LAUSR

Dear Editor, Shah et al. [1] have highlighted a lacuna of the current clinical education driven by competency-based medical education (CBME) and how the ‘hermeneutic window’ approach can provide a powerful exploration of the hidden curriculum as well as create new understanding. An essential process of this approach for clinical teachers would be to become cognisant of the influences of external mainstream systems whether they are medical or educational ones such as CBME. This might pose a challenge since some mainstream systems are so pervasive that their influences can be embedded in conventional clinical and educational practices and perceived as if they are right and neutral. On this point, structural competency, which is proposed in the context of approaches to stigma and inequalities, would provide an analytical lens to clarify what clinical supervisors have to learn. Structural competency is the trained ability to discern how a host of issues defined clinically as symptoms, attitudes or diseases also represent the downstream implications of a number of upstream decisions [2]. This framework illustrates what educational supervisors have to achieve in the use of the hermeneutic windows in two folds. First, clinical supervisors have to discern how their trainees’ clinical performance is shaped by a range of surrounding structural forces formed by upstream decisions. The framework suggests that such forces are generated not only by health care and other social systems but also by the terms and definitions describing illness and health [2]. This point is illustrated in the case by Shah et al. [1] in which the supervisor explored the influence of the healthcare system on the patient as well as the effect of the label of personality disorder on her trainee and the patient. Second, clinical teachers should be aware that their trainees’ learning behaviours (such as their selection of supervisory cases) are shaped by external forces including the current curricular assumptions. On this point, structural competency can be applied to educational settings as the trained ability to discern how a host of learning issues also represent the downstream implications of a number of upstream curricular decisions including educational delivery, assessment process and the very definitions of learning and outcome. This point is particularly important for the use of the hermeneutic window since it is intended to resist the dominant forces of CBME, the mainstream curricular system [1]. So, this dual awareness of the structure would be essential to achieve the effective use of the hermeneutic window. Some attempts to raise the structural competency are reported in various settings in medical education including postgraduate family medicine training [3,4]. So, it is potentially useful for educational specialists who design faculty development to apply some elements of these approaches. By doing so, structural competency will become a key for clinical supervisors to open up the hermeneutic window with their learners and help them create a new meaning to be prepared for the uncertainty and the complexity of general practice.