Accounting for agency in structural competency.

To emphasize to learners how factors outside individual control impact health, scholars introduced the concept of structural competency. Structural competency refers to the development of analytical skills that reveal the larger societal context beyond the patient-clinician interaction that shapes health outcomes. The growing adoption of structural competency curricula, however, has revealed that prelicensure and early career health professionals can feel overwhelmed by the mismatch between the wide scale of entrenched problems and the limited scope of their therapeutic skills. In this Reflections paper, I draw on theories from Giddens, Bourdieu, and Foucault to restore a role for individual agency in promoting health. Conceiving of structure and agency as mutually constituting suggests that structures are human-made and can be vulnerable to challenge. Structures, however, disperse power to such an extent that people internalize their rules and discipline themselves to follow them without explicit enforcement. It is precisely in those local sites of power that health professions learners and educators can intervene to interrupt the reproduction of structures harmful to health. As I demonstrate with an example from a reproductive health emergency, being structurally competent may also include contesting agreed upon norms at the level of the learning and clinical environments rather than only macro-level societal forces. Rewriting norms within health professions education and clinical practice is not necessarily a simpler task, but it provides learners and educators with more accessible targets for action.