Welcome, everyone, to our session on competencies for trainees. My name is Auralit Padilla-Candelario, and I'm the program director for the residency program at the University of Massachusetts Medical School, and I'm also the director for diversity, equity, and inclusion for our department. I am delighted to be moderating this session today and introduce you to the amazing panel of speakers that we have. First, we'll start with Dr. Enrico Guanson-Castillo. Dr. Castillo is an assistant professor in the Center for Social Medicine in the Department of Psychiatry and Behavioral Sciences at the University of California, Los Angeles. Dr. Castillo's research focuses on health equity and health justice, serious mental illness, and community-public-academic partnerships. He is currently leading an NIMH-funded project on the jail-to-homelessness pipeline experienced by individuals with serious mental illness. He's also an associate director of residency education at UCLA and teaches about homelessness and structural competency. Next, we'll have Dr. Michelle Durham, and Dr. Durham is the vice chair of education in the Department of Psychiatry at Boston University School of Medicine, Boston Medical Center. She is a board-certified physician specializing in pediatric and adult psychiatry with additional board certification in addiction medicine. Her public health and clinical roles have always been in marginalized communities. She is dedicated to health equity and advocacy for equitable mental health treatment globally and locally. And lastly, we'll have Dr. Dwight Kemp, and Dr. Kemp is a psychiatry resident at the University of Alabama at Birmingham Medical Center, and is an American Psychiatric Association public psychiatry fellow. His clinical and scholarly pursuits focus on the service and empowerment of marginalized minority and underserved populations, including mental health policy, academic psychiatry, leadership development, and mental health equity. So today, we're going to be talking about the importance of revising and evaluating the expectations and competencies for trainees to incorporate social political issues in their training. So we'll get started with Dr. Castillo. Thank you so much for that kind introduction and for this invitation. It's really an honor for me to be a part of this panel with Drs. Padilla, Durham, and Kemp. I'm going to be talking today about structural competency, health equity, social responsibility, and medical education, the competencies that I believe trainees need for the future. So here are my disclosures. I don't have any conflicts of interest. And up front, I really want to acknowledge the leadership and the creativity of our residents who make this work possible. Okay, so at UCLA, I oversee the community and global psychiatry curriculum. And we use that curriculum here at UCLA to teach structural competency and health equity. So my remarks are going to touch on the content of these two articles that you see here, with the main idea being, these are the new competencies that we need to equip psychiatrists to eradicate health and social inequities. And so these articles were written together with a group of authors at UCLA, Yale, and Howard. So in our publication in academic medicine, the one that you see on the top, we talked a lot about the ACGME. So the ACGME is a body that governs residency and fellowship education. And I want to take a couple of slides, a few minutes to talk about the ACGME competencies, what they are, how they were created, and why. Why do they even exist? So in the 1990s, the ACGME, they wanted to systematize medical education. So they went through a process of literature reviews, stakeholder interviews, expert consensus meetings. And they ultimately created the six core competencies that we still have today. So you can see them here on the screen. They're patient care, medical knowledge, interpersonal communication skills, professionalism, practice-based learning and improvement, and systems-based practice. So these competencies, they focus on things that, at the time, they felt that all residents need to achieve during their training. And competencies, they're important because they're agenda-setting. They create medical education values and priorities. So if we've ever heard about the milestones, maybe we've struggled with them or struggled to implement them, they're based on these competencies. And if we think about audits and accreditation of our training programs, programs have to show how they're teaching to these competencies. So like any agenda, any priorities, these competencies have blind spots. And I think that they're worth examining. And that was the focus of that article. So I wanted to focus on systems-based practice a little bit. So systems-based practice is the core competency that focuses on complex systems and then physicians' roles within them. A lot of the other competencies are very focused on the individual trainee. So when they created systems-based practice, the goal was to move physicians away from this idea, this image that they had of the solo practitioner toward a professional identity as a leader of complex healthcare systems. And a quote from that time, when they were creating the competency, was that residents of the future will diagnose and treat systems as they do patients. And the thing I want to highlight here is that it's a problematic competency because it's highly healthcare-centric, and it invites questions that it doesn't answer. So I highlighted a couple of areas that you can see in red. So for example, the competency talks about working in healthcare systems and settings, but what are physicians' roles as systems actors outside of healthcare, you know, working alongside communities, for example. The competency, it also talks about advocating for quality patient care and optimal patient care systems. But what do we do as physicians if they're in conflict? You know, what if optimizing a system, for example, optimizing profits, harms patients? And then, you know, it also talks about considerations of value, cost awareness, delivery, and payment. But what if those considerations