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Teaching Culturally Appropriate Care: A Review of Educational Models and Methods
Abstract
The disparities in health care and health outcomes between the majority population and cultural and racial minorities in the United States are a problem that likely is influenced by the lack of culturally competent care. Emergency medicine and other primary-care specialties remain on the front lines of this struggle because of the nature of their open-door practice. To provide culturally appropriate care, health care providers must recognize the factors impeding cultural awareness, seek to understand the biases and traditions in medical education potentially fueling this phenomenon, and create a health care community that is open to individuals' otherness, thus leading to better communication of ideas and information between patients and their health care providers. This article highlights the rationale for and current problems in teaching cultural competency and examines several different models implemented to teach and promote cultural competency along the continuum of emergency medicine learners. However, the literature addressing the true efficacy of such programs in leading to long-lasting change and improvement in minority patients' clinical outcomes remains insufficient.
... There is wide recognition of the need to graduate emerging healthcare practitioners who possess highly specialized disciplinary knowledge and are also empathetic, effective communicators who can work within a DEIJ framework to address health disparities [13,[63][64][65][66][67][68]. However, there is not yet strong consensus on the most effective ways to accomplish these outcomes. ...
... While this analysis also suggested that immersive experiences, such as community-based education and clinical rotations, may be highly impactful [75], other studies have found that clinical experiences alone may not prepare students to provide culturally proficient care or shift beliefs and attitudes [69,71,72,76]. The latter may be particularly true if trainees witness behaviors from formal or informal educators (e.g., faculty, attendings, residents, etc.) that do not model CP or do not emphasize its value in healthcare [45,63]. Results from the present study indicated that while many students understood the importance of CP to both clinical and educational practices (at rates similar to those seen in others throughout healthcare [73,77,78]), many respondents estimated that they observed CP modeled strongly in the clinic or classroom by peers, faculty, and staff once a week on average. ...
... This rate may have important implications for how students integrate information across their learning experiences. For example, students may encounter messaging from instructors about how important CP is (or come into the training with this understanding), but if they don't observe their mentors frequently applying those skills in professional practice, these two inputs may conflict with one another [45,63,74,79]. ...
Background
Health disparities are often a function of systemic discrimination and healthcare providers’ biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP.
Methods
Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students’ implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions.
Results
The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students’ perception of the training varied substantially (e.g., training range = 1–100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes.
Conclusions
These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.
... One of these strategies is the role modeling of the " how-to " of an integrated approach to taking a health history and performing a physical exam that is responsive to a diverse clientele and provider population. Since the 1970s, numerous scholars have called for and supported the reduction of health disparities through education and increasing the multicultural representation of health care providers (Anderson, Calvillo, & Fongwa 2007; Department of Health and Mental Hygiene, Office of Minority Health and Health Disparities, 2007; Hobgood et al., 2006; Petrucka et al., 2007). By 2020, approximately 25% of the total population in the United States and Canada will consist of visible minority groups (Altshuler & Kachur, 2001; Statistics Canada, 2013). ...
... By 2020, approximately 25% of the total population in the United States and Canada will consist of visible minority groups (Altshuler & Kachur, 2001; Statistics Canada, 2013). There are several ways to teach health and physical assessment within a cultural context, including lectures, literature, small-group discussion, immersion, role-playing, storytelling, case scenarios, skills laboratories, simulations, and AV media (Eshleman & Davidhizar, 2006; Hobgood et al., 2006; Rapp, 2006; Woolley & Jarvis, 2006). Nursing education uses the basic elements of simulations, skills laboratories, immersion, and AV materials in a safe learning environment to prepare students for a complex health care setting. ...
... We live in an era of distance learning and online education, and health care professionals have turned to AV materials to educate the next generation of health care providers in this new teaching mode. The development of curricula and teaching tools to accommodate students learning online varies widely as educators grapple with this new learning environment and search for resources to enhance the excellence of distance learning (Anderson et al., 2007; Hobgood et al., 2006). Health and physical assessment AV materials can be accessed through library resources and/or a web-based format to teach assessment skills in various geographic locations . ...
Currently used audiovisual (AV) teaching tools to teach health and physical assessment reflect a Eurocentric bias using the biomedical model. The purpose of our study was to (a) identify commonly used AV teaching tools of Canadian schools of nursing and (b) evaluate the identified tools. A two-part descriptive quantitative method design was used. First, we surveyed schools of nursing across Canada. Second, the identified AV teaching tools were evaluated for content and modeling of cultural competence. The majority of the schools (67%) used publisher-produced videos associated with a physical assessment textbook. Major findings included minimal demonstration of negotiation with a client around cultural aspects of the interview including the need for an interpreter, modesty, and inclusion of support persons. Identification of culturally specific examples given during the videos was superficial and did not provide students with a comprehensive understanding of necessary culturally competent skills.
... In a systematic review examining the effectiveness of cultural competence (CC) curricula13, Beach and colleagues found 52 studies addressing impact on provider competencies but only 3 addressing patient outcomes; they concluded that evidence that CC training improves patient adherence and health care equity was lacking. CC training reviews have focused on the effect of training on learners’ acquisition of skills, knowledge and attitudes13, and the rigor of the methods and assessments of curricular dissemination and replication10,14,15. Two reviews addressed training effect on health care systems and mental health services16,17; both concluded that the evidence for effectiveness of training on service delivery and health status was limited. ...
... There is an implicit understanding that providing culturally effective care will lead to improved quality of care1,8–11. But there remains a need for evidence that links carefully developed curricula with patient-centered and clinical outcomes6,10–12. ...
... Subsequent bibliographic review of these and the previously conducted reviews10,12–17 yielded another 5 articles for a total of 17 articles representing 17 different studies. Of the 17 articles that underwent full-text review, 10 were excluded from further quality assessment because of (1) having no curricular intervention (n = 5), (2) having no patient or health care utilization outcomes (n = 4), and (3) being interim reports with results pending (n = 2), leaving 7 studies in the final quality analysis16,29–34. Among the seven studies, quality rating discrepancies occurred in two studies using STROBE and two using MERSQI, with final rating achieved by adjudication involving secondary reviewers. ...
Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities.
The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research.
The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included.
Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted.
Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect.
There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.
... 5,6 Since then, several authors have addressed cultural competency and disparities as they relate to graduate medical education and the delivery of health care. 7,8 The Diversity Interest Group (DIG) of the Society for Academic Emergency Medicine (SAEM) continues to explore a variety of issues related to health care disparities and to promote its cultural competency monograph. 9 The American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and SAEM have all developed position statements on matters of diversity. ...
... A recent article by Hobgood et al. 8 provides an extensive review of various educational models and methods to teach culturally appropriate care. The review provides several educational methods that may be used to teach cultural competency such as portfolios, cultural immersion, simulation, and didactics. ...
ACADEMIC EMERGENCY MEDICINE 2011; 18:S104–S109 © 2011 by the Society for Academic Emergency Medicine
Abstract
An emergency medicine (EM)‐based curriculum on diversity, inclusion, and cultural competency can also serve as a mechanism to introduce topics on health care disparities. Although the objectives of such curricula and the potential benefits to EM trainees are apparent, there are relatively few resources available for EM program directors to use to develop these specialized curricula. The object of this article is to 1) broadly discuss the current state of curricula of diversity, inclusion, and cultural competency in EM training programs; 2) identify tools and disseminate strategies to embed issues of disparities in health care in the creation of the curriculum; and 3) provide resources for program directors to develop their own curricula. A group of EM program directors with an interest in cultural competency distributed a preworkshop survey through the Council of Emergency Medicine Residency Directors (CORD) e‐mail list to EM program directors to assess the current state of diversity and cultural competency training in EM programs. Approximately 50 members attended a workshop during the 2011 CORD Academic Assembly as part of the Best Practices track, where the results of the survey were disseminated and discussed. In addition to the objectives listed above, the presenters reviewed the literature regarding the rationale for a cultural competency curriculum and its relationship to addressing health care disparities, the relationship to unconscious physician bias, and the Tool for Assessing Cultural Competence Training (TACCT) model for curriculum development.
... Clark, Zuk, & Baramee (2000) argue that Fadiman's life writing is a beautifully written compelling story that is well-suited for pedagogical purposes as it can enrich teaching and sensitize students to cultural issues in healthcare. Similarly, Hobgood et al. (2006) commend it for bringing to light the existing racial biases and prejudices in medical education and practices. ...
... Lack of time during the busy residency training schedule, lack of faculty role models, and lack of formal cultural competency evaluation were identified as barriers to implementing cross-cultural curricula and patient care approaches. 13,17 Healthcare providers' lack of cultural diversity awareness and skills might be an important contributing factor to the healthcare disparities existing in the U.S.2 Few studies have demonstrated successful results of teaching culturally effective patient care through specially-tailored curricula18-20 or using standardized patients. 21 The challenge is to develop training curricula in cultural sensitivity for students, residents and attending physicians while providing appropriate culturally sensitive care at each patient encounter. ...
Teaching cultural sensitivity to healthcare professionals is critical in providing appropriate care todiverse patient populations. Constantly increasing U.S. immigrant population and growing numbers ofinternational medical graduates practicing in the U.S. bring the issue of appropriate cross-culturaltraining to the forefront of addressing health disparities.Cultural competence training of healthcare professionals and provision of culturally sensitive patientcare is the responsibility of healthcare leadership.1 Acquiring awareness and knowledge about culturaldifferences requires focused development of skills to communicate with patients from diverse cultures;this is a process developed through professional training and experience.2 Few professionalcontinuous education programs have been offered to prepare mentors and role models in the field ofhealthcare to ensure culturally sensitive approach in patient service.
... The analysis of the literature on the research problem shows that its various aspects are reflected in the scientific works of a number of researchers. In modern educational theory and practice, the scientific background for a comprehensive study of the individual's aesthetic competence obviously is the research in the field of: philosophy (Johnson, 2019, Marini, 2006 and psychology (Murno, 1996;Scrutton, 1996), ethnography (Mytre, 2012, anthropology (Ochs 2012); professional training (Hobgood et al., 2006;Knipper, 2013;Vasiagina, 2019). ...
