Shifting Curricula

Metzl, M. Jonathan, and Helena Hansen.”Structural competency: theorizing a new medical engagement with stigma and inequality.Social Science and Medicine  2014 Feb;103:126-33.

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.

Click here for the full article: http://www.sciencedirect.com/science/article/pii/S0277953613003778

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Lee, S. Agnes, and Michelle Farrell. “Is Cultural Competency a Backdoor to Racism?” Anthropology News 47.3 (2006): 9-10. Web.

In the US, medical and public health professionals recognize that there is a disparity in health care and that the disparity is correlated with ethnicity and “race.” In an attempt to deal with this disparity, cultural competency models have been incorporated into the curricula of most health professions and into many healthcare institutions. These models, in general, call for sensitivity to cultural differences between the health care provider and the patient. What is of interest to us is that these models fail to capture the diverse and fluid nature of culture and self-identity. Instead, these models tend to focus on constructed categories of race that are reaffirmed and reified by the myriad of health studies that neither question nor explain the racial divisions.

Click here for the full article: http://understandingrace.org/resources/pdf/rethinking/lee_farrell.pdf

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Pon, G. (2009). “Cultural Competency as New RacAtrism: An Ontology of Forgetting.” Journal of Progressive Human Services 20(1): 59-71.

This article argues that cultural competency promotes an obsolete view of culture and is a form of new racism. Cultural competency resembles new racism both by otherizing non-whites and by deploying modernist and absolutist views of culture while not using racialist language. Drawing on child welfare, cultural competence is shown to repeat what Lowe (1993) calls an ontology of forgetting Canada’s history of colonialism and racism. A recommendation is made for jettisoning cultural competency and emphasizing instead a self-reflexive grappling with racism and colonialism.

Click here for the full article: http://www.tandfonline.com/doi/abs/10.1080/10428230902871173

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Tervalon, M. and J. Murray-Garcia (1998). “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.” Journal of Health Care for the Poor and Underserved 9(2): 117-125.

Researchers and program developers in medical education presently face the challenge of implementing and evaluating curricula that teach medical students and house staff how to effectively and respectfully deliver health care to the increasingly diverse populations of the United States. Inherent in this challenge is clearly defining educational and training outcomes consistent with this imperative. The traditional notion of competence in clinical training as a detached mastery of a theoretically finite body of knowledge may not be appropriate for this area of physician education. Cultural humility is proposed as a more suitable goal in multicultural medical education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.

Click here for the full article: https://pritzker.uchicago.edu/documents/CulturalCompetency.pdf

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Metzl, J. M. and D. E. Roberts (2014). “Structural competency meets structural racism: race, politics, and the structure of medical knowledge.” Virtual Mentor 16(9): 674-690.

Physicians in the United States have long been trained to assess race and ethnicity in the context of clinical interactions. Medical students learn to identify how their patients’ “demographic and cultural factors” influence their health behaviors [1]. Interns and residents receive “cultural competency” training to help them communicate with persons of differing “ethnic” backgrounds [2]. And clinicians are taught to observe the races of their patients and to dictate these observations into medical records—“Mr. Smith is a 45-year-old African American man”—as a matter of course [3]. To be sure, attention to matters of diversity in clinical settings has been shown to affect a number of factors central to effective diagnosis and treatment [4]. Yet an emerging educational movement challenges the basic premise that having a culturally competent or sensitive clinician reduces patients’ overall experience of stigma or improves health outcomes. This movement, called “structural competency” [5], contends that many health-related factors previously attributed to culture or ethnicity also represent the downstream consequences of decisions about larger structural contexts, including health care and food delivery systems, zoning laws, local politics, urban and rural infrastructures, structural racisms, or even the very definitions of illness and health. Locating medical approaches to racial diversity solely in the bodies, backgrounds, or attitudes of patients and doctors, therefore, leaves practitioners unprepared to address the biological, socioeconomic, and racial impacts of upstream decisions on structural factors such as expanding health and wealth disparities [6].

Click here for the full article: http://journalofethics.ama-assn.org/2014/09/pdf/spec1-1409.pdf

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Kumagai, A. K. and M. L. Lypson (2009). “Beyond cultural competence: critical consciousness, social justice, and multicultural education.” Academic Medicine 84(6): 782-787.

In response to the Liaison Committee on Medical Education mandate that medical education must address both the needs of an increasingly diverse society and disparities in health care, medical schools have implemented a wide variety of programs in cultural competency. The authors critically analyze the concept of cultural competency and propose that multicultural education must go beyond the traditional notions of “competency” (i.e., knowledge, skills, and attitudes). It must involve the fostering of a critical awareness–a critical consciousness–of the self, others, and the world and a commitment to addressing issues of societal relevance in health care. They describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking, and suggest that both are essential in the training of physicians. The authors also propose that the object of knowledge involved in critical consciousness and in learning about areas of medicine with social relevance–multicultural education, professionalism, medical ethics, etc.–is fundamentally different from that acquired in the biomedical sciences. They discuss how aspects of multicultural education are addressed at the University of Michigan Medical School. Central to the fostering of critical consciousness are engaging dialogue in a safe environment, a change in the traditional relationship between teachers and students, faculty development, and critical assessment of individual development and programmatic goals. Such an orientation will lead to the training of physicians equally skilled in the biomedical aspects of medicine and in the role medicine plays in ensuring social justice and meeting human needs.