harm vulnerable populations and obstruct access to care? And then lastly, you know, for what purpose and in whose best interests are we acting? You know, for minoritized patients and communities or for healthcare systems. So speaking to how important competencies are in setting the agenda for American medical education, citizen-based practice has inspired curriculum development across the country. And so these are examples of published citizen-based practice curricula. You know, examples include training residents on how to reduce costs for hospitals, their curriculum on integrating hospital costs into M&M conferences. There's a curriculum that places residents to staff the front desks of clinics so that they can learn how to code and bill for maximum reimbursements. And then there's even a curriculum on how to create financial profits for healthcare systems. You know, that curriculum was called a win-win curriculum because residents would learn while hospitals would get richer, hence the win-win. So I want to go back to this slide. You know, our article begins with this sentence. It says that it is striking that among the six ACGME core competencies, the terms disparities, inequities, justice, community, underserved, vulnerable, and minority do not appear once. So you know, it makes you think, you know, who was in the room when these competencies were made and who wasn't? What are the values that we're taking in in medical education? How can we interrogate them? How can we reform them? And so, you know, I want to say this isn't the 90s, right? You know, we need new competencies now. We need new ways of thinking, new tools to train physicians to address the health and social inequities faced by our patients, faced by Black, Latinx, Indigenous, and other minoritized communities. So you know, thinking about what the new competencies are, you know, I think a lot about this slide when I'm thinking about psychiatric education, curriculum development. So this slide, it shows at a population level, so not an individual level, but at a population level, all the different things that contribute to variations in health and mortality. You know, so much of our education is focused, you know, the circle on the bottom is focused on healthcare, you know, and that makes sense if physicians are healthcare delivery workers. But I want to put forward that we're not, you know, physicians are healers. And so if we think of ourselves as healers, you can see all the different things that contribute to health that we're insufficiently trained in, you know, the physical environment, social determinants of health. And then on the right side, you know, that I circled, you know, you can see all the different structural determinants of health, racism, laws and policies, institutions, social context. And so what I'm trying, you know, what I'm all about is trying to answer the question, you know, how do we train physicians differently to end inequities, you know, what competencies do they need to break inertia, you know, to reimagine healthcare and to heal the structures and eradicate inequities. So in our article, you know, we write out what we think a new competency should be. And we go into it into much more detail. And we include a sample case show how healthcare, you know, could look different if people were trained with this competency, you know, but in a nutshell, our competency had three parts. The first part was structural competency, and it draws from the amazing work of Drs. Helena Hansen and Jonathan Metzl, which calls on us to understand the upstream structures, laws, institutions, racism, social norms that create inequities. The second part is structural action, you know, giving trainees the skills to reform policies and develop community partnerships. And then the last part is social responsibility, attitudes, you know, using reflective and change processes to think critically about ourselves, our biases, our everyday decisions. And I'm going to go through each of these three individually. Focusing first on structural competency, you know, when teaching residents about the social and the structural determinants of health, you know, I think it's so important not to teach that material in a theoretical way, but to ground it in local context, you know, local laws, history, challenges, strengths, culture, social movements, and at the end of their training, residents need to be well-versed in their local communities, you know, even if they end up moving away from that city or that town, it teaches them the importance of understanding their communities when practicing psychiatry, understanding that all different local things impact their patient's mental health. And to do this, you know, you can use current events like you see here on this slide. You can also draw on non-physicians as teachers. And so we at UCLA, we partner with a museum, with attorneys, with community organizers because of their wisdom about our local communities and also the issues that we face. It's also critical that trainees develop skills in structural action. So one skill is recognizing and reforming inequitable policies. You know, there are structures in every institution, system, program that need to change. And what we don't want is to train residents to simply go along with inequities. You know, by the time that they graduate, we want residents to have the tools and the hands-on experiences in shaking things up, right? Building coalitions, leading change efforts, having brave conversations, and rewriting policies. And so you can see an example here of our residents' leadership and health system policy work on this slide. And then also on the topic of structural action, it's important that we encourage and give trainees the opportunity to develop community partnerships and to work alongside non-physicians with humility. You know, there's this adage in psychiatric education that if you don't prescribe an MAOI in training, you never will. You know, and I want to say that the same thing goes with community partnerships, perhaps. You know, if we don't build residents' experiences in working with communities in