Reimagining 'the Social' in Education and Practice: A Longitudinal Study of Perceptions of Structural Competency in Medicine

RESEARCH OBJECTIVE: As clinicians are increasingly called to recognize and act on social needs contributing to their patients' health, health professional schools are incorporating discussions of social factors and health equity into required curricula to help physicians navigate the intersections of society and medicine. This study aims to evaluate perceptions and attitudes of physicians and medical students as they interact with these topics in the setting of medical education. In addition, this study aims to explore how physicians and medical students interpret, engage with, and use ‘structural competency’ in the clinic. STUDY DESIGN: This longitudinal qualitative study consisted of semi‐structured interviews about the use of a ‘structural competency’ framework during a preclinical medical education course called Introduction to Medicine and Society. ‘Structural competency,’ an emerging educational framework for addressing patient's social needs, reframes clinical issues and disease as the downstream result of upstream social, political, and economic decisions (Metzl and Hansen, 2014). Interviews were conducted at three time points during the course: before participation in a structural competency based module, after participation in the module, and after the full course was completed. POPULATION STUDIED: We conducted 53 interviews with 12 first‐year medical students, 15 upper‐level student course facilitators, and 8 physician facilitators who participated in the course. PRINCIPAL FINDINGS: This paper focuses on three interrelated findings: (1) how medical students and faculty describe complex concepts like ‘structure’ and what developing a ‘competency’ of structures means; (2) what the barriers and facilitators are to developing and using structural competency in education and clinical practice; and (3) how participants understand their actions in the clinic as potential opportunities to enact structural competency or intervene on the structural factors that impact patients' health. CONCLUSIONS: Because structural competency gives an expansive lens for physicians to recognize the connection between health and society, it also highlights the ways in which physicians are constrained by the structure of health care itself, hindering their abilities to fully engage with the social aspects of their patients' well‐beings or meaningfully promote health equity. This further impacts physician efficacy and well‐being, contributing to feelings of frustration and hopelessness. IMPLICATIONS FOR POLICY OR PRACTICE: These findings have practical implications for how clinicians are trained to conceptualize and act on social factors to not only address patients' needs within the clinical encounter, but also to respond to their own professional and emotional experiences within the broader social world of US healthcare. This study also has conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader social processes by better incorporating the lived experiences of clinicians who are practicing at these intersections everyday.