For Students for a National Health Program SNaHP Summit on March 3 2018 By Matthew Musselman OMS III TUCCOM and on behalf of the Structural Competency Working Group structcomporg Healthcare Disparities ID: 755605
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Slide1
Structural Competency in Medical Education
For Students for a National Health Program (
SNaHP
) Summit on March 3, 2018
By Matthew Musselman, OMS III, TUCCOM
and on behalf of the Structural Competency Working Group -
structcomp.orgSlide2
Healthcare Disparities -
IOM Report Summary
Exist. Associated with worse health outcomes.
(
IOM Report on Racial/Ethnic Health Disparities & Alicia Fernandez, MD)
Stereotypes and bias contribute
Bias is the norm and not indicative of personal shortcomings
Educational strategies can raise awareness, impart knowledge, and teach skills to address bias and disparities, but this has not been demonstrated (
yet
).Slide3Slide4
Vocabulary Check...
What are we talking about?
Need a “shared language” to identify how
structures affect healthSlide5
Cultural Competency
Cross cultural communication = important
Competency implies an endpoint
INCOMPETENT
COMPETENTSlide6
Cultural Competency
a
trend in medical education, and seeks to “counteract the marginalization of patients by race, ethnicity, social class religion, sexual orientation, or other markers of
difference“
by emphasizing a patient-centered approach that takes into account “culturally specific sources of stigma”
Cultural Competency
does not address “the
complex relationships between
clinical symptoms
and social, political, and economic systems.”Slide7
Interpersonally…
“Sit down.”
“Be humble.”
Embrace
Cultural Humility
.
Further Reading on this topic:
Tervalon
, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), pp 117-25.
Link
.
https://
en.wikipedia.org/wiki/Cultural_humility
good old Wikipedia...Slide8
Structural Competency
The capacity for health professionals to recognize and respond to
health
and
illness
as the downstream effects of
social
,
political
,
economic
&
environmental
structures.
(adapted from conversations with Josh Neff & Seth Holmes)Slide9
“Structural determinants of the social determinants of health”
Poor health outcomes
Poverty/ Inequality
Policies
Economic systems
Structures
Social Determinants of Health &
Health Disparities Curricula
Structural Competency
Social Hierarchies
(e.g. racism)
(SCWG; Josh Neff)Slide10
Structural Violence
“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way
…
The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.”
– Farmer et al, 2006.
Structural Vulnerability is the risk an individual experiences as a result of structural violence – including their location in socioeconomic hierarchies. It is not caused by, nor can it be repaired soley by, individual agency or behaviors.Slide11
Naturalizing Inequality
When social inequalities are preserved through the perception that the status quo is appropriate, deserved and
natural.
Those at the top are seen as deserving their position at the top, and, especially, those at the bottom are seen to be
at the bottom due to their own faults.
As shaped by the lens of “individualization,” an the common perception in healthcare that the most important causes of a patient’s sickness lie in their individually chosen actions and habits and/or their individual biology (genetics, etc.)
Treatment plans focus primarily on education and incentive for individual level behavior change
(SCWG & Josh Neff)Slide12
Components of Structural Competency
1. Recognizing influence of structures on patient health
2. Recognizing influence of structures on the clinical encounter, including implicit frameworks common in healthcare
3
. Responding to structures in the clinic
3
. Responding to structures beyond the clinic
3
. Structural Humility
Collaboration with patients and populations in developing responses to structural vulnerabilitySlide13
Structural Competency in Med Ed
A framework for navigating toward
Health Justice
.
Dialogue-driven. Collaborative. Respectful.
Student-run part of the Curriculum
at
Touro
.
Sitting & Doing
…
“be here now”
Further Reading on this topic:
Neff, J et al. (2016). Teaching structure: a qualitative evaluation of a structural competency training for resident physicians. Journal of General Internal Medicine, 32(4), pp 430--433.
LINK
.
Metzl
, J. & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, pp. 126-133
.
LINK
.
Pigg
, S.L. (2013). On sitting and doing: ethnography as action in global health.
Soc
Sci Med, 99, pp. 127-134. LINK.Slide14
Evaluate Structural Vulnerability
How do the Social Determinants of Health affect your patient
?
Heiman, H.J. (2015). Beyond health care: the role of social determinants in promoting health and health equity. Kaiser Family Foundation - Disparities Policy.
LINK
.
…
How do these affect the Social Determinants of Health?
Economic policy?
Social
norms?
Political disagreements?Slide15
Bourgois
, P., Holmes, S.M., Sue, K. & Quesada, J. (2017). Structural vulnerability: operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), pp. 299-307.
LINK
.Slide16
Making space for *dialogue*
Debate
Dialogue
assumes there is a right answer
– and I have it.
assumes that many people have pieces of the answer and that together, they can craft a solution.is combative –
participants attempt to prove the other side wrong.is collaborative – participants work toward common understanding.
is about winning.
is about exploring common good.
entails listening to find flaws and make counter arguments.
entails listening to understand
and find meaning and agreement.
