Beyond Our Walls

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Editor’s Note: This blog post complements a collection of articles in our March issue that explores physicians’ and trainees’ understanding of how social structures and structural competency influence health. Check back throughout the month for additional perspectives on this topic.

Within our hospitals and clinics, it is easy to focus on the crowds of patients, the remarkable new technology, and the numerous resources that have to come together to care for patients with increasingly complex health care needs. We assemble teams to manage the most challenging problems–the multisystem trauma patient, the patient with sepsis and an organ transplant, the patient who is pregnant and the premature infant who may be born. We train our students to understand the pathophysiology of these conditions and to provide the lifesaving care to alter the trajectory of these illnesses or injuries. And we make a difference in many cases.

What we don’t do well is understand why the trauma patient was injured, why the woman in early labor did not receive prenatal care, or how the organ failure might have been prevented. These problems are beyond our walls, beyond our control. In many cases, there are structural conditions within the environment or the patient’s life experience that have contributed to these medical issues. In the March issue, Hansen and Metzl introduce several articles related to the concept of structural competency and explain its importance for medical education. Structural competency addresses the social conditions and institutions that affect health and lead to inequalities in health and health care. They encourage educational experiences for our students to deepen their understanding of these structural issues and to teach them how to overcome these structural barriers to health and health care.

This work reminds me of a recent patient who came to my hospital with a rash. She lived in her car and had no access to running water. She lived in her car because she had lost her job, she had no family, and the resources for people who are homeless in her town were inadequate. She also felt that a life in shelters and on the streets was dangerous, and she described past experiences with assaults and arrests. She felt safer living in her car. As the intern and I performed our history and physical, we discovered that the woman had severe hypertension, which wasn’t being treated and was already causing renal damage. While our medical education system might emphasize the differential diagnosis of the rash and the pathophysiology of the hypertension and renal insufficiency–making her “an interesting learning case”–it likely wouldn’t teach how to address the homelessness that was complicating her health problems. Providers have access to medications to treat rashes and hypertension, but they feel powerless to change the social structures at the root of her illness. We did try to connect our patient to social services, but the barriers were substantial.

In his blog post, Martin describes his personal experience as someone living on the street attempting to navigate the health care system and how difficult and frustrating that can be. I worry that his experience is not an isolated case. While the expansion of Medicaid under the Affordable Care Act has increased access to health insurance for people who are homeless in many states, proposed legislative changes could reverse these improvements.

While it is sometimes frightening to venture beyond our walls as physicians, we must do so to fully understand the health problems of our communities. Training in structural competency and in physician advocacy, as Geiger encourages in the March issue, could provide our trainees with the understanding and compassion for patients like Martin and help us see beyond our walls to better the health of all.

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