Structural Competency and the Medical Learning Environment—An Overdue Paradigm Shift in Medical Education

Abstract

Structural competency (SC) is a framework that assists clinicians in naming and analyzing the structural drivers that fundamentally contribute to morbidity and mortality. Undergraduate and graduate medical education is grounded in the experiential learning model where trainees learn through supervised, hands-on, real-world training and caring for patients within hospital and clinic settings. However, our present-day clinical settings fail to create a learning environment in which SC skills can be effectively taught and operationalized. The SC framework is designed to engender praxis, but to make this move upstream, healthcare institutions and medical education leaders need to do more to adapt their learning environment. We posit five elements and associated key actions that are essential to an SC learning environment: (1) the structural analysis of institutional policies and practices; (2) academic freedom and interdisciplinary discourse; (3) redefining medical education standards and metrics; (4) collective action to drive effect change; and (5) community integration and accountability.

1. Introduction

Despite decades of Healthy People initiatives and advances in knowledge, structurally perpetuated inequities in health persist (Social Determinants of Health n.d.). Medical education traditionally focuses on individual-level factors like personal behaviors or inherited genes instead of the root causes that govern and dictate population health. The conceptual framework of structural competency (SC), developed by Metzl and Hansen in 2014, provides a roadmap towards education for these root causes. SC refers to the ability to recognize how upstream structural decisions contribute to health outcomes. The SC framework assists clinicians in naming and analyzing how structural drivers (e.g., systemic racism, institutional practices, economic forces, political systems, and public policies) fundamentally contribute to morbidity and mortality. While traditional medical training offers the opportunity to learn to look into the microscope, Petri dish, or human genome for solutions, SC provides a pathway toward identifying and describing how structural forces give rise to poor health and articulating upstream solutions in the form of structural changes (Metzl and Hansen 2014). Models and standards to bolster SC learning have been published by the Association of American Medical Colleges and the Liaison Committee on Medical Education (Aamc 2022; Liason Committee on Medical Education n.d.). We propose key features of clinical learning environments that will allow for more effective structural competency in experiential education.

Undergraduate and graduate medical education is grounded in the experiential learning model (Kolb 2014), where trainees learn through supervised, hands-on, real-world training and caring for patients within hospital and clinic settings. However, our present-day clinical settings fail to create a learning environment in which structural competency skills can be effectively taught and operationalized. As medical educators who teach SC, we believe that SC curricula (National Academies of Sciences, Engineering, and Medicine et al. 2016; Braveman and Gottlieb 2014; Mabeza and Legha 2023) must be administered within structurally competent learning environments for authentic experience, reflection, conceptualization, and active experimentation to occur. To stay true to the SC mission and engender the trust of the learners, educators must develop an andragogical environment that parallels the structure and principles of SC.

There is a strong precedent for purposeful medical education changes inclusive of the learning environment. The most compelling example of this is the overhaul of medical education that occurred after the publication of the Flexner report, which led to a “modernized” U.S. medical education structure designed to train a healthcare provision workforce severed from awareness of or accountability for societal health. Integrated into this effort to increase the standards and rigor of medical education was a narrowing of physician’s scope to exclude an understanding of public health and both African Americans and women from the physician workforce. Since Flexner, there has been a growing recognition of the need to correct courses when it comes to both medical education training and our healthcare systems’ approach to treating illness and disease (Miller et al. 2010).

In the healthcare delivery sphere, recent efforts to center value-based care have pushed health systems to focus on social drivers of health in recognition that these drivers contribute the most to health outcomes. Starting in 2023 regulatory guidelines from the Centers for Medicaid and Medicare Services, Health Resources and Services Administration, and the Joint Commission have required healthcare institutions to incorporate screening for social needs as part of clinical care (Centers for Medicare & Medicaid Services 2022; Bureau of Primary Health Care 2023; The Joint Commission n.d.). These efforts necessitate concomitant medical education training that equips clinicians with the skills to respond to positive social needs screeners and engage with the upstream structural factors that result in increased social risk burdens, which is equally important.