The article is devoted to the experimental testing of aesthetic competence of future philologists by means of ethnology. The principles (national character, humanization, ethnicization, cultural conformity, integration) are considered and stages of model implementation (orientative, training, creative) are elaborated and characterized. Structural and functional components, criteria and indicators of the levels of forming the future philologists' aesthetic competence are defined. The characteristic of levels of aesthetic competence development in philology students (reproductive, constructive, creative) is given. The characteristics of the levels with the help of the coefficient of tasks completeness related to knowledge, skills and abilities for aesthetic competence development of the philology students by means of ethnology were determined. The paper concludes by calling attention to the enhancement of the educational process forms and methods in order to develop the aesthetic competence of future philologists by means of ethnology, urging to instill the aesthetic competences more purposefully and integrally throughout the Bachelor program.
... Many scholars [17][18][19][20] stress upon improving communication between health professionals and patients in order to achieve high-quality healthcare. In these studies, a structured training on communication skills has been advocated as an integral component of undergraduate, postgraduate, and continuing professional development of healthcare, providers to prevent communication-related issues. ...
Communication is defined as a two-way process involving speech, writing or non-verbal means that aim to create shared interpretation for those involved [1]. Effective communication between health professionals and patients is the key ingredient to a safe, and quality healthcare system [2]. It is also responsible for building a satisfactory and conducive relationship between all stakeholders of the healthcare system. Between doctor and patient, it helps in building rapport, improving patient satisfaction, coping with prescriptions, and ensuring desired positive outcomes. On the other hand, effective communication between health professionals (doctors, undergraduate and post-graduate trainees, nurses, auxiliary medical staff) helps in building safe, trustworthy, supportive, and professional working environment [3].
... Two meta-analyses identified shortcomings in study methodology, such as the lack of randomized controlled designs (only two of 64 identified studies used Randomized Controlled Trial [RCT] methodology) and a large variety in assessment methods (Beach et al., 2004(Beach et al., , 2005. This lack of emergency medicine-specific cultural training, coupled with the increasing worldwide diversity of patient population, mandates that educational systems be established to train and facilitate cultural-competence among health providers (Ezenkwele, & Roodsari, 2013;Hobgood, Sawning, Bowen, & Savage, 2006). ...
Aims:
The current study is aimed at developing a culturally-informed education program to increase cultural competence in emergencies among health care students and to examine its effectiveness using a randomized controlled trial.
Design:
This is a mixed-methods study, which comprises two phases: (1) Development of educational intervention to increase cultural competence, based on a review of published scientific literature and primary data collection from qualitative semi-structured interviews with key informants; (2) Implementation and assessment of the intervention effectiveness in increasing cultural competence in health students, using a randomized controlled trial.
Methods:
The qualitative phase will include semi-structured interviews with ten key informants. Data will be analyzed using Interpretative Phenomenological Analysis. The assessment of intervention efficacy will be examined by a randomized controlled trial. This phase will include a total of 200 undergraduate health profession students who will be randomized (1:1 ratio) to intervention or non-intervention group. Both study groups will complete pre and post-intervention questionnaires assessing three principles of cultural competence: attitudes, knowledge and skills. The study is supported by two-year funding, beginning in September 2018.
Discussion:
Although the importance of culturally-sensitive health services has long been recognized, there is a lack of cultural competence training in the medical education system, especially in the context of emergencies. Incorporating cultural competence education into the curricula offers an appealing strategy to enhance systematic understanding of cultural diversity at the early stages of professional training.
Impact:
The development of cultural competence training and curricula focusing on situations that may arise during emergencies may play a significant role in minimizing cultural dissonance, improve patient-provider communication and produce better clinical outcomes.
... 7-10 Medical training must guide efforts to reduce both bias and health care disparities through approaches that are sensitive to health beliefs and behaviors, epidemiology, and treatment efficacy in different population groups. 11,12 While incorporation of sex and gender medicine into EM simulation education programs has been recommended, 13 this study is the first to implement a defined curriculum into EM residency programs from a toolkit designed by the SGEM Interest Group of SAEM. ...
Background:
Emergency medicine (EM) residents do not generally receive sex- and gender-specific education. There will be increasing attention to this gap as undergraduate medical education integrates it within their curriculum.
Methodology:
Members of the Sex and Gender in Emergency Medicine (SGEM) Interest Group set out to develop a SGEM toolkit and pilot integrating developed components at multiple residency sites. The curriculum initiative involved a pre- and posttraining assessment that included basic demographics and queries regarding previous training in sex-/gender-based medicine (SGBM). It was administered to PGY-1 to -4 residents who participated in a 3-hour training session that included one small group case-based discussion, two oral board cases, and one simulation and group debriefing.
Analysis:
Components of the developed toolkit (https://www.sexandgenderhealth.org) were implemented at four unique SGEM Interest Group member residency programs. Residents (n = 82/174, 47%) participated; 64% (n = 49) were male and 36% (n = 28) were female. Twenty-six percent (n = 21) of the residents reported that they had less than 1 hour of training in this domain during residency; 59% (n = 48) reported they had 1 to 6 hours and 16% (n = 13) reported they had >6 hours. The average preassessment score was 61% and postassessment was 88%. After training, 74% (n = 60) felt that their current practice would have benefited from further training in sex-/gender-based topics in medicine during medical school and 83% (n = 67) felt their clinical practice would have benefited from further training in this domain during residency.
Implications:
The majority of EM residents who participated in this training program reported that they had limited instruction in this domain in medical school or residency. This initiative demonstrated a method that can be emulated for the incorporation of SGBM educational components into an EM residency training educational day. After training, the majority of residents who participated felt that their current practice would have benefited from further training in sex- and gender-based topics in residency.
... Non-White pracademics should share in the classroom their real-world experiences with biases and stereotyping within their own clinical encounters. Areas of unequal and mistreatment of patients can potentially be avoided by educating and training the members of the healthcare team (Hobgood, Sawning, Bowen, & Savage, 2006;Smedley, Stith, & Nelson, 2003). Diversity engagement involves helping people understand the impact that they have on one another (Shelton, 2011). ...
Diversity is the new majority in the United States. Its definition has meaning beyond race and ethnicity. The comprehensive context of diversity requires healthcare administration faculty to foster a culturally competent environment in the classroom and throughout the academic program. Healthcare administration faculty should deploy diverse and inclusive pedagogy so that healthcare administration students learn to navigate our diverse society and the global economy. Such a workplace skill is invaluable to program graduates. Healthcare administration faculty should practice cultural competence in the classroom. Cultural humility, the lifelong practice to cultural competency, means to address one's own cultural blind spots. We review the long-term practical benefits received within a California postsecondary institution when students are immersed in a healthcare administration curriculum that is diverse and inclusive in preparation for the healthcare workplace. We examine these benefits through three distinct yet combined perspectives by interviewing an academic (i.e., a healthcare administration professor); a pracademic (i.e., a clinical practitioner who is also a healthcare administration professor); and an executive (i.e., a former C-Suite member of a multispecialty medical group). Lastly, we propose a practice to guide healthcare administration faculty to take the first steps toward developing cultural humility.
... If we hope to move forward, "[a]ccreditation standards need to be more precisely defined" (Quist & Law, 2006, p. 425), and they must consist of evidence-based recommendations, assessments, and improvement feedback (Hobgood, Sawning, Bowen, & Savage, 2006). ...
This phenomenological study describes the experiences of primary care physicians trained in the United States who participated in an international clinical immersion rotation during medical school or residency. Five central themes emerge relating to their experience: (a) Participants chose the international rotation for developmental purposes. (b) The lifestyle in their destination country was different than in the U.S., and this had an impact on participants. (c) There were positive outcomes for participants and their future practice. (d) Harmful external forces (at the rotation site) shortened patients’ lifespans and had a negative impact on their quality of life. And, (e) participants wonder whether they have chosen the right profession. The process of participating in the immersion experience helped participants grow, think, and feel in new ways, both professionally and personally. They developed observational skills by living in the same environment as their patients. They learned resourcefulness as they solved practical problems with no one to support them. They became more confident through their daily work and by being considered “the doctor.” They learned to adapt to the ways of people and cultures that “slow down” and live at a different pace compared to people in the U.S. One particularly significant observation is that they described changes and awareness consistent with growth in cultural competence, even though this was not their primary intention. The essence of the immersion experience is a constellation of developmental growth areas for primary care physicians who participated, but evidence of possible cultural competence development is at the forefront. Adviser: Gina S. Matkin
... Similarly, the Accreditation Council for Graduate Medical Education outlined comprehensive cultural competency elements in the areas of patient care, professionalism, and interpersonal and communication skills (7). These standards make clear that cultural competence education must be integrated into training programs at every learner level (8). With these competencies, healthcare providers can cross the barriers of cultural differences, communicate successfully with patients, and achieve the goal of holistic care (9Á11). ...
Purpose
To use mini-ethnographies narrating patient illness to improve the cultural competence of the medical students.
Methods
Between September 2013 and June 2015, all sixth-year medical students doing their internship at a medical center in eastern Taiwan were trained to write mini-ethnographies for one of the patients in their care. The mini-ethnographies were analyzed by authors with focus on the various aspects of cultural sensitivity and a holistic care approach.
Results
Ninety-one students handed in mini-ethnographies, of whom 56 were male (61.5%) and 35 were female (38.5%). From the mini-ethnographies, three core aspects were derived: 1) the explanatory models and perceptions of illness, 2) culture and health care, and 3) society, resources, and health care. Based on the qualities of each aspect, nine secondary nodes were classified: expectations and attitude about illness/treatment, perceptions about their own prognosis in particular, knowledge and feelings regarding illness, cause of illness, choice of treatment method (including traditional medical treatments), prejudice and discrimination, influences of traditional culture and language, social support and resources, and inequality in health care.
Conclusions
Mini-ethnography is an effective teaching method that can help students to develop cultural competence. It also serves as an effective instrument to assess the cultural competence of medical students.
... These beliefs range broadly from disease causation, interpretation of symptoms, and appropriate treatment and prevention, to values attached to medical interventions and physical examination (4,5). It has been concluded that cultural competency should be a part of the training of Emergency Medicine professionals (1,6,9). Some studies have reported health care providers' belief that ''treating patients equally, regardless of their ethnicity and culture'' is sufficient (10). ...
