An analysis of social determinants of health and structural competency training in global emergency medicine fellowship programs in the United States

INTRODUCTION

The emergency department (ED) is widely recognized for providing care to diverse populations of patients.¹ Specifically, older adults, uninsured individuals, and historically marginalized patients, independent of insurance status, have been shown to have the highest utilization of the ED.^{2, 3} The need to provide high-intensity and fast-paced care in the ED consequently allows for the potential to overlook complex inequities in health care and health care access that can pose a risk to the well-being of vulnerable populations.^{2, 4, 5} Previous pedagogical approaches in medical education, aimed at alleviating health care disparities, emphasized cultural competency at the level of the individual patient.^{6, 7} However, the paradigm has shifted to framing individual cross-cultural interactions within a structural context, where the interplay of larger social, economic, and political factors affect health outcomes.^8-10

Social determinants of health (SDH) are the complex circumstances, such as access to health care, education, healthy food, safe neighborhoods, and environmental conditions, that directly impact health outcomes and lead to health inequities.¹¹ Moreover, structural competency (SC) has been described as a language and set of interventions aimed at reducing health inequalities at the structural level upstream of SDH, including policies, economic systems, and social hierarchies such as institutional racism. The SC framework illuminates how such structures produce and perpetuate health disparities, often along lines of nationality, race, ethnicity, class, citizenship status, language, religion, geography, gender, and age.¹² The medical teams' SC allows them to comprehend the interrelations between the individual clinical level and the social–political structural level.¹³ This improves treatment and patient experience by inspiring health professionals to actively engage in broader social, political, and policy issues that impact marginalized individuals' health and encouraging them to advocate for policy change in collaboration with disadvantaged communities.^{13, 14} The SC framework acknowledges that the individual patient–physician interaction is not necessarily the source of stigma, but rather the stage where previously entrenched biases and prejudices are perpetuated to negatively impact patient health outcomes.^{9, 15} Therefore, it is critical to include upstream structural factors in educational initiatives to combat health inequities.

Emergency medicine (EM) is now a global specialty with the International Federation of Emergency Medicine representing over 50 countries.¹⁶ The development of the specialty in lower- and middle-income countries is often facilitated via partnership with established programs. This often involves needs assessment and curriculum development. Moreover, in these countries, the structural forces and processes that impact health are of utmost significance. In addition to internal structures found in programs in the United States, such as policies, economic systems, and other institutions that maintain modern social inequities, many other structures increase health disparities between the global north and global south and affect mortality and morbidity rates, disabilities, and other markers of inequity. In these contexts, SC curriculum development is particularly essential.^{15, 17} The mode of teaching in these programs is often hands-on and facilitated by visiting faculty and via teleconferencing.¹⁸

Global emergency medicine (GEM) fellowships have been developed to provide advanced training in international skills and systems development to residency-trained emergency physicians. Clinicians, particularly those involved in the health care sector on a global scale, must be aware of the structural forces that affect their patients to appropriately address their unique health care needs. Additionally, a greater understanding of SDH and SC among ED faculty may improve access to care and health outcomes for the diverse populations of patients who disproportionately seek care at the ED.¹⁹

However, due to a lag in the adoption of SC as an additional layer to cultural competency that broadens the perspective and prevents using culture in an essentializing and homogenizing way, we posit gaps in the GEM fellowship curriculum regarding formal training in SDH and SC. While online courses on SDH have been offered by global organizations and consortia, such as the World Health Organization or Coursera, these offerings are not specific for EM.^{20, 21} Moreover, the current literature lacks studies that attempt to investigate this form of instruction in EDs. As such, this study uniquely aims to assess the participation of GEM fellowship programs in formal SDH and SC training to evaluate the existence and procedures of such programs.

MATERIALS AND METHODS

RESULTS

Eighty percent (20/25) of GEM fellowship directors responded to the survey. Table 1 demonstrates the characteristics of the 20 participating fellowship programs regarding training on SC and SDH. All (20/20) of participating fellowship programs included SDH and SC training in their didactic curriculum, and eight of 20 (40%) of programs offered similar training for faculty. Of the fellowship program directors that responded to the survey, 18 of 20 (90%) of respondents had personally received EM-based formal training in caring for minority populations. Additionally, three of 20 (15%) programs have a way to measure fellows’ comfort with SDH and SC (Table 1).

The different modalities of educational training are detailed in Table 2. Many of the trainings included education on race and ethnicity (65%), gender identity and sexual orientation (50%), patients with limited English proficiency (50%), and SDH and its impact on health outcomes (85%). A majority of the trainings involved journal club (70%) and lectures (80%), while others included Web-based modules (50%) and other modalities (40%) such as coursework from master of public health programs, small-group sessions, and conferences (Table 2).

