Toward Structural Competency in Emergency Medical Education

Abstract

As the emergency department (ED) is the “front door” of the hospital and the primary site by which most patients access the health care system, issues of inequity are especially salient for emergency medicine (EM) practice. Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians that are cognizant and attentive to their needs in and out of the medical encounter. EM resident education has traditionally incorporated a “cultural competency” model to equip residents with tools to combat individual bias and stigma. Although this framework has been influential in drawing attention to health inequities, it has also been criticized for its potential to efface differences within groups (such as socioeconomic differences), overstate cultural or racial differences, and unintentionally reinforce stereotypes or blaming of patients for their ill health or difficult circumstances. In contrast, emerging frameworks of structural competency call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health. We present here the framework of structural competency, extending it to the unique ED setting. We provide tangible illustrations of the ways in which this framework is relevant to the ED setting and can be incorporated in EM education.

Health policy, material deprivation, inequality, and stigma are implicated in poor health outcomes among emergency department (ED) patients.1, 2, 3 Researchers have emphasized the role of the social determinants of health,4, 5 structural racism,6 gender discrimination,7 homophobia,8, 9 and transphobia10, 11 on the health of ED patients. These topics continue to gain interest and attention as their ties to medical education, clinical care, and population health are elucidated and emphasized. A unifying thread in this emerging research is the contextualization of individual patient encounters within structural conditions (i.e., historical, political, and material factors). These considerations influence the choices and resources available to patients and emergency providers before, during, and after the clinical encounter. Thus, they become embodied in the health and welfare of patients, communities, and systems.12, 13 Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians (EPs) that are cognizant and attentive to their needs in and out of the medical encounter.

Attention to health inequities is not new to emergency medicine (EM). Since the Institute of Medicine’s landmark report on health disparities,14, 15 EPs have paid greater attention to the ways in which implicit bias and stereotyping16, 17, 18 along with access‐related factors (e.g., insurance and income)19, 20, 21, 22 contribute to health inequalities among patients. The Accreditation Council on Graduate Medical Education (ACGME) created six core competencies to “define the foundational skills that every practicing physician should possess” and as a way “to shape and evaluate the education of residents.”23, 24 For example, the systems‐based practice milestone requires that residents demonstrate an awareness of and responsiveness to the larger context and system of health care.25 In response, educational programs have traditionally incorporated a “cultural competency” model to equip residents with the tools to “enhance health professionals’ awareness of how cultural and social factors influence health care, while providing methods to obtain, negotiate, and manage this information clinically once it is obtained.”15 The cultural competency framework has been influential in EM, drawing attention to the ways in which understandings and expressions of health and illness can vary across racial, ethnic, gender, and other lines.

Although this was an important development in medical education, cultural competency has been increasingly critiqued for a tendency to frame “culture” as a static attribute of a group, thereby inadvertently reinforcing misconceptions or prejudice. For example, relying on broad cultural terms to understand and describe ethnic or racial groups can obscure intra‐group variations. These variations, which may arise from material conditions or socioeconomic constraints, can instead be chalked to up to “the way people just are.”26 Indeed, work from medical sociology and anthropology has convincingly shown that variations attributable to culture are often the result of entrenched structural inequalities and profound material deprivation.27, 28, 29 Moreover, cultural competency implicates individual physician behavior, interpersonal relationships, and within‐hospital practices without critically interrogating upstream causes of social inequity—whose impact on health outcomes eclipses that of clinical care.30, 31, 32, 33

Emerging frameworks of structural competency, first introduced by Metzl and Hansen,34 call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health.35 Throughout this paper, we use “structure” as a shorthand reference to the way that a society is hierarchically organized through institutions, political and economic policies, and normative beliefs. Metzl and Hansen define structural competency as:

The trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “noncompliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of health and illness.

This definition draws upon robust traditions in the humanities, social sciences, and public health and proposes five core structural competencies integral to this framework: 1) recognizing the structures that shape clinical interactions, 2) developing an extraclinical language of structure, 3) articulating “cultural” presentations in structural terms, 4) observing and imagining structural interventions, and 5) developing structural humility.