Cultural competency is important for delivering quality health care, particularly for cultural and religious minorities, and can reduce discrimination and health disparities. Muslim Americans represent diverse ethnic groups yet bound together by a religious identity with common values. This community is generally under-researched and not well understood, and thus receives the less than optimal level of health care that results when providers are not culturally attuned. Accordingly, this chapter reviews the salient religious values, beliefs, and cultural tendencies that impact health care behaviors among this population, and provides guidance regarding cultural accommodations that can promote the delivery of culturally sensitive health care to this community.
... Move on to a discussion by the course director (H. M. Shields) on disparities in healthcare that are relevant to GI, liver, and biliary organ systems and their diseases (10 min) (10,18,30). ...
A specific faculty development program for tutors to teach cross-cultural care in a preclinical gastrointestinal pathophysiology course with weekly longitudinal followup sessions was designed in 2007 and conducted in the same manner over a 6-yr period. Anonymous student evaluations of how "frequently" the course and the tutor were actively teaching cross-cultural care were performed. The statements "This tutor actively teaches culturally competent care" and "Issues of culture and ethnicity were addressed" were significantly improved over baseline 2004 data. These increases were sustained over the 6-yr period. A tutor's overall rating as a teacher was moderately correlated with his/her "frequently" actively teaching cross-cultural care (r = 0.385, P < 0. 001). Course evaluation scores were excellent and put the course into the group of preclinical courses with the top ratings. Students in the Race in Curriculum Group asked that the program be expanded to other preclinical courses. In conclusion, from 2007 to 2012, a faculty development program for teaching cross-cultural care consistently increased the discussion of cross-cultural care in the tutorial and course over each year beginning with 2007 compared with the baseline year of 2004. Our data suggest that cross-cultural care can be effectively integrated into pathophysiology tutorials and helps improve students' satisfaction and tutors' ratings. Teaching cross-cultural care in a pathophysiology tutorial did not detract from the course's overall evaluations, which remained in the top group over the 6-yr period.
Copyright © 2015 The American Physiological Society.
... The main reasons for exclusion were: articles were commentary or opinion pieces, articles were of primary studies, review articles examined cultural competency assessment tools and review articles but did not include any studies with interventions. Six review articles were excluded for not providing information on search strategy and details of included studies [26][27][28][29][30][31]. ...
Cultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.
A systematic review of review articles published between January 2000 and June 2012 was conducted. Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites were searched. Reviews of cultural competency in health settings only were included. Each review was critically appraised by two authors using a study appraisal tool and were given a quality assessment rating of weak, moderate or strong.
Nineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included a variety of health care settings/contexts and a range of study types. There were three main categories of study outcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.
This review of reviews indicates that there is some evidence that interventions to improve cultural competency can improve patient/client health outcomes. However, a lack of methodological rigor is common amongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future research should measure both healthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorous study designs.
... A lack of or minimal cultural diversity education and minimal experience with different ethnic groups may keep the self-efficacy levels at moderate. Furthermore, healthcare professionals may believe that clinical skills are more of a priority to teach and learn, over the importance of understanding cultural diversity (Hobgood, Sawning, Bowen, & Savage, 2006;Kulwicki & Bolonik, 1996). ...
... The curricula were flexible and were evaluated by direct observation or OSCE (objective structured clinical examination) experiences. 19 A study by Symington and Cooper described that there were key components of curricula from PA programs. These included teaching culturally appropriate history taking skills, using problem-based learning, clinical experiences with self reflection, a curriculum that begins early in the didactic year and understanding that evaluation of patients individually was necessary. ...
... The study of the humanities -literature, creative writing, history, philosophy, visual arts, and anthropology -has emerged in medical training as a means of conveying skill in the interpretive, relational, and reflective areas otherwise hard to teach. Numerous innovative programs have been described in the past two decades [14][15][16][17][35][36][37][38][39][40][41]. Included among the teaching methods to emerge is the field of narrative medicine. ...
Objective:
This study sought to explore the perceived influence of narrative medicine training on clinical skill development of fourth-year medical students, focusing on competencies mandated by ACGME and the RCPSC in areas of communication, collaboration, and professionalism.
Methods:
Using grounded-theory, three methods of data collection were used to query twelve medical students participating in a one-month narrative medicine elective regarding the process of training and the influence on clinical skills. Iterative thematic analysis and data triangulation occurred.
Results:
Response rate was 91% (survey), 50% (focus group) and 25% (follow-up). Five major findings emerged. Students perceive that they: develop and improve specific communication skills; enhance their capacity to collaborate, empathize, and be patient-centered; develop personally and professionally through reflection. They report that the pedagogical approach used in narrative training is critical to its dividends but misunderstood and perceived as counter-culture. CONCLUSION/PRACTICE IMPLICATIONS: Participating medical students reported that they perceived narrative medicine to be an important, effective, but counter-culture means of enhancing communication, collaboration, and professional development. The authors contend that these skills are integral to medical practice, consistent with core competencies mandated by the ACGME/RCPSC, and difficult to teach. Future research must explore sequelae of training on actual clinical performance.
... Health-care providers should also have cross-cultural communication skills. This includes skills to obtain culturally relevant data, such as those used in conducting cultural assessments and culturally based physical assessments (Campinha-Bacote, 2002;Kim-Godwin et al., 2001;DeRosa & Kochurka, 2006;Hobgood, Sawning, Bowen, & Savage, 2006). It also includes skills needed in ''identifying and negotiating different styles of communication, decision-making preferences, roles of family, sexual and gender issues, and issues of mistrust, prejudice, and racism'' (Betancourt et al., 2003). ...
According to the Census, racial/ethnic minority populations are growing at such a fast rate that by 2050 more than 50% of the population will belong to a minority group (US Census, 2001). The increasing diversity of the U.S. population is one of the many changes that health-care delivery organizations need to proactively address in order to better serve their community and improve their performance. In this paper, we argue that cultural competency not only is important from a societal perspective, i.e., reducing health disparities, but can also be a strategy for health-care organizations to improve quality, lower cost, and attract customers. We provide detailed recommendations for health-care leaders and managers to adopt in order to successfully serve a diverse patient population.
... [1][2][3] Over the past decade, many educational interventions have led to the creation of innovative materials and curricula intended to foster culturally competent behaviors among students and residents. [4][5][6] However, despite such innovations, teaching and reinforcing cultural competency behaviors in clinical settings remain challenging. 7-10 Murray-Garcia and Garcia 10 suggest that informal messages about cultural competency experienced by medical students working in clinical contexts can be much different than what is written into the formal curriculum. ...
Enhancing the cultural competency of students is emerging as a key issue in medical education; however, students may perceive that they are more able to function within cross-cultural situations than their teachers, reducing the effectiveness of cultural competency educational efforts.
The purpose of our study was to compare medical students' perceptions of their residents, attendings, and their own cultural competency.
Cross-sectional study.
A questionnaire containing previously validated instruments was administered to end-of-third-year medical students at four institutions throughout the US. Repeated measures multivariate analysis was used to determine differences in student ratings.
Three hundred fifty-eight medical students from four schools participated, for an overall response rate of 65%.
Analysis indicated overall statistically significant differences in students' ratings (p < 0.001, eta(2) = 0.33). Students rated their own cultural competency as statistically significantly higher than their residents, but similar to their attendings. For reference, students rated the patient care competency of themselves, their residents, and their attendings; they rated their attendings' skills as statistically significantly higher than residents, and residents as statistically significantly higher than themselves. There were differences between cultural competency and patient care ratings.
Our results indicate that students perceive the cultural competency of their attendings and residents to be the same or lower than themselves. These findings indicate that this is an important area for future research and curricular reform, considering the vital role that attendings and residents play in the education of medical students.
... When compared with traditional models, such as didactic lectures, role playing, and mock patient encounters, these hands-on, real-life experiences will better fulfill the goal of creating physicians that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency. [50][51][52] Most (94.4%) participants in the Regan Fellowship stated that the mission experience improved their perspective on worldwide disparities in health care access and gave them an increased appreciation for the impact of a person's culture on their health. There was widespread improvement in selfconfidence and nearly all participants reported feeling invigorated as a doctor. ...
Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency.
Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences.
One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence.
A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.
... According to Velde and Wittman (2001), a key component in instruction aimed at successfully transitioning students from cultural blindness to cultural precompetency is involving members of the minority culture in the creation of culturally relevant interventions. Using a situated cognition approach, future instructional designs would include an African American facilitator, who would guide participants in a collaborative team effort to select appropriate treatment plans based on virtual African American clients (Hobgood et al., 2006). Since most of the participants in the current study stated a readiness to accommodate verbalized needs of African American clients, simulations that support culturally sensitive interaction between therapists and authentic members of the Black culture would be beneficial. ...
The purpose of this study was to increase understanding of the subjective experience of 13 white, female occupational therapists in Louisiana as they participated in a 6-hour workshop on cultural competency. The study employed a mixed method design using qualitative data, obtained from structured reflection questions, and quantitative data, obtained from two objective outcome measures. Three themes emerged from the qualitative data regarding the participants' conflicting attitudes towards African American clients. Therapists believed that: (1) healthcare disparities are not due to racial discrimination; (2) therapists should listen to and educate African American clients; and (3) racial bias and stress contribute to health issues in African American clients. Results from the two outcome measures, the Racial Argument Scale and the Racial Attitude Implicit Association Test, indicate that overall, the study participants held significantly negative attitudes towards African Americans which was not ameliorated by the intervention.
The small convenience sample in this study precludes generalization to a broader population, and further investigation into the attitudes of healthcare professionals in Louisiana is needed. Future instructional interventions should take into account the participants' developmental stage of cultural competence. Copyright
Introduction: There are various difficulties in treating foreign patients; however, the existing educational programs are still insufficient for addressing this issue. The purpose of this study is to investigate what difficulties are encountered in the treatment of foreigners in emergency departments, and to create scenarios for simulation-based education using real-life cases. Methods: A cross-sectional anonymous survey to 457 emergency departments was conducted in 2018. Additionally, we conducted a survey of 46 foreign residents who had visited hospitals for treatment in Japan. The data was analysed quantitatively, and the narrative responses were thematically analysed. Results: Of the 141 hospitals that responded (response rate: 30.9%), 136 (96.5%) answered that they had treated foreign patients. There were 51 and 66 cases with cultural and linguistic difficulties, respectively. In the qualitative analysis, different ideas/beliefs towards treatments or examinations (51.0%) and communication with non-English speaking patients (65.2%) were most common categories in the cases with cultural and linguistic difficulties, respectively. The survey of 46 foreign residents on the surprising aspects of Japanese healthcare showed, 14% mentioned difference in treatment plans between own country and Japan, 12% each mentioned a lack of explanation by medical staff, and a lack of privacy in the examination room. Based on the survey results, we created 2 scenarios of simulation. Conclusions: Scenarios of simulation-based education using real-life cases may be effective materials for cultivating cultural awareness of medical staff.