Furthermore, of the programs that offered faculty training on SDH and SC, six of eight (75%) respondents indicated the use of Web-based models and lectures, while seven of eight (88%) offered lectures and didactics and three of eight (38%) involved journal club (Table 3). Of respondents who have personally had EM-based formal training in caring for minority populations, 13 of 18 (72%) received lectures and didactic training, 11 of 18 (61%) attended a relevant conference, and 10 of 18 (56%) participated in topical residency training (Table 3). Finally, 19 of 20 (95%) respondents indicated interest in an open-source tool for EM fellowship training in SDH and SC.

DISCUSSION

We found that while all of the participating fellowship programs included formal SDH and SC training in their didactic curriculum, notable gaps exist in program offerings for similar faculty training. Most of the fellowship trainings involved educational objectives focused on race and ethnicity, gender identity and sexual orientation, patients with limited English proficiency, and SDH and its impact on health outcomes. The format of the fellowship programs favored journal clubs and lectures over Web-based modules and other modalities, such as coursework from the master of public health programs, small groups, and conferences.

Furthermore, the majority of fellowship program directors that responded to the survey had personally received EM-based formal training in caring for minority populations, most often through didactics, topical residency training and relevant conference attendance. However, most of the programs lacked a method to measure fellows' comfort with SDH and SC. Finally, interest in an open-source tool for EM fellowship training in SDH and SC was almost universally indicated by respondents.

Other studies of programs teaching SDH or SC in medical training have found a similar need for standardization of curriculum content and evaluation practices. A systematic review of existing U.S. residency curricula designed to teach primary care residents about SDH found both the educational material and the implementation of the programs to be variable. The authors also noted gaps in evaluation of the change in residents' knowledge and competencies after completing the programs.²⁴ Additionally, an analysis of a SC curriculum for medical students, residents, and interdisciplinary teams found that participants who completed the program reported reframing their thinking about patients to avoid blaming or misconceptions. However, the authors also pointed out a need for further evaluation methods.¹⁵

The study after which our survey was modeled evaluated formal cultural competency training in EM residency programs.²² Similar gaps in faculty program offerings and resident competency metrics were found as well as the unmet need for a shared tool to uniformly teach and evaluate cultural competency within EM residency. However, cultural competency–based education has faced criticism for the potential to promote racial and cultural profiling and stereotyping of patients that can facilitate poorer patient outcomes.^25-27 A SC-focused approach to medical education seeks to emphasize the upstream factors that affect SDH and health inequities beyond the individual patient–physician interaction.^{8, 15} While this framework is particularly critical in EM education, because the ED is often the first point of care for diverse populations of patients, there is a lack of literature assessing this form of training.²⁸ Therefore, this unique evaluation of GEM fellowship programs is needed to identify gaps in the shift of formal training to the SC paradigm.

LIMITATIONS

While survey-based studies are helpful in obtaining data and outlining trends, it is important to be aware that these studies are more vulnerable to subjectivity and interpretation. As with any survey, it is possible that responders may have interpreted some of the questions and answer choices differently. However, this survey was based on a previously published and validated survey developed by Mechanic et al. in 2017.²²

Additionally, the survey questions did not distinguish between SDH and SC. Asking about these concepts together allowed for a shorter questionnaire and more valid and reliable responses by mitigating inaccurate interpretations of the terms. Future research, however, should capture a nuanced distinction between the incorporation of these two frameworks into GEM programs.

CONCLUSION

While multiple global emergency medicine programs offer formal training on social determinants of health and structural competency, gaps exist regarding similar training for faculty. Additionally, there is a lack of metrics to determine fellows' comfort with the content of this training. As a majority of Global Emergency Medicine Fellowship Consortium programs requested, an open-source tool would allow a uniform curriculum and measurement of emergency medicine fellowship training in social determinants of health and structural competency.

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

AUTHOR CONTRIBUTIONS

Lindsay G. Grossman, Oren J. Mechanic, Eric C. Cioe-Peña, Josh Greenstein, Evan Avraham Alpert study concept and design. Lindsay G. Grossman, Eric C. Cioe-Peña, Josh Greenstein: acquisition of the data. Lindsay G. Grossman, Josh Greenstein: analysis and interpretation of the data. Lindsay G. Grossman, Zvika Orr: drafting of the manuscript. Lindsay G. Grossman, Oren J. Mechanic, Zvika Orr, Eric C. Cioe-Peña, Alden Landry, Shifra Unger, Josh Greenstein, Evan Avraham Alpert: critical revision of the manuscript for important intellectual content.