ascertaining resident physicians’ attitudes, perceptions and practices related to cultural...

Ascertaining Resident Physicians’ Attitudes, Perceptions and Practices

Related to Cultural Competency Training

Ilana S. Mittman, PhD, MS; David A. Mann, MD, PhDCarlessia A. Hussein, DrPH, RN and Mary C. Russell, PhD

Maryland Department of Health and Mental HygieneOffice of Minority Health and Health Disparities

Sixth National Conference on Quality Health

Care for Culturally Diverse Populations

Minneapolis, Minnesota

September 23, 2008

1409 – Resident Physicians’ Attitudes on Cultural Competency

1409 - Resident Physicians’ Attitudes on Cultural Competency

Benefits of Cultural Competence• Greater quality of provider-patient communication• More successful patient education (higher

information recall)• Increased patient health-seeking behavior• Increased patient satisfaction• Increased use of preventive services, and reduced use

of acute care services.• Fewer diagnostic errors• Greater adherence to treatment regimen • Increased trust in the provider

Cooper et al., 2003; The Diversity Research Forum, Summer 2007


Should Cultural Competency Training (CCT) Be Mandated?

• Mandating health professionals’ education in cultural competency (and in general) has been controversial

• Historically, traditional measures of continuing education mandate only attendance not learning and have no measurable performance end point

• Although states have taken steps to mandate CCT, providers’ attitudes about the utility of CCT and issues of enforcement have not been studied yet

• Comparisons between states that have implemented mandatory training to others than have not yet taken place

• The effectiveness of encouragements only - not studied


Cultural Competency Legislation in the U.S.• New Jersey SB 144 – physicians required to receive CCT as pre-requisite for

licensure/re-licensure

• California AB 144 – All continuing medical education courses must contain CC curricula (unless exempt)

• Washington SB 6194 – Each program poised to train healthcare providers in an accredited discipline must include a course in “multicultural health”

• Maryland SB 905, 942 and 883 – Recommending development of cultural competency training; mandating reporting of cultural diversity efforts and cultural competency courses

• New Mexico SB 600 – Enactment of health education cultural competency task force


Legislation Mandating or Strongly Requiring CulturalCompetency Training – U.S.Source: US Dept of Health and Human Services, 2008

Purple – Legislation referred to committee

Navy Blue – Legislation passed, requiring or strongly recommending CCT

Royal Blue – Legislation died in committee or vetoed

WA

CA

NMAZ

CO IL

FL

NJ

NY

OH

GA

MD


Cultural Competency Directives U.S.

• The Joint Commission on Hospital Accreditation (JCOHA)

• The Liaison Committee on Medical Education (LCME)

• The Accreditation Council for Graduate Medical Education (ACMGE)

• Center for Medicare and Medicaid Services (CMS)


The Maryland Case• Maryland ranks second nationally with respect to

active physicians, with 355.0 per 100,000

• Maryland ranks 6th in training of resident physicians

• Maryland is home to prestigious teaching hospitals taking in trainees from around the nation and the world

• Maryland is highly diverse with its population being 41% racial/ethnic minority, and 12.2% being foreign born in 2006


Encouraging Cultural Competency Training: Maryland House Bill 883 (2003)

• 20-801: “encourage courses or seminars that identify and eliminate Health care services disparities of minority populations”

• 20-803: “health care professionals licensing may offer/require staff to take courses on disparities”


First Attempt to Mandate CCTMaryland HB 1295 (2006)

• Proposed requiring schools of medicine to include instruction on cultural competency as a pre-requisite for graduation

• Proposed requiring completion of cultural competency education as a pre-requisite for licensure and re-licensure

• Faced fierce opposition and was amended to require the Department of Health and Mental Hygiene (DHMH) to organize a workgroup of representatives from the Health Occupations Boards and the Office of Minority Health and Health Disparities (MHHD) to discuss specific recommendations

• Amended bill failed and a voluntary partnership between DHMH and the Boards was established


Second Attempt to Mandate CCTMaryland HB 100 (2007)

• Stipulated the convening of a workgroup to require each health occupational board to develop recommendations for requiring individuals licensed by the boards to receive instruction in cultural competency

• Facing fierce opposition the bill was withdrawn in March of 2007


Mandated Reporting of CCT ActivitiesMaryland HB 905 & HB 942 (2008)

Public and private higher education institutions required to report their “cultural diversity” initiates to the legislature, state bodies overseeing higher education and the Office of Minority Health and Health Disparities


A Study to Inform Future Cultural

Competency Legislation Exploratory Questions:

1. Given encouragement only (HB 883) what is the existing degree of cultural competency training in Maryland Hospitals?

2. What are existing attitudes about cultural competency training among Maryland healthcare providers?

3. What is the providers’ knowledge about national guidelines on cultural competency training?

4. Are there differences in the responses based on participant demographics?


Research Design

Develop and disseminate a survey to assess existing practices, perceptions and preferences on CCT

a) Pilot a survey to resident physicians in three community hospitals in Maryland

b) Amend survey based on responses and expand to include additional hospital and health workers in Maryland

c) Collaborate with states who already have mandated CCTd) Make comparisons among disciplines and among states

This presentation focuses on the pilot study only


Target Population

1. Three community-based hospitals serving medically underserved areas - internal medicine residency program

2. One large teaching hospital situated within a diverse low-income population – anesthesiology residency program


The Survey

Administered on-line (SurveyMonkey)

