E.G. Castillo is a psychiatrist, Los Angeles County Department of Mental Health, and assistant professor, Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Center for Social Medicine and Humanities, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; ORCID: https://orcid.org/0000-0002-3807-1125.
J. Isom is a community psychiatrist, Codman Square Health Center, Dorchester, Massachusetts.
Acad Med. 2020 Dec;95(12):1817-1822. doi: 10.1097/ACM.0000000000003559.
Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.
健康不平等源于系统的、普遍存在的社会和结构性力量。这些力量使人们边缘化，并创造了使这些群体处于不利地位的环境，这反映在预期寿命和婴儿死亡率等结果的差异以及医疗保健资源获取和提供方面的不平等上。为了帮助消除这些不平等，医生必须了解种族主义、性别歧视、压迫、历史边缘化、权力、特权以及其他维持和造成不平等的社会政治和经济力量。需要一种新的教育模式，强调实现健康公平所需的知识、技能和态度。以系统为基础的实践是研究生医学教育的核心能力，侧重于复杂系统和医生在其中的角色；它包括多学科团队为基础的护理、患者安全、成本控制、临终目标和质量改进等主题。然而，这种能力主要是以医疗保健为中心的，并没有培训医生去应对健康的社会和结构性决定因素的复杂性，也没有与医疗保健之外的系统和社区合作。作者提出了一个以健康公平、社会责任和结构能力为中心的新核心能力，以解决研究生医学教育中的这一差距。为了发展这一新的能力，作者借鉴了现有的、创新的本科和研究生医学教学以及公共卫生、卫生服务研究和社会医学框架。他们描述了这一新的能力将如何为研究生医学教育和临床护理提供信息，并鼓励未来的医生参与健康公平工作。
