2009 cultural competency arthur gomez md & arleen brown md phd cultural competency curriculum...

2009Cultural Competency

Arthur Gomez MD & Arleen Brown MD PhD

Cultural Competency Curriculum Development

Art Gomez, MD & Arleen Brown MD, PhDDGSM at UCLA

NIH Grant K07 HL-04-012



Culture and MedicineOur increasingly diverse society. The impact of culture on patient’s health. Evidence of Health DisparitiesCross-Cultural Curricula neededNo Consensus RE- Educational ObjectivesQuestion of appropriate approach

Patient-Centered Care. Ethnic and Racial Database

Background



Purpose

Develop a set of common learning objectives for medical students linking health disparities research to cross-cultural medical education.

Gain MEC approval of these objectives Use them in developing curricula



Methods Use an Expert Consensus Panel to

produce a set of objectives Delphi Technique Faculty members recognized as experts in the area of

culture and health from Drew, UCLA and UCSF

Review existing sets of objectivesThe California Endowment Office of Minority Health AAMC

Review existing UCLA Curriculum



Educational Objectives

The Conceptual Approach

Most Cross-Cultural Curricula can be classified according to their emphasis on one of the three general conceptual approaches: Attitudes, Knowledge or Skills

Betancourt JR Cross-Cultural medical education: Conceptual approaches and frameworks for evaluation. Acad Med 2003 78(6):560-569



Educational Objectives The proverbial three-legged stool

“to support any weight not fully supported by the other two”



Learning Objectives

Affective Domain

Cognitive Domain

Psychomotor Domain



Learning ObjectivesAffective Domain

Demonstrate respect to the values and beliefs of patients, family members and the self-treatments that they impart

Intentionally identify personal bias and stereotyping when facing clinical uncertainty or time constraints

Demonstrate a commitment to equal quality care for all and fairness in the health care setting regardless of personal beliefs

Revise personal judgments and change professional behaviors in order to avoid stereotyping.

**Assess one’s own proficiency in languages other than English.



Learning Objectives

Cognitive Domain

Identify medically relevant ethnic/cultural differences among diverse populations including the use of CAM

Identify the pharmacologic response differences among ethnic groups.

Demonstrate knowledge about the legal, regulatory and accreditation issues which address cultural and linguistic issues in health care

Describe the kinds and degrees of disparities in health status, health care access and use of preventive strategies across racial, ethnic, gender and other discrete population groups in the United States



Learning ObjectivesCognitive Domain

Recognize the significance of variations within different ethnic groups when considering the epidemiology of disease

Describe how a patient-centered care approach differs from approaching a patient based on cultural characteristics of the patient’s group

Analyze how systems of care contribute to health disparities and how these barriers might be overcome

Demonstrate the ability to use and apply the following conceptual framework in health disparities: “The Multiple Determinant Model”



Learning Objectives Psychomotor Domain

Demonstrate effective communication when dealing with cultural differences with:

Limited English Proficiency (LEP) patients. Family members. Other health care practitioners.

Demonstrate a patient-centered approach to diagnosis, management and prevention:

Eliciting the patient’s perspective Empowering the patient to ask questions Negotiating management options Showing self-respect

Elicit information that might interfere with the patient adherence to treatment:

Socioeconomic status Support network Polypharmacy Access to care Personal beliefs and values



Learning Objectives

Psychomotor Domain When encountering LEP patients, demonstrate

effective use of interpreters, including working with an untrained interpreter, a trained interpreter and telephone interpreting

Demonstrate ability to search and look for demographic and epidemiologic date for specific communities in which one is providing care



Our solution

– a) understand culture’s role in doctor-patient relations

– b) appreciate complexity of cultural awareness

– c) incorporate a bio-psychosocial perspective,

– d) appreciate racial, spiritual, cultural diversity

– e) interview effectively with diverse populations

– f) become aware of health

We addressed this challenge by introducing a cultural competence curriculum:

to develop UCLA medical student knowledge, skills, and attitudes to deliver patient-centered care,



