ChangeMedEd Initiative

Ending health inequity requires new skill: structural competency

Timothy M. Smith , Contributing News Writer

Huge health inequities that have become more apparent during the COVID-19 pandemic have provided further evidence of systemic racism in the U.S. and added urgency to calls to better understand the discrimination experienced by people of color. A recent AMA webinar explores how to undo systemic racism by applying an important new concept to medical education: structural competency.

Explore Health Equity

This web series features diverse speakers touching on the impact of existing structural issues and the COVID-19 pandemic on health equity.

The webinar, “Applying Systems Thinking to Address Structural Racism in Health Professions Education: Curriculum, Structural Competency and Institutional Change,” was produced by the AMA Accelerating Change in Medical Education initiative, in collaboration with Beyond Flexner Alliance, and details what structural competency is and how it can be applied in practice.

“We are now moving toward a language of social determinants of health in medical schools and places where the term has not been used before,” said Helena B. Hansen, MD, PhD, associate professor in the Department of Psychiatry at NYU Grossman School of Medicine. “What we need to do is broaden the lens even further [to include] the structural drivers of social determinants of health.”

Dr. Hansen is co-editor of Structural Competency in Mental Health and Medicine: A Case-Based Approach to Treating the Social Determinants of Health, a textbook published by Springer.

One notorious example of systemic racism in the U.S., Dr. Hansen noted, is redlining—the bank practice dating to at least the 1960s of denying mortgages and small business loans to Black, brown and immigrant communities.

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While the practice was outlawed by the Community Reinvestment Act in 1977, it “has had enduring effects, as homeownership is the primary source of wealth among Americans,” Dr. Hansen said. “Neighborhoods without access to home ownership see progressive deterioration in wealth and ability to finance, for example, education and medical bills, with serious consequences—just like the preventable diseases of poverty, like diabetes, vascular disease, asthma and HIV.”

Learn more about how racism and segregation drive health disparities.

Breaking down the term structural competency, Dr. Hansen explained that the concept first requires shifting one’s focus from the individual to the social structures that determine health, such as clinical, educational and correctional institutions, as well as public policies. It then requires building competencies to expand one’s scope of clinical intervention and responsibility.

Dr. Hansen identified four levels where physicians and administrators can build structural competencies at their organizations and in their communities.

Look for interventions that can be launched in clinic. This is the low-lying fruit, such as screening for social needs during evaluation and referring patients and families as indicated to community resources for legal aid, food and housing assistance.

Create partnerships with community organizations. An example is providing addiction and mental health services through Black and Latinx churches and Native American healing circles.

Collaborate with nonhealth sectors. Education, law enforcement and urban planning all have huge downstream effects.

Train clinicians as policy advocates. Their voices carry weight in debates over harmful policies, such as drug laws that feed mass incarceration, and they can help reframe policies as health issues.

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Structural competency, Dr. Hansen said, “could not be better suited to the current moment of collision of racial inequalities in COVID testing, treatment and outcomes and protests against the racial violence of policing and incarceration.”

Read about why African American communities are being hit hard by COVID-19 and how the disease is affecting Latinx communities.

The one-hour webinar also features a presentation by Michelle Morse, MD, social medicine course director and assistant professor at Harvard Medical School, with numerous real-world examples of structural racism in health care, as well as practical solutions at the organizational level.

In addition, Robert Rock, MD, family medicine resident at Montefiore Health System, in the Bronx, summarized his experience creating a new course aimed at fostering a socially accountable health justice curriculum while he was a medical student at Yale School of Medicine.

The webinar slides and a video recording are available in the “Resources” section of the AMA Accelerating Change in Medical Education digital community (registration required).

The second edition of the AMA textbook, Health Systems Science, has an expanded chapter on structural and social determinants of health—guided with input from the AMA Center for Health Equity—that further illustrates many of these issues. The Accelerating Change in Medical Education consortium has published a guide to evaluating educational programs for potential racism and bias.

The AMA has developed a COVID-19 resource center as well as a physician’s guide to COVID-19 to give doctors a comprehensive place to find the latest resources and updates from the Centers for Disease Control and Prevention and the World Health Organization. 

The AMA has also curated a selection of resources to assist residents and medical students during the COVID-19 pandemic to help manage the shifting timelines, cancellations and adjustments to testing, rotations and other events.