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Burson RC, Familusi OO, Clapp JT. Imagining the 'structural' in medical education and practice in the United States: A curricular investigation. Soc Sci Med 2021; 300:114453. [PMID: 34663541 PMCID: PMC9035321 DOI: 10.1016/j.socscimed.2021.114453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
A number of conceptual frameworks have emerged with the goal of helping clinicians understand and navigate the intersections of the health system and broader political, economic, and cultural processes when they care for patients. In this study, we analyze the impact that one emerging framework, "structural competency," had on medical students' and physicians' understanding of societal problems affecting patient health and the practices of health systems. In this sub-analysis of a longitudinal qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe "structures" and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work interprofessionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients' social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians' perspectives "upstream" to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes.
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Affiliation(s)
- Randall C Burson
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd. 6th Floor, Philadelphia, PA, 19104, USA; Department of Anthropology, University of Pennsylvania, 3260 South St., Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, 3641 Locust Walk #210, Philadelphia, PA, 19104, USA.
| | - Olivia O Familusi
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd. 6th Floor, Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, 3641 Locust Walk #210, Philadelphia, PA, 19104, USA
| | - Justin T Clapp
- Department of Anthropology, University of Pennsylvania, 3260 South St., Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, 3641 Locust Walk #210, Philadelphia, PA, 19104, USA; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA
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Irvine A, Drew P, Bower P, Ardern K, Armitage CJ, Barkham M, Brooks H, Connell J, Faija CL, Gellatly J, Rushton K, Welsh C, Bee P. 'So just to go through the options…': patient choice in the telephone delivery of the NHS Improving Access to Psychological Therapies services. Sociol Health Illn 2021; 43:3-19. [PMID: 32959917 DOI: 10.1111/1467-9566.13182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 06/11/2023]
Abstract
This article considers patient choice in mental healthcare services, specifically the ways that choice is enabled or constrained in patient-practitioner spoken interaction. Using the method of conversation analysis (CA), we examine the language used by practitioners when presenting treatment delivery options to patients entering the NHS Improving Access to Psychological Therapies (IAPT) service. Analysis of 66 recordings of telephone-delivered IAPT assessment sessions revealed three patterns through which choice of treatment delivery mode was presented to patients: presenting a single delivery mode; incrementally presenting alternative delivery modes, in response to patient resistance; and parallel presentation of multiple delivery mode options. We show that a distinction should be made between (i) a choice to accept or reject the offer of a single option and (ii) a choice that is a selection from a range of options. We show that the three patterns identified are ordered in terms of patient-centredness and shared decision-making. Our findings contribute to sociological work on healthcare interactions that has identified variability in, and variable consequences for, the ways that patients and practitioners negotiate choice and shared decision-making. Findings are discussed in relation to tensions between the political ideology of patient choice and practical service delivery constraints.
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Affiliation(s)
- Annie Irvine
- Department of Language and Linguistic Science, University of York, York, UK
| | - Paul Drew
- Department of Language and Linguistic Science, University of York, York, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Centre for Health Informatics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kerry Ardern
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Christopher J Armitage
- Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michael Barkham
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Helen Brooks
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Janice Connell
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Cintia L Faija
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Judith Gellatly
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Kelly Rushton
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Charlotte Welsh
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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