EM has already taken important steps toward recognizing and addressing the ways in which stigma and disenfranchisement affect the health of ED patients. Yet there remains an important opportunity to incorporate structural competency into resident education, thus giving trainees a foundation to provide the best care to the individual and populations of patients. The aims of this paper are: 1) to define structural competency and its relevance to the unique setting of the ED, 2) to provide tangible and useful illustrations of the ways in which this framework is relevant to the ED, and 3) to illustrate how this can be incorporated in EM graduate medical education.

Methods

This concept paper was developed from a needs assessment based on the experiences of members of the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM, an academy of the Society for Academic Emergency Medicine [SAEM]), whose mission includes the promotion of “equal access to quality healthcare and the elimination of disparities in treatment and outcomes through education and research.”36 The concept of this paper was introduced at the ADIEM business meeting during the 2019 SAEM Annual Meeting in Las Vegas, Nevada, which was open to all SAEM meeting attendees. The writing group consists of five EM physician educators and one EM resident with a mutual interest and expertise in social medicine, health inequality, residency education, and diversity and inclusion in EM. All members of the writing group are members of ADIEM from institutions that represent broad geographic locations and diverse patient demographics: Emory University, The University of Colorado, Thomas Jefferson University, and Yale University. In this concept paper, we aimed to provide a conceptual framework to develop resident education towards minimizing health inequalities, aligning EM education with broader trends in EM research and advocacy, furthering the mission of ADIEM, and improving patient care.

Structural Competency and EM

Structural competency challenges the prevailing tendency to think of health as the sum total of genetic predisposition and individual choice. Instead, it affirms the position that health is a product of the policies, economic systems, and institutions (e.g., health care, educational, housing, carceral) that contribute to and maintain social inequalities. These policies, systems, and institutions produce disenfranchisement and marginalization that operate along lines of socioeconomic class, race, gender, and sexual orientation, to which health inequities necessarily correspond in parallel.37, 38

Nuanced theorization of social inequalities has required researchers and medical educators to draw from the social sciences. Using principles and literature from fields such as public health, sociology, medical anthropology, and history, scholars are able to illustrate how social cohesion, inequality, and material deprivation are critical to understanding health disparities and poor health outcomes of ED patients.39, 40, 41, 42, 43 EPs have advocated for ways to diversify the workforce of emergency providers,44 to combat implicit bias in the clinical encounter,16 to address the material needs of patients that extend well beyond the ED,4 and to equip EDs with the resources to meet the diverse social needs of our patients. In fact, the ACGME has recognized these steps as crucial to creating an inclusive workplace, now requiring residency programs, departments, and hospital systems to have plans in place to assure their makeup reflects their community’s makeup and diversity.

Each of these represents a powerful step toward the development of a social EM agenda for research, advocacy, and education. There remain opportunities to draw on the social sciences to expand our understanding of social forces and the ways that they manifest in the clinical encounter and our patients’ health. For instance, historians analyze the ways in which categories and understandings of health vary across time.45, 46 Medical anthropologists and sociologists illuminate how systems of inequality can manifest at individual, community, and regional levels.47, 48, 49 Economists demonstrate that financial systems and funding priorities influences health outcomes and life expectancies.50, 51

We do not expect that EPs will become experts in these varied disciplines during their medical education. Each of these disciplines has important contributions to EM practice but alone are not sufficient to account for the multiplicity of conditions under which we practice. We present these examples as opportunities for interdisciplinary engagement to better illuminate the ways in which seemingly simple or mundane patient interactions can represent manifestations of interrelated economic, historical, cultural, and political conditions. Indeed, it is clear that progress in the realm of health justice mandates collaboration between these fields. We firmly believe that the scholarship of social sciences is critical to improving the health of our patients and education of our trainees.

Structural competency is therefore not a replacement for EM’s increasing attention to social circumstances and their relationships to health. Rather, it is a framework that seeks to unify and teach the ways that ostensibly disparate aspects of social organization influence health and play out in the ED.

The Structurally Competent Emergency Physician

To operationalize cultural competency within medical education, Metzl and Hansen propose five core structural competencies, which we present below, adapted for EM training and explicated through relevant clinical examples.

