psychiatry Metzl, Jonathan M; Hansen, Helena
JAMA psychiatry (Chicago, Ill.),
02/2018, Letnik:
75, Številka:
2
Journal Article
The structural drivers of disadvantage and poverty that are antecedents of health inequity in the COVID-19 pandemic are examined. The implementation of proportionately structural changes to how ...health and medical education systems operate is suggested. Heeding this suggestion will advance the health of individuals, communities and their surrounding environments.
Four assumptions frequently arise in the aftermath of mass shootings in the United States: (1) that mental illness causes gun violence, (2) that psychiatric diagnosis can predict gun crime, (3) that ...shootings represent the deranged acts of mentally ill loners, and (4) that gun control "won't prevent" another Newtown (Connecticut school mass shooting). Each of these statements is certainly true in particular instances. Yet, as we show, notions of mental illness that emerge in relation to mass shootings frequently reflect larger cultural stereotypes and anxieties about matters such as race/ethnicity, social class, and politics. These issues become obscured when mass shootings come to stand in for all gun crime, and when "mentally ill" ceases to be a medical designation and becomes a sign of violent threat.
This essay chronicles the history of medical associations between schizophrenia and Blackness that emerged during the tumultuous decades of the 1960s and 1970s, when American psychiatrists ...overdiagnosed schizophrenia in Black men in ways that undermined brain science of the era. I provide data to show how racially disparate diagnostic outcomes resulted not solely from the attitudes or biases of clinicians, but from a series of larger political and social determinants, most notably changing frameworks surrounding mental illness and political protest. I conclude by highlighting how training clinicians to examine their own cultural biases also needs to include training in how structures and institutions produce symptoms and diseases, and how we can only build better structures to support health if we can individually and then communally imagine them.
This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, ...researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.
After two decades of relative silence, many of the nation's leading public health organizations, medical groups, and research universities have now come out against the research ban. Yet this stance ...has often led to mistrust of knowledge about gun safety and best practices most salient, not in ivory tower institutions or liberal coastal cities, but in red-state communities where there are the most guns and the greatest need for public health interventions. 3 WHITE PROTECTIONISM Freed of the so-called ban, public health research could also pioneer new large-scale analysis of charged tensions of race surrounding American gun culture.
The inclusion of structural competency training in pre-health undergraduate programs may offer significant benefits to future healthcare professionals. This paper presents the results of a ...comparative study of an interdisciplinary pre-health curriculum based in structural competency with a traditional premedical curriculum. The authors describe the interdisciplinary pre-health curriculum, titled Medicine, Health, and Society (MHS) at Vanderbilt University. The authors then use a new survey tool, the Structural Foundations of Health Survey, to evaluate structural skills and sensibilities. The analysis compares MHS majors (n = 185) with premed science majors (n = 63) and first-semester freshmen (n = 91), with particular attention to understanding how structural factors shape health. Research was conducted from August 2015 to December 2016. Results suggest that MHS majors identified and analyzed relationships between structural factors and health outcomes at higher rates and in deeper ways than did premed science majors and freshmen, and also demonstrated higher understanding of structural and implicit racism and health disparities. The skills that MHS students exhibited represent proficiencies increasingly stressed by the MCAT, the AAMC, and other educational bodies that emphasize how contextual factors shape expressions of health and illness.
•Posits structural competency as a conceptual framework for training premed students.•Assesses whether structural competency enhances education about diversity issues.•Details interdisciplinary pre-health curriculum integrating structural competency.•Presents Structural Foundations of Health Survey to assess analytic skills.
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 collectionperceiving 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.
PROBLEMStructural competency is a framework for conceptualizing and addressing health-related social justice issues that emphasizes diagnostic recognition of economic and political conditions ...producing and racializing inequalities in health. Strategies are needed to teach prehealth undergraduate students concepts central to structural competency (e.g., structural inequity, structural racism, structural stigma) and to evaluate their impact.
APPROACHThe curriculum for Vanderbilt University’s innovative prehealth major in medicine, health, and society (MHS) was reshaped in 2013 to incorporate structural competency concepts and skills into undergraduate courses. The authors developed the Structural Foundations of Health (SFH) evaluation instrument, with closed- and open-ended questions designed to assess undergraduate students’ core structural competency skills. They piloted the SFH instrument in 2015 with MHS seniors.
OUTCOMESOf the 85 students included in the analysis, most selected one or more structural factors as among the three most important in explaining U.S. regional childhood obesity rates (85%) and racial disparities in heart disease (92%). More than half described individual- or family-level structural factors (66%) or broad social and political factors (56%) as influencing geographic disparities in childhood obesity. Nearly two-thirds (66%) described racial disparities in heart disease as consequences of socioeconomic differences, discrimination/stereotypes, or policies with racial implications.
NEXT STEPSPreliminary data suggest that the MHS major trained students to identify and analyze relationships between structural factors and health outcomes. Future research will include a comparison of structural competency skills among MHS students and students in the traditional premedical track and assessment of these skills in incoming first-year students.
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