Road to Cultural Competency Curriculum at UCLA

• COE / UCLA Cultural Competency Task Force– Recommendation for Cultural Competency – Goals Objectives to MEC

• Cultural Competency Faculty Development– Tomorrows Leadership: Eliminating Health Disparities

• Curricular Implementations– Updating current Modules and Module Development Doctoring– Foundations– Clinical Clerkship– process for Future



Faculty Development

• Instructors: – Paula Henderson, Art Gomez, Jacqueline Bowles, Felice Miller. LuAnn

Wilkerson,Kenneth Wolf, Robert Collins, Johanna Shapiro (UC Irvine)• Participants:

– Stuart Slavin (Pediatrics)– Denise Sur (Family Medicine)– Anna Chirra (GIM/HSR)– Alice Kuo (Med/Peds)– Josephine Isabel-Jones (Asst. Dean Student Affairs)– Daphne Calmes (Peds-Drew)– Patricia Barreto (Peds)

• COE Funded Protected Time• Train the trainers through 7 sessions



Evaluation of Faculty DevelopmentFACULTY LEADERS (* p<= .1; ** p<=.05) Pre-Curric Post-

Curric

Knowledge Mean

SD Mean

SD

I am well versed in most current proven practices, treatments, interventions among ethnically and culturally diverse groups served by my agency or program.*

2.29 .76 3.0 .63

My knowledge of health disparities adequate to lead discussion on causes, implications.**

2.71 .49 3.33 .52

I am knowledgeable about cultural beliefs and practices that impact the delivery of care.**

2.86 .55 3.5 .49

Skills

I can assess the application of cultural competency in the clinic setting.* 2.57 1.13

3.5 .54

I have the skills to develop a workshop curriculum on cultural competency* 2.71 .76 3.5 .55



Faculty Fellow Products

• New advanced history taking skill (Akin to HEADSS)– The 3 C’s ( Call, Cause and Cope)

• 2007 Orientation (Play and added exercise)– Targeting awareness

• Doctoring Modules targeted for cultural content on knowledge and skill building– Doctoring 1 (Breast Cancer), Doctoring 2 ( interpreter) Doctoring 3

(Ethics/Abortion)• Clinical Clerkships targeting attitude/knowledge/skills

– Literature in Medicine– Institute of Medicine Report– Debriefing in Doctoring 3 sessions

• Evaluation – OSCE assessing patient-centered interaction (Baseline Skills Assessed)



The Four C’s of Patient Centered Care– Mnemonic prompts students to use these 4 questions which they practice at

each session– Adapted from Arthur Kleinman’s “8 questions”

• CALL – What do you call your situation?– Clarifies information on education level, traditional explanations

• CAUSE – What do you think is the cause of your situation?– Elicits belief systems, hidden meanings behind ailments

• CONCERNS – What concerns do you have regarding your situation?– Obtains difficult to disclose fears and perceptions

• COPE – What have you been doing to cope with your situation?– Elicits spirituality, alternative/complementary therapies



Sample Standardized Patients in Doctoring

• A Homeless Mother– Communicate with a vulnerable patient– Elicit barriers to care

• A Diabetic– Address adherence to diet and

medication– Assess a patient with alternative beliefs

on pathophysiology– Convince a patient with no symptoms

• Cardiac Transplant Candidates– Discuss in mock panels the listing of

patients for cardiac transplant– Assess education, spirituality,

adherence, socioeconomic and cultural factors

– Discuss disparities in the delivery of technology

• An Immigrant Parent and Son– Interview a mother of a patient through

an interpreter– Face challenge of the triadic interview– Show sensitivity and respect toward

alternative treatments including herbals

• Trust in Relation to Health and Adherence– Ascertain long history of mistrust based

on cultural grounds– Address particular barriers to care faced

by vulnerable populations with alternative lifestyles

• Sexual Assault– Check assumptions related to a patient’s

religious/spiritual sexual mores and ideas on abortion



Using the Arts to Teach

• “A Slice of Rice, Frijoles and Greens" A Great Leap Production– Day one, students introduced to