Issue: Resident teachers play an essential role in medical education and can support broader efforts to advance anti-racism and health equity in medicine. The Accreditation Council for Graduate Medical Education requires programs to provide education about health care disparities so residents can contribute to and lead work in this area. However, the literature includes few examples, frameworks, or strategies for preparing residents to develop the knowledge and skills needed to promote health equity, including in their role as clinical teachers. Evidence: In this article, the authors propose leveraging Resident-as-Teacher training to support residents in learning and teaching for health equity. Gorski’s conceptualization of equity literacy provides an evidence-based framework for four main abilities (recognizing, responding, redressing, and cultivating/sustaining) residents and medical students can develop through co-learning about health equity in the clinical learning environment. The authors discuss preconditions, example activities, and assessments strategies for effective health equity education. Based on the principles of social learning theory, the authors recommend that Resident-as-Teacher training be part of an institutional strategy to cultivate a community of practice for health equity education. Implications: Incorporating health equity education into Resident-as-Teacher curriculum offers a potentially transformative part of the broader strategy needed to prepare the next generation of physicians to enact anti-racism and advance health equity.
Objectives
The Accreditation Council for Graduate Medical Education expects specialties to teach and assess proficiency in culturally competent care. However, little guidance has emerged to achieve these goals. Clinical training within socioeconomically disparate settings may provide an experiential learning opportunity. We sought to qualitatively explore resident experiences working in the generic clinical learning environments (i.e., exposure to socioeconomically diverse patients across different training sites) and how it shapes cultural competency–related skill development.
Methods
Residents were recruited from emergency medicine (EM) programs. We used purposeful sampling across all postgraduate years and elicited experiences related to working at the different sites related to cultural identity, frustrating patient encounters, vulnerable populations, and development of health disparities/social determinants of health knowledge. Individual structured interviews were conducted via phone between May and December 2016. Interviews were audiotaped, transcribed, anonymized, and analyzed using systematic and iterative coding methods.
Results
Twenty-four interviews revealed three main themes. EM residents’ experiences caring for patients across sites shaped their understanding of: (1) potential patient attributes that affected the clinical encounter, (2) difficulties in building rapport had adverse effect on the clinical evaluation, and (3) residency program and training experiences shaped their clinical preparedness and willingness to work in underserved areas.
Conclusion
Assessing the impact disparate clinical setting exposures have on trainees’ preparedness to care for socioeconomically diverse patients can provide valuable insight for medical educators into barriers and facilitators to delivering optimal learning and patient care. Participants provided a breadth of stories illuminating their real-world consciousness and competency with meeting the needs of diverse populations and their access to varied educational outlets to grapple with the disparities they observed. More research is needed to uncover effective strategies to help residents thrive and feel more prepared to care for diverse populations.
The U.S. physician population lacks diversity, and this lack of diversity is reflected in the
medical student population. Medical schools have implemented various types of
programs to increase the diversity of their student population and, by extension, the
physician population. A public Northeastern medical school implemented a postbaccalaureate premedical (PBPM) program for military-enlisted service members with a goal to increase diversity among its medical school cohorts. A quantitative causal- comparative ex post facto study compared diversity variables of the PBPM military-enlisted students with the public medical school student group as well as the national student group. Chi-square analysis found significant differences between the military-enlisted students and the two other comparison groups in four of five diversity measures. The military students were statistically different in age, marital status, number of
dependents, and socioeconomic background. The groups did not differ significantly in
terms of their racial/ethnic demographics. The study validated Tinto’s framework of
student persistence with a military population.
Background
Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.
Methods
A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.
Results
109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ “eye opening” content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.
Conclusions
The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.
Effective communication is a key essential in clinical practice. The practice of good communication skills is of utmost importance for the development of a trustworthy relationship between the doctor and the patient. It also results in benefits such as reduction in errors and better compliance leading to cost effectiveness. Since many litigation cases occur due to medical errors, communication plays key role in preventing such cases. While patients will derive better care, the health professionals are likely to have better job satisfaction [1, 2]. On the other hand, ineffective communication has been one of the main reasons for growing dissatisfaction among patients and the general public.
Background: Diversity issues play a key role in medical practice and have recently been more explicitly integrated into undergraduate medical curricula in Europe and worldwide. However, research on students´ perspectives on the relevance and curricular integration of diversity issues, such as sex/gender and culture-sensitive competencies, is still limited.
Methods: The Charité Berlin (Germany) ran in parallel a traditional and a competency-based medical program. Diversity perspectives, especially sex and gender aspects, were systematically integrated into the new curriculum. In 2016, an online questionnaire was sent to all medical students in their final clerkship year of both programs. Students provided diversity-related information (sex/gender, age, number of children, migration background or disability) and rated the relevance of sex/gender and culture-sensitive competencies and the integration into their study program. They also rated their preparedness for the final year clerkships and for working as a physician.
Results: The included 184 students considered sex/gender and culture-sensitive competencies to be very relevant or relevant (62%; 73%). The ratings of the relevance are independent of the curriculum and significantly higher in female students. Regarding curricular integration, 69% of the students of the traditional curriculum evaluated the degree of implementation as minor, whereas 83% students of the new curriculum rated the degree of implementation as extensive. Degrees of preparedness for the workplace were significantly higher in students from the new curriculum, with no significant effects by sex/gender. Age group, having a child, migration background or a disability had separate effects on the students’ ratings.
Conclusions: Medical students in their final clerkship year rated sex/gender and culture-sensitive competencies as relevant; this was independent from their study program. Their ratings provide complementary evidence that our systematic approach to implementation resulted in a successful curricular integration.
This chapter will examine the development of diversity teaching and clinical communication. It will review the literature that has informed current practice, offer a working definition of ?culture? and describe what diversity teaching is and what it is not. It will consider the changing and diverse student group in a global context and whether academics are being effectively trained to consider the impact of their own prejudices. The final section will discuss any gaps and the importance of a whole curriculum commitment, effective evaluation and assessment of diversity teaching in order to move forward.
A national, random sample of 1000 graduating pediatric residents was surveyed in 2014 on receipt of training in medical home activities and preparedness to engage in same in practice. Of 602 survey respondents (60% response), 71.8% reported being very/fairly knowledgeable about medical homes. Most residents (70.0% to 91.3%) reported they received training in 6 medical home activities; more than one fourth wished for more training in 4 of 6 activities. The majority (62.5% to 77.3%) reported very good/excellent perceived preparedness. Residents with continuity clinic experiences at 2 or more sites and with continuity clinic experience at a community health center were more likely to report very good/excellent preparedness in multiple medical home activities. Overall, residents feel knowledgeable, trained, and prepared to engage in medical home activities as they are leaving residency. Opportunities exist to further explore the influence of additional training in specific activities and the number and type of training site experiences on perceived preparedness.
Introduction
The objective of this study was to analyze the content and volume of literature that has been written on cultural competency in emergency medicine (EM) since its educational imperative was first described by the Institute of Medicine in 2002.
Methods
We conducted a comprehensive literature search through the PubMed portal in January 2015 to identify all articles and reviews that addressed cultural competency in EM. Articles were included in the review if cultural competency was described or if its impact on healthcare disparities or curriculum development was described. Two reviewers independently investigated all relevant articles. These articles were then summarized.
Results
Of the 73 abstracts identified in the initial search, only 10 met criteria for inclusion. A common theme found among these 10 articles is that cultural competency in EM is essential to reducing healthcare disparities and improving patient care. These articles were consistent in their support for cross-cultural educational advancements in the EM curriculum.
Conclusion
Despite the documented importance of cultural competency education in medicine, there appears to be only 10 articles over the past 12 years regarding its development and implementation in EM. This comprehensive literature review underscores the relative dearth of publications related to cultural competency in EM. The limited number of articles found is striking when compared to the growth of EM research over the same time period and can serve as a stimulus for further research in this significant area of EM education.
Many efforts to design introductory “cultural competence” courses for medical students rely on an information delivery (competence) paradigm, which can exoticize patients while obscuring social context, medical culture, and power structures. Other approaches foster a general open-minded orientation, which can remain nebulous without clear grounding principles. Medical educators are increasingly recognizing the limitations of both approaches and calling for strategies that reenvision cultural competence training. Successfully realizing such alternative strategies requires the development of comprehensive models that specify and integrate theoretical frameworks, content, and teaching principles.
In this article, the authors present one such model: Introduction to Medicine and Society (IMS), a required cultural competence course launched in 2013 for first-year medical students at the Perelman School of Medicine at the University of Pennsylvania. Building on critical pedagogy, IMS is centered on a novel specification of “critical consciousness” in clinical practice as an orientation to understanding and pragmatic action in three relational domains: internal, interpersonal, and structural. Instead of transmitting discrete “facts” about patient “types,” IMS content provokes students to engage with complex questions bridging the three domains. Learning takes place in a small-group space specifically designed to spur transformation toward critical consciousness. After discussing the three key components of the course design and describing a representative session, the authors discuss the IMS model’s implications, reception by students and faculty, and potential for expansion. Their early experience suggests the IMS model successfully engages students and prepares future physicians to critically examine experiences, manage interpersonal dynamics, and structurally contextualize patient encounters.
Approach:
This qualitative study utilized a grounded theory approach. Between December 2012 and January 2014, the principal researcher conducted one-on-one telephone and in-person small-group interviews, as well as web-based telephone feedback sessions, with Black/African American and Hispanic/Latino medical students.
