The American Medical Association recently published an article in the Journal of Ethics arguing that Merit is not 'just' today, and that there is an 'equitable' way to make merit 'just' through holistic admission policies.

Written by faculty from UCSF, UofM and Yale, the article is intended to promote the concept of Structural Competency. They also take the opportunity to tie equity-based admissions at the graduate level to the concept of structural competency.

The authors state that

"one way to motivate equity in merit-based admissions is to frame structural competency as a source of merit in a candidate."

Aside from the argument that merit bias should be solved long before merit is achieved--i.e. in elementary, middle, and high school--a graduate level equity based admissions policy could theoretically solve for structural competency in the short-term but as anyone can imagine, it creates a divided society if that is the only lever used to solve for health equity. What's interesting is that even if we add the second lever of education, we will find that it is not enough to solve for health equity. What's good in theory is not always good in practice.

Structural competency is one of the most important trends in medical education today and one that has been shown to impact health outcomes. Therefore, it is important to at least shine a light on this concept and hopefully get the medical community as well as enterprising innovators to discuss different solutions.

The Problem:

There are patient care needs that are not aligned with existing medical school education. This need is referred to as 'Structural Competency'.

The Solution:

Increase the number of medical students with already learned 'structural competency' and otherwise teach the ones without it or who need to expand their understanding.

In a 2018 article on reproductive health disparities, structural competency is defined is:

Structural competency, an emerging paradigm in health care, seeks to address medicine’s overemphasis on the individual (e.g., biology, behaviors, characteristics) while addressing the hierarchies that produce unjust health conditions. Structural competency responds to dominant paradigms in health care education that neglect the ways in which access to the resources needed to make health changes and choices are influenced by unjust social determinants such as the differential treatment patients receive from health care institutions and professionals with respect to race, class, or immigration status, for example.

This is borrowed and worked on from the original paper on structural competency by Jonathan Metzl and Helena Hansen called Structural Competency: Theorizing a new medical engagement with stigma and inequality.

The idea is not complicated and essentially boils down to understanding the structural context of a patient's life including their social determinants that might affect their health outcomes. One example given is that a structurally competent learner should recognize that a patient living in a food desert (limited access to fresh groceries because business owners don't want to build a grocery store where the patient lives) will be less likely to control their type 2 diabetes. Social determinants can span from employment opportunities, living conditions, food and transportation insecurity, and even social isolation. All these can account for 30-40% of healthcare outcomes.

That is a lot!

The goal is to operationalize structural competency into courses and experiences. There are plans to update the medical curriculum to include teachings on bias, cultural humility, and public health as well as increasing the number of community health experiences.

The five skill-sets that shape the paradigm of structural competency are as follows:

1. Recognizing the structures that shape clinical interactions (how economic, physical, and socio-political forces impact medical decisions)

2. Developing an extra-clinical language of structure (research and literature to give physicians the language skill to articulate health problems in the context of structure)

3. Rearticulating “cultural” presentations in structural terms (accept that what we know as 'cultural' differences could likely be 'structural' differences)

4. Observing and imagining structural intervention (structural impediments are not immutable and have solutions)

5. Developing structural humility (no one will ever be 100% structurally competent, regardless of background)

What about the problem of time? Physicians are some of the smartest and most compassionate professionals we know and structural competency might not be enough for healthcare equity. If you are a physician and you already have structural competency, you might meet the needs of your patient in the 15 minute encounter that insurance reimbursement allows for. But what if you do not have the specific structural competency for the patients you are seeing? Would 15 minutes give you enough time to unpack all the structural impediments to achieving equitable health outcomes?

I think the reality of the situation of not being able to spend that much time with a single patient opens the door for multiple possible solutions.

One solution is sharing the responsibility of health equity with a population health AI algorithm or an army of competent social workers to do what the physician can not spend time on. This is an area where a lot of innovation will be seen in the future and one where healthy equity can also be solved by non-physicians, and even non-healthcare providers such as insurance companies or local health departments.

Until more people step up to take responsibility for health equity, all attention will be on physicians, and so physicians will need to be the early adopters of new technology that can scale the identification, stratification, and interventions needed to fix structural impediments to optimum health.