cultural competency – the evolution of early, integrated education for medical students, residents...

Cultural Competency – The Evolution of Early, Integrated

Education For Medical Students, Residents and Faculty at One

Institution

Maria L. Soto-Greene, M.D.Maria L. Soto-Greene, M.D.

Vice President, Hispanic Serving Health Professions Vice President, Hispanic Serving Health Professions Schools, Inc.Schools, Inc.

Senior Associate Dean for EducationSenior Associate Dean for Education

Director, Hispanic Center of ExcellenceDirector, Hispanic Center of Excellence

New Jersey Medical SchoolNew Jersey Medical School

Newark, New JerseyNewark, New Jersey

Overview

Developing, integrating, and evaluating a Developing, integrating, and evaluating a cultural competency curriculum for:cultural competency curriculum for:

Medical studentsMedical students Medical residentsMedical residents FacultyFaculty Hospital interpretersHospital interpreters

Overall Goal

Adapted from the Promoting, Reinforcing, and ImprovingAdapted from the Promoting, Reinforcing, and ImprovingMedical Education (PRIME) project by the AmericanMedical Education (PRIME) project by the AmericanMedical Student Association (AMSA) and HRSA with Medical Student Association (AMSA) and HRSA with expectation that:expectation that: Students will learn about culture and diversity’s role in Students will learn about culture and diversity’s role in

medicinemedicine Students will learn the importance of being culturally Students will learn the importance of being culturally

competentcompetent Students will develop cultural and linguistic competency Students will develop cultural and linguistic competency

through participation in a variety of clinical experiences through participation in a variety of clinical experiences while completing a community learning experiencewhile completing a community learning experience

Comprehensive Curriculum

11stst year year Art of Medicine CourseArt of Medicine Course History & Physical Exam CourseHistory & Physical Exam Course Administration of the Health BELIEF Attitude SurveyAdministration of the Health BELIEF Attitude Survey

22ndnd year year Communications exercise during the Introduction to Communications exercise during the Introduction to

Clinical Medicine courseClinical Medicine course Teach students how to conduct a triadic interviewTeach students how to conduct a triadic interview

Comprehensive Curriculum (cont’d) 33rdrd year year

Expansion of training into third year clerkships with Expansion of training into third year clerkships with concomitant faculty training.concomitant faculty training.

44thth year year Graduation Objective Structured Clinical Examination Graduation Objective Structured Clinical Examination

(OSCE) that assesses our graduate’s cultural and (OSCE) that assesses our graduate’s cultural and linguistic competency skills.linguistic competency skills.

Re-administering the Health BELIEF Attitude Survey.Re-administering the Health BELIEF Attitude Survey.

“The Art of Medicine begins with the communication between a physician and the patient.”

Introduced new components to the historyIntroduced new components to the history Trained H & P faculty on these additional Trained H & P faculty on these additional

componentscomponents Introduced the appropriate use of an interpreterIntroduced the appropriate use of an interpreter Integrated these components into the ambulatory Integrated these components into the ambulatory

preceptorships in the communitypreceptorships in the community

Students’ Views

The Health BELIEF Attitude Survey is an The Health BELIEF Attitude Survey is an instrument used to assess how important instrument used to assess how important students consider obtaining a patients health students consider obtaining a patients health care view points. care view points.

This survey was developed and piloted at This survey was developed and piloted at UTHSC at San Antonio by their HCOE, a UTHSC at San Antonio by their HCOE, a HSHPS member, and Society of Teachers HSHPS member, and Society of Teachers of Family Medicine Foundation.of Family Medicine Foundation.

ETHNIC: A Framework for Culturally Competent Clinical Practice

EE: Explanation: ExplanationWhat do you think may be the reason you have these What do you think may be the reason you have these

symptoms?symptoms?What do friends, family, and others say about these What do friends, family, and others say about these

symptoms?symptoms?Do you know anyone else who has had or who has this Do you know anyone else who has had or who has this

kind of kind of problem?problem?Have you heard about/read/seen it on Have you heard about/read/seen it on

TV/radio/newspaper?TV/radio/newspaper?(If the patient cannot offer an explanation, ask what most (If the patient cannot offer an explanation, ask what most

concerns them about their problems).concerns them about their problems).

Developed by:Developed by: Steven J. Levin, M.D.Steven J. Levin, M.D.Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.Department of Family MedicineDepartment of Family MedicineUMDNJ-Robert Wood Johnson Medical SchoolUMDNJ-Robert Wood Johnson Medical School

ETHNIC: Cont’d

TT: Treatment: Treatment What kinds of medicines, home remedies or other What kinds of medicines, home remedies or other treatments have you tried for this illness?treatments have you tried for this illness?

Is there anything you eat, drink or do (or avoid) on a Is there anything you eat, drink or do (or avoid) on a regular basis to stay healthy? Tell me about regular basis to stay healthy? Tell me about

it.it.What kind of treatment are you seeking from me?What kind of treatment are you seeking from me?