Findings:
Thirty-three students participated, including 23 Black/African American and 10 Hispanic/Latino medical students. Participants represented 25 U.S. allopathic medical schools. Emergent themes are categorized under 2 headings: (a) motivations for a career in medicine and (b) barriers and supports. Motivations for a career in medicine include perceived fit, prior experience or knowledge, encouragement and role models, desire to help others, interest in science, and perceived benefits. Barriers and supports included information, guidance and social support, financial and academic factors, and persistence. Insights: Building on theories of student college choice and academic capital formation, the researcher's analysis and interpretations result in the proposal of a conceptual model describing minority applicants' experience in medical school admissions. The study also suggests research and practice implications related to premedical advising, mentoring, financial assistance, information, outreach, and data collection.
As the locus of health care migrates from institutional to home- and community-based settings, designers face news challenges in developing consumer health information technology (health IT) to support patients and informal caregivers with their new self-care and self-management responsibilities. For such technologies to be appropriately designed, they must be aligned, in part, with the cultural context within which these consumers are embedded. Designing culturally-informed consumer health IT is challenging partly because of the tensions that exist between engineering and cultural anthropological approaches to studying the intersection of culture and technology. This paper proposes both a framework for conceptualizing these tensions and a potential embedded, sequential integration of these approaches to capitalize on the strengths and mitigate the weaknesses of each methodological perspective. Copyright 2010 by Human Factors and Ergonomics Society, Inc. All rights reserved.
To identify the attributes of an effective medical teacher that students value the most.
A quantitative survey was performed in the College of Medicine, Qassim University, Buraidah, Kingdom of Saudi Arabia, between April and May 2012, using a pretested self-administered questionnaire distributed to all students. It captured their opinions on the qualities and attributes of good teachers. Each item was measured on a 5-point Likert scale. Data were entered and analyzed using the Statistical Package for Social Sciences Version 17.
Three hundred and fifty-six students from all years responded. The most important attributes from the students' perspectives were `respectful to students`, `expert on the subject`, `organizes good lectures`, `understands/relates to students`, and `good communication skills`. On the other hand, `good sense of humor`, `explains and shares personal experiences`, `self-sacrificing`, `gives good marks to all students`, and `dresses up appropriately` were least valued by students. Attributes related to performance were valued more by students compared to personality attributes.
Medical teachers and administrators should focus on improving the attributes identified most important to the students. Future studies could define the important attributes more explicitly.
In today’s medical education environment, surgical training is severely compromised by several issues
including: fewer surgeries performed; shorter work hours; fewer years of clinical experience. Currently,
learning to perform surgery utilizes: non-surgical laparoscopic skills exercises, simulation and actual
operating room experience. Clearly, additional innovative educational tools are required to augment
surgical training.1 We have created a unique interactive laparoscopic hysterectomy trainer that provides a
new method to improve cognitive proficiency and enhance the mastery of pelvic anatomy. This is
achieved prior to performing live surgery, on a patient, in the operating room. Figure 1 is one frame from
the trainer demonstrating an example of an interactive step. The student, in this frame, is challenged to
find and place the correct instrument with which to cauterize the round ligament. The trainer uses
multiple didactic modalities: interactive learning; high definition video; animations; annotated stills, written
and auditory instructional material. These provide a consistent, iterative and coordinated building-block
approach to teaching the details of anatomy and surgery, including errors and complications. Each
surgical step has an overview that is then divided into its component segments. To proceed to the next
step, the learner: selects the appropriate instrument; assigns the correct surgeon; places the instrument
into the proper port and then is required to designate the accurate anatomic site. The video of the actual
surgical step is then shown with audible and written instructions detailing the correct surgical technique.
Each step is then followed by an interactive quiz to further enhance anatomic and surgical learning. The
trainer also provides formative and summative feedback to the learner and, at the conclusion of the
program is available as a printout to the supervising faculty. We hypothesize that completion of this
training program will assure a high and consistent level of knowledge for residents before they perform
their first hysterectomy of any type. This allows the surgical learner, in the operating room, to concentrate
on improving surgical skills having already mastered the cognitive material. Adaptations of the Trainer
may be useful for teaching anatomy to medical students as well as a tool for teaching continuing
education courses for practicing gynecologists. Testing the validity of this hypothesis is required.
Residents are required to learn practical academic information, such as pelvic anatomy, surgical steps,
complications and avoidance of errors. We have developed an evaluation instrument that uses still frame
and video material to establish a “hysterectomy knowledge curve.” Test question design includes
multiple-choice, fill-in-the-blank, matching and interactive identification of anatomy and surgical steps on
surgical photos. Faculty, fellows and residents of six academic institutions will take the pre-test to
establish a “knowledge curve.” PGY 1 and 2 residents from those institutions will then utilize the trainer
and take a comparable post-test. A control group of residents will take both tests without using the trainer.
STUDY GOAL
Evaluate the ability of the Hysterectomy Trainer to enhance surgical cognitive knowledge for PGY 1and 2
Gynecology Residents.
REFERENCE
1. Malcolm G. Munro, MD, FRCS; Surgical Simulation: Where Have We Come From? Where Are We
Now? Where Are We Going?; Journal Of Minimally Invasive Gynecology (2012) 19, 272-283 .
Racial and ethnic healthcare disparities remain after differences in income, access, and insurance status have been considered, partly because of the healthcare delivery system’s failure to respond to cultural differences. The Institute of Medicine has called for the development and deployment of culturally appropriate healthcare services to mitigate these disparities. This complex problem of determining how to address the cultural components of racial and ethnic healthcare disparities is an example of what Russell Ackoff terms “messes.” Given consumer health information technology (IT)’s increasing role in patients’ self-care and self-management, one potential solution lies in designing consumer health IT that is culturally-informed. Although both the healthcare informatics community and the engineering design community have begun to seriously consider the role of culture in design to enhance usability, much work remains. Unfortunately, creating culturally-informed consumer health IT can seem daunting, limiting designers’ efforts. We propose the Culturally-Informed Design Framework as a guide for designers of consumer health IT. Designers may use this framework to conceptualize four dimensions of a consumer health IT – technology platform, functionality, content, user interface—in which design choices should be informed by a deep understanding of the users’ culture.
Purpose
This paper aims to compare and contrast quality improvement in the domain of health care disparities with quality improvement in other domains.
Design/methodology/approach
The author provides a descriptive essay and review to put forward the findings of their research.
Findings
In the USA, health care quality improvement systems have largely been accepted and institutionalized. Most if not all hospital and health care systems now have quality monitoring and improvement teams. In contrast, despite a plethora of stark reports in the literature showing that the US health care system has failed to deliver health care with equity when the care of Whites is compared with that of racial and ethnic minorities, there is not a parallel health care disparities improvement system in most health care settings.
Practical implications
Paralleling many steps that have been taken to improve quality in general, health care workers and health systems must take steps to improve structures and processes of care to reduce health care disparities.
Originality/value
Pinpoints some important distinctions between improving structures and processes of care related to health care disparities, and those related to other aspects of quality improvement. Doing so will save lives, and in the process improve overall quality.
This study was conducted to identify key issues for students in an undergraduate medical course with cross border delivery and the impact of these issues on the students’ ability to learn. Data relating to the student experience and perceived student needs were collected from transnational students and teaching staff from Australia and Malaysia. The results highlight the complexities of migration from one learning environment to another and suggest the need for a cohesive institutional approach to support medical student movement between culturally diverse settings as well as the translation of medical curriculum from one cultural context to another. We describe how the particular needs of transnational students moving across borders align with Maslow’s hierarchy of unmet needs and can be met through low cost, long reach institutional initiatives. These must be supplemented by interpersonal approaches in which institutions can also foster. The outcomes will benefit local as well as transnational students and staff.
Cultural competence is considered an important skill in health care delivery; accordingly, it requires an effective and efficient course of training. Web-based teaching has increasingly been used in medical education with a few reports also in the dental field; however, there is a lack of evidence of its full application and usefulness. The objective of this study was to evaluate the efficacy of web-based case scenarios in comparison with seminar-based training to deliver cultural competency material to the health care provider in training. Eighty-one fourth-year dental students attending a mandatory Special Patients' Care clinical rotation were randomly allocated to receive first either a session of seminar or web-based case scenarios on cultural competence, with all students receiving a manual containing information about various cultures and the issues of cultural diversity on the first day of the training. All students underwent pre- and post-training examinations, which were conducted using a multiple-choice questionnaire and a self-analytic evaluation. Both the seminar and the web-based case scenarios resulted in significant improvement (p≤0.001) of scores comparing the pre- and posttest outcomes. Training either as a seminar or a series of web-based case scenarios combined with written material presented in a manual was found to increase students' cultural competence.
Background:
Cultural competency is crucial to the delivery of optimal medical care. In Emergency Medicine, overcoming cultural barriers is even more important because patients might use the Emergency Department (ED) as their first choice for health care. At least 2.2 million Muslims from Middle Eastern background live in the United States.
Objective:
We wanted to create a succinct guideline for Emergency care providers to overcome cultural barriers in delivering care for this unique population.
Method:
A compensative search on medical and health databases was performed and all the articles related to providing healthcare for Muslim-Americans were reviewed.
Result:
The important cultural factors that impact Emergency care delivery to this population include norms of modesty; gender role; the concept of God's will and its role in health, family structure, prohibition of premarital and extramarital sex; Islamic rituals of praying and fasting; Islamic dietary codes; and rules related to religious cleanliness.
Conclusions:
The Muslim-American community is a fast-growing, under-studied population. Cultural awareness is essential for optimal delivery of health care to this minority. We have created a succinct guideline that can be used by Emergency Care providers to overcome cultural barriers. However, it is important to consider the heterogeneity and diversity of this population and to use this guideline on an individual basis.
The incorporation of "culture" into U.S. biomedicine has been increasing at a rapid pace over the last several decades. Advocates for "cultural competence" point to changing patient demographics and growing health disparities as they call for improved educational efforts that train health providers to care for patients from a variety of backgrounds. Medical anthropologists have long been critical of the approach to "culture" that emerges in cultural competence efforts, identifying an essentialized, static notion of culture that is conflated with racial and ethnic categories and seen to exist primarily among exotic "Others." With this approach, culture can become a "list of traits" associated with various racial and ethnic groups that must be mastered by health providers and applied to patients as necessary. This article uses an ethnographic examination of cultural competence training to highlight recent efforts to develop more nuanced approaches to teaching culture. I argue that much of contemporary cultural competence education has rejected the "list of traits" approach and instead aims to produce a new kind of health provider who is "open-minded," willing to learn about difference, and treats each patient as an individual. This shift, however, can ultimately reinforce behavioral understandings of culture and draw attention away from the social conditions and power differentials that underlie health inequalities.