Recognizing the Structures That Shape Clinical Interactions

The first component of structural competency is to recognize how political, economic, and material conditions (i.e., structures) influence the clinical encounter. This recognition is critical to achieving the ACGME’s patient care competency. Indeed, it is impossible to provide effective, appropriate, and compassionate care without consideration of the obstacles and conditions. Consider, for example, the following case:

Ms. Navarian is a 74‐year‐old woman who presents to the ED with a complaint of chest pain and dyspnea. Her work‐up reveals AFib and an NSTEMI. She is treated appropriately, and the decision is made to admit her for further management. When her resident informs her of the need for admission, she adamantly refuses and asks to sign out against medical advice. When evaluating her, the resident notes that she recently lost her husband and questions if she may have undiagnosed dementia that could be affecting her capacity to participate in the medical decision‐making process.

While Ms. Navarian’s decision‐making capacity is a worthwhile consideration, one must also be careful not to conflate aging with cognitive decline and to consider other variables in her treatment.52 To illustrate, when asked, Ms. Navarian states that being admitted would leave her home unattended, thereby making her vulnerable to burglary. Moreover, she states that the death of her husband has left her with unpaid bills related to his end‐of‐life care and funeral expenses and she is concerned about accruing further debt with this admission. Within this case lie important issues of housing affordability, eviction and tenants’ rights, and the financial precarity associated with aging.53 As the U.S. population ages, there is growing concern and evidence that elder patients face marked instability and insecurity stemming from difficulty or inability to access essential resources—circumstances that will regularly manifest within the ED.54, 55, 56

Thus, the resident treating Mrs. Navarian may recognize that the loss of her spouse may unveil cognitive deficits, but may also expose her to personal and material hardships. Consequently, the resident may inquire further about her living arrangements, the availability of social support, and her most immediate concerns beyond the stated chief complaint. This information may reveal immediate solutions to ease some of her burdens (e.g., a trusted friend may stay in her home to ease her concerns of burglary). However, even if no immediate solutions present themselves, this information could have important implication for her follow‐up care, treatment, and linkage to resources.

Structural constraints are not unique to patients within the clinical encounter. EPs are under pressure to treat patients expeditiously and to balance patients with a wide range of complaints and acuities. EPs often do not have time to delve into the difficulties of each patient’s circumstances, as with Ms. Navarian. Further, EPs may be constrained by the availability of social services, outpatient services, drug pricing, and local and state laws that limit the scope of their practice. These are all factors under which physicians have little control, yet awareness of the existence of these structures and constraints provides a productive way to articulate the circumstances under which we deliver care—to patients, colleagues, hospital administrators, and policy makers. Therefore, attention to structure should not be approached as an additional task or competency that EPs have to undertake, but rather a reorientation of the physician’s role and the clinical encounter toward the macro‐level structures in which we are all implicated. Of note, the EM Model of Clinical Practice explicitly states that these issues are crucial for the knowledge and practice of EPs. For example, the model states that EPs must “recognize age, gender, ethnicity, barriers to communication, socioeconomic status, underlying disease, and other factors that may affect patient management.”57

Developing an Extraclinical Language of Structure

Structural competency draws on a range of disciplines within the social sciences to push the limits of medical education and to challenge what the role of the physician might be with regard to patient safety and health. This dovetails with the ACGME’s “interpersonal and communication skills” competency, which requires that residents demonstrate the ability to effectively communicate with and understand the conditions of patients from a variety of backgrounds. To illustrate, we offer the following case:

Ms. Gomez is a young immigrant from Honduras with a prior medical history of untreated hypertension. She presents to the ED with a complaint of progressively worsening dyspnea for one month. Her ED work‐up reveals a diagnosis of end‐stage renal disease (ESRD) and prompts her admission and the initiation of emergent hemodialysis. Once stabilized, she states that she is undocumented and delayed seeking care because she was concerned that she would be jailed or deported if she sought treatment for her symptoms.

