Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education

Abstract

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed. Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians’ roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care. The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.

Call to action in academic emergency medicine: Going beyond the appreciation of diversity, equity, and inclusion to true practice

“…The next step is to have these accrediting bodies take the lead by creating milestones that address the training and competence around topics on cultural humility and social and structural drivers of health. 12 This will ensure that programs integrate this content into their training to satisfy their accreditation requirements.…”

Social Accountability and Graduate Medical Education

“…The ACGME, as an accreditor, can play an important role building social accountability in GME by requiring monitoring of the impact of GME on community health. 27 ACGME should set standards for and require measures of social accountability in institutional accreditation standards, specifically focusing on the following recommendations.…”

How Pharmaceuticals Mask Health and Social Inequity

“…Medical schools dedicate semesters to organ systems and understanding the pharmaceutical mechanisms of action on intracellular targets but, in general, dedicate relatively little time to teaching students about the cities in which they live and the ways in which local laws and social conditions create inequitable burdens of illness and death. 12 When the social world is included in illness models, as in the allostatic load model of chronic stress 13 or the 2-hit model of tumorigenesis, 14 it is funneled into broad categories of psychosocial and environmental stressors that activate neuroendocrine or transcriptional regulation of genes, respectively, directing physicians' gaze intracellularly instead of to the social world itself. 13,14,15 Similarly, the Centers for Disease Control and Prevention's report on the 10 leading causes of death in the United States lists only 2 causes of death, suicide and unintentional injury, without clear biological targets.…”

“…11 We must insert structural competency, health equity, and social responsibility into medical care and ourselves into sociopolitical movements, in humble allyship with community leaders and for the benefit of our most vulnerable patients. 12 To guide such reforms, we can look to leaders like those in the Student National Medical Association who put forward a detailed "Petition for Racial Justice in Academic Medicine and Research," which calls for a thorough integration of structural competency, antioppression, and antiracism in medical curricula and urges reforms to support Black, Indigenous, and other minoritized professionals in medicine. 38 Alongside other social medicine and medical education researchers, these student leaders recognize that medical education without "structural or socioecologic context inevitably reinforces an inadequate and detrimental understanding of how to best treat our patients" and that "individuals and institutions-including academic medicine and research-perpetuate systems of inequality" that in turn fuel health and social inequity.…”