Journal of General Internal Medicine

, Volume 32, Issue 4, pp 430–433 | Cite as

Teaching Structure: A Qualitative Evaluation of a Structural Competency Training for Resident Physicians

  • Joshua Neff
  • Kelly R. Knight
  • Shannon Satterwhite
  • Nick Nelson
  • Jenifer Matthews
  • Seth M. Holmes
Original Research

Abstract

Background

The influence of societal inequities on health has long been established, but such content has been incorporated unevenly into medical education and clinical training. Structural competency calls for medical education to highlight the important influence of social, political, and economic factors on health outcomes.

Aim

This article describes the development, implementation, and evaluation of a structural competency training for medical residents.

Setting

A California family medicine residency program serving a patient population predominantly (88 %) with income below 200 % of the federal poverty level.

Participants

A cohort of 12 residents in the family residency program.

Program Description

The training was designed to help residents recognize and develop skills to respond to illness and health as the downstream effects of social, political, and economic structures.

Program Evaluation

The training was evaluated via qualitative analysis of surveys gathered immediately post-training (response rate 100 %) and a focus group 1 month post-training (attended by all residents not on service).

Discussion

Residents reported that the training had a positive impact on their clinical practice and relationships with patients. They also reported feeling overwhelmed by increased recognition of structural influences on patient health, and indicated a need for further training and support to address these influences.

KEY WORDS

structural competency social determinants of health structural vulnerability cultural competency medical education 