This article briefly reviews the history of the inclusion of culture within child and adolescent psychiatry. This history is a reflection of broader trends within medical education and psychiatry, more generally. The authors then present an approach for incorporating culture within the clinical setting termed the cultural sensibility model. In addition to outlining the model and its philosophical basis, they present brief case examples and a sample curriculum in support of this model.
Medical Education 2010:44:613–620
Objectives In an effort to provide preventive advice, this paper aims to acknowledge what has not worked with regard to cultural competency initiatives. A successful cultural competency training initiative should have lasting impact on its participants in terms of long-term, ideally permanent changes to attitudes, knowledge and skills resulting in the provision of optimum care, regardless of a patient’s cultural background. Legal mandates mean there is an assumed need for cultural competency curricula and training programmes for medical students and postgraduate medical trainees. However, policy and practice have bypassed ‘proof’ that such programmes are effective and result in better patient care. Often only positive results are reported, which may minimise the difficulties involved in programme implementation.
Methods Utilising the example of a cultural competency initiative introduced into a postgraduate general surgery training programme, this paper discusses mistakes that were made during the implementation phase, particularly with regard to underestimating potential resistance by the trainees. Also presented are the lessons learned and efforts that were made to mitigate the problems that arose. None of what is discussed in this paper is new. However, the literature often does not discuss in detail the difficulties that can be or have been faced and how these obstacles can be adequately mitigated.
Conclusions The glow of cultural competency training initiatives is fading in the light of higher expectations for an evidence base prior to acknowledgement that their introduction has had a positive impact. For these initiatives to advance, there needs to be a clear understanding of terms utilised, buy-in and a long-term commitment at both individual and organisational levels, and use of standardised and validated tools to measure outcomes. An understanding of potential pitfalls can help to advance cultural competency training to the next level, namely, a solid evidence base that justifies both an individual’s and an institution’s investment in this effort.
Given the race and gender disparities in cardiac care for women and minorities, it is important to evaluate how we teach in this content area, because it may influence this bias.
We assessed the American Heart Association's Advanced Cardiac Life Support (ACLS) materials, published in 2006, for examples of race and gender sensitivity that depicted culturally competent health education.
Precourse materials, manuals, illustrations, case vignettes, compact discs (CDs), algorithms, and tests were evaluated for culturally competent opportunities. An opportunity was defined as each question or scenario that could have been edited to reflect race or gender. Minority status was interpreted as skin color other than white. Each individual component was counted separately. After the quantitative tally, an analysis was performed using simple percentile comparisons. Interpretations were based on these percentages.
The majority of teaching opportunities (54%) did not reflect race or gender. Of 149 patient opportunities to adequately represent those at risk, none clearly represented a minority female. In the simulated cases on the provider CD, all patients were white males. The mannequin had a male haircut and an open shirt. No mannequin had female characteristics (eg, earrings, breasts, or women's clothing). None of the provider CD cases illustrated patients or mannequins with skin color other than white.
The current ACLS provider and instructor materials do not maximize opportunities to illustrate vulnerable segments of the population. Future studies designed to evaluate the effect of improved representation of women and minorities in teaching models should be considered.
A commitment to enhancing the diversity of the nursing workforce is reflected in the recruitment and retention strategies designed by Stony Brook University with support of a grant received from the Department of Health and Human Services, Health Resources and Services Administration. Three specific student retention strategies are evaluated in terms of their influence on student inclusion and promotion of student success. A review of the cultural competence of teaching and learning strategies and the promotion of cultural self-awareness underpinned these strategies. A mentorship program designed to provide individual support for students, particularly for those engaged in distance learning, proved to be challenging to implement and underused by students. Students found other means of support in their workplace and through individual connections with the faculty. Instructional programs that enhanced individual skills in the use of computer hardware and software were particularly effective in promoting student success.
In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors. Cross-cultural curricula have been developed to address these issues but are not widely used in medical education. Many curricula take a categorical and potentially stereotypic approach to cultural competence that weds patients of certain cultures to a set of specific, unifying characteristics. In addition, curricula frequently overlook the importance of social factors on the cross-cultural encounter. This paper discusses a patient-based cross-cultural curriculum for residents and medical students that teaches a framework for analysis of the individual patient's social context and cultural health beliefs and behaviors. The curriculum consists of five thematic units taught in four 2-hour sessions. The goal is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds.
The development of Intercultural sensitivity demands attention to the subjective experience of the learner. The key to such sensitivity and related skills in Intercultural communication is the way in which learners construe cultural difference. This article suggests a continuum of stages of persona! growth that allows trainers to diagnose the level of sensitivity of individuals and groups and to sequence material according to a developmental plan. The developmental continuum moves from ethnocentrisrn to ethnorelativism. Earlier stages of the continuum define the parochial denial of difference, the evaluative defense against difference, and the universalist position of minimization of difference. Later stages define the acceptance of difference, adaptation to difference, and the integration of difference into one's world view. The stages of development are illustrated with typical statements and behaviors of learners that can be used to diagnose levels of sensitivity, and strategies to facilitate movement from each stage to the next are suggested. Special attention is given to questions of ethics and credibility that often arise in intercultural training situations.
Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such concepts is described as illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capable of translating concepts from cultural anthropology into clinical language for practical application. The implementation of this approach in medical teaching and practice requires more support, both curricular and financial.
To determine whether Hispanic patients with isolated long-bone fractures are less likely to receive emergency department (ED) analgesics than similar non-Hispanic white patients.
Retrospective cohort study.
The UCLA Emergency Medicine Center, a level I trauma center.
All Hispanic and non-Hispanic white ED patients aged 15 to 55 years, seen between January 1, 1990, and December 31, 1991, with isolated long-bone fractures, identified by ICD-9 codes 812, 813, 821, and 823, were eligible for inclusion. Exclusion criteria included injury more than 6 hours prior to presentation, "possible" or chip fractures only, altered mentation, or ethanol intoxication.
Emergency department administration of analgesic or no analgesic.
The study group consisted of 139 patients meeting inclusion criteria, of whom 31 were Hispanic and 108 non-Hispanic white. Non-Hispanic whites were significantly more likely to speak English, be insured, and suffer nonoccupational injuries. Hispanics were twice as likely as non-Hispanic whites to receive no ED pain medication (crude relative risk [RR], 2.12; 95% confidence interval [CI], 1.35 to 3.32; P = .003). The RR for ethnicity was similar and significant (P < .05) after controlling by stratification for covariates related to patient, injury, or physician characteristics. After controlling for several covariates simultaneously through multiple logistic regression, ethnicity remained the strongest predictor of ED analgesic administration (odds ratio [OR], 7.46; 95% CI, 2.22 to 25.04; P < .01).
Hispanics with isolated long-bone fractures are twice as likely as non-Hispanic whites to receive no pain medication in the UCLA Emergency Medicine Center. No covariate measured in this study could account for this effect. An ethnic basis for variability in analgesic practice needs to be further characterized.
In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors. Cross-cultural curricula have been developed to address these issues but are not widely used in medical education. Many curricula take a categorical and potentially stereotypic approach to "cultural competence" that weds patients of certain cultures to a set of specific, unifying characteristics. In addition, curricula frequently overlook the importance of social factors on the cross-cultural encounter. This paper discusses a patient-based cross-cultural curriculum for residents and medical students that teaches a framework for analysis of the individual patient's social context and cultural health beliefs and behaviors. The curriculum consists of five thematic units taught in four 2-hour sessions. The goal is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds.
Explicit cross-cultural learning experiences in medical education are provided within the context of implicit experiences provided by a greater "hidden curriculum." The authors conducted a content analysis of 983 cases presented in the 1996-1998 year one and year two curriculum at the University of Minnesota Medical School to determine in what ways they might embody elements of the hidden curriculum, i.e., how they either supported or undermined explicit messages about diverse patient populations. Cases were coded for demographic variables, potential risk factors, and diagnoses or presenting problems. The findings revealed that cases featuring males out-numbered those featuring females; this ratio differed across courses, and appeared to differ from the actual epidemiology of the conditions. Sexual orientation was specified infrequently. When sexual orientation and behavior were specified, these appeared in the context of a risk assessment for particular diseases (e.g., HIV infection). Most cases did not provide racial or ethnic descriptions. For many of the ethnic descriptors, links to genetic, cultural, or socioeconomic factors were apparent; no such link was apparent when the racial terms "white" or "Caucasian" were used. Analysis of the 983 cases shows that the pattern of demographics and associations of particular groups with diseases or risk factors in cases conveys messages, as does the lack of mention of sexual orientation and race or ethnicity. These messages are inconsistent with and may undermine the formal multicultural medical curriculum. The results suggest a need for formal deliberation of this aspect of the curriculum by curriculum planners.
We sought to examine whether physician recommendations for cardiac revascularization vary according to patient race.
We studied patients scheduled for coronary angiography at 2 hospitals, one public and one private, between November 1997 and June 1999. Cardiologists were interviewed regarding their recommendations for cardiac resvacularization.
African American patients were less likely than Whites to be recommended for revascularization at the public hospital (adjusted odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.12, 0.77) but not at the private hospital (adjusted OR = 1.69; 95% CI = 0.69, 4.14).
Physician recommendations for cardiac revascularization vary by patient race. Further studies are needed to examine physician bias as a factor in racial disparities in cardiac care and outcomes.
The Liaison Committee on Medical Education recently set standards for cultural diversity training as part of the medical school curriculum. To the authors' knowledge, this is the first description of a faculty-development program designed to develop the capacity of the clinical faculty to integrate culture and advocacy education into clinical training. The paper describes the first two years of the development of an ongoing cultural competence curriculum that has been integrated into the training of community preceptors from 13 medical schools in New England and New York. The training, entitled"Teaching the Culture of the Community," consists of four 2.5-hour modules that include interactive lectures and small-group role-play exercises on cultural needs assessment, patient-centered interviewing, feedback on cultural issues and use of the community to enhance cultural understanding. The 137 participants in the first two years of the program (1999-00 and 2000-01) reported a high level of acceptance of the curriculum. In the second year, the program began to document participants' self-reported"intention to change" in relation to the cultural competence curriculum. Many participants reported plans to change aspects of their clinical care and their teaching practices. Intentions to change were most frequently expressed in the context of content on effective communication skills. In summary, cultural competency training has been successfully integrated into an existing faculty-development program for community-based preceptors.