Los Angeles’ Diversity– Series of poignant and

memorable skits on culture, disability and ethnicity

– Debriefing sessions and awareness exercise called “First Memory of Difference” or “Genogram”

Artists from left: Chic Street Man, Paulina Sahagun, Dan Kwong and Arlene Malinowski Great Leap, Inc. ~ 1145 Wilshire Boulevard Suite 100-D, Los Angeles CA 90017 (213) 250-8800 ~ Fax (213) 250-8801



Using the Arts to Teach• “Book Club” During a Required Clerkship

– 3rd year Ambulatory Medicine critique book by Anne Fadiman– Discuss consequences of faulty cross-cultural communication– Discuss Patient Centered Care in context of 3rd year– Share experiences on patients and insensitive residents/faculty


Arthur Gomez MD & Arleen Brown MD PhD• Over 40 hours complement clinical training with diverse Los Angeles patients

Curricular Activity Year Hours

A. Theatrical performance: Slice of Rice, Frijoles, & Greens 1 1.5

B. Cultural identity exercise: First Memory of Difference 1 1.5

C. Diversity exercise: My Genogram 1 3.5

D. Lecture: U.S. Health Care System in the 21st Century 1 1

E. SP exercise: Homeless Mother 1 3.5

F. SP exercise: Latina with Diabetes 1 7

G. PBL exercise: Multi-media case of 50 year-old Latina with stomach pain and family in Guatemala

2 4

H. Workshop: The L.E.A.R.N. model for cultural competent care 2 3.5

I. SP exercise: Mother with Limited English Proficiency, skills using translator 2 3.5

J. SP exercise: African American woman with focus on health care access and health beliefs, sexual orientation

2 3.5

K. SP exercise: Cardiac Transplant Candidates, distribution of technology 2 3.5

L. Lecture: Health Disparities, The Institute of Medicine Report 3 1

M. Book club: The Spirit Catches You and You Fall Down, communication techniques during clerkships

3 4

N. SP exercise: Rape Victim, potential spiritual barriers to pregnancy termination

3 4

O. OSCE: measuring PATIENT CENTERED CARE 3 2

P. OPTIONAL Summer Research Health Services Vulnerable PopulationsQ. OPTIONAL Immersion Experiences (Aesculapian Mexico/Nicaragua)R. OPTIONAL Medical SpanishS. OPTIONAL Primary Care College Discussions on Culture/ Spirituality

1-21-21-24

TOTAL 47 hrs



Working with Interpreters: How student behavior affects quality of patient interaction when

using interpreters

• 152 MSIIs completed the 3-hour workshop

• 1-station OSCE eight weeks later to assess skills

• Based on a 70% passing standard, 39.4% of the class failed.

Psychomotor skills assessed

Emphasis of confidentialityIntroduction of all interview

participantsProper positioningClear communicationObservation of non-verbal cues



Working with Interpreters: How student behavior affects quality of patient interaction when using interpreters

– Two skills seemed particularly problematic: assuring confidentiality (missed by 50%) and positioning the interpreter (missed by 70%).

– While addressing confidentiality did not have a significant impact on standardized-patient satisfaction, interpreter position did. Pre-interview discussion of goals, length, and topics

M SD

Scale Scores

History Taking Overall (12 items) 0.75 0.14

Interview Quality Overall (5 items) 4.60 0.67

Sub-categories

Setting the Stage (4 items) 0.62 0.22

Management (5 items) 0.87 0.16

Patient-Centeredness (3 items) 0.73 0.27



CPX Evaluates Students

28 Items

(3): elicited my explanatory model of my illness (4): took my perspective into account when negotiating treatment (5): appropriately explored my perspective(5): addressed my feelings(5): met my needs(6): a 44 year-old African American male hypertensive

investigated my beliefs about my illness and medications in the historyDiscussed the prevalence of HTN among African-American population



Using OSCEsEvaluation / Lessons Learned

Student

Quintile

Scoreof 28

STUDENT QUINTILE CHARACTERISTICS

1st 12.75 FOCUSED ON DISEASE did not gain perspective of illness or how the patients are affected by the signs or symptoms.