Ms. Gomez is one of thousands of undocumented immigrants who depend on scheduled dialysis to survive but are unable to access it in the outpatient setting.58 They rely on EDs for dialysis, many of which have varying policies and inconsistent definitions of “medical necessity” for emergent dialysis.59

One can understand Ms. Gomez’s situation in terms of pathophysiology and access to care, specifically her exclusion from the Social Security Amendment of 1972, which guaranteed the provision of dialysis to U.S. citizens with ESRD. One cannot fully understand her situation, however, without contextualizing it within the broader debates about citizenship and their hidden, normative assumptions about who has “the right to have rights.”60 Social scientists, including medical anthropologists, sociologists, legal scholars, and historians, have made considerable headway in theorizing the gap between codified civil rights and their enforcement.28, 61, 62, 63, 64 They have pointed out the ways in which certain groups (e.g., women, African Americans, immigrants, or members of the LGBTQ community) rely on powerful institutions to secure their rights, which may change depending on popular opinion or the political climate.65

While these issues may seem overly abstract for EM practice, they contribute directly to inequality in conditions such as immigration, housing, education, and incarceration—all of which contribute to health inequalities that manifest in EDs across the United States.31 Seen in this light, Ms. Gomez’s case can be articulated in more complex terms than a simple indication for dialysis. Thus, instead of asking, “What are the clinical indications for emergent dialysis and does Ms. Gomez meet them today?” one may ask, “How is healthcare implicated in the local, regional, and national immigration policies that make Ms. Gomez continually choose between her health and safety?” Adding a language of structure to aid EPs in articulating patients’ barriers to care may facilitate empathy, discourage individual blame, and make complex patient care less daunting. We argue that structural fluency is needed to achieve the interpersonal and communication skills competency. Further, this framework presents opportunities to engage in advocacy, pushing the limits of our current imagination and breaking existing silos within EM.

Rearticulating “Cultural” Presentations in Structural Terms

Cultural competency has been criticized for its potential to efface differences within groups (such as socioeconomic differences) and reduces “culture” to a static set of traits to be committed to memory.26 Not only does this approach sometimes overstate cultural or racial differences in preferences to treatment, but it can also have the unintended effect of engendering frustration and reinforcing the idea of the patient as “other.”66, 67 Moreover, cultural competency frameworks often conceptualize culture as an attribute of patients, thereby rendering invisible the culture inherent to medicine and its workforce.68 This is not to deny the existence of culture or to minimize the headway that cultural competency has made in humanizing medicine and making EPs aware of the variations in approaching health and illness. Nevertheless, it is time to address the critiques of cultural competency.

Reframing the encounter in structural terms may help address these critiques and give EPs the ability to produce sound medical plans that attempt to overcome barriers of inequality. We present the following case to further illustrate this point.

Mr. James is a middle‐aged African American man with a history of diabetes. He presents to the ED with a complaint of hyperglycemia. Upon questioning, he reports that he has not been taking insulin as prescribed during his previous ED visit for the same complaint.

This is a common case that can be approached in a variety of ways. Traditional cultural competency approaches may reference the infamous Tuskegee Syphilis Study69 as a reason to explain (or blame) Mr. James’ behavior as part of a pervasive culturally or racially based distrust of the health care system. This implicitly reinforces the idea that Mr. James’ health is a product of personal beliefs and decisions. Moreover, this approach operationalizes race as an explanatory model of individual behavior (i.e., this patient believes X because he is Y) and detracts from a more accurate conceptualization of race as a marker of discrimination and disenfranchisement. Thus, at worst, a resident may dismiss the extensive history of medical racism and misconduct as bygones, stereotype Mr. James as lacking health literacy, or view his condition as unchangeable. At best, a resident treating Mr. James may be encouraged to elicit his personal understandings of his diagnosis of diabetes and his subjective experiences of his illness to build trust and to encourage medication adherence. The resident may focus on Mr. James’ diet, recognizing that knowledge and attitudes toward foods are culturally learned and attempting to educate him on healthier food choices.

