Why Competency Frameworks Are Insufficiently Nuanced for Health Equity Teaching and Assessment

Abstract

This article suggests how competency-based medical education should robustly integrate health equity by focusing on physicians' responsibilities to (1) know why and how underlying structural mechanisms contribute to health equity and then (2) take action to achieve health equity in their practice. This article first canvasses currently available frameworks for helping trainees cultivate these 2 specific skills of discernment and action. This article then offers strategies for teaching and assessing these skills in specific learning activities. CaseDr A is a general pediatrician working alongside Dr B, a pediatric intern at a primary care clinic. Today is Dr A's first day working with this intern, but Dr A has already been impressed with Dr B's skills and attention to detail. Dr B says: "David is a 6-year-old boy here for a well-child visit. Dad is here today; he reports issues at school, including suspensions. His school reports suspensions are related to behavioral concerns: aggression, inattention, tearfulness. Dad reports concerns about bullying and says managing his boy's behavior at school has been difficult." Although Dr A has confidence in the intern's clinical skills, Dr A wonders if Dr B can incorporate in David's care the social determinants of health that contribute to his presentation today. Dr A has had experience with families like David's and knows that children of color like David often face interpersonal, structural, and internalized racism that affects their behavioral health. 1,2 Moreover, Dr A is aware of the well-documented racial disparities in behavioral management and school suspensions. 3,4,5 How might Dr A appropriately assess this intern's developing awareness and skills in asking, listening, and addressing these potential racial disparities? Which, if any, existing competency literature could help Dr A teach this intern effectively about health equity and how to integrate it into David's care? While Dr A is aware of numerous ways to assess general clinical competencies, such as examinations and direct observation, Dr A is not comfortable in assessing health equity skills.