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.From the

Addressing Racism in Medicine Through a Resident-Led Health Equity Retreat

“…Four senior residents leading the residency’s Social Emergency Medicine group designed the retreat after conducting a literature review of existing EM curricula on race 7 – 9 and holding working group meetings. A deliberate decision was made to base the retreat on the facilitated reflection of our own residents’ experiences of race, racism, and disparities in their specific clinical practice environments in order to emphasize these concepts’ relevance to all participants.…”

“…While some curricula exist to teach EM residents about social determinants of health and implicit bias, 7 – 9 dedicated didactic teaching about racism in medicine is not required in EM residency curricula or in graduate medical education more broadly. We describe an innovative health equity retreat designed to teach residents about racism and its manifestations in medicine.…”

Structural Competency: What Is It, Why Do We Need It, and What Does the Structurally Competent Emergency Physician Look Like?

“…Indeed, they argue that cultural competency may reinforce bias and misconceptions. As a result, there is the potential for trainees to “become frustrated and/or resort to stereotyping, stigmatizing, and blaming patients.” The definition of cultural competency is too myopic and does not train residents to see the effect of structural competency (i.e., social determinants of health).…”

“…Emergency medicine residency training that is attuned to the elements of structural competency “need not be approached as an additional task or competency that EPs have to undertake, but rather a reorientation of the physician’s role” in the clinical encounter with attention to the five elements of structural competency. So what does the structurally competent emergency physician look like?…”

“…In this issue, Salhi et al introduce the academic emergency medicine (EM) community to the concept of “structural competency” and provide compelling rationale for why we need to move “Toward Structural Competency in Emergency Medical Education.” The authors’ objective is to translate the original concept, developed with the broader landscape of medical education in mind, into an EM‐relevant framework. The authors effective link the five domains of structural competency to the ACGME EM Core Competencies and provide examples of how this framework will serve as the launch point for enhancing resident education on the social determinants of health in the clinical learning environment.…”