their future careers, they may not think to reach out to that nonprofit that's next door to their clinic, or they may not have that confidence to reach out to that politician or to that community organizer to offer their medical expertise. So try to think about ways to build partnerships into everything that you do, you and your trainees do, clinical work, case conferences, didactics, community service presentations. Try to build in partnerships into that work. And then lastly, in our article, we focus on attitudes, you know, specifically building social responsibility as an important competency. And it's essential, I think, that we incorporate reflection and change processes into our training cultures so that we can teach residents how to reflect on ourselves, on our power, our privileges, our biases, and the ethics of our everyday decisions. You know, too many inequities in our systems, in our medical education, they go unchallenged because we don't even see them. You know, we don't have that space for critical reflection and change. And so I want to challenge us to build this into our daily rounds, for example, our feedback sessions, our case presentations. You know, as an example, you know, talking on rounds about a patient's social needs, you know, we can create a room for residents to share their reactions, our reactions, and also to process our moral injury as well. And so on this topic of reflection, I wanted to take a little bit of time to do this reflection with you all, and so you all in the audience, you know, as I'm reading these questions, I hope you'll take a second to reflect on your training programs, your clinics, your institutions, and how these may apply to you. The first question is, you know, whose voices and what topics are centered and whose are marginalized? In what ways do local context, community partners and social movements enter education? How does education challenge or even reinforce racism and structures that cause inequities? And who are the teachers, you know, any non physicians, how are they valued for their time and their expertise? So I wanted to end on this quote, the quote says, the lack of nonwhite professionals across the industry and persistence of racial health inequities for nonwhite patients reveal processes that empower and normalize, favor and reward white people as a population. This is evident in every health care setting. The solution requires reordering the industry to dissolve the dominant racial hierarchy and its manifestations in decision making structures, access points and resource flows that result in the violence of racial exclusion and the devastation of inequitable disease. This from Dr. Rhea Boyd, the case for desegregation in Lancet 2019. And so I want to end on this quote because it really speaks to me. You know, it talks about how racism can go unseen or uninterrogated because it's so prevalent. And she encourages us to examine racism in all the small facets of what we do in health care. And then to that, I'll add medical education as well. We need to reexamine every decision making structure, every access point, every resource flow. And, you know, to to wrap up, you know, this work is possible. It's a team sport. It's enlivening. I really love my job. And at UCLA, you know, we're not perfect, but I'm so excited about the ways that we're continuing to evolve in our education. So this is a photo of an advocacy event that we did on ending jail expansion in L.A. County. You know, and you can just see a lot of smiles. We have community partners, peers, agency leaders, different disciplines, just a whole community of us working toward system level change. And lastly, if you want to learn more about these topics, please take a screenshot of this. I hope you'll learn. You'll check out these articles. I've included names and article titles here. Thank you very much. Thank you so much, Dr. Castillo for that presentation, for really highlighting the gap, the existing gaps in our the way that we think about competencies in medical training, but also the opportunities to expand the field and ensure that the workforce can really take care of our vulnerable populations in the most holistic and comprehensive way. And now we're going to hear from Dr. Durham, a more concrete way of how programs, training programs, despite these gaps, can really mold their curriculum to make sure that they're including these topics in training residents to take care of our vulnerable populations. Dr. Durham. Thank you, Dr. Castillo and Dr. Padilla, Dr. Kemp, I'm happy and delighted to be a part of this discussion with you all today. I think Dr. Castillo really set up what I'm about to talk about in a really nice way. We he described a lot about what we don't see right now in medical education and some of the ACGME standards. And I'm going to take it in the next step that even though we don't have this embedded in sort of our core competencies now, how programs can start initiating and should be initiating particular topics around racial and health equity and psychiatric education. So I'm Michelle Durham, adult and child and adolescent psychiatrist at Boston Medical Center and the vice chair of education and a clinical associate professor at Boston University School of Medicine. I have no relevant financial disclosures. I do get funded through SAMHSA, HRSA and two private foundations here in the Boston area, as well as working for Boston University Medical Group. I wanted to highlight how the ACGME recognizes how increasing diversity in the physician workforce impacts health care access and patient outcomes. And they have said that this is a key part of the organization's mission to really think about how do we have a diverse and to build a safe, inclusive and equitable learning environment for physicians. And I'd like to take that a step further and think about it's not only needs to be equitable and safe for physicians, but also for the patients that we serve. We've talked a bit about we want to increase diversity in the physician workforce, but we do know, even if we think about psychiatry specifically, that about two percent of psychiatrists