Although increased attention has been paid to sex and racial differences in the management of myocardial infarction, it is unknown whether these differences have narrowed over time.
With the use of data from the National Registry of Myocardial Infarction, we examined sex and racial differences in the treatment of patients who were deemed to be "ideal candidates" for particular treatments and in deaths among 598,911 patients hospitalized with myocardial infarction between 1994 and 2002.
In the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy (for white men, white women, black men, and black women: 86.5, 83.3, 80.4, and 77.8 percent, respectively; P<0.001), use of aspirin (84.4, 78.7, 83.7, and 78.4 percent, respectively; P<0.001), use of beta-blockers (66.6, 62.9, 67.8, and 64.5 percent; P<0.001), and coronary angiography (69.1, 55.9, 64.0, and 55.0 percent; P<0.001). After multivariable adjustment, racial and sex differences persisted for rates of reperfusion therapy (risk ratio for white women, black men, and black women: 0.97, 0.91, and 0.89, respectively, as compared with white men) and coronary angiography (relative risk, 0.91, 0.82, and 0.76) but were attenuated for the use of aspirin (risk ratio, 0.97, 0.98, and 0.94) and beta-blockers (risk ratio, 0.98, 1.00, and 0.96); all risks were unchanged over time. Adjusted in-hospital mortality was similar among white women (risk ratio, 1.05; 95 percent confidence interval, 1.03 to 1.07) and black men (risk ratio, 0.95; 95 percent confidence interval, 0.89 to 1.00), as compared with white men, but was higher among black women (risk ratio, 1.11; 95 percent confidence interval, 1.06 to 1.16) and was unchanged over time.
Rates of reperfusion therapy, coronary angiography, and in-hospital death after myocardial infarction, but not the use of aspirin and beta-blockers, vary according to race and sex, with no evidence that the differences have narrowed in recent years.
Excellent communication and interpersonal (C-IP) skills are a universal requirement for a well-rounded emergency physician. This requirement for C-IP skill excellence is a direct outgrowth of the expectations of our patients and a prerequisite to working in the increasingly complex emergency department environment. Directed education and assessment of C-IP skills are critical components of all emergency medicine (EM) training programs and now are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. In keeping with its mission to improve the quality of EM education and in response to the ACGME Outcome Project, the Council of Emergency Medicine Residency Directors (CORD-EM) hosted a consensus conference focusing on the application of the six core competencies to EM. The objective of this article is to report the results of this consensus conference as it relates to the C-IP competency. There were four primary goals: 1) define the C-IP skills competency for EM, 2) define the assessment methods currently used in other specialties, 3) identify the methods suggested by the ACGME for use in C-IP skills, and 4) analyze the applicability of these assessment techniques to EM. Ten specific communication competencies are defined for EM. Assessment techniques for evaluation of these C-IP competencies and a timeline for implementation are also defined. Standardized patients and direct observation were identified as the criterion standard assessment methods of C-IP skills; however, other methods for assessment are also discussed.
Given that understanding the sociocultural dimensions underlying a patient's health values, beliefs, and behaviors is critical to a successful clinical encounter, cross-cultural curricula have been incorporated into undergraduate medical education. The goal of these curricula is to prepare students to care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, and gender biases in health care delivery. Despite progress in the field of cross-cultural medical education, several challenges exist. Foremost among these is the need to develop strategies to evaluate the impact of these curricular interventions. This article provides conceptual approaches for cross-cultural medical education, and describes a framework for student evaluation that focuses on strategies to assess attitudes, knowledge, and skills, and the impact of curricular interventions on health outcomes.
Objective.
—To determine whether Hispanic patients with isolated long-bone fractures are less likely to receive emergency department (ED) analgesics than similar non-Hispanic white patients.Design.
—Retrospective cohort study.Setting.
—The UCLA Emergency Medicine Center, a level I trauma center.Participants.
—All Hispanic and non-Hispanic white ED patients aged 15 to 55 years, seen between January 1,1990, and December 31,1991, with isolated long-bone fractures, identified by ICD-9 codes 812, 813,821, and 823, were eligible for inclusion. Exclusion criteria included injury more than 6 hours prior to presentation, "possible" or chip fractures only, altered mentation, or ethanol intoxication.Main Outcome Measures.
—Emergency department administration of analgesic or no analgesic.Results.
—The study group consisted of 139 patients meeting inclusion criteria, of whom 31 were Hispanic and 108 non-Hispanic white. Non-Hispanic whites were significantly more likely to speak English, be insured, and suffer nonoccupational injuries. Hispanics were twice as likely as non-Hispanic whites to receive no ED pain medication (crude relative risk [RR], 2.12; 95% confidence interval [Cl], 1.35 to 3.32; P=.003). The RR for ethnicity was similar and significant (P<.05) after controlling by stratification for covariates related to patient, injury, or physician characteristics. After controlling for several covariates simultaneously through multiple logistic regression, ethnicity remained the strongest predictor of ED analgesic administration (odds ratio [OR], 7.46; 95% Cl, 2.22 to 25.04; P<.01).Conclusions.
—Hispanics with isolated long-bone fractures are twice as likely as non-Hispanic whites to receive no pain medication in the UCLA Emergency Medicine Center. No covariate measured in this study could account for this effect. An ethnic basis for variability in analgesic practice needs to be further characterized.(JAMA. 1993;269:1537-1539)
This book is a "how-to" manual for incorporating psychotherapy into the daily practice of primary care medicine. In the universe of primary care patients, many, if not all, have a behavioral component as part and parcel of their visit to a physician. Successfully recognizing and addressing these issues in a time-effective manner will benefit the patient while at the same time increasing the satisfaction of the caregiver. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Excellent communication and interpersonal (C-IP) skills are a universal requirement for a well-rounded emergency physician. This requirement for C-IP skill excellence is a direct outgrowth of the expectations of our patients and a prerequisite to working in the increasingly complex emergency department environment. Directed education and assessment of C-IP skills are critical components of all emergency medicine (EM) training programs and now are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. In keeping with its mission to improve the quality of EM education and in response to the ACGME Outcome Project, the Council of Emergency Medicine Residency Directors (CORD-EM) hosted a consensus conference focusing on the application of the six core competencies to EM. The objective of this article is to report the results of this consensus conference as it relates to the C-IP competency. There were four primary goals: 1) define the C-IP skills competency for EM, 2) define the assessment methods currently used in other specialties, 3) identify the methods suggested by the ACGME for use in C-IP skills, and 4) analyze the applicability of these assessment techniques to EM. Ten specific communication competencies are defined for EM. Assessment techniques for evaluation of these C-IP competencies and a timeline for implementation are also defined. Standardized patients and direct observation were identified as the criterion standard assessment methods of C-IP skills; however, other methods for assessment are also discussed.
We previously reported that Hispanic ethnicity was an independent risk factor for inadequate analgesic administration among patients presenting to a single emergency department. We then attempted to generalize these findings to other ethnic groups and EDs. Our current study objective is to determine whether black patients with extremity fractures are less likely to receive ED analgesics than similarly injured white patients.
We conducted the following retrospective cohort study at an urban ED in Atlanta, GA. All black and white patients presenting with new, isolated long-bone fractures over a 40-month period were studied. After abstracting demographic information from the medical record and subsequently removing ethnic identifiers, we submitted the medical record to a physician who recorded characteristics of the patients' injury and treatment. We then submitted the records to a nurse, again blinded to ethnicity, who recorded analgesic administration. We used multiple logistic regression to determine the independent effect of ethnicity on analgesic use while controlling for multiple potential confounders. Our main outcome measure was the proportion of black versus white patients receiving ED analgesics.
The study group consisted of 217 patients, of whom 127 were black and 90 were white. White patients were significantly more likely than black patients to receive ED analgesics (74% versus 57%, P =.01) despite similar records of pain complaints in the medical record. The risk of receiving no analgesic while in the ED was 66% greater for black patients than for white patients (relative risk 1.66, 95% confidence interval, 1.11 to 2.50). This effect persisted after controlling for multiple potential confounders.
Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in this ED. No covariate measured in this study could account for this effect. Our findings have implications for efforts to improve analgesic practices for all patients.
Significant demographic changes in patient populations have contributed to an increasing awareness of the impact of cultural diversity on the provision of health care. For this reason methods are being developed to improve the cultural sensitivity of persons responsible for giving health care to patients whose health beliefs may be at variance with biomedical models. Building on methods of elicitation suggested in the literature, we have developed a set of guidelines within a framework called the LEARN model. Health care providers who have been exposed to this educational framework and have incorporated this model into the normal structure of the therapeutic encounter have been able to improve communication, heighten awareness of cultural issues in medical care and obtain better patient acceptance of treatment plans. The emphasis of this teaching model is not on the dissemination of particular cultural information, though this too is helpful. The primary focus is rather on a suggested process for improved communication, which we see as the fundamental need in cross-cultural patient-physician interactions.
To determine the role of the clinical training environment and a medical education community in reaffirming medical professionalism among physicians-in-training and faculty.
Published articles on undergraduate and graduate medical education and sociology works on professionalism were identified through research.
Studies were selected that illustrated barriers to professionalism in medical education and patient care and the professional conduct of medical students, residents, and faculty.
Factors that undermined the medical education community were the specialization of medicine, the faculty reward systems, and the service demands of residency because of the economics of health care.
Establishment of a firm system with a core teaching faculty, creation of mentoring and role modeling programs, implementation of a longitudinal curriculum on medical professionalism, evaluation of physicians on professional conduct, and evaluation of the clinical training environment are suggested as strategies to re-establish an education community and reaffirm professionalism in medicine.
Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors.
This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children.
Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol.
Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months.
We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.
