Medicine has traditionally focused on diagnosing and treating what is happening inside the patient. But what happens when the factors contributing to a patient’s health problems exist outside the exam room?
A patient’s health can be influenced by much more than genetics, lifestyle, and individual choices. Where someone lives, their access to transportation and healthy food, their financial resources, housing conditions, education, employment, insurance coverage, and experiences with discrimination can all affect health outcomes.
This is where structural competency comes into play.
Structural competency is a framework that encourages physicians and other healthcare professionals to recognize how social, economic, political, and institutional structures influence health and contribute to health disparities. The concept was formally introduced into medical education by Jonathan Metzl and Helena Hansen in 2014.
What Does Structural Competency Mean?
Structural competency is the ability to recognize that health problems seen in the clinical setting may be the downstream consequences of larger systems and policies.
For example, a physician may treat a patient with poorly controlled hypertension. Traditionally, the conversation might focus on medication adherence, diet, exercise, and other individual behaviors.
A structurally competent approach asks additional questions:
- Can the patient afford their medications?
- Do they have reliable transportation to medical appointments?
- Is healthy food readily available where they live?
- Do they have stable housing?
- Do they have access to a pharmacy?
- Does their work schedule allow them to attend appointments?
- Have previous experiences with the healthcare system affected their trust in medical providers?
- Are there broader policies or community conditions contributing to the patient’s health risks?
The goal is not to ignore individual responsibility or clinical treatment. Instead, structural competency encourages clinicians to understand the larger context in which health and illness occur.
Structural Competency Goes Beyond Cultural Competency
Structural competency is often discussed alongside cultural competency and cultural humility, but the concepts are not identical.
Cultural competency traditionally emphasizes understanding and communicating effectively with patients from different cultural backgrounds. Cultural humility takes this further by emphasizing lifelong learning, self-reflection, and recognizing that a healthcare professional cannot become an expert in another person’s culture.
Structural competency adds another layer by asking clinicians to examine the systems and structures that shape patients’ experiences and health outcomes.
Research describing structural competency argues that focusing exclusively on individual or cultural factors can overlook the larger forces contributing to health inequities.
For example, rather than simply asking why a patient repeatedly misses appointments, a structurally minded physician might consider whether transportation, work requirements, childcare, insurance restrictions, or limited access to healthcare are creating barriers.
The question changes from “What’s wrong with this patient?” to “What circumstances are making it difficult for this patient to achieve good health?”
The Five Core Areas of Structural Competency
Metzl and Hansen originally described five core competencies that form the foundation of the framework.
- Recognizing Structures That Shape Clinical Interactions
Physicians learn to recognize how healthcare systems and social structures influence what happens between patients and providers.
Insurance policies, transportation systems, housing, employment, healthcare availability, and other factors can affect whether patients receive care and how they experience the healthcare system.
- Developing a Language for Understanding Structure
Structural competency gives healthcare professionals a vocabulary for discussing issues such as structural inequality, social determinants of health, structural vulnerability, and structural violence.
This language can help physicians move beyond describing disparities as isolated patient problems and instead identify the systems contributing to them.
- Reframing “Cultural” Issues in Structural Terms
A patient’s behavior or health outcome can sometimes be attributed to culture when structural factors may be playing a significant role.
Structural competency encourages physicians to consider whether what appears to be a cultural difference is actually connected to access, economic circumstances, discrimination, policy, or other structural conditions.
- Identifying and Imagining Structural Interventions
Recognizing a problem is only the first step.
Structural competency also encourages healthcare professionals to consider what can be changed. Solutions may include improving clinic processes, partnering with community organizations, connecting patients with legal or social services, changing institutional policies, or advocating for broader improvements.
- Developing Structural Humility
Structural humility recognizes that no physician can fully understand every system affecting every patient.
Instead, clinicians should remain open to learning, examining their own assumptions, listening to patients and communities, and recognizing the limits of their own knowledge.
Why Does Structural Competency Matter to Physicians?
Healthcare professionals regularly see the consequences of social and structural inequities.
A patient may present with diabetes, depression, asthma, cardiovascular disease, substance use disorder, or another condition, but the factors contributing to that illness may extend well beyond the clinical environment.
Structural competency gives physicians a way to connect those individual clinical experiences with broader social realities.
This can be particularly important when caring for populations that experience significant health disparities. Research has connected structural factors, including social and economic policies, access to resources, discrimination, and social stratification, with unequal health outcomes.
For physicians, developing structural competency can therefore mean becoming better equipped to recognize barriers that might otherwise be overlooked.
Structural Competency and Medical Education
Structural competency is increasingly being incorporated into health professions education.
A 2023 scoping review identified structural competency training across medical, pharmacy, nursing, residency, social work, and pre-health programs. Educational approaches have included case-based learning, community engagement, neighborhood exploration, photovoice, team-building exercises, and peer teaching.
Medical education programs have also developed curricula designed to help students, residents, faculty, and interprofessional teams understand how social, economic, and political structures affect patient health.
One published curriculum found that clinicians with prior clinical experience reported that structural competency training helped them reframe how they thought about patients and better understand the relationship between structural factors and clinical care.
Why Structural Competency Matters for the Future of Medicine
Physicians are trained to look for causes of illness. Structural competency expands that responsibility by encouraging them to look beyond the immediate clinical presentation.
It asks physicians to recognize that health is influenced by an interconnected network of medical, social, economic, environmental, and political factors.
That does not mean physicians are expected to solve every social problem their patients encounter. Rather, it means recognizing when those problems are affecting health and understanding how healthcare professionals and organizations can respond.
As medicine continues to focus on health equity, disparities, diversity, and access to care, structural competency can provide physicians with another important tool for understanding the patients they serve.
Ultimately, treating the patient requires more than understanding the disease. It also requires understanding the circumstances in which the disease occurs.
Structural competency helps physicians make that connection.