2nd 13.4

3rd 14.4 WILLING TO CHECK A FEW ASSUMPTIONS and if they agreed with treatment plans, may not have explored the patient’s perspective, what contributed to their illness, offered education as to disease.

4th 15.8

5th 16.4 INSTILLED TRUST, ASKED PATIENT HIS/HER INTERPRETATION some probed alternative therapies and spiritual practices, even in this group, four C’s were not always addressed



Using Script Concordance



Comparing to OSCE determined Cultural Competence

•Physician-Patient Interaction items (rated on a 6 point likert scale)

• Appropriately explored my perspective--encouraged me to identify everything that I needed to say • Addressed my feeling--acknowledged and demonstrated interest in my expressed and/or unexpressed

feelings and experience • Met my needs--worked toward a plan which addressed both the diagnosis and my concerns about my

illness•

History taking (checklist rated 1 if done, 0 if omitted)• Explored my belief that medications need only be taken when symptoms are present • Explored my fear of being experimented on • Explored my understanding of high blood pressure • Explored my concerns about having high blood pressure•

Information sharing (checklist rated 1 if done, 0 if omitted)• Explained the complications of high blood pressure • Mentioned the prevalence and/or severity of high blood pressure • Discovered life style risk factors for high blood pressure AND negotiated a plan to help me comply with

a difficulty area.



Correlation SCT and OSCESebastian Uijtdehaage

• Methods• 101 students completed OSCE and responded to clinical vignette of the SCT

– 18 items related to hypertension.– SCT scores were correlated with ten items of the hypertension OSCE that were predetermined to

be relevant to culturally competent care.

• Results– The internal consistency of the SCT was 0.75. – Students who failed to explore the patient’s fear and understanding of hypertension had

significantly lower SCT scores (P = .008)– Modest but significant correlations were found between SCT scores and OSCE cultural

competency scores.

• Findings show that our SCT for culturally competent care has promising psychometric properties. A larger multi-institution validation study is currently underway.

• Next Step to correlate with findings at University of Michigan – Monica Lypson



Ethnopharmacology in a Required Third Year Clerkship

• To address teaching objective determined via Delphi process

• To integrate into a medical school requirement• To make relevant case based during a clinical

rotation– Diabetes as pilot case– Coumadin will be follow yup case



Ethnopharmocology in Diabetes Care

Type II DiabetesThe Roles of Race, Culture, Genetics, Environment, and

Behavior

Ajay Dharia, MS IV

Arleen Brown, MD, PhD



EvaluationPretest/posttest & the Spector of questions on Final



Evaluation / Lessons Learned

• Curricular impact: – Intermittent instruction has yet achieved behaviors to our satisfaction

– We propose 4 years of Patient-Centered Care Curriculum will make a difference

– Goal for students with 4 years, to perform 80% (22 items on CPX)

• All faculty and residents should model Patient-Centered Care at all sites

– Students describe enormous pressure toward insensitivity on rotations

• Sustained cultural competence training to more faculty and students will help



Future Directions• Evaluate results• Use of validated measures (IAPCC)?• Outcomes measures?• Focus groups?• Cross NHLBI collaborations

• DOCTORING/CLINICAL SKILLS– 4 C’s, documentation

• Rest of HB&D– What about more ethnopharmacology, knowledge of epidemiological patterns of disease by race ethnicity and genetics in PBL cases????

• CLINICAL YEARS– Most influential year– Lost opportunities????



Art Gomez, MDArleen Brown, MD PhD

[email protected]@mednet.ucla.edu

mailto:[email protected]

2009 cultural competency arthur gomez md & arleen brown md phd cultural competency curriculum...

Documents

patients health

health caredescribe

health status

health care access

health disparities research

different ethnic groups

use of camidentify

medical students