Structural Competency and Psychiatry

The essays in this Viewpoints section emerge from a growing body of literature that posits structural competency as a new conceptual framework for reducing inequalities and promoting social justice in US medicine and psychiatry. Whereas previous models such as cultural competency focus on identifying clinician bias and improving communication at moments of clinical encounter, structural competency encourages clinical practitioners to recognize how social, economic, and political conditions produce health inequalities in the first place. Structural competency calls on health care professionals to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases, and to mobilize for correction of inequalities as they manifest both in physician-patient interactions and beyond the clinic walls.

Structural Competency and Psychiatry 
Jonathan Metzl, MD PhD., Helena Hansen MD, PhD.

From Cultural to Structural Competency– Training Psychiatry Residents to Act on social Determinants of Health and Institutional Racism
Helena Hansen, MD, PhD., Joel Braslow, MD, PhD., Robert M Rohrbaugh, MD.

Advocacy as Key to Structural Competency in Psychiatry
Laurence J. Kirmayer, Knorick R, Rousseau C.

Health Effects of Dramatic Societal Events — Ramifications of the Recent Presidential Election
David R. Williams, Ph.D., M.P.H., and Morgan M. Medlock, M.D., M.Div.

This article explores the pathways through which stressful societal events (such as presidential elections) may result in negative psycho-social and physiological consequences for vulnerable — and sometimes targeted, —  populations due to the correlated or ensuing feelings of discrimination and prejudice. The authors offer suggestions for how healthcare providers can respond to such events.

America: equity and equality in health
Editorial, The Lancet

The Lancet publishes a new Series about US health and health care, which highlights how widening gaps of income inequality are driving increases in health inequity. Other contributory factors, including mass incarceration and structural racism, are evaluated, as is the impact of the Affordable Care Act. The Series warns of a 21st century health-poverty trap unless new interventions are implemented.”

Social justice should be a key part of educating health professionals
By Michael Westerhaus, Amy Finnegan, Jennifer Goldsmith, Evan Lyon, Casey Fox, and Michelle Morse

The authors highlight the importance of considering social determinants of health in U.S. healthcare reform, as they significantly contribute to health disparities. Using liberation theology’s “preferential option for the poor” framework, the authors urge healthcare providers to offer the best healthcare options for populations who are most vulnerable to the negative health effects of unjust social systems.

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

Hansen HMetzl JM.
Acad Med. 2017 Mar;92(3):279-281. doi: 10.1097/ACM.0000000000001542.

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.

Article references:
Integrating and Assessing Structural Competency in an Innovative Prehealth Curriculum at Vanderbilt University.
Metzl JM, Petty J.
Acad Med. 2017 Mar;92(3):354-359.

Queer Frontiers in Medicine: A Structural Competency Approach.
Donald CA, DasGupta S, Metzl JM, Eckstrand KL.
Acad Med. 2017 Mar;92(3):345-350.

The Political Future of Social Medicine: Reflections on Physicians as Activists
Geiger, H. Jack
Academic Medicine . 92(3):282-284, March 2017.

The Medical–Legal Partnership Approach to Teaching Social Determinants of Health and Structural Competency in Residency Programs
Paul, Edward G.; Curran, Mallory; Tobin Tyler, Elizabeth
Academic Medicine . 92(3):292-298, March 2017.

Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care
Bourgois, Philippe; Holmes, Seth M.; Sue, Kim; More
Academic Medicine . 92(3):299-307, March 2017.

Integrating Theory, Content, and Method to Foster Critical Consciousness in Medical Students: A Comprehensive Model for Cultural Competence Training
Dao, Diane K.; Goss, Adeline L.; Hoekzema, Andrew S.; More
Academic Medicine . 92(3):335-344, March 2017.