The medical education community is pushing back against a proposal by the nation’s primary accreditor of medical schools to backtrack on explicit requirements to teach structural competency—or how social, economic and political systems influence health outcomes.
If approved, no longer will medical schools have to explicitly teach students the basic principles of culturally and structurally competent health care or the importance of health-care disparities and health inequities.
“Ultimately, patients are the end users of medical education standards. When accreditation requirements are weakened, patients—especially those already facing barriers to care—bear the consequences,” reads an online petition urging the Liaison Committee on Medical Education (LCME) to reject the proposed changes it’s expected to consider adopting at a private meeting this week. “Strong standards help ensure that physicians are equipped not only to diagnose and treat disease, but also to understand the conditions that influence whether care is accessible, appropriate, and effective.”
Some medical education experts say that potentially changing the structural competency requirements now is a puzzling move by the LCME, given that it first adopted structural competency standards just a few years ago in an effort to enhance both physician training and patient care.
The proposal from the LCME—which sets the accreditation standards for medical schools in the United States and Canada—comes amid heightened state and federal scrutiny of diversity, equity and inclusion initiatives across higher education, including medical schools.
Last April, President Donald Trump—who has characterized accreditation reform as his “secret weapon”—issued an executive order calling on the Education Department to suspend or terminate an accreditor’s federal recognition if it violates federal civil rights law, including engaging “in unlawful discrimination in accreditation-related activity under the guise of ‘diversity, equity, and inclusion’ initiatives.” The order also directed the federal government to investigate both the LCME and the American Bar Association, which accredits law schools.
One month later, the LCME voted to stop evaluating diversity programs as a measure of a medical school’s quality. And in October, the accreditor released proposed changes to its curricular standards, including those on structural competencies, and said it would review public comment at the meeting slated for this week. If approved, the revised standard and elements would take effect during the 2027–28 academic year.
But those potential changes are a dramatic departure from the LCME’s priorities of the recent past.
“It was considered a victory a couple of years ago. The fact that the LCME is turning [back on it] seems very aggressive,” said Jonathan M. Metzl, a psychiatrist and chair of medicine, health and society department at Vanderbilt University, who helped develop the idea of structural competency. If it is in response to DEI crackdowns, “the irony is that [structural competency] is not DEI or based on identity politics at all. There are social pathogens that doctors need to know about.”
What Is Structural Competency?
Momentum for training doctors to recognize those social pathogens—such as housing instability—has been building over the past decade.
“Before structural competency, clinicians were trained through a cultural competency framework to recognize individual bias in the exam room,” Metzl said. “While that’s really important, research shows that biases of clinicians don’t correlate directly with health outcomes.”
Instead, “upstream factors”—such as a patient’s ability to access healthy food or emergency medical care—“are much more likely to be correlated with health outcomes,” he said. “That was a huge blind spot in medical education.”
In 2014, Metzl co-authored a paper advocating for the adoption of structural competency in medical school curricula, sparking widespread interest in the new framework. After years of discussion, LCME adopted a structural competency standard that went into effect in 2023.
It requires medical school faculty to ensure that students “learn to recognize and appropriately address biases in themselves, in others, and in the health care delivery process.” To make that happen, the standard specifies that the curriculum must include content that address the following issues:
- The diverse manner in which people perceive health and illness and respond to various symptoms, diseases and treatments;
- The basic principles of culturally and structurally competent health care;
- The importance of health-care disparities and health inequities
- The impact of disparities in health care on all populations and approaches to reduce health-care inequities;
- The knowledge, skills and core professional attributes needed to provide effective care in a multidimensional and diverse society.
But the proposed changes to the standard eliminate much of that specific language.
Instead, they offer more vague directives for medical students “to exhibit professionalism and ethical behavior in caring for patients from a variety of backgrounds” and for the curriculum to include “instruction and experiential learning in the social and structural determinants of health, the structure and functioning of health care delivery systems, and the resources within and beyond the health care system needed to optimize patient, community, and population health outcomes.”
That language doesn’t go far enough, according to the Coalition for Structural Competency in Medical Education, the group that created the online petition opposing the changes.
“While inclusivity is essential, broad statements without clear expectations do not ensure that students gain the skills needed to recognize bias, address inequities, or respond to the structural barriers their patients face,” reads the petition, which had been signed by almost 700 medical educators, students, physicians, public health professionals, social scientists and community members as of Tuesday evening. “Without specificity or accountability, important competencies risk becoming optional rather than essential.”
And beyond the implications for patients, medical education experts are also troubled by the LCME’s willingness to backtrack on a standard it embraced so recently.
“The rapid change in response to some sort of external input raises the most alarm,” said Ariana Thompson-Lastad, an assistant professor at the University of California, San Francisco, School of Medicine and co-leader of the Structural Competency Working Group. “If [LCME] knew that this was what medical students needed to learn two or three years ago, and if medical education is meant to be objective and clinically relevant, why do medical students need to learn something different three years later?”