The SC framework is designed to engender praxis, but to make this move upstream, healthcare institutions and medical education leaders need to do more to adapt their learning environment. We posit five elements that are essential to an SC learning environment: (1) the structural analysis of institutional policies and practices; (2) academic freedom and interdisciplinary discourse; (3) redefining medical education standards and metrics; (4) collective action to drive effect change; and (5) community integration and accountability. It should be noted that these five elements mirror the domains of the SC framework: identifying structures that affect our clinical interactions, developing extra-clinical structural language, re-articulating “cultural” formulations in structural terms, imagining structural interventions, and embedding structural humility (Metzl and Hansen 2014) (

Table 1. Toward a structurally competent clinical learning environment.

Essential Elements	Structural Competency Principle	Key Actions
Structural analysis of institutional policies and practices	Identifying structures that affect clinical interactions	Critical assessment of institutional policies and practices Data transparency Upstream quality improvement to address institutional contributors to health inequities
Academic freedom and interdisciplinary discourse	Developing extra-clinical structural language	Commitment to academic freedom and lack of censorship Collective political education Interdisciplinary team-based collaboration
Redefining medical education standards and metrics	Rearticulating “cultural” formulations in structural terms	Ongoing faculty and staff development Reconceptualizing standard forms of clinical communication Integrating structural competency within longitudinal curricula Embedding structural competency into formal medical education assessments
Collective action to effect change	Imagining structural interventions	Grassroots organizing to disrupt existing power structures Unionization Academic–community partnerships Legislative advocacy
Community integration and accountability	Embedding structural humility	Dedicated time for community engagement Community co-created pedagogy Community input on education and health resource allocation

).

2. Five Essential Elements of Structurally Competent Learning Environments

2.1. Looking Within: Structural Analysis of Institutional Policies and Practices

Healthcare institutions are themselves structures, and a move towards SC requires active critique and critical reflection on one’s own policies, practices, and norms. Studies have shown that there is wide variability in medical schools when it comes to contributing to the social mission of medical training (Mullan et al. 2010); academic health centers should be held accountable for an implicit social contract to advance public health and address the unjust social structures that disproportionately impact communities of color and marginalized populations. Academic health centers, like large corporate organizations, have often prioritized financial sustainability and operational efficiency. For example, they have continued to deliver healthcare according to the patient’s health insurance status, often with separate faculty clinics for patients with private insurance and resident-run clinics for those on Medicaid insurance. These centers could do more to address segregated care within their walls and to work with communities to change financial policies that perpetuate the historical legacies of racism (Blum et al. 2023). More recently, to defend their bottom line in response to recent executive orders, many academic health centers have practiced anticipatory obedience by slashing academic freedom; dismantling websites; and erasing research and curricula that support diversity, equity, inclusion, and gender-affirming care (American Association of University Professors 2025). SC calls for critical reflection on institutional practices and policies and their potential role in worsening health outcomes and exacerbating inequities (Hassan and Bui 2022).

A major barrier to practicing and teaching SC is the limited time allocated for meaningful patient interactions, especially for those with complex social needs and language barriers. Appointment scheduling prioritizes efficiency, often penalizing patients requiring additional support and limiting educational time to discuss structural drivers of health. A standard 15 or 20 min slot for patients is insufficient for discussions on health education, lifestyle coaching, strength and support, structural barriers, and community resources. Additionally, administrative tasks such as clinical alerts, benchmarking, and billing documentation further erode valuable patient-facing time and educational time. Longer visit times should be made available for patients with higher social risks and language barriers. Furthermore, debriefing and reflection times should be embedded within clinical workflows to enhance learning and support trainees and clinician-educators.

To facilitate the structural analysis of healthcare institutions, data transparency on hospital policies and procedures and resource allocation is required. Public-facing health equity dashboards could provide data visualizations for hospitals, communities, and relevant stakeholders on health and social factors, healthcare utilization, and health outcomes. This data transparency will help to ensure that healthcare systems are able to demonstrate meaningful community benefits. Such tools will not only engage learners in system-based practice but can guide the improvement of quality and efforts to address health disparities (Gallifant et al. 2023).

