Structural Competency in Medical Education

1. Structural Competency in Medical Education For Students for a National Health Program (SNaHP) Summit on March 3, 2018 By Matthew Musselman, OMS III, TUCCOM and on behalf of the Structural Competency Working Group - structcomp.org

2. Healthcare Disparities - IOM Report Summary • Exist. Associated with worse health outcomes. • Stereotypes and bias contribute • Bias is the norm and not indicative of personal shortcomings • Educational strategies can raise awareness, impart knowledge, and teach skills to address bias and disparities, but this has not been demonstrated (yet). (IOM Report on Racial/Ethnic Health Disparities & Alicia Fernandez, MD)

4. Vocabulary Check...What are we talking about? Need a “shared language” to identify how structures affect health

5. Cultural Competency • Cross cultural communication = important • Competency implies an endpoint INCOMPETENT COMPETENT

6. Cultural Competency • a trend in medical education, and seeks to “counteract the marginalization of patients by race, ethnicity, social class religion, sexual orientation, or other markers of difference“ • by emphasizing a patient-centered approach that takes into account “culturally specific sources of stigma” • Cultural Competency does not address “the complex relationships between clinical symptoms and social, political, and economic systems.”

7. Interpersonally… • “Sit down.” • “Be humble.” • Embrace Cultural Humility. • Further Reading on this topic: • Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), pp 117-25. Link. • https://en.wikipedia.org/wiki/Cultural_humility good old Wikipedia...

8. Structural Competency • The capacity for health professionals to recognize and respond to health and illness as the downstream effects of social, political, economic & environmental structures. (adapted from conversations with Josh Neff & Seth Holmes)

9. “Structural determinants of the social determinants of health” Policies Poverty/ Inequality Economic systems Poor health outcomes Structures Social Hierarchies (e.g. racism) Social Determinants of Health & Health Disparities Curricula Structural Competency (SCWG; Josh Neff)

10. Structural Violence “Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.” – Farmer et al, 2006. Structural Vulnerability is the risk an individual experiences as a result of structural violence – including their location in socioeconomic hierarchies. It is not caused by, nor can it be repaired soley by, individual agency or behaviors.

11. Naturalizing Inequality When social inequalities are preserved through the perception that the status quo is appropriate, deserved and natural. Those at the top are seen as deserving their position at the top, and, especially, those at the bottom are seen to be at the bottom due to their own faults. As shaped by the lens of “individualization,” an the common perception in healthcare that the most important causes of a patient’s sickness lie in their individually chosen actions and habits and/or their individual biology (genetics, etc.)  Treatment plans focus primarily on education and incentive for individual level behavior change (SCWG & Josh Neff)

12. Components of Structural Competency 1. Recognizing influence of structures on patient health 2. Recognizing influence of structures on the clinical encounter, including implicit frameworks common in healthcare 3. Responding to structures in the clinic 3. Responding to structures beyond the clinic 3. Structural Humility  Collaboration with patients and populations in developing responses to structural vulnerability

13. Structural Competency in Med Ed • A framework for navigating toward Health Justice. • Dialogue-driven. Collaborative. Respectful. • Student-run part of the Curriculum at Touro. • Sitting & Doing… “be here now” • Further Reading on this topic: • Neff, J et al. (2016). Teaching structure: a qualitative evaluation of a structural competency training for resident physicians. Journal of General Internal Medicine, 32(4), pp 430--433. LINK. • Metzl, J. & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, pp. 126-133. LINK. • Pigg, S.L. (2013). On sitting and doing: ethnography as action in global health. SocSci Med, 99, pp. 127-134. LINK.

14. Evaluate Structural Vulnerability • How do the Social Determinants of Health affect your patient? • Economic policy? • Socialnorms? • Political disagreements? …How do these affect the Social Determinants of Health? Heiman, H.J. (2015). Beyond health care: the role of social determinants in promoting health and health equity. Kaiser Family Foundation - Disparities Policy. LINK.

15. Bourgois, P., Holmes, S.M., Sue, K. & Quesada, J. (2017). Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), pp. 299-307. LINK.