HH: Healers: Healers Have you sought any advice from alternative/folk Have you sought any advice from alternative/folk healers, friends or other people (non-doctors) for healers, friends or other people (non-doctors) for

help help with your problems? Tell me about it.with your problems? Tell me about it.


ETHNIC: Cont’d

NN: Negotiate: Negotiate Negotiate options that will be mutually Negotiate options that will be mutually acceptable to you and acceptable to you and your patient and that do not contradict, but rather your patient and that do not contradict, but rather

incorporate incorporate your patient’s beliefs.your patient’s beliefs.II: Intervention: Intervention Determine an intervention with your patient. May include Determine an intervention with your patient. May include

incorporation of alternative treatments, incorporation of alternative treatments, spirituality, and spirituality, and healers as well as other cultural healers as well as other cultural practices (e.g. food eaten or practices (e.g. food eaten or avoided in general and when sick).avoided in general and when sick).

CC: Collaboration: Collaboration Collaborate with the patient, family members, other Collaborate with the patient, family members, other health care team members, healers and health care team members, healers and

community community resources.resources.


Introduction of Culture

Glossary of Cultural TermsGlossary of Cultural Terms Case studies from the AMSA projectCase studies from the AMSA project Cultural and Spiritual BeliefsCultural and Spiritual Beliefs Complementary and Alternative Medicine Complementary and Alternative Medicine

(CAM)(CAM)

Definition of Culture

We adopted, with some modification, the broader definitionWe adopted, with some modification, the broader definition

of cultural and linguistic competency recommended byof cultural and linguistic competency recommended by

HRSA in its publication: “Cultural Competence Works 2001.HRSA in its publication: “Cultural Competence Works 2001.

Cultural & Linguistic isCultural & Linguistic is: “…a set of congruent behaviors, : “…a set of congruent behaviors, attitudes, policies and procedures that come together in a attitudes, policies and procedures that come together in a system, agency or among professionals which enable they system, agency or among professionals which enable they system, agency, or those professionals to work effectively system, agency, or those professionals to work effectively and efficiently in cross-cultural and diverse linguistic and efficiently in cross-cultural and diverse linguistic situations on a continuous basis.”situations on a continuous basis.”

INTERPRET

I:I: Prior to session, Prior to session, introductionsintroductions take place. Interpreter introduces take place. Interpreter introduces her/himself to provider. Provider introduces interpreter to patient.her/himself to provider. Provider introduces interpreter to patient.

N:N: Interpreter tells provider if patient says she/he is a Interpreter tells provider if patient says she/he is a non-citizennon-citizen or an or an illegal immigrant.illegal immigrant.

T:T: The provider and interpreter should developThe provider and interpreter should develop trust trust between between themselvesthemselves

and with the patient.and with the patient.

E:E: To achieve To achieve effectivenesseffectiveness, provider talks directly to patient in the , provider talks directly to patient in the first first person; speaks in small segment; and clarifies technical terms. person; speaks in small segment; and clarifies technical terms.

Interpreter is linguistically competent; speaks simply and clearly in Interpreter is linguistically competent; speaks simply and clearly in the the first person; explains cultural and linguistic topics; interprets first person; explains cultural and linguistic topics; interprets everything everything said without adding or deleting; stops provider and patient said without adding or deleting; stops provider and patient if they are if they are speaking too long; and refrains from offering advice. speaking too long; and refrains from offering advice.

INTERPRET (cont’d)

R:R: The provider has the lead role. When working with an untrained The provider has the lead role. When working with an untrained interpreter, the provider is also responsible for explaining the interpreter, the provider is also responsible for explaining the interpreter’s interpreter’s rolesroles and duties as outlined on this card to the interpreter. and duties as outlined on this card to the interpreter.

P:P: Proper Proper positioningpositioning is crucial. Provider faces patient. Interpreter sits is crucial. Provider faces patient. Interpreter sits beside and slightly behind patient. Avoid triangular dynamics.beside and slightly behind patient. Avoid triangular dynamics.

R:R: Useful Useful resourcesresources include the following: include the following:

Diversity Rx Diversity Rx http://www.DiversityRX.orghttp://www.DiversityRX.org

Bilingual Dictionaries Bilingual Dictionaries http://www.ibdltd.comhttp://www.ibdltd.com

MA Medical Interpreter Assoc. MA Medical Interpreter Assoc. http://www.mmia.orghttp://www.mmia.org

E:E: The provider and interpreter put The provider and interpreter put ethicsethics into practice. They exercise into practice. They exercise confidentiality and a non-judgmental attitude.confidentiality and a non-judgmental attitude.

T:T: A culturally competent triadic interview involves an ample A culturally competent triadic interview involves an ample timeframetimeframe. . Learn to work effectively and efficiently.Learn to work effectively and efficiently.

