Residents Lead Drive to Include Structural Competency in Medical Training

Psychiatry residents at the University of California, Los Angeles (UCLA), took center stage during a session at IPS: The Mental Health Services Conference last month, where they discussed their successful effort to integrate structural competency training into the UCLA residency program.

Structural competency is an emerging concept in medical training that focuses on the structural determinants of health and illness; these include social and demographic factors but also the infrastructure in a community, such as the quality of housing and education (Psychiatric News, http://apapsy.ch/StructuralCompetency). To promote mental and physical health in patients, proponents of structural competency say physicians need to both understand these structures and collaborate with the people who oversee them.

Structural competency is an outgrowth of culturally competent care, in which physicians take a patient’s background and culture into account when providing care, session chair Helena Hansen, M.D., Ph.D., told attendees. Hansen is an associate professor of psychiatry at New York University and vice chair of APA’s Council on Minority Mental Health and Health Disparities.

Another speaker, Nichole Goodsmith, M.D., was a third-year psychiatry resident in 2017, when she approached Enrico Castillo, M.D., the associate director of residency education, with ideas about expanding opportunities for residents with an interest in community psychiatry and structurally based care.

Earlier that year, Goodsmith had organized a monthly lunchtime seminar series for psychiatry residents, where psychiatrists who worked in community settings spoke about their careers. According to Goodsmith, the lunchtime sessions helped spur more interest in community psychiatry, and they decided to try to establish more activities that would let residents interact with people in the the surrounding communities.

Castillo was already developing some new educational modules on community psychiatry topics for the existing residency lectures. “Then the residents came to me with all these ideas for events and I saw they wanted to take this to another level,” he told IPS attendees.

Over the next year, the residents, with the help of Castillo and other faculty with interests in community psychiatry and the social determinants of health, helped organize a range of activities for residents who wanted to learn more. In addition to the monthly career seminars, the group organized site visits to jails and supportive housing centers, as well as a quarterly series where residents discuss case studies in which structural and/or social issues contribute significantly to the diagnosis.

The residents have also established a recurring dinner series called “Policy and Change,” where they discuss a relevant national or local policy topic that affects community structure—such as the recent separations of migrant children from their parents at the U.S. border—and brainstorm ways they can advocate for policy changes.

The university now offers first-year psychiatry residents the option to take introductory courses on community psychiatry and the structural determinants of health, said Isabella Morton, M.D., a third-year UCLA resident, who also helped launch these initiatives. Second- and third-year residents have the option to take short, focused modules on mental health and the justice system, global mental health, homelessness, and peer support services, she said.

Residents who participate in these and other courses are eligible to graduate with a concentration in community psychiatry or global psychiatry. (Goodsmith and Morton are the current co-chief residents of community and global psychiatry at UCLA.)

“Launching that concentration really was the capstone of this first year,” said Castillo. “It mainstreamed all of the residents’ efforts.”

Castillo added that even residents who do not want to specialize in community psychiatry can benefit from taking some of these modules or participating in the various activities.

“Every patient interaction involves structural and social influences,” he told the audience. “Structural competency teaches residents core competencies of good medicine,” including interprofessional teamwork, how to work effectively in different health settings, and how to advocate for quality care.

“It has been so gratifying to see what we have done in this short time,” said Goodsmith, who along with the other panelists hoped their story would encourage early career psychiatrists at other institutions to try a grassroots approach to foster change. “It takes time and energy … but do not be afraid to take ownership of your institution,” she advised. ■