16. Making space for *dialogue* Listen to learn. Speak to share from your own experience. The goal is to learn as much as possible from others. (Yankelovich 2001 “The Differences between Dialogue and Debate”)

17. VALUES  FACTS  POLICY • Values • “All Lives Matter” or “All Men are Created Equal” • Facts • OECD spends $2 on social services for every $1 spent on health care • USA spends 55¢ on social services for every $1 spent on health care • Policy • Unemployment benefits • Housing benefits • Tuition-Free College/University • Expanded & Improved Medicare-for-All • …. (Tony Iton, MD)

18. Breaking the ice Taken from twitter page @socializm_

19. A Patient CAse Some slides borrowed from Zea Malawa, MD

20. Meet “Ben” • Ben is a 6 yr old African American boy • Ben lives in the Bayview area of SF with his parents and grandmother • Ben’s family is very worried because Ben has asthma which has been hard to control • Every 3 months, Ben’s mother misses work to take him to the pulmonologist. On the bus, it takes 1.5 hours in either direction to get there. (ZeaMalawa, MD)

21. I was calling to let you know that I have admitted your patient Ben for an asthma exacerbation… His parents did not pick up his controller med refill last week and he’s missed a lot of school recently because of wheezing. His father was arrested last month for drugs! I called CPS. These parents need to learn to get serious about their son’s health. (ZeaMalawa, MD)

22. Has Racism affected Ben’s health?

23. What is Racism?

24. What if the pulmonologist knew… I cannot afford to pick up his refill until I get paid next week. Median incomes for Blacks in San Francisco is $27,000 compared with $89,000 for Whites, a disparity twice as large as the national average. (New York Times, 2016) (ZeaMalawa, MD)

25. The Bayview district has more Black residents than any other SF neighborhood. • (City-data.com) • Because of it’s proximity to freeways and industrial sites, it has the highest concentration of air and surface pollutants in SF. • (Environmental Defense Scorecard, 2005) I usually give him his medicine everyday but he still can’t stop wheezing. (ZeaMalawa, MD)

26. His father just had a little weed in his pocket. The police are always harassing us. (ZeaMalawa, MD)

27. Black children are 3 times more likely to enter foster care compared to white families with the same characteristics. • Families of color receive fewer services than White families do and experience lower rates of reunification. • (Annie E Casey Foundation. Report: Race Matters: Unequal Opportunity within the Child Welfare System, 2006) I cannot believe that doctor called CPS on us. I don’t want to bring my son to her any more. (ZeaMalawa, MD)

28. What is Race? Templeton, A.R. (2013). Biological races in humans. Studies in History and Philosophy of Science, 44(3), pp. 262--271. LINK.

29. Racism 101—What Is Racism? A system (ZeaMalawa, MD)

30. Racism 101—What Is Racism A system of structuring opportunity and assigning value (ZeaMalawa, MD)

31. Racism 101—What Is Racism A system of structuring opportunity and assigning value based on the social interpretation of how we look (“race”) Further Reading: Coates, T. (2013, May 15). What we mean when we say ‘race is a social construct.’ The Atlantic. LINK. (ZeaMalawa, MD)

32. Racism 101—What Is Racism A system of structuring opportunity and assigning valuebased on the social interpretation of how we look (“race”) • Unfairly disadvantages some individuals and communities (ZeaMalawa, MD)

33. Racism 101—What Is Racism A system of structuring opportunity and assigning valuebased on the social interpretation of how we look (“race”) • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities (ZeaMalawa, MD)

34. Racism 101—What Is Racism A system of structuring opportunity and assigning valuebased on the social interpretation of how we look (“race”) • Unfairly disadvantages some individuals and communities • Unfairly advantages other individuals and communities • Saps the strength of the entire society through the waste of human resources Source: Jones, CP (2003) (ZeaMalawa, MD)

35. Race is a distinct construct from racism • USA is a racially stratified society1  Being Black vs Being Black in America • Privilege Exists2 • Implicit Bias is extremely common3 Further Reading on this topic: García, J.J. & Sharif, M.Z. (2015). Black lives matter: a commentary on racism and public health. Am J Public Health, 105, pp. e27-e30. LINK. Campos, P.F. (2017, July 29). White economic privilege is alive and well. New York Times. LINK. Gladwell, M. BLINK. Chapter 3: The Warren Harding Error.

36. Racialized Health Disparities Racism CDC. (2017). Health, United States, 2015 with special features on racial and ethnic health disparities. Page 28. LINK (PDF). Paradieset al. (2015). Racism as a determinant of health: a systematic review and meta-analysis. PLOS ONE. LINK.

