title: Structural competency: theorizing a new medical engagement with stigma and inequality.
abstract: This paper describes a shift in medical education away from pedagogic approaches to stigma and inequalities that emphasize cross-cultural understandings of individual patients, toward attention to forces that influence health outcomes at levels above individual interactions. It reviews existing structural approaches to stigma and health inequalities developed outside of medicine, and proposes changes to U.S. medical education that will infuse clinical training with a structural focus. The approach, termed "structural competency," consists of training in five core competencies: 1) recognizing the structures that shape clinical interactions; 2) developing an extra-clinical language of structure; 3) rearticulating "cultural" formulations in structural terms; 4) observing and imagining structural interventions; and 5) developing structural humility. Examples are provided of structural health scholarship that should be adopted into medical didactic curricula, and of structural interventions that can provide participant-observation opportunities for clinical trainees. The paper ultimately argues that increasing recognition of the ways in which social and economic forces produce symptoms or methylate genes then needs to be better coupled with medical models for structural change.
authors: Center for Medicine, Health, and Society, Vanderbilt University, Nashville, TN, United States. Electronic address: jonathan.metzl@vanderbilt.edu.
authors: Jonathan M
authors: JM
authors: Metzl
authors: New York University, New York, NY, United States; Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, United States.
authors: Helena
authors: H
authors: Hansen
mesh_terms: D054521:Cultural Competency; D003479:Curriculum; D004501:Education, Medical / Q000458:organization & administration*; D054624:Health Status Disparities; D006801:Humans; D057545:Social Stigma; D012959:Socioeconomic Factors; D014481:United States
keywords: Cultural competency; Medical education; Social determinates of health; Stigma