Out of the Ivory Tower: Successes From a Community-Engaged Structural Competency Curriculum.

Abstract

To the Editor: We appreciate Barwise and Liebow’s comments 1 on Sharma and colleagues’ article 2 about teaching the social determinants of health (SDOH), and we concur with Sharma and colleagues’ response 3 that institutions, not trainees, bear primary responsibility for changing the way SDOH are taught. In the wake of national conversations on addressing the devastating health impacts of structural racism across the medical education continuum, community-engaged approaches can enhance both theoretical and personal understanding of the SDOH. Our insights from implementing a structural competency curriculum may add an informative viewpoint.4 In fall 2019, our institution (University of Nebraska Medical Center) implemented a first-year medical student curriculum called “Structural Challenges and Inequities in Healthcare Delivery.” We (a medical student, a director of community engagement, and an infectious diseases physician) designed and continue to refine this curriculum in collaboration with 18 community stakeholders, ranging from the owner of a local soul food restaurant to the leader of our city’s largest public housing agency. Our shared mission is simple: get students out of the “ivory tower” of academia and into the community, and ensure that community stakeholders are at the table throughout development, facilitation, and evaluation of the curriculum. As Sharma and colleagues discuss, 2 our approach seeks to build structural competence by reforming SDOH curricula to meaningfully address “physician–patient and physician–society dynamics.” Our institutional investment in this effort and the subsequent student outcomes contradict Barwise and Liebow’s 1 assertion that shifting curricula in this direction is too formidable a task. The curriculum’s accompanying didactic components include lectures highlighting the sociopolitical forces driving local inequities, reflective writing, and a capstone project asking students to propose a health intervention in response to community-identified priorities. Learners’ feedback has been clear: they have overwhelmingly indicated that they find the curriculum valuable for their professional development, highlighted community-engaged components as the most impactful, and expressed desire for additional depth of training. To us, this clearly illustrates that medical students are motivated to learn about structural inequity and crave direct, community-led teaching within formal SDOH education. We are not the first group to successfully implement curricular reforms of this nature, and we firmly believe we will not be the last. Author’s Note: While the COVID-19 pandemic resulted in necessary changes to the curriculum’s second iteration this year, we sustained a focus on our proximate community through the addition of novel content that addressed structural causes of local COVID-19 inequities. We intend to reintegrate the community-based experiences when safely able.