identify as black in the U.S. And so that means that we still have a long way to go to achieving that diversity and where it really reflects the patients that we serve in various parts of the U.S. The U.S., as many people have said, is the browning of a nation. And so there's much to be said about that. And we that means that all of our trainees in the physician workforce in general really needs to learn more about where our patients are coming from, understand their own biases and understand how to care for them for better patient outcomes. There's also great literature out there where we talk about, you know, access and utilization of mental health services in particular are negatively effective if ethnic and racial minority groups are not included in the care that they provide. Minority groups and these negative impacts are often associated with factors like socioeconomic and insurance status, stigma, cultural beliefs about mental illness that influence how patients are going to seek help. And so this lack of congordance, whether it be linguistically, culturally or racially, it really impacts how patients decide to receive care or if they're going to stay in care. And so it really is up to us that are teaching the next generation of psychiatrists to think about cultural aspects, think about race, think about the impacts of society. And as Dr. Cascio mentioned earlier, the politics and how we got here in the history is just so critical so that they do a good job whenever they're in that clinical encounter and thinking about all the things this person in front of them is coming into the room with. I want to take a minute to talk about Boston Medical Center specifically, why this was important to us years ago to start really changing our curriculum and what we did, what we do here in the residency. We are dedicated to producing leaders and community and academic psychiatry, really advocates for equity in mental health care and substance use treatment and thinking about innovative leaders in psychiatry. As mentioned earlier, who is not at the table? And most of the times our patients that we serve here at BMC are not at the table when decisions are made about their health. And so we do need physicians and advocates at every stage of the system to advocate on behalf of our patients. Typically, they're just excluded from some of these decisions. Our training sites really span the safety net hospital that is Boston Medical Center and also the VA and then federally qualified health centers. And so helping them understand how to provide high quality, comprehensive, culturally sensitive mental health care regardless of status or ability to pay is critical because all of their training sites, most people are on the state Medicaid or Medicare. They're not privately insured. They don't have the financial means to pay out of pocket. And last but not least, really committed to developing leaders in social justice and advocacy and as it relates to research and clinical care for our patients. We do know that the literature out there on many of the medications we use and how we treat folks is really centered around white people and not necessarily the people we serve here, which are traditionally immigrants, refugees, Black and Latinx. And so our research is they're actually very focused on who we serve and thinking about people who have comorbid conditions and also a lot of substance use issues as well. I won't belabor this particular point, but just thinking about so in doing all of that, we really have to aim of thinking about how do we think about psychotherapy and psychopharmacology from an ethnic, cultural, linguistic perspective because of the patients that we serve because of structural inequities. Many of our patients are also coming in with a lot of comorbid health conditions because of the communities that they're living in, segregation, not enough access, and so on. And so really thinking about how do they treat the whole patient, thinking critically, you know, and and having a lot around advocacy is so critical to our program as well. From day one, getting them involved in our state to state, local mass psych society to other public health programming in the city and really encouraging that. Modeling that as well in the leadership team as many of us get involved as faculty, we're seeing the trainees get more involved as well. Just wanna highlight that this is a lot of us involved from the leadership standpoint on developing this curriculum over the last few years and that it does, I think it takes a lot of folks and not just one person within the department that's leading DEI to really think about how do we move psychiatric education forward? And I just wanna highlight that particular aspect that it really does take a lot of different faculty members and different people at the table to do this work. Boston Medical Center, I think is unique because we are thinking a lot about public health initiatives. To Dr. Castillo's point earlier, we are healers and there is much more to this than just that clinical encounter and providing a medication. And so because of that, we have as a health system invested in housing in the communities where our patients serve. There's a rooftop garden, there's food pantries here in the hospital. The garden, it actually supplies the cafeteria and the food and also a demonstration kitchen where people can get access to understanding a little bit more of how to cook healthier foods. So going beyond the walls of that clinical encounter, going beyond thinking about just a medication, as we all know, health is much more than just taking a medicine. And so that's the critical mission of Boston Medical Center and what we do here. Why over the last few years we've changed our curriculum and are constantly changing it is because of this. 70% of our patients identify as black or Latinx, 30% do not speak English as their primary language and greater than 50% are at or below the federal poverty level. So we have to have trainees and residents that are understanding what people are coming into the health system with, that understand the other structural