Mechanisms to change policies and procedures should be streamlined and formalized through open channels of communication and the integration of continuous quality improvement (QI) with equity-focused benchmarks. Upstream QI training should facilitate partnerships between health systems and community organizations to address patients’ health-related social needs, broader social drivers of health, and structural inequities (Gusoff et al. 2023; Webber et al. 2018). Dedicated time in the curricula of health professionals should be allocated for interdisciplinary students to critically reflect on institutional policies and practices and to engage in longitudinal projects addressing equity gaps in healthcare and social services. These projects require the support of hospital executives, administrators, faculty, and staff to succeed.

2.2. Academic Freedom and Interdisciplinary Discourse

Academic freedom and interdisciplinary dialog are necessary to the discourse surrounding SC. Currently, academic freedom is facing a crisis, with high levels of harassment, gag orders, censors, and firings for speech (Balch 2023). Recently highly publicized Immigrations and Customs Enforcement detentions of non-citizens for engaging in free speech illustrate the escalating level of attack on academic freedom (Fadel et al. 2025). For meaningful engagement around upstream structural contributors, which include the political determinants of health (Kickbusch 2015), medical education must commit to open dialog and a lack of censorship. Medical, institutional, and individual complicity in historical and present-day, national and global, structural racism, colonization, oppression, exploitation, and structural violence must be openly discussed and contended with. Faculties and students should be critical of narratives devoid of data, evidence, or power analysis. Collective political education is fundamental to changing structures that impact health, given the fundamental role of policies in shaping structures, and must, therefore, be an essential component of medical education (Mishori 2019).

Interdisciplinary education fosters collaboration across professions while emphasizing the impact of societal structures on health and the actions needed to address them (Recto et al. 2022). Institutional mechanisms must support joint appointments, co-location, shared funding, and the hiring of additional non-clinical staff in primary care clinics and hospital service lines. These include patient representatives, lawyers, community health workers, social workers, and case managers. A multidisciplinary approach requires faculty training and structured course times across multiple schools and departments to organize these experiences effectively. The ReThink Clinical Reasoning Conference exemplifies efforts to incorporate systemic considerations into clinical decision-making by inviting diverse perspectives, including patients, nurses, and case managers, to explore social justice, healthcare systems, and artificial intelligence in clinical reasoning (Monteiro et al. 2024). Collaboration with fields such as urban planners, policymakers, economists, sociologists, anthropologists, political scientists, climate scientists, and historians can allow for a richer understanding of the structural forces that impact health (Metzl and Roberts 2014; Balhara et al. 2022). Such team-based collaborative reasoning and information exchange can improve both diagnostic and management outcomes while promoting collective action toward health equity in spheres of influence beyond individual patients.

2.3. Redefining Medical Education Standards and Metrics

A structurally competent learning environment necessitates deep and systemic changes to how medical education is delivered in clinical and non-clinical settings across both the formal and hidden curricula. The process of re-articulating “culture” to “structure” involves shifting how we communicate about, conceptualize, and teach clinical care. To ensure faculties are helping to create an SC learning environment, faculty development in structural competency is essential. Faculty training must move beyond teaching implicit bias and cultural humility to explicitly incorporating structural drivers of health. Several faculty development programs on SC have been published that integrate ready-to-use teaching tools (Scott et al. 2025; Sotto-Santiago et al. 2022). Faculty training is key not only to the sustained transformation of clinical communication, curricula, and educational metrics but also to the development of a structurally competent learning environment as a whole.

