Structural Competency as a Simulation Performance Domain.

Abstract

To the Editor: In the past few months, many in the medical education community have been defending social justice as a central tenet in medical education in response to a Wall Street Journal op-ed by Stanley Goldfarb, MD, a former associate dean of curriculum at the University of Pennsylvania.1 In his piece, Dr. Goldfarb laments the current trend toward incorporating social justice and policy into medical school curricula. He opines that these curricular elements come at the expense of teaching diagnostic and procedural skills. However, we in the simulation community know that the fidelity of any learning experience depends on integrating complex factors to fully represent the whole patient. In examining our current programs of simulation-based medical education, we daresay that social justice and public health are not emphasized enough. This is particularly true when we consider that academic medicine has previously been criticized for failing its social responsibility to promote health equity by teaching social determinants of health as “facts to be known” rather than “conditions to be challenged.”2 Simulation-based clinical scenarios, particularly when paired with facilitated debriefing, provide an ideal transformative learning framework to explore disorienting experiences, thus promoting critical reflection and social discourse.3 Historically, simulation debriefing has focused on cognitive disequilibrium in relation to select performance domains, which are nicely summarized in the PEARLS Healthcare Debriefing Tool (ie, Decision Making, Technical Skills, Communication, Resource Utilization, Leadership, Situational Awareness, and Teamwork).4 However, these domains exclude a deeper exploration of the contexts shaping our simulated medical emergencies and scenarios. In addition to technical and situational competencies, simulation-based medical educators have a unique opportunity to build “structural competency,” which can be understood as the trained ability to discern inequity at individual, organizational, community, and societal levels to meaningfully address disparity and injustice.2,5 Structural competency goes beyond the mere recognition of social determinants of health; it pragmatically demands a language by which learners may recognize health conditions to be rooted in structural inequities that demand action.2 As such, structural competency should be an added performance domain in our debriefing toolkit. This may sound daunting, but in our work with the pediatric emergency medicine team at Columbia University's Department of Emergency Medicine, we piloted integrating a “language of structure” into our weekly, interprofessional, in situ simulations. Adding elements of structural competency to learning objectives and debriefing stems allowed us to incorporate topics such as urban poverty and heat insecurity into a simulated case of a hypothermic infant; vaccine hesitancy and public mistrust into a case of pediatric measles encephalitis; pharmaceutical price gouging and insulin rationing into a case of diabetic ketoacidosis; and structural racism into a case of penetrating trauma. Our simulations highlight that medical emergencies are rooted in a complex tapestry of physical, social, psychological, and environmental forces beyond the trauma bay, which must be explored, understood, and changed to achieve optimal health. Structural competency is a trained skill, and medical simulation with facilitated debriefing provides an ideal learning environment to cultivate it through a “pedagogy of discomfort.”2 As simulation-based medical educators, it is imperative to social justice, to training “doctor-citizens,”6 and to simulation fidelity that we strive to integrate structural competency into our daily work. Selin T. Sagalowsky, MD, MPH Department of Emergency Medicine New York University School of Medicine New York City, NY [email protected]David O. Kessler, MD, MSc Department of Emergency Medicine Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY