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Physicians Urged to Become 'Political Advocates' for Patients

 |  By John Commins  
   March 19, 2014

Two advocates for public health want healthcare workers trained to be "structurally competent" in basic economics, urban infrastructure, and other societal factors that can negatively impact patients' health.


Jonathan Metzl, MD
UPMC/Director of Vanderbilt University's Center for Medicine, Health and Society

Physicians must become vocal and assertive political advocates for their patients and possess "structural competence" to identify and address social ills that harm public health. Teaching that structural competence should be part of pre-med and medical school curriculum, two public health advocates say.

In an essay published this month Social Science and Medicine, psychiatrists Jonathan Metzl, MD, director of Vanderbilt University's Center for Medicine, Health and Society and Helena Hansen, MD, of New York University, say it's clear that people's health and wellness can be linked to their zip codes as much as their genetic codes. As a result, they say, physicians need to understand and identify the "social factors" that can make their patients sick.

"The impetus behind this project is that the voice of medicine in standing up for better infrastructure for people has been absent," Metzl said in a telephone interview. "We are not asking anyone to advocate any particular position. We are saying that since we know that social factors can cause illnesses, medicine needs to be more vocal and using its moral voice to stand up for improving social infrastructure factors."

Metzl and Hansen want healthcare workers trained to be "structurally competent" in basic economics, urban infrastructure, and other societal factors that can harm health. They two psychiatrists say that training could be part of pre-med undergraduate curriculum or included in employee orientations at hospitals and clinics.


Helena Hansen, MD
New York University

"Doctors are well trained to address the individual needs of patients. We train doctors about communication with patients, diagnosing the individual patient in front of them in the exam room," Metzl says.

"But increasingly we know there are medical conditions that are caused by a host of social and economic problems. We know that growing up in a poor area is bad for someone's brain development. It causes a host of psychiatric and other mental conditions. We know that dietary factors are linked to diabetes that is worse off in low-income areas where there are no grocery stores. The evidence mounts every day that infrastructures, economic issues, [and] wealth imbalances are all causing medical conditions. The point we are trying to make is that doctors need to be aware of the ways these social factors can impact people's lives and livelihoods."

To gain structural competency, Metzl says physicians must first adopt an attitude of "structural humility" and accept that they may not understand many of the issues confronting their patients and must therefore be willing to collaborate with community activists, local political leaders and the patients themselves.

Metzl says the idea of adopting structural competency courses as part of medical school or pre-med education is growing in popularity among medical students.

"Medical students are seeking us out for this particular kind of stuff. We are seeing a lot of desire among socially active medical students for this kind of training. They are frustrated they're not getting it," he says. "It is incumbent upon medical schools to listen to that. Curriculum is very tight but medical students are demonstrating that there is a need for this kind of training. The market bears that out. When medical students graduate and enter the real world, training in health economics are pretty important for the careers they are pursuing."

Metzl says becoming a political advocate on behalf of patients does not mean that a doctor has to adopt a particular political philosophy such as liberal or conservative or Democrat or Republican.

"Caring about the infrastructure and the health of people in relation to the health of their communities, it is sad for me that that would be a liberal or a conservative issue. If we really care about health, the data is pretty clear about what sorts of things people need to do to live healthy lives," he says.

"Any responsible democracy should advocate for those positions no matter what side you're aligned with. Whether or not this curriculum gets picked up by every medical school medicine itself needs to be making that argument much more loudly. Medicine needs a vocabulary for saying that infrastructure and access to healthcare are not a liberal or conservative issue. It's a societal issue. Part of what we are trying to do through this is develop a new language for medicine itself to take up some of these issues. Medicine has been far too quiet."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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