The standard medical history and physical, considered the universal language of professional clinical communication, must become structurally competent. This transformation entails centering patients’ structural and social histories, contexts, and circumstances at the forefront of care, explicitly naming structural and social root causes on clinical problem lists and incorporating upstream factors in clinical assessments (Hassan and Bui 2022). Crucial to this is replacing clinical impressions that imply causative relationships between patients’ cultures or identities and their health behaviors or outcomes with ones rooted in the effects of relevant structural realities. The transformation of normative clinical communication from the articulation of health as a result of culture to the articulation of health as a result of structure is a mandatory prerequisite to institutional responsibility and accountability. Several efforts to transform expectations for clinical presentations have included the H&P 360 project (Williams et al. 2023), the structurally competent one-minute preceptor model (Scott et al. 2025), and the structurally competent “Summarize, Narrow, Analyze, Probe, Plan, Select” (SNAPPS) precepting model (Scott et al. 2025). Until these formats become universally recognized methods of clinical presentation, the integration of structural competency into everyday clinical care will be limited.

All formal medical school and graduate medical education curricular sessions should exhibit principles of SC through the explicit naming of structural root causes and the incorporation of at least one structurally competent learning goal (Scott et al. 2025). The longitudinal integration of SC into every teaching session, as opposed to relying on isolated, one-off teaching sessions, helps to embed SC into the fabric of medical educational and clinical care. In addition to traditional lectures, seminars, and problem-based learning sessions, case conferences (Scott et al. 2025), health equity rounds (Perdomo et al. 2019), and morbidity and mortality sessions (Ganguly et al. 2024) are ideal forums for structurally competent redesign. These sessions can serve to foster critical reflection on policies and practices that result in health inequities and contribute to patient health outcomes.

Beyond formal curricula, the hidden curriculum has also been shown to have a significant impact on learner training and development (Hafferty 1998). Key to the hidden curriculum is the spoken and unspoken expectations of faculty and staff. Learner and faculty educational assessments help to set expectations for performance and impact both the formal and hidden curriculum. All assessment surveys observe structural clinical exam assessments, and workplace-based assessments should incorporate an explicit evaluation of structural competency. Structural competency should also be a key component of summative feedback sessions given by faculties and program leadership.

2.4. Collective Action to Effect Change

SC necessitates not only the critical analysis of systemic inequities but also collective action (Butel and Braun 2019) to dismantle them. Collective action is traditionally defined as any action that aims to improve the status, power, or influence of an entire group (Beadle and Graham 2011). Collective action through grassroots organizing, strategic activism, legislative advocacy, and intentional partnerships with community leaders to drive systemic transformation is needed to actualize real change and disrupt existing power structures. Grassroots organizing is central to building structurally competent learning environments, as it fosters solidarity and mobilizes those most affected by inequities to lead change. Drawing from the legacy of Black, queer, and feminist scholarship, particularly the work of Audre Lorde (Lorde 1984) and the Combahee River Collective (1977) (The Combahee River Collective Statement 2015), collective action in medical education must prioritize the voices and experiences of marginalized communities. These scholars emphasize the fact that liberation is inextricably linked to addressing intersecting oppressions, making it imperative that medical institutions dismantle hierarchical structures that perpetuate harm. Partnerships with community leaders are crucial for sustained change. Scholars such as bell hooks (hooks 1994) advocate for an engaged pedagogy that dissolves the boundaries between academia and community, positioning lived experience as a vital form of knowledge. By co-creating curricula, designing research initiatives that center around community priorities, and implementing policies guided by those most affected by health inequities, medical institutions can foster transformative change. By embedding grassroots organizing, strategic activism, and community partnerships into medical education, structurally competent learning environments can actively dismantle oppressive systems and advance health justice through collective action.

Unionization efforts embody community-oriented grassroots organizing. Learners can challenge the status quo of large health systems to shift power and resources back to workers and the community (Leigh and Chakalov 2021). The process of unionizing requires fostering multidisciplinary longitudinal relationships with key stakeholders, including patients, local organizations, labor unions, and legislators, to identify and prioritize shared values and goals. Through contract negotiations, learners have a direct way to influence resource allocation in ways that are aligned with those values, beginning to shift power (Weiner 2022). Founded in 1957, the Committee for Interns and Residents (CIR) allocated funds to patient care improvement and community-proposed projects through its Patient Care Funds, including nutrition education, community walking tours, and refugee health clinics, which underscore upstream factors (Patient Care Funds n.d.).