Despite significant clinical and research efforts aimed at recognizing and managing "difficult" patients, such patients remain a frustrating experience for many clinicians. This is especially true for primary care residents, who are required to see a significant volume of patients with diverse and complex problems, but who may not have adequate training and life experience to enable them to deal with problematic doctor-patient situations. Literature--short stories, poems, and patient narratives--is a little-explored educational tool to help residents in understanding and working with difficult patients. In this report, the authors examine the mechanics of using literature to teach about difficult patients, including structuring the learning environment, establishing learning objectives, identifying teaching resources and appropriate pedagogic methods, and incorporating creative writing assignments. They also present an illustrative progression of a typical literature-based teaching session about a difficult patient.
Cardiovascular disease disproportionately affects minority populations, in part because of multiple sociocultural factors that directly affect compliance with antihypertensive medication regimens. Compliance is a complex health behavior determined by a variety of socioeconomic, individual, familial, and cultural factors. In general, provider-patient communication has been shown to be linked to patient satisfaction, compliance, and health outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of linguistic and contextual barriers that preclude effective provider-patient communication. These factors may further limit compliance. The ESFT Model for Communication and Compliance is an individual, patient-based communication tool that allows for screening for barriers to compliance and illustrates strategies for interventions that might improve outcomes for all hypertensive patients.
To prepare students to be effective practitioners in an increasingly diverse United States, medical educators must design cross-cultural curricula, including curricula in women's health. One goal of such education is cultural competence, defined as a set of skills that allow individuals to increase their understanding of cultural differences and similarities within, among, and between groups. In the context of addressing health care needs, including those of women, the author states that it is valid to define cultural groups as those whose members receive different and usually inadequate health care compared with that received by members of the majority culture. The author proposes, however, that cross-cultural efficacy is preferable to cultural competency as a goal of cross-cultural education because it implies that the caregiver is effective in interactions that involve individuals of different cultures and that neither the caregiver's nor the patient's culture offers the preferred view. She then explains why cross-cultural education needs to expand the objectives of women's health education to go beyond the traditional ones, and emphasizes that learners should be trained in the real-world situations they will face when aiding a variety of women patients. There are several challenges involved in both cross-cultural education and women's health education (e.g., resistance to learning; fear of dealing openly with issues of discrimination; lack of teaching tools, knowledge, and time). There is also a need to assess the student's acquisition of cross-cultural efficacy at each milestone in medical education and women's health education. Components of such assessment (e.g., use of various evaluation strategies) and educational objectives and methods are outlined. The author closes with an overview of what must happen to effectively integrate cross-cultural efficacy teaching into the curriculum to produce physicians who can care effectively for all their patients, including their female patients.
After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital.
A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO.
African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94).
African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.
The field of cross-cultural medical education has blossomed in an environment of increasing diversity and increasing awareness of the effect of race and ethnicity on health outcomes. However, there is still no standardized approach to teaching doctors in training how best to care for diverse patient populations. As standards are developed, it is crucial to realize that medical educators cannot teach about culture in a vacuum. Caring for patients of diverse cultural backgrounds is inextricably linked to caring for patients of diverse social backgrounds. In this article, the authors discuss the importance of social issues in caring for patients of all cultures, and propose a practical, patient-based approach to social analysis covering four major domains--(1) social stress and support networks, (2) change in environment, (3) life control, and (4) literacy. By emphasizing and expanding the role of the social history in cross-cultural medical education, faculty can better train medical students, residents, and other health care providers to care for socioculturally diverse patient populations.
Many aspects of the medical education system lead trainees to a host of maladaptive reactions and behaviors, but far too little attention has been focused on the impact that interactions between teacher and learner can have on the development of professionalism. The authors discuss the concept of "social influence," a change of attitude, belief, or behavior resulting from the actions of another person in the context of the medical education setting. Using the example of a medical student who has not adequately completed his inpatient medicine requirements, they identify ten strategies of social influence that a medical educator might invoke to change the student's behavior and evaluate the benefits and drawbacks of these strategies. This overview can be used by faculty to explore new strategies of teaching and to reflect on their current teaching styles.
Medical schools are placing more emphasis on students' personal and professional development (PPD) and are seeking ways of assessing student progress towards meeting outcome goals in relation to professionalism. The Faculty of Medicine at the University of Sydney sought an assessment method that would demonstrate the value of reflection in attaining PPD, provide feedback and encourage students to take responsibility for setting and achieving high standards of performance.
The instruments used to assess Year 1 students in PPD are a portfolio and interview. This assessment format encourages students to explore ideas and values that are important to them and relevant to the PPD theme. A confidential interview, based on the PPD goals, is held with a faculty member who has read the student's portfolio.
In 1997/98, 96% of students agreed that they had engaged in useful reflection on their approach to the course and 91% agreed that the experience was worthwhile. A further 76% of students agreed that they could see opportunities to modify their approach in some ways as result of this exercise.
Sustained PPD is essential in equipping doctors for the varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1 assessment, both students and faculty members found the process of value. This form of assessment acknowledges that the most valid assessment formats cannot always be made reliable and that in some parts of the curriculum it is more important to demonstrate trust in students' own motivation to become competent and mindful practitioners. The fact that the portfolio and interview are the only summative assessments in the first year emphasises the importance that the Faculty places on PPD.
The BELIEF Instrument is a cultural interviewing tool for preclinical medical students that does not require diagnostic or therapeutic skills.
An expert panel developed and taught the instrument to 200 first-year medical students in (1) a didactic session, (2) standardized patient interviews, and (3) clinical correlation sessions with community physicians and third-year medical students. Standardized patients evaluated students on the BELIEF questions in a graded interview.
A total of 93.5% (range 86% to 97%) of 197 students elicited information on each of the BELIEF items.
The BELIEF instrument works as a cultural interviewing tool. It is unknown if students' interviewing behavior generalizes to real patients in clinical settings.
The purpose of this paper is to provide a perspective from New Zealand on the role of medical education in addressing racism in medicine. There is increasing recognition of racism in health care and its adverse effects on the health status of minority populations in many Western countries. New Zealand nursing curricula have introduced the concept of cultural safety as a means of conveying the idea that cultural factors critically influence the relationship between carer and patient. Cultural safety aims to minimize any assault on the patient's cultural identity. However, despite the work of various researchers and educators, there is little to suggest that undergraduate medical curricula pay much attention yet to the impact of racism on medical education and medical practice. The authors describe a cultural immersion program for third-year medical students in New Zealand and discuss some of the strengths and weaknesses of such an approach. The program is believed to have great potential as a method of consciousness raising among medical students to counter the insidious effects of non-conscious inherited racism. Apart from the educational benefits, the program has fostered a strong working relationship between an indigenous health care organization and the medical school. In general, it is hoped that such programs will help medical educators to engage more actively with the issue of racism and be prepared to experiment with novel approaches to teaching and learning. More specifically, the principles of cultural immersion, informed by the concept of cultural safety, could be adapted to indigenous and minority groups in urban settings to provide medical students with the foundations for a lifelong commitment to practicing medicine in a culturally safe manner.
Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical school's approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.
Encounters between physicians and patients from different cultural backgrounds are becoming commonplace. Physicians strive to improve health outcomes and increase quality of life for every patient, yet these discordant encounters appear to be a significant factor, beyond socioeconomic barriers, in creating the unequal and avoidable excess burden of disease borne by members of ethnic minority populations in the United States. Most clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences. New strategies are required to expand medical training to adequately address culturally discordant encounters among the physicians, their patients, and the families, for all three may have different concepts regarding the nature of the disease, expectations about treatment, and modes of appropriate communication beyond language. The authors provide an anthropological perspective of the fundamental relationship between culture and health, and outline systemic changes needed within the social and legal structures of the health care system to reduce the risk of cross-cultural miscommunication and increase the likelihood of improving health outcomes for all populations within the multicultural U.S. society. The authors define the strengths inherent within every culture, provide a guideline for the clinician to evaluate disease and illness within its cultural context, and outline the clinical skills required to negotiate among potential differences to reach mutually desired goals for care. Last, they indicate the structural changes required in the health care setting to enable and support such practice.
Given that understanding the sociocultural dimensions underlying a patient's health values, beliefs, and behaviors is critical to a successful clinical encounter, cross-cultural curricula have been incorporated into undergraduate medical education. The goal of these curricula is to prepare students to care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, and gender biases in health care delivery. Despite progress in the field of cross-cultural medical education, several challenges exist. Foremost among these is the need to develop strategies to evaluate the impact of these curricular interventions. This article provides conceptual approaches for cross-cultural medical education, and describes a framework for student evaluation that focuses on strategies to assess attitudes, knowledge, and skills, and the impact of curricular interventions on health outcomes.
The teaching and cultivation of professionalism have long been part of medical education and have had recent special emphasis because professionalism has been identified as a core competency by the Accreditation Council for Graduate Medical Education. The author focuses on two complementary teaching initiatives that contribute to the development of professionalism in the academic environment: a resident-as-teacher program and an approach to faculty bedside teaching that mirrors and extends the lessons of the resident-as-teacher effort. These have been implemented and refined over the previous 15 years by the author and his colleagues at Mount Auburn Hospital in Cambridge, Massachusetts. The commitment to the development and refinement of residents' teaching skills serves to promulgate the fundamental elements of professionalism, with emphasis on caring and the educational well-being of the team. The author describes the elements and benefits of these approaches and shows how they can foster the development of professionalism in graduate medical education.
The need for cross-cultural training (CCT) increases as physicians encounter more culturally diverse patients. However, most medical schools relegate this topic to non-clinical years, hindering skills development. Some residency programs have successfully addressed this deficit by teaching cross-cultural communication skills in a teaching objective structured clinical examination (tOSCE) context. The authors developed and evaluated a CCT workshop designed to teach cross-cultural communication skills to third-year medical students using a tOSCE approach. A 1 and 1/2-day workshop incorporating didactic, group discussion and tOSCE components taught medical students cross-cultural awareness, interviewing skills, working with an interpreter, attention to complementary treatments, and consideration of culture in treatment and prevention. Six standardized patient cases introduced various clinical scenarios and the practical and ethical aspects of cross-cultural care. Student evaluation of the workshop was positive concerning educational value, skills advancement and pertinence to their clinical activities. Survey of students before and after the workshop demonstrated improvement in students' abilities to assess the culture and health beliefs of patients and negotiate issues regarding treatment. CCT in the context of medical student clinical training can be carried out effectively and efficiently using a dedicated multi-modal workshop including standardized patients.