A new structural approach to address stigma and inequality in medicine (& mentoring)

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine (1982), 103, 126–133. https://doi.org/10.1016/j.socscimed.2013.06.032

Summarized by Ariel Ervin

Notes of Interest:

• Cultural competency has raised awareness of how bias and stigma have impacted treatment decisions.
• However, current systemic issues indicate that social, cultural, & political factors also contribute to healthcare inequality.
• This paper explores the ongoing discussion about redefining cultural competence to account for structural influences. A model proposes how a structural approach can improve medical engagement to address health inequality and stigma.
• Five core structural competencies are discussed.
  • Acknowledge how socio-political, economic, & physical forces affect medical decisions.
  • Become more aware of how social structures impact health & mental illness in communities.
  • Shift the ways the word “culture” is understood to provide more nuance on how policies and institutions promote cultural barriers
  • Once there’s a strong understanding of how structural forces affect clinical decisions and interactions, practitioners have to develop the skills necessary to assess how they can treat their clients.
  • Acknowledge the limitations of structural competency
• Raising awareness of structural influences on health inequality is the first step towards understanding the myriad of social, political, socioeconomic, and environmental factors that impact clinical interactions.
• It’s important to remember that structural competency doesn’t eliminate the importance of interpersonal communication in clinical interactions.
• These findings can also apply to the field of psychology and mentoring since they a) explain how systemic issues impact the mental health of underrepresented communities and b) how clinicians and mentoring practitioners can provide more structurally and culturally competent care and support.

Introduction (Reprinted from the Abstract)

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.

Implications (Reprinted from the Conclusion)

Addressing stigma and inequality in clinical settings requires that clinicians attend to the social structures that shape and enable stigma’s underlying assumptions. However, these structures are frequently rendered invisible in medical education. Promoting awareness of structural forces serves as a first step toward promoting recognition of the web of interpersonal networks, environmental factors and political/socioeconomic forces that surround clinical encounters and of better understanding the conversations that take place there within. Starting with medical education is a modest attempt to begin to promote new forms of coalition in which knowledge about diseases and bodies combines with expert analysis of social systems in ways that might, over time, might help put notions of structural stigma at the center of conceptualizations of illness and health.

It is of course the case that some of the interventions we describe above, and many that we do not, already appear in certain medical-school curricula. For instance, Albert Einstein medical college in New York promotes a “research-based health activism program” that combines clinical research and epidemiology with grass-roots advocacy in an attempt to train future doctors to “advocate for public health, social justice, and health equality” (Albert Einstein College of Medicine). Meanwhile, two physicians at the University of Michigan, Kumagai and Lypson (2009), developed a medical school curriculum aimed at developing “critical consciousness” —a skill that “places medicine in a social, cultural, and historical context and which is coupled with an active recognition of societal problems and a search for appropriate solutions.” And the Accreditation Council for Graduate Medical Education boasts an impressive list of “healthcare disparities competencies” for residents (abp.org).

Structural competency is an attempt to broaden these types of skills into more expansive realms of education and practice. We recognize that a call to competency risks promoting checklists of facts for didactic instruction, rather than preparation for career-long engagement with learning and acting on the structural determinants of stigma and health across disciplines and communities. At the same time, competency emphasizes ability, and the promise of remediation. Competency also indicates a set of proclivities that are essential to the role of health care provider, including the duty of providers to cultivate in themselves, and the duty of medical educators to impart to trainees.

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