Imagining the 'structural' in medical education and practice in the United States: A curricular investigation

Accounting for agency in structural competency

To emphasize to learners how factors outside individual control impact health, scholars introduced the concept of structural competency. Structural competency refers to the development of analytical skills that reveal the larger societal context beyond the patient-clinician interaction that shapes health outcomes. The growing adoption of structural competency curricula, however, has revealed that prelicensure and early career health professionals can feel overwhelmed by the mismatch between the wide scale of entrenched problems and the limited scope of their therapeutic skills. In this Reflections paper, I draw on theories from Giddens, Bourdieu, and Foucault to restore a role for individual agency in promoting health. Conceiving of structure and agency as mutually constituting suggests that structures are human-made and can be vulnerable to challenge. Structures, however, disperse power to such an extent that people internalize their rules and discipline themselves to follow them without explicit enforcement. It is precisely in those local sites of power that health professions learners and educators can intervene to interrupt the reproduction of structures harmful to health. As I demonstrate with an example from a reproductive health emergency, being structurally competent may also include contesting agreed upon norms at the level of the learning and clinical environments rather than only macro-level societal forces. Rewriting norms within health professions education and clinical practice is not necessarily a simpler task, but it provides learners and educators with more accessible targets for action.

A Qualitative Study of Perceptions and Preferences Regarding Social and Behavioral Risk Screening Among Primary Care Patients

BACKGROUND

Despite its relevance for healthcare settings, social and behavioral risk screening is not systematically performed by clinicians or healthcare systems.

OBJECTIVE

To address clinician concerns, such as social and behavioral risk screening disrupting the clinician-patient relationship and lack of resources to respond, we interviewed primary care patients at an academic medical center regarding their perceptions and preferences on social and behavioral risk screening.

PARTICIPANTS

Between September and December 2020, we recruited a convenience sample of 14 English-speaking primary care patients 18 years + from three clinics affiliated with an academic medical center.

APPROACH

Using a semi-structured interview guide, we asked about the importance of social and behavioral risk screening, whether or not and how to share social and behavioral risk factors, and how social and behavioral risk factors are addressed. We used a multi-step analytic process to identify the range and commonality of participants' responses thematically.

KEY RESULTS

Participants recognized that social and behavioral risk factor domains were relevant to primary care and important for treating the patient as a whole person. Participants preferred a conversation regarding social and behavioral risk factor with their primary care providers (PCPs), and suggested that, if surveys are used, they be followed with an open-ended, in-person discussion. Participants also suggested framing the discussion as something that is done routinely with all patients so that patients do not feel judged. Participants felt comfortable sharing social and behavioral risk factors when they trusted their PCPs, and felt that discussing social and behavioral risk factors with their PCPs built trust. Participants recognized that resources exist outside of the clinic, and suggested that PCPs distribute lists of relevant community resources to patients.

CONCLUSION

In our study of primary care patients on perceptions and preferences about screening and addressing social and behavioral risk factors, we found that patients were willing to share social and behavioral risk factors with their PCP, preferred an in-person discussions with or without a survey, and wanted a list of community resources to address their needs.

U.S.-Based Obstetrician/Gynecologists' Experiences with Delivering Care to Women with Female Genital Cutting

Background: There has been an increase of women living in the United States who have experienced female genital cutting (FGC). However, limited research exists evaluating the experiences of obstetrician/gynecologists delivering care to this patient population. This study aimed to assess the overall experiences, including barriers and facilitators, of U.S.-based obstetrician/gynecologists (OBGYNs) with delivering care to patients with female genital cutting at a single academic health center in the United States. Materials and Methods: This is a qualitative study of OBGYNs at a large, U.S., urban, academic health center. OBGYNs participated in a one-on-one semistructured interview. Thematic analysis using a grounded theory approach was conducted to identify predominating themes regarding the overall experiences, barriers, and facilitators to delivering care to patients with FGC. Results: Analysis of 15 study interviews revealed 4 main themes impacting the ability of OBGYNs to deliver care to patients with FGC: (1) limited educational training on FGC, (2) challenges with identifying that a patient had FGC and with using the World Health Organization classification system, (3) questions regarding "normative" anatomy and reinfibulation after vaginal procedures, and (4) navigating affective responses of patient and self when FGC is encountered. Conclusion: The above findings have practical implications, showing that the limited educational experience and lack of a clear policy on how to manage the care of women with FGC lead to variation and even limitations in how care is delivered to these women. We encourage OBGYN professional societies to consider creating education and policy to aid clinicians in caring for patients with FGC.