I defend my assumptions as truth.
I reveal my assumptions for re-evaluation.
I critique
the other side’s position.I re-examine all positions.I defend my own views against those of others.I admit that others’ thinking can improve my own.
I search for weaknesses in others’ positions.I search for strength and value in other’s positions.
I seek a conclusion or vote that ratifies my position.I discover new options.
(Yankelovich 2001 “
The Differences between Dialogue and Debate”)
Listen to
learn.
Speak
to share from your own experience.
The goal is to learn as much as possible from others.Slide17
VALUES FACTS POLICY
Values
“All Lives Matter” or “All Men are Created Equal”
Policy
Unemployment benefits
Housing benefits
Tuition-Free College/University
Expanded & Improved Medicare-for-All
…
.
Facts
OECD spends $2 on social services for every $1 spent on health care
USA spends 55¢ on social services for every $1 spent on health care
(Tony
Iton
, MD)Slide18
Breaking the ice
Taken from twitter page @
socializm
_Slide19
Some slides borrowed from
Zea
Malawa, MD
A Patient
CAseSlide20
Meet “Ben”
Ben is a 6 yr old African American boy
Ben lives in the Bayview area of SF with his parents and grandmother
Ben’s family is very worried because Ben has asthma which has been hard to control
Every 3 months, Ben’s mother misses work to take him to the pulmonologist. On the bus, it takes 1.5 hours in either direction to get there.
(
Zea
Malawa
, MD)Slide21
I was calling to let you know that I have admitted your patient Ben for an asthma exacerbation…
His parents did not pick up his controller med refill last week and he’s missed a lot of school recently because of wheezing.
His father was arrested last month for drugs!
I called CPS. These parents need to learn to get serious about their son’s health.
(
Zea
Malawa
, MD)Slide22
Has Racism affected Ben’s health?Slide23
What is Racism?Slide24
What if the pulmonologist knew…
I
cannot afford to pick up his refill until I get paid next week.
Median incomes for Blacks in San Francisco is $27,000 compared with $89,000 for Whites, a disparity twice as large as the national average.
(New York Times, 2016)
(
Zea
Malawa
, MD)Slide25
I usually give him his medicine everyday but he still can’t stop wheezing.
The Bayview district has more Black residents than any other SF neighborhood.
(City-data.com)
Because of it’s proximity to freeways and industrial sites, it has the highest concentration of air and surface pollutants in SF.
(Environmental Defense Scorecard, 2005)
(
Zea
Malawa
, MD)Slide26
His father just had a little weed in his pocket. The police are always harassing us.
(
Zea
Malawa
, MD)Slide27
I cannot believe that doctor called CPS on us. I don’t want to bring my son to her any more.
Black children are 3 times more likely to enter foster care compared to white families with the same characteristics.
Families of color receive fewer services than White families do and experience lower rates of reunification.
(Annie E Casey Foundation. Report:
Race Matters: Unequal Opportunity within the Child Welfare System,
2006)
(
Zea
Malawa
, MD)Slide28
What is Race?
Templeton, A.R. (2013). Biological races in humans. Studies in History and Philosophy of Science, 44(3), pp. 262--271.
LINK
.Slide29
Racism 101—What Is Racism?
A system
(
Zea
Malawa, MD)Slide30
Racism 101—What Is Racism
A system
of structuring opportunity and assigning value
(
Zea Malawa, MD)Slide31
Racism 101—What Is Racism
A system of structuring opportunity and assigning value
based on the social interpretation of how we look (“race”)
Further Reading: Coates, T. (2013, May 15). What we mean when we say ‘race is a social construct.’ The Atlantic.
LINK.
(Zea Malawa
, MD)Slide32
Racism 101—What Is Racism
A system of structuring opportunity and assigning value
based on the social interpretation of how we look (“race”)
Unfairly disadvantages some individuals and communities
(Zea Malawa, MD)Slide33
Racism 101—What Is Racism
A system of structuring opportunity and assigning value
based on the social interpretation of how we look (“race”)
Unfairly disadvantages some individuals and communitiesUnfairly advantages other individuals and communities
(Zea
Malawa, MD)Slide34
Racism 101—What Is Racism
A system of structuring opportunity and assigning value
based on the social interpretation of how we look (“race”)
Unfairly disadvantages some individuals and communitiesUnfairly advantages other individuals and communities
Saps the strength of the entire society through the waste of human resourcesSource: Jones, CP (2003)
(Zea Malawa, MD)Slide35
Race is a distinct construct from
racism
USA is a racially stratified
society
1
Further Reading on this topic:
García
, J.J. & Sharif, M.Z. (2015). Black lives matter: a commentary on racism and public health. Am J Public Health, 105, pp. e27-e30
.
LINK
.
Campos, P.F. (2017, July 29). White economic privilege is alive and well. New York Times
.
LINK
.