These are important ways with which to provide care, but they are based on the implicit assumption that the medication regimen prescribed to Mr. James is correct and that his nonadherence is based in subjective belief or misunderstanding. The resident treating Mr. James may therefore overlook material difficulties that are more important contributors to his current health. For instance, a structurally based approach to the history may illicit that his diet is restricted not by his knowledge but by the fact that he is concerned about being evicted from his home and often must choose between paying for food and basic utilities and paying for rent. Having intermittent access to electricity makes it difficult to refrigerate insulin and, coupled with its high price and his limited income, makes it untenable for him to take regularly. Thus, instead of insisting on a treatment plan outside of Mr. James’ reach, a resident treating him may brainstorm ways to modify his treatment regimen by prescribing more affordable drugs or linking him to discounted prescription drug programs.

Emergency physicians may draw upon structural vulnerability frameworks to ask Mr. James about what barriers he faces, what he is able to accomplish with his existing resources, and what he would find helpful in accomplishing specific health goals.28 EM residents, for example, may be taught to use a questionnaire developed by Bourgois et al.70 to address structural barriers to good health. Suggested patient questions include: “Do you have enough money to live comfortably—pay rent, get food, pay utilities, telephone?”; “Do you have friends, family, or other people who help you when you need it?”; “Do you have any legal problems?”; “Are you afraid of getting in trouble because of your legal status?” Bourgois et al. also suggest that providers reflect on their own position within an interaction, asking themselves questions such as: “May some service providers (including me) find it difficult to work with this patient?” and “Could the interactional style of this patient alienate some service providers, eliciting potential stigma, stereotypical biases, or negative moral judgment?” These questions provide useful starting points for conversations that may otherwise be uncomfortable for EPs and patients.

Reorienting the clinical encounter to focus on the structural constraints that Mr. James navigates daily does not undermine the historical indignities visited upon African Americans by the medical community. Indeed, the same systems of prejudice that facilitated unethical experimentation also contributed to disenfranchisement from housing, education, employment, and public services that persist today. A structural approach illuminates continuities between these historical injustices and inequalities and their contemporary relevance, rather than flattening them to isolated incidents that live on only in individuals’ or communities’ memories.

Observing and Imagining Structural Interventions

Central to a structural competency approach to EM education is a conviction that physicians can and should act in their capacity on behalf of patients outside the ED. This is critical to achieving the “systems‐based practice” competency, which addresses residents’ response to the larger system of health care and requires a facility with resource utilization. Residents may feel intimidated by this prospect or protest that a physician’s role is limited to the patient encounter. We argue, however, that steps toward the amelioration of suffering can range anywhere from being empathetic at the bedside to dedicating one’s career to social advocacy. These are not mutually exclusive decisions. To help residents recognize this, we propose integrating structural interventions into the systems‐based practice competency curriculum in two steps.

First, residents should be exposed to organizations and initiatives working to provide food, employment, and stable housing. Some programs have integrated visits to local institutions tackling poverty into their intern orientation,71 thereby exposing their incoming interns to the ways in which local organizations support people living in poverty or experiencing other forms of stigma or marginalization. We note that observation and exposure to such organizations is a critical component of structural competency because it reinforces the importance of listening and engenders iterative learning among residents—qualities that are critical in their advocacy and in caring for patients. Not only does this have the potential to empower residents, but also it can broaden their network of allies, experts, and teachers.

Second, having observed successful structural interventions as noted above, residency programs may use their didactic curriculum to debrief residents on their clinical experiences, to place these with structural frameworks, and to propose informed interventions. Metzl and Hansen propose the following questions, which represent productive starting points for discussion and resident engagement: 1) What “problems” do organizations or interventions aim to address? 2) Which notions of structure from parts 1, 2, and 3 above—e.g., medical, anthropological, sociological, historical—are most helpful when identifying problems and conceptualizing solutions? 3) What are the barriers to, and benchmarks of, treatment or success over time? 3) What types of interventions can you imagine or enact that might also address structural health issues (in your ED, hospital, city, or state)?