Click here for the full article: http://www.ncbi.nlm.nih.gov/pubmed/19474560

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Tsevat, R. K., et al. (2015). “Bringing Home the Health Humanities: Narrative Humility, Structural Competency, and Engaged Pedagogy.” Academic Medicine.

As health humanities programs grow and thrive across the country, encouraging medical students to read, write, and become more reflective about their professional roles, educators must bring a sense of self-reflexivity to the discipline itself. In the health humanities, novels, patient histories, and pieces of reflective writing are often treated as architectural spaces or “homes” that one can enter and examine. Yet, narrative-based learning in health care settings does not always allow its participants to feel “at home”; when not taught with a critical attention to power and pedagogy, the health humanities can be unsettling and even dangerous. Educators can mitigate these risks by considering not only what they teach but also how they teach it.In this essay, the authors present three pedagogical pillars that educators can use to invite learners to engage more fully, develop critical awareness of medical narratives, and feel “at home” in the health humanities. These pedagogical pillars are narrative humility (an awareness of one’s prejudices, expectations, and frames of listening), structural competency (attention to sources of power and privilege), and engaged pedagogy (the protection of students’ security and well-being). Incorporating these concepts into pedagogical practices can create safe and productive classroom spaces for all, including those most vulnerable and at risk of being “unhomed” by conventional hierarchies and oppressive social structures. This model then can be translated through a parallel process from classroom to clinic, such that empowered, engaged, and cared-for learners become empowering, engaging, and caring clinicians.

Click here for the full article: http://www.ncbi.nlm.nih.gov/pubmed/25945967

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Gregg, J., & Saha, S. (2006). Losing Culture on the Way to Competence: The Use and Misuse of Culture in Medical Education. Academic Medicine, 542-547.

Most cultural competence programs are based on traditional models of cross-cultural education that were motivated primarily by the desire to alleviate barriers to effective health care for immigrants, refugees, and others on the sociocultural margin. The main driver of renewed interest in cultural competence in the health professions has been the call to eliminate racial and ethnic disparities in the quality of health care. This mismatch between the motivation behind the design of cross-cultural education programs and the motivation behind their current application creates significant problems. First, in trying to define cultural boundaries or norms, programs may inadvertently reinforce racial and ethnic biases and stereotypes while doing little to clarify the actual complex sociocultural contexts in which patients live. Second, in attempting to address racial and ethnic disparities through cultural competence training, educators too often conflate these distinct concepts. To make this argument, the authors first discuss the relevance of culture to health and health care generally, and to disparities in particular. They then examine the concept of culture, paying particular attention to how it has been used (and misused) in cultural competence training. Finally, they discuss the implications of these ideas for health professions education.

Click here for the full article: http://www.ncbi.nlm.nih.gov/pubmed/16728802

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Kleinman A, Benson P (2006) Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Med 3(10): e294. doi:10.1371/journal.pmed.0030294

Cultural competency has become a fashionable term for clinicians and researchers. Yet no one can define this term precisely enough to operationalize it in clinical training and best practices. It is clear that culture does matter in the clinic. Cultural factors are crucial to diagnosis, treatment, and care. They shape health-related beliefs, behaviors, and values [1,2]. But the large claims about the value of cultural competence for the art of professional care-giving around the world are simply not supported by robust evaluation research showing that systematic attention to culture really improves clinical services. This lack of evidence is a failure of outcome research to take culture seriously enough to routinely assess the cost-effectiveness of culturally informed therapeutic practices, not a lack of effort to introduce culturally informed strategies into clinical settings [3].

Click here for the full article: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0030294

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Brooks, K. C. (2015). “A silent curriculum.” JAMA 313(19): 1909-1910.
It wasn’t that I didn’t receive any education on race. In fact, there have been many well-intentioned curricular attempts to understand the intersections between race and medicine. Since first year, I’ve been inundated with lecture PowerPoint slides that list diseases with higher rates among minorities. But few of them delved into an explanation as to why these disparities exist. Many electives boasted discussions of health inequalities between communities, but rarely did we discuss how skin color played a role. And in doctoring small groups, we avidly discussed the association between poor health outcomes and poverty, but less enthusiastically talked about why standards of care are still not met for black patients with chest pain. As soon as racism was mentioned, conversations fizzled, highlighting the palpable discomfort in the room.

Click here for the full article: http://jama.jamanetwork.com/article.aspx?articleid=2293299

 

 

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