References

  1. 1.
    Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(2):19–31.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Centers for Disease Control and Prevention. Establishing a Holistic Framework to Reduce Inequalities in HIV, VIral Hepatitis, STDs, and Tuberculosis in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2010. http://ses.sp.bvs.br/local/File/Establishing%20a%20Holistic%20Framework%20to%20Reduce%20Inequities%20in%20HIV,%20Viral%20Hepatitis,%20STDs,%20and%20Tuberculosis%20i. Accessed 20 November 2016.
  3. 3.
    Krieger N. Proximal, distal, and the politics of causation: what’s level got to do with it? Am J Public Health. 2008;98(2):221–30.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    CSDH. Closing the gap in a generation: health equity through action on the socialdeterminants of health. Final Report of the Commission on Social Determinants of Health.Geneva, World Health Organization; 2008.Google Scholar
  5. 5.
    Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. No easy solution. JAMA. 1993;269(24):3140–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Marmot M. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury Publishing; 2015.Google Scholar
  7. 7.
    Virchow RC. Report on the typhus epidemic in Upper Silesia. Am J Public Health. 2006;96(12):2102–5.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health. 2001;91(10):1592–601.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Farmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med. 2006;3(10):e449.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Westerhaus M, Finnegan A, Haidar M, Kleinman A, Mukherjee J, Farmer P. The necessity of social medicine in medical education. Acad Med. 2015;90(5):565–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Acad Med. 2016.Google Scholar
  12. 12.
    Chin MH, Clarke AR, Nocon RS, et al. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med. 2012;27(8):992–1000.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Gonzalez CM, Fox AD, Marantz PR. The evolution of an elective in health disparities and advocacy: description of instructional strategies and program evaluation. Acad Med. 2015;90(12):1636–40.CrossRefPubMedGoogle Scholar
  14. 14.
    Kumagai AK, Lypson ML. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. 2009;84(6):782–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Ross PT, Wiley Cene C, Bussey-Jones J, et al. A strategy for improving health disparities education in medicine. J Gen Intern Med. 2010;25(Suppl 2):S160–3.CrossRefPubMedGoogle Scholar
  16. 16.
    Vela MB, Kim KE, Tang H, Chin MH. Innovative health care disparities curriculum for incoming medical students. J Gen Intern Med. 2008;23(7):1028–32.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126–33.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–25.CrossRefPubMedGoogle Scholar
  19. 19.
    Hansen H. Faculty Roundtable Discussion on Curricular Reform. 6th Biennial National Conference for Clinician-Scholars in the Social Sciences and Humanities: Policies and Politics of Care, Philadelphia, April 18, 2015.Google Scholar
  20. 20.
    Quesada J, Hart LK, Bourgois P. Structural vulnerability and health: Latino migrant laborers in the United States. Med Anthropol. 2011;30(4):339–62.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Holmes SM. The clinical gaze in the practice of migrant health: Mexican migrants in the United States. Soc Sci Med. 2012;74(6):873–81.CrossRefPubMedGoogle Scholar
  22. 22.
    Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.CrossRefPubMedGoogle Scholar
  23. 23.
    Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.CrossRefPubMedGoogle Scholar
  24. 24.
    Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284–93.CrossRefPubMedGoogle Scholar
  25. 25.
    Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18(8):670–4.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Wear D, Kuczewski MG. Perspective: medical students’ perceptions of the poor: what impact can medical education have? Acad Med. 2008;83(7):639–45.CrossRefPubMedGoogle Scholar
  27. 27.
    Bourgois P, Schonberg J. Righteous Dopefiend. Berkeley: University of California Press; 2009.Google Scholar
  28. 28.
    Holmes SM. Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States. Berkeley: University of California Press; 2013.Google Scholar
  29. 29.
    Waitzkin H. The Micropolitics of the Doctor-Patient Relationship. The Second Sickness: Contradictions of Capitalist Health Care. New York: Rowman & Littlefield; 2000:119–164.Google Scholar
  30. 30.
    Wear D, Aultman JM. The limits of narrative: medical student resistance to confronting inequality and oppression in literature and beyond. Med Educ. 2005;39(10):1056–65.CrossRefPubMedGoogle Scholar
  31. 31.
    Rivkin-Fish M. Learning the moral economy of commodified health care: “community education,” failed consumers, and the shaping of ethical clinician-citizens. Cult Med Psychiatry. 2011;35(2):183–208.CrossRefPubMedGoogle Scholar
  32. 32.
    Calman NS. Out of the shadow. Health Aff. 2000;19(1):170–4.CrossRefGoogle Scholar
  33. 33.
    Wear D, Zarconi J, Aultman JM, Chyatte MR, Kumagai AK. Remembering Freddie Gray: Medical Education for Social Justice. Acad Med. 2016.Google Scholar
  34. 34.
    Knight KR. addicted.pregnant poor. Durham, NC: Duke University Press; 2015.Google Scholar
  35. 35.
    Davenport BA. Witnessing and the medical gaze: how medical students learn to see at a free clinic for the homeless. Med Anthropol Q. 2000;14(3):310–27.CrossRefPubMedGoogle Scholar
  36. 36.
    Willen SS. Confronting a “big huge gaping wound”: emotion and anxiety in a cultural sensitivity course for psychiatry residents. Cult Med Psychiatry. 2013;37(2):253–79.CrossRefPubMedGoogle Scholar
  37. 37.
    Metzl J. The Protest Psychosis: How Schizophrenia Became a Black Disease. Boston: Beacon Press; 2009.Google Scholar

Copyright information

© Society of General Internal Medicine 2016

Authors and Affiliations

  • Joshua Neff
    • 1
  • Kelly R. Knight
    • 2
  • Shannon Satterwhite
    • 3
    • 4
  • Nick Nelson
    • 5
    • 6
  • Jenifer Matthews
    • 7
  • Seth M. Holmes
    • 1
    • 2
    • 3
    • 4
    • 5
    • 8
    • 9
  1. 1.Joint Medical ProgramUC Berkeley-UCSFBerkeleyUSA
  2. 2.Department of Anthropology, History, and Social MedicineUCSFSan FranciscoUSA
  3. 3.Medical Scientist Training ProgramUCSFSan FranciscoUSA
  4. 4.Joint Program in Medical AnthropologyUC Berkeley-UCSFSan FranciscoUSA
  5. 5.Department of MedicineHighland HospitalOaklandUSA
  6. 6.Department of MedicineUCSFSan FranciscoUSA
  7. 7.Department of Adolescent MedicineUCSF Benioff Children’s Hospital OaklandOaklandUSA
  8. 8.School of Public HealthUC BerkeleyBerkeleyUSA
  9. 9.University of California BerkeleyBerkeleyUSA

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