Residents may be encouraged to partner or participate within these organizations or to find other avenues for civic engagement. For instance, some residency programs have taken their residents to state capitals to meet local legislators and to demystify the legislative process and to demonstrate the role physicians can play in the political process. Residency programs may also encourage residents to participate in their hospital or university committees, to develop and deliver lectures to medical students and fellow residents on a topic of interest to them, to write op‐eds and participate in public scholarship, or to provide medical evaluations for asylum seekers in their region. There is no shortage of issues or opportunities for engagement and advocacy, and residents should be reminded of the social capital that comes along with their medical training and should be given the tools to deploy their social capital on behalf of their patients. Resident advocacy may be supported (with time, institutional resources, or funding) and incentivized (through recognition and praise). In this way, residency leadership is uniquely positioned to facilitate resident advocacy in their cultural valuing of these initiatives.

Developing Structural Humility

We recognize that the concepts, issues, and frameworks introduced thus far are broad and do not lend themselves to easy solutions. An important aspect of structural competency is the recognition that structures are constantly and rapidly changing. In part, the point of structural competency is to deprioritize “solutions” in favor of productive, active engagement with these issues, and a cultivated self‐awareness among EPs. To that end, structural humility should be incorporated in the “practice‐based learning and improvement” competency. It refers to the trained ability for EPs to recognize the boundaries of their knowledge, the fallibility of their perceptions, and the limits of medical interventions. Like structures themselves, these are constantly changing across time, regions, individuals, and even hospitals. The very idea of “competency” proposed here does not refer to a once‐and‐for‐all mastery of issues of structure. Like other skills within EM (e.g., airway management and medical resuscitation), EPs should not expect to learn a set of skills that they can continue to apply without modification throughout their clinical careers. Rather, they should make a commitment to lifelong learning from their patients and taking seriously the ways that structural forces play out in patient care.

The “structurally humble” EP is therefore one who strives to provide the best care for her patients and is simultaneously aware of her own abilities or constraints. She recognizes the limits of medical practice and the unintended consequences of medicalizing social problems. She does not promise or expect that the ED will immediately solve patients’ housing difficulties or change their immigration status. She bears witness to the ways in which these issues manifest in the ED; develops a structural fluency that builds trust and understanding in the patient encounter; and continually learns from patients, colleagues, and other content experts.

Residency programs may foster structural humility in residents by providing a platform for non‐physicians to share their perspectives and expertise (e.g., at departmental grand rounds or journal clubs). Residency programs may partner with local organizations to offer social medicine electives to their residents. Residents may also be encouraged to seek advice or feedback from social scientists and/or community organizations when developing scholarly or quality improvement projects. These efforts demonstrate the value of our colleagues’ perspectives outside of EM and model structural humility for our trainees.

Conclusion

The ED’s unique role as the “safety net” of American health care makes the structural competency framework especially salient for emergency medicine practice and education. In adapting structural competency for the emergency medicine context, we aim to provide a theoretical framework to underpin the development of emergency medicine curricula. Emergency medicine educators are uniquely positioned to train the next generation of emergency physicians to deliberately incorporate structural competencies into their medical practice and professional development. By building on this framework, we can train emergency physicians who are structurally competent (knowledgeable about the structures that create disparities) and who are structurally humble (understand the limits of their knowledge and the care that they provide). They “entertain multiple interpretations for scenarios whose tensions are, in the heat of the moment, too‐often reduced to explanatory models based in cultures, ethnicities, and other urgencies of here‐and‐now clinical encounters.”34 These emergency physicians do not rush to attribute Mrs. Navarian’s difficulties to old age, dismiss Ms. Gomez’s fears as unfounded or as byproducts of her own choices, or write off Mr. James as “noncompliant.” Structurally competent and humble emergency physicians simultaneously recognize their social capital, their own structural constraints, and the limits of their knowledge.

As the emergency medicine research and advocacy agendas evolve to include attention to social medicine, social determinants of health, and historically and structurally based inequalities, so too must resident education intentionally incorporate these issues toward meeting Accreditation Council on Graduate Medical Education and emergency medicine core competency requirements. This can be done through formal didactic presentations, assigned readings, and small‐group discussion and can easily be incorporated into case scenarios that are frequently used in simulation. Drawing on the experience and expertise of our colleagues in public health and the humanities and social sciences and incorporating those insights into emergency medicine will bring us closer to our goals of improving patient care and minimizing health inequities for our patients.

AEM Education and Training 2020;4:S88–S97