37. From the New England Journal of Medicine “…even as research on health disparities has helped to document persistent gaps in morbidity and mortality between racial and ethnic groups, there is often a reluctance to address the role of racism in driving these gaps. A search for articles published in the Journal over the past decade, for example, reveals that although more than 300 focused on health disparities, only 14 contained the word “racism” (and half of those were book reviews)…” Bassett, M.T. (2015). #BlackLivesMatter -- A Challenge to the Medical and Public Health Communities. NEJM, 372(12), pp. 1085 -- 1087. LINK. (ZeaMalawa, MD)

39. Your Case HPI: Patient is a 37-year-old Spanish-speaking male presenting with AMS PMH: Has not seen a doctor in >10 years PSH: Appendectomy1989 SH: Works in strawberry fields. Heavy EtOH use, other habits unknown. Homeless. Meds: currently noncompliant with all meds, D/C’ed after last hospitalization on folate, thiamine, multivitamin, and seizure prophylaxis Neuro/Mental Status: pt. muttering in incoherent Spanish, inconsistently able to answer “yes/no” and follow simple commands

40. Case Cont’d • Mr. Fuentes was diagnosed with ESLD and hepatic encephalopathy • He was discharged home to his family, who reluctantly accepted to put him up. Discharge medicines included lactulose. He was instructed to stop drinking alcohol, to eat healthier foods and to obtain more physical activity. • 1 week later, he returned to the hospital ER for therapeutic paracentesis and died. Do these details change your Structural Assessment?

41. In Emergency Department After Found on the Street Begins Drinking More Heavily Gets Assaulted Standard Medical History Begins Working as Day Laborer Injury, Can’t Work Can’t Pay Rent, Moves to Street Influx of Cheap US Corn; Can’t Make a Living Moves to San Francisco 4th Generation Corn Farmer in Oaxaca

42. In Emergency Department After Found on the Street Begins Drinking More Heavily Gets Assaulted City & federal policies contributing to gentrification & displacement Legacy of colonialism; Systematic marginalization & violence against indigenous communities in S. Mexico Begins Working as Day Laborer Injury, Can’t Work Can’t Pay Rent, Moves to Street North American Free Trade Agreement (NAFTA) US healthcare system (no access to care) Influx of Cheap US Corn; Can’t Make a Living Moves to San Francisco 4th Generation Corn Farmer in Oaxaca Racism/ racialized low-wage labor markets; US immigration policy

43. Naturalizing Inequality #1: When asked why very few Triqui people were harvesting apples, the field job known to pay the most, the Tanaka Farm’s apple crop supervisor explained in detail that “they are too short to reach the apples, and, besides, they don’t like ladders anyway.” He continued that Triqui people are perfect for picking berries because they are “lower to the ground.” When asked why Triqui people have only berry-picking jobs, a mestiza Mexican social worker in Washington state explained that “a losOaxaquenos les gustatrabajaragachado [Oaxacans like to work bent over],” whereas, she told me, “Mexicanos [mestizo Mexicans] get too many pains if they work in the fields.” In these examples and the many other responses they represent, perceived bodily difference along ethnic lines serves to justify or naturalize inequalities, making them appear purely or primarily natural and not also social in origin. Thus, each kind of ethnic body is understood to deserve its relative social position. -Seth Holmes “An Ethnographic Study of the Social Context of Migrant Health in the US,” 2006 Biology/Genetics Culture?

44. Vocabulary is important… • Social Structures • Structural Violence • Structural Vulnerability • Naturalizing Inequality • Implicit Frameworks • Individualization • Cultural Frameworks

45. So now what? • Overcoming institutional barriers to a student-led curriculum • Teamwork • Sitting & Doing • Bringing Structural Competency to your school next? Who is game?? Raise your hand!

46. Thank you / Questions? / The End • 11:45am break / get lunch in cafeteria • Vegetarian/Vegan/Gluten-Free have separate box lunches! • 12:00pm SNaHP Chat Mentoring Sesh in the cafeteria • A time to get to know Physician Advocates in a casual setting! • Ask them questions! Hang out! They’ll each have their own table/area • Mentors include: • Dr. Woolhandler • Dr. Lazarus • Dr. Glass • Dr. Chao • Dr. Rigamer • 1:00pm SNaHP Group Photo in the lobby area (by registration)