barriers at play and not just thinking about this, only this clinical encounter, what medicine do I have to give? But really trying to think holistically about patients. They learn a lot about all the programming that we have in the hospital. I know there's a lot on this slide, but it's really to that point of, again, that the medicine isn't the only thing. And we drive this message home from the beginning when folks come into the program, even when they are interviewing at our program, that there are a lot of different avenues for providing care for patients and why we have to have all this programming and not just relying on those clinical visits. But we are trying to address the social determinants of health with the multitude of programming that we have in the health system. So the year in PGY-1 starts out, even at orientation, really helping people understand the local context, where are folks coming from and actually doing community tours. These are some of the highlights on that particular tour. Many of our patients are homeless as well. And so we actually visit the shelters that most of our folks come from. They're all right in walking distance from the hospital. Pine Street Inn is dedicated to, it has a shelter for men and for women and for transgender folks. They have a lot of mental health programming and public programming. It helps the trainees understand what services are accessible there and what do patients get if they are living at Pine Street. The top right is Boston Healthcare for the Homeless. Again, another place where many of our patients are getting care. They actually do have an outpatient mental health clinic within Boston Healthcare for the Homeless system. But getting a tour and really understanding what services are there also helps them when they're coming into contact with folks, whether it be on the medical floor or in a psychiatric visit or in the psychiatric emergency room, where they can discharge folks and what services they could potentially get at these places. The bottom picture on the left is Rosie's Place, which is a women's shelter, also within walking distance of our hospital. And then an understanding of what neighborhoods our patients are coming from, because some of them at some point in training also rotate through our federally qualified health centers, so our community health centers, which are in the Roxbury and Dorchester areas of Boston. The circle around South End is exactly where BMC sits in these communities. All these surrounding communities are affected, unfortunately, by lots of poverty, very low income communities. And those are the majority, predominantly black folks, predominantly Latinx and or immigrant and refugees. So our curriculum goals, when we start thinking about what we're doing is really to increase awareness and understanding of factors shaping mental health inequities, to understand those structural and cultural factors that impact health outcomes, to develop an understanding of identity, its development and the role of the psychiatrist. We enhance and develop advocacy skills to improve systems of care for minoritized groups, thinking a lot about the cultural formulation and how to concretely use this approach with case presentations and case discussions, with the emphasis on cultural humility as well. And then last but not least, to reduce mental health inequities and biases by teaching specific skills and knowledge to effectively treat all minoritized groups. Teaching methods vary. I mentioned our community tour that we do in the beginning of the year. There's core didactics. We've made sure in grand rounds to also incorporate a lot around these various topical areas. I think right now I'm talking a lot about our trainees, but I do think we can't forget that there are some faculty and probably many of our organizations that don't understand a lot of this. And so our trainees are getting lots of great education, but we also want our faculty to understand this as well. People that may not have been thinking about this in their training or never got trained around thinking about all of these topics that are so important to who we're serving. I think it's also important that they're providing supervision for our residents. And so a lot of faculty development programming is thinking about that too. When you don't identify with your supervisee, how do you incorporate some of those concepts and reflect on that within even the supervision time? There's a lot of optional seminars, peer teaching. We do a lot of group discussion and case conferences and then obviously some selected readings. So I'm just gonna go briefly through some of the core topics across the four PGY years. So the first year is thinking about economic and health equity. This is very aligned with Dr. Castillo's work as well in thinking about the healthcare system, the systems and models of care delivery, but also incorporating the, how does structural inequities and racism and structural competency impact all of these systems that we learn so much about? Many of our patients are also coming from the Department of Mental Health or have disability services. We want our residents to understand what that means. What are some of the economics of this? They may get asked to write letters for patients at some point in time. So thinking about it from that policy framework and the financial framework as well. And thinking a lot about community-based work and starting to help them understand the different systems that people can get treatment. The PGY2 year, we do a lot around thinking about, they start outpatient. They start seeing, having their own continuity clinic in the second year. So it becomes really important to think about identity and doing a lot of self-reflection. What biases do you bring into that patient encounter yourself? They actually each present as a group. We have eight per year in our residency program about themselves, who they are, where they come from, how do they identify from many different aspects. And many folks have intersectioning identities, but really taking time and space to reflect on that as a group. There's