Gladwell, M. BLINK. Chapter 3: The Warren Harding Error.
Privilege Exists
2
Implicit Bias is extremely common
3
Being Black
vs
Being Black in AmericaSlide36
Racialized Health Disparities
CDC
. (2017). Health, United States, 2015 with special features on racial and ethnic health disparities. Page 28.
LINK (PDF).Paradies
et al. (2015). Racism as a determinant of health: a systematic review and meta-analysis. PLOS ONE. LINK.
Racism
Slide37
From the New England
Journal of Medicine
A search for articles published in the
Journal
over the past decade, for example, reveals that although more than 300 focused on health disparities, only 14 contained the word “racism” (and half of those were book reviews)…”
Bassett, M.T. (2015). #BlackLivesMatter -- A Challenge to the Medical and Public Health Communities. NEJM, 372(12), pp. 1085 -- 1087. LINK.
(Zea Malawa, MD)
“…even as research on health disparities has helped to document persistent gaps in morbidity and mortality between racial and ethnic groups, there is often a reluctance to address the role of racism in driving these gaps.Slide38Slide39
Your Case
HPI:
Patient is a 37-year-old Spanish-speaking male
presenting with AMS
PMH
:
Has not seen a doctor in >10 years
PSH
:
Appendectomy1989
SH
:
Works in strawberry fields. Heavy
EtOH
use, other habits unknown.
Homeless.Meds: currently noncompliant with all meds, D/C’ed after last hospitalization on folate, thiamine, multivitamin, and seizure prophylaxis
Neuro/Mental Status: pt. muttering in incoherent Spanish, inconsistently able to answer “yes/no” and follow simple commandsSlide40
Case Cont’d
Mr. Fuentes was diagnosed with ESLD and hepatic encephalopathy
1 week later, he returned to the hospital ER for
therapeutic paracentesis and
died.
He was discharged home to his family, who reluctantly accepted to put him up. Discharge medicines included lactulose. He was instructed to stop drinking alcohol, to eat healthier foods and to obtain more physical activity.
Do these details change your Structural Assessment?Slide41
Begins Drinking More Heavily
Can’t Pay Rent, Moves to Street
Injury,
Can’t Work
Begins Working as Day Laborer
Moves to San Francisco
Influx of Cheap US Corn; Can’t Make a Living
4
th
Generation Corn Farmer in Oaxaca
In Emergency Department After Found on the Street
Gets Assaulted
Standard Medical HistorySlide42
North American Free Trade Agreement (NAFTA)
City & federal policies contributing to gentrification & displacement
US healthcare system (no access to care)
Begins Drinking More Heavily
Can’t Pay Rent, Moves to Street
Injury,
Can’t Work
Begins Working as Day Laborer
Moves to San Francisco
Influx of Cheap US Corn; Can’t Make a Living
4
th
Generation Corn Farmer in Oaxaca
In Emergency Department After Found on the Street
Gets Assaulted
Legacy of colonialism; Systematic marginalization & violence against indigenous communities in
S. Mexico
Racism/ racialized low-wage labor markets; US immigration policySlide43
Naturalizing Inequality
#1: When asked why very few
Triqui
people were harvesting apples, the field job known to pay the most, the Tanaka Farm’s apple crop supervisor explained in detail that “they are too short to reach the apples, and, besides, they don’t like ladders anyway.” He continued that
Triqui
people are perfect for picking berries because they are “lower to the ground.” When asked why
Triqui people have only berry-picking jobs, a mestiza Mexican social worker in Washington state explained that “a los
Oaxaquenos
les
gusta
trabajar
agachado
[
Oaxacans like to work bent over],” whereas, she told me, “Mexicanos [mestizo Mexicans] get too many pains if they work in the fields.” In these examples and the many other responses they represent, perceived bodily difference along ethnic lines serves to justify or naturalize inequalities, making them appear purely or primarily natural and not also social in origin. Thus, each kind of ethnic body is understood to deserve its relative social position.
-Seth Holmes
“An Ethnographic Study of the Social Context of Migrant Health in the US,” 2006
Biology/Genetics
Culture?Slide44
Vocabulary is important…
Social Structures
Structural Violence
Structural VulnerabilityNaturalizing InequalityImplicit Frameworks
IndividualizationCultural FrameworksSlide45
So now what?
Overcoming institutional barriers to a student-led curriculum
Teamwork
Sitting & DoingBringing Structural Competency to your school next?
Who is game?? Raise your hand!Slide46
Thank you / Questions? / The End
11:45am break / get lunch in cafeteria
Vegetarian/Vegan/Gluten-Free have separate box lunches!
12:00pm SNaHP
Chat Mentoring Sesh in the cafeteriaA time to get to know Physician Advocates in a casual setting!Ask them questions! Hang out! They’ll each have their own table/areaMentors include:Dr.
WoolhandlerDr. LazarusDr. GlassDr. ChaoDr. Rigamer1:00pm
SNaHP Group Photo in the lobby area (by registration)