• Participant demographics

• Assessment of existing cultural competency training

• Measure attitudes and perceptions related to cultural competency training (A four-point Likert Scale)

• Measure knowledge of national and state guidelines pertaining to cultural competency


Survey Participants Demographics (n=55)

Asian 16 29.1%White (US born) 18 32.7%White (foreign-born) 9 16.4%Black 3 5.4%Hispanic 3 5.4%American Indian 1 1.8Unknown 5 9.2%

Females 27 50.9%


Survey Participants Demographics (n=55)

Anesthesiology 17 31%Internal Medicine 38 69%

Attending 2 3.6%Chief 2 3.6%Students 2 3.6%R-1 25 45.5%R-2R-3

1419

25.5%18.2%


“Cultural competency training is mandatory in my hospital”

0

2

4

6

8

10

12

A B C D

Hospitals

Yes

No

Unsure


PerceptionsAgree (%)

Disagree (%)

My institution currently has a formal cultural competency training program for house staff

54.5 41.8

Cultural competency is important 94.5 5.6

CCT is too difficult to implement in residency 21.8 78.2

CCT can improve providers’ cultural competency 94.5 5.6

I am satisfied with the existing CCT in my institution 70.9 27.3

There is evidence that CC enhances health outcome 81.8 14.5

CCT increases quality of care 94.5 5.6

Ethnic/racial concordance not important 32.7 63.6

Cultural competency should be acquired at home and can not be taught

5.4 92.7

On-line training is better for my schedule 52.7 43.6


Perceptions by Specialty Type(statistically significant comparisons)

Item Median (Mean)

(Since the distribution is not normal, and the variables are ordinal we have conducted the Mann-Whitney Test. Both medians and means are displayed because medians of the groups overlap. See next graph for illustration)

AnesthesiaN=17

Internal MedicineN= 38

P value(Mann-Whitney Test)

Cultural competency is important 3 (2.8) 4 (3.5) 0.001

CCT too difficult to implement in residency 2 (2.3) 2 (1.9) 0.017

CCT can improve providers’ cultural competency 3 (2.8) 3 (3.3) 0.003

Cultural competency should be acquired at home and cannot be taught

2 (1.9) 2 (1.6) 0.036


Perceptions by Gender(statistically significant comparisons)

Item Median (Mean)

(Since the distribution is not normal, and the variables are ordinal we have conducted the Mann-Whitney Test. Both medians and means are displayed because medians of the groups overlap. See next graph for illustration)

FemaleN=27

MaleN= 26

P value(Mann-Whitney Test)

Cultural competency is important 4 (3.5) 3 (3.0) 0.007

CCT too difficult to implement in residency 2 (1.8) 2 (2.3) 0.01

There is evidenced that enhanced CCT improves health outcome

3.0 (3.2) 3.0 (2.7) 0.05


Example of Distribution of Responses by Specialty to the Statement:

“Cultural competency is important in healthcare delivery”

2

01

0

12

20

2

18

0

2

4

6

8

10

12

14

16

18

20

Number of Responses

StronglyDisagree

Disagree Agree StronglyAgree

Anesthesia

Internal Medicine


Awareness of National Guidelines: Responses to the Statement:

“Do the following bodies either require or recommend cultural competency preparedness of medical staff?”

0

5

10

15

20

25

30

35

40

Number

AAMC LCME JCAHO AAFP HRSA

Accreditation Bodies

Yes

No

Not Sure


Reported Training StylesTraining Style Number %

Web-based 16 29.1

Didactic 13 23.6

Workshops/

seminars

14 25.4

Community Immersion

10 18.2

Grand rounds 10 18.2


Results Highlights (1)

• The majority of respondents agreed with the importance and utility of CCT

• The majority of respondents disagreed that CCT is too difficult to teach in residency

• There is confusion about requirements related to CCT even within one’s institution

• The vast majority of respondents were unsure about licensing and accreditation boards’ recommendations related to CCT


Results Highlights (2)• There were no statistically significant differences in

perceptions related to CCT between minorities and non-minorities

• There were significant differences by specialty type in the strength of agreement that CCT is important (internal medicine agreeing more strongly)

• There were significant differences by gender in the strength of agreement that CCT is important (women agreeing more strongly)

• Some findings of this study (regarding interest and level of formal training) are supported by earlier studies (Park et al., 2006)


Conclusions and Recommendations• Overall, in our study, physicians in residency regardless of

race and ethnicity recognize the importance of CCT and do not view the training as a hard task

• Residents with more limited patient contact may be less likely to value CCT

• Teaching faculty and residency directors must communicate CCT recommendations and guidelines put forth by the institution and by external accreditation agencies

• CCT is essential in residency, often the last point of supervised medical training


Study Limitations

• Convenience sampling – external validity• Small sample size• Volunteer participation may introduce a

selection bias (in favor of CCT)• Comparisons between specialties should be

made with physicians within the same hospital


Future Studies

• Survey to be disseminated to the entire healthcare workforce in Maryland hospitals comparing specialties (60 hospitals in MD)

• Perceptions related to mandated training for graduation; licensing and re-licensing to be ascertained

• Comparisons to be made with states that have implemented mandatory training


Contact Information

Minority Health and Health DisparitiesMaryland Department of Health and Mental Hygiene

201 West Preston Street, Room 500Baltimore, MD 21201Phone: 410-767-7117

Fax: 410-333-5100Email: [email protected]

Website: www.mdhealthdisparities.org

mailto:[email protected]

http://www.mdhealthdisparities.org/

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