coursework around racial identity development, thinking about racism as a social determinant of health. We talk a lot about white privilege, the racist patient, if there are racist encounters, thinking about that upstander and bystander. And then also incorporating spirituality and mental health because many of our patients do identify with thinking about a spiritual connection or religious connection, going to church, especially if our Latino and black patients here specifically identify a lot with that. And so how do we bring that into understanding folks where they're coming from, even if you yourself don't necessarily see yourself as a spiritual or religious person. Our third year, it incorporates a lot more about culturally responsive therapy in particular. We have a center for multicultural training in psychology here. So we do a lot of co-facilitation with that particular group with the psychology interns and psychology faculty. And it's very case-based. And so bringing in cases from their own continuity clinics, using a psychodynamic framework, but thinking through a multicultural lens. It's a really rich case discussion throughout their third year and different trainees present with different faculty as facilitators and moderators of this. Also psychodynamic is one form, but also there's CBT lectures, really thinking about racial trauma and discrimination and how to incorporate that into some of their sessions that they're, when they're actively seeing patients in their own continuity clinics in third year. Last but not least is the PGY-IV year and more journal clubs focused on selected articles around these various topics. We do have a global and local pathway. They can start the global and local pathway in the second or third year, but really honing in on the fourth year. And I think that that also is instrumental in the work we're doing. We do feel like the work we do globally impacts the work we do locally because of the many immigrant and refugees that we have here that we serve here at Boston Medical Center. It also gives them an opportunity to think about, get more didactics in what we've already given across the four years, because in both of these tracks, they have separate didactics monthly. The Achieving Cultural Confidence in Equitable Substance Use Services is an access pathway that's also focused on thinking about the comorbid mental health and substance use issues to specifically, again, in marginalized communities. And they actually get to rotate and spend a continuity clinic at a FQHC that predominantly serves black folks and people of color. And through this, they also get even more didactics, really focusing in on that particular patient population and thinking about it from a framework of what does it mean to use substances as a black person, as a Latinx person? How do we need to, how do services need to differ and center those folks? Because we do, which is probably a whole other topic of thinking about how addiction in general and substance use treatment has really centered around white people and not necessarily black people or other people of color. So that rounds out sort of our curriculum and how we've developed it and use some of what Dr. Castillo mentioned earlier that regardless of the ACGME, we do believe they need to change the way they look at the competencies. But we also, as leaders in psychiatric education, need to incorporate these topics early, often, and throughout the four years of training in order to have trainees and psychiatrists that are out in the field that can do this work better for the public. And do it better for the populations that we're serving. Thanks so much for your time today. And I'm gonna enjoy the questions and answer period when we have that. Thank you so much, Dr. Durham. I hope the audience is feeling as inspired as I am and in listening to all the wonderful things that you both are doing at your institutions. And I think the point of the impact that listening topics such as social justice, cultural humility, structural competency can have in education, but also ultimately in patient care has been very clear. And I'm excited to invite Dr. Kemp to talk now because he's gonna take us in a different direction where a very important one. And from the resident voice, we're gonna hear how listening and understanding structural competency can have an impact on the trainees in the way of making them feel empowered and also improve their wellness. So Dr. Kemp. Thank you, Dr. Padilla, Drs. Durham and Castillo. It's an honor to be with you. My name is Dwight Kemp and I'm a fourth year resident at the University of Alabama, Birmingham. And today I will be contributing to this conversation by discussing the benefits of structural competency from a trainee perspective and ways that structural competency can, as Dr. Padilla mentioned, empower us, but also be helpful in protecting against physician burnout and can serve as a tool to help address efforts to diversify the physician workforce. Medical students and residents expressed strong desire for medical and psychiatric curricula that incorporates structural analysis of health and healthcare as evidenced by recent advocacy efforts, publication and social media outcry, such as white coats for black lives. Qualitative studies on existing structural competency curricula implemented as described earlier in this presentation suggests that it's pedagogical approach and practical application may help alleviate and protect against trainee and physician burnout. Further, as the field of psychiatry strives to diversify the workforce to become more representative of U.S. demographics, structural competency curricula may serve as a recruitment tool to attract and retain young talent, including black, indigenous, and other people of color. As well as other minoritized underrepresented in medicine groups. Qualitative study of existing structural competency curricula suggests that structural action, the skills component of the curricula, may help protect against and alleviate physician burnout by teaching psychiatrists and trainees to respond to social and structural determinants