Third year medical students

Began by pilot testing a cross cultural Began by pilot testing a cross cultural curriculum with 40 third year medical curriculum with 40 third year medical students during their medicine clerkship.students during their medicine clerkship.

Assessed level of competency at baseline Assessed level of competency at baseline and after the curriculum using 2 modalities.and after the curriculum using 2 modalities.

Medical Student Objective Structured Clinical Examination

Results

Students in the cross cultural curriculum had Students in the cross cultural curriculum had higher exam scores and higher levels of higher exam scores and higher levels of confidence and satisfaction. All 40 students had confidence and satisfaction. All 40 students had the same level of interest in cross cultural issues.the same level of interest in cross cultural issues.

Goal: to develop an integrated third year medical Goal: to develop an integrated third year medical student curriculum that emphasis sociocultural student curriculum that emphasis sociocultural issues throughout their rotations.issues throughout their rotations.

Graduation Objective Structured Clinical Examination (OSCE) At the core of this examination is the doctor-At the core of this examination is the doctor-

patient communication.patient communication. OSCE’s are used to assess the core skills, OSCE’s are used to assess the core skills,

knowledge and attitudes of tomorrow’s physicians knowledge and attitudes of tomorrow’s physicians including more recently in licensure.including more recently in licensure.

Specifically, our OSCE will test a student’s ability Specifically, our OSCE will test a student’s ability to communicate using cross cultural principles.to communicate using cross cultural principles.

Cultural Competency Training: Medical Residents Assess level of need and competency at baseline.Assess level of need and competency at baseline. Assess effectiveness of curriculum with the goal Assess effectiveness of curriculum with the goal

of implementing a formal cultural competency of implementing a formal cultural competency residency training program.residency training program.

A determinant of success is whether the medical A determinant of success is whether the medical resident trained receives increased patient resident trained receives increased patient satisfaction when working with diverse cultural satisfaction when working with diverse cultural groups.groups.

Medical Residents

Medical Interpreter Training

Pilot project funded by the State of NJ to Pilot project funded by the State of NJ to train volunteer hospital medical interpreters.train volunteer hospital medical interpreters.

16 interpreters participated in a one day 16 interpreters participated in a one day medical interpreting and cultural medical interpreting and cultural competency training program.competency training program.

curriculum focused on attitudes, curriculum focused on attitudes, knowledge, and skillsknowledge, and skills

Medical Interpreter Training Program: Results and Outcomes Trained interpreters received high patient and Trained interpreters received high patient and

physician satisfaction scores in the clinical setting.physician satisfaction scores in the clinical setting. Trained interpreters found that physicians do not Trained interpreters found that physicians do not

know how to use an interpreter appropriately.know how to use an interpreter appropriately. An Interpreter Training Curriculum was submitted An Interpreter Training Curriculum was submitted

to the State of NJ.to the State of NJ. University Hospital now funds a program to train University Hospital now funds a program to train

all interpreters.all interpreters.

Clinicians must “check their own pulse” and become aware of personal attitudes, beliefs, biases, and behaviors that may influence (consciously or unconsciously) the care of their patients.

Every clinical encounter is cross-cultural

No “one” way to treat a racial or ethnic No “one” way to treat a racial or ethnic group given the great “sociocultural” group given the great “sociocultural” diversitydiversity

Need to have a “Framework” of Need to have a “Framework” of interventions that can be individualizedinterventions that can be individualized

A “one size fits all” health care system A “one size fits all” health care system cannot meet the needs of an increasingly cannot meet the needs of an increasingly diverse American populationdiverse American population

Organizational and Health Care Policies

Develop a mission statement that articulates Develop a mission statement that articulates principles, rationale, and values for principles, rationale, and values for culturally and linguistically competent culturally and linguistically competent health care service deliveryhealth care service delivery

Ensure consumer and community Ensure consumer and community participationparticipation

Organizational and Health Care Policies (cont’d)

Implement processes that review policies and Implement processes that review policies and procedures to assess relevance of initiatives procedures to assess relevance of initiatives launchedlaunched

Implement legislation that provides resources Implement legislation that provides resources (i.e. funding from Titles VII & VIII, NIH, (i.e. funding from Titles VII & VIII, NIH, private sector, etc.) that supports ongoing private sector, etc.) that supports ongoing professional development and in-service professional development and in-service training for culturally and linguistically diverse training for culturally and linguistically diverse communitiescommunities

Cultural Competency Training and Education

To succeed, we must have:To succeed, we must have: Research AgendasResearch Agendas Evaluation ToolsEvaluation Tools Uniformity at all levels - both state and Uniformity at all levels - both state and

federalfederal Legislation with appropriate levels of Legislation with appropriate levels of

funding to ensure that there is the level of funding to ensure that there is the level of training that ensures equal access and care training that ensures equal access and care for all Americansfor all Americans..

cultural competency – the evolution of early, integrated education for medical students, residents...

Documents

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competent students

important students

community slide

health belief attitude

year clerkships

new components

clinical medicine course