The case for structural competency

Doctors should get beyond the clinic walls [From our Healthier magazine out now]

A guest column by Dr. Jonathan Metzl, the Frederick B. Rentschler II Professor of Sociology and Psychiatry and director of the Center for Medicine, Health and Society at Vanderbilt University

Several years ago, a Vanderbilt University medical student named Ravi Patel noticed during one of his clinical rotations that patients from low-income neighborhoods often failed to comply with doctors’ orders to eat healthy diets or take their medications with food. Patel listened as health care providers wondered whether this phenomenon resulted from doctor-patient communication difficulties, lack of patient education, or “noncompliance” with medical advice.

But a different story emerged when he asked the patients themselves. It turned out that most had very high rates of nutritional literacy and wanted to eat healthy diets. But they had no access to the types of food that doctors prescribed because they lived in so-called food deserts in the poorest sections of Nashville. Their neighborhoods had neither grocery stores nor workable public transportation lines and few persons had access to cars. Patel learned that these patients, many of whom were ill, traveled up to two hours to obtain fresh meat and produce.

And so Patel intervened. He formed a coalition of students, community leaders and nonprofit support groups. The coalition polled community members about their food tastes and dietary preferences. It then performed a market analysis of food-delivery mechanisms, contacted distributers and rented several refrigerated food trucks. Soon thereafter, the group’s rolling grocery stores brought fresh food to low-income areas five times a week. And an organization now known as the Nashville Mobile Market was born.

The Nashville market is but one of a number of recent initiatives that demonstrates a new medical skill called “structural competency” — an idea pioneered in collaboration between medical educators at Vanderbilt’s Center for Medicine, Health and Society and NYU. Previously, doctors were taught that the best way to address social issues was through empathy or referral. Doctors learned to listen empathetically to patients’ economic woes before referring them to social workers. While such approaches were often well intentioned, they left physicians woefully unprepared to address how illness itself resulted not just from biological factors, but also from economic stressors — such as the food deserts that Patel’s patients encountered.

“Structural competency” — a play on the “cultural competency” concept doctors have been taught for decades — emphasizes recognition of the complex ways that matters such as rising income inequalities, decaying infrastructure, poor food-distribution networks and other economic factors lead to worse health. This contention is based on research showing that living in resource-poor environments can produce risk factors for cardiovascular disease that last for generations, or that the poverty found in U.S. cities and suburbs hampers brain development and causes various forms of mental illness in children.

Structural competency is also based on the study of a number of small social-enterprise programs that attempt to intervene into these economic health issues. In addition to the Mobile Market, such initiatives include a Boston organization called Health Leads — which mobilizes volunteers who help with food-assistance, housing improvement and heating fuel subsidies for patients in the waiting rooms of urban hospital clinics — or a Michigan program in which doctors work with architects to design “healthy” buildings and neighborhoods.

Over the past two years, structural competency has gained popularity and acceptance in U.S. medical schools, signaling a growing desire from within medicine to become more socially engaged. Medical schools at NYU, Vanderbilt and UCF have hosted medical-student conferences on this theme. Journals and magazines ranging from Social Science and Medicine to Psychology Today have published articles describing structural competency as a “new way” to combat the health implications of wealth imbalances. And medical writers such as Rhea Boyd have used structural competency to call for more study of the ways that inequality drives poor health.

Perhaps not coincidentally, Ravi Patel’s mobile market idea thrives as well. The Mobile Market has garnered several major funders and awards, including a Nashville Area Chamber of Commerce and the Entrepreneur Center NEXT Award, and is currently being adapted as a model food-delivery system in other cities nationwide.

In its current iteration, the structural approach is a five-step model of training physicians to ask not just how patients feel, but also questions such as "How do you pay for your medications?" as well as “Where do you get you food?” and “How long did it take you to travel to the clinic?”

Such an approach aims to teach doctors to better recognize how illnesses such as hypertension, depression and obesity can sometimes represent the downstream effects of societal decisions about food distribution networks, transit systems or urban or rural infrastructure. Emphasizing the importance of recognizing these factors, structural competency also argues that doctors need to be more involved in communities, “beyond the walls of the clinic.”