There are several examples of meaningful education models of community-based collaboration that emphasize equitable partnerships and collective asset building, where community members lead initiatives and serve as educators (Hufford et al. 2009; Casapulla 2021). These efforts should not be limited to academic and community partnerships but should extend to community mobilization and policy advocacy. Systems and legislative advocacy should be the core curricular components, not elective or pilot programs. Support for advocacy educators to mentor trainees and model examples of how to move beyond the individual level of influence or focus is needed (Agrawal et al. 2023). Programs should consider outcome-oriented strategies that go beyond didactic teaching. Some health systems have successfully addressed upstream factors such as housing rehabilitation, park revitalization, and food access through structured upstream QI initiatives (Mercy Housing et al. 2018; The Connection Between Hospitals and Housing Properties 2020; Enterprise Community Partners 2019).

2.5. Community Integration and Accountability

A structurally competent learning environment extends beyond the clinic and hospital walls. Community engagement should not be an afterthought but an integral component of structurally competent education. Patients and community members experiencing the downstream effects of structures should be centered and part of dialogs themselves. Community members believe it is critical for clinicians and those in training to know the community and become familiar with the neighborhood characteristics, neighborhood history, structural barriers, and available resources (Lichtenstein et al. 2023). Home visits provide unique insights into social drivers of health, allowing discussions about housing quality, neighborhood safety, social support, and community resources (Hassan et al. 2023). Additionally, the faculty and trainees should have dedicated time to visit and engage with community-based organizations such as food banks, community centers, shelters, and after-school programs, providing opportunities for learning and partnership-building. Patients believe their involvement in the education of health professionals is critical, yet more work is needed. The incorporation of patient experiences is often only a one-time activity rather than a longitudinal initiative (Towle et al. 2010).

Consistent, sustained community engagement can help foster collective action to improve structures in ways that maintain structural humility when paired with community accountability and leadership. Community accountability ensures that medical institutions are principally invested in the health of the population they serve. Increasing institutions’ accountability to local communities has the potential to increase the alignment of their policies with local health outcomes and away from competing interests. True community-engaged andragogy is bidirectional and entails power-sharing and strength-based approaches (Khazanchi et al. 2021). It recognizes community member expertise and provides continuous opportunities for co-created educational and service delivery improvements. Faculty appointments should extend to community members who engage in these efforts, and more robust mechanisms are needed for the community regulation of educational and health resource allocation. Notable examples of this model in action are the community health centers established by Jack Geiger and colleagues, which combine community-oriented primary care, public health interventions, and community empowerment (Geiger 2005), as well as the health clinics and community health worker programs of the Black Panther Party (Morabia 2016).

3. Toward Structurally Competent Learning Environments

Learning health systems must integrate SC frameworks through evidence-based knowledge generation, data transparency, community engagement, and quality improvement. Equity should be a central focus, extending beyond healthcare institutions to include community partnerships and governmental entities. Faculties must be prepared to teach and engage trainees in community settings. Trainees, patients, and community leaders must actively participate in discussions on equity gaps and solutions, thereby deconstructing hierarchical power dynamics and fostering the co-production of innovative interventions (Parsons et al. 2021). The transformations needed to realize a structurally competent learning environment are deep, broad, and systemic and require forces for change both from within and outside academic institutions.

While SC has been discussed in the medical education curriculum—particularly in areas such as microaggressions, racism in medicine, trauma-informed care, social determinants of health, and advocacy—it remains imperative for trainees to recognize that expertise in health often resides outside academic medical centers and even beyond Western medicine. A structurally competent learning environment should encourage reflection, innovation, and leadership, empowering trainees to become agents of change in the pursuit of equitable healthcare delivery and improved health outcomes.