inside and outside the clinic that lead to poor mental health outcomes. Those social and structural determinants collectively contribute more to mental health and wellbeing than the totality of health and mental health care services. Many physicians report lacking the skills and confidence to respond to and address these key determinants to health and mental health. Perceived failure and failure perceived failure to improve patient outcomes have been associated with professional burnout and departure from clinical practice. Structural action as a part of structural competency training helps positions develop the skills needed to improve mental health outcomes. Furthermore, it has been argued that collective action to address the structural roots of these issues afflicting patients and providers as structural competency encourages can help address burnout. In the American Academy of Medical College's Journal of Teaching and Learning Resources, Neth et al. publishes qualitative analysis of structural competency curricula. In that study, trainees reported that the curricula led them to reframe their thinking about patients away from blaming and other possible misconceptions. In the curriculum, participants found a section discussing implicit frameworks that naturalize an equity particularly useful. The training highlights how focusing primarily or exclusively on behavioral, cultural and genetic explanations for healthcare disparities can result in overlooking structural influences on health and thereby lead providers to inadvertently blame patients. Frequently misinterpreting non-adherence to treatment protocols and inability to pursue healthy lifestyle modifications to be willful moral choice of their patients rather than effects of social structural inequities. Which are causes of structural violence. Those study participants did not describe what they were moving towards. The shift in perspective away from blaming patients could plausibly promote empathy for structurally vulnerable patients. In the same study, some participating trainees spontaneously reported that structural competency training, quote, reconnected them to their original motivations to pursue healthcare careers. Provider empathy and a sense of meaning or purpose in one's work has been found to be inversely correlated with physician burnout. Further research is needed, but structural competency training could help reduce burnout by promoting provider empathy. Structural competency curricula provide trainees and other positions with shared vocabulary for identifying, describing, and discussing social and structural forces impacting patient's health, mental health, and healthcare. Such as structural violence and political, social, and economic forces that drive inequities. In preliminary analysis of structural competency curriculum, trainees reported that commonly understood concepts and terms learned from structural competency training lowers the barrier to having conversations about inequity and their impact on their patient's health. Some additional opportunities for structural competency training. Some additional opportunities for structural competency training. They include tools that may be used to attract, retain, and help integrate young talent from underrepresented in medicine minority groups to psychiatry. Minority underrepresented in medicine groups who may come from communities subject to structural violence and marginalization frequently self-select to work in underserved, poorly resourced areas where they feel that they can make a difference that remind them of the reason they chose medicine. These communities and clinical institutions frequently lack adequate infrastructure and struggle financially, which increases the risk of professional burnout. Structural competency curriculum trains physicians to develop responses to these and other structural forces from the interpersonal to the policy level. This solution oriented approach and training from structural competency curriculum may attract and help retain minority underrepresented in medicine groups who seek to improve mental health and promote wellness for underserved and vulnerable groups. Additionally, residency training is an emotionally and physically demanding period for all trainees. Black, Hispanic, and Native American trainees experience additional burden secondary to race and ethnicity. And as a result, are at greater risk of burnout, extended leave, and withdrawal from residency than their white counterparts. Shared vocabulary learned from structural competency curriculum operationalized to facilitate formal and informal dialogue about these inequities observed in and outside of the clinical setting may serve as a tool to help reduce isolation experienced by minority underrepresented in medicine group trainees and serve as a platform for innovative, for innovative and other interventions. I'd like to take this opportunity to thank you all for giving me the opportunity to speak with you today. I hope you enjoyed the answer question portion. Thank you. Thank you, Dr. Kemp for that presentation. I really appreciate you bringing the resident voice as I mentioned before and bringing that perspective which I don't think gets talked about enough. And it's important to think about the impact that not having the appropriate tools and understandings to navigate the social inequities that we see that our patients face and the issues related to social justice and racism that can have a great impact in our wellbeing and also our motivation and commitment to the field. So I really appreciate your perspective and I am really excited and inspired by all of our speakers today. I hope that the listeners are walking out of this presentation with some tools and some ideas to bring back to their workplace, their institutions to implement and see the possibilities. I look forward to the question and answer session and I hope that you have enjoyed this presentation. Thank you so much.

structural competency

medical education

psychiatric education

health equity

social responsibility

social determinants of health

advocacy

physician workforce