The Role of Culture in the The Role of Culture in the Training of Health Care Training of Health Care

Professionals: Professionals: A Multidisciplinary Panel A Multidisciplinary Panel

Danny M. Takanishi, Jr., MD, FACSDanny M. Takanishi, Jr., MD, FACS

Professor and ChairProfessor and Chair

Department of SurgeryDepartment of Surgery

University of HawaiiUniversity of Hawaii

October 7, 2011October 7, 2011

DISCLOSUREDISCLOSURE• No DisclosuresNo Disclosures• The content of this presentation reflects my The content of this presentation reflects my

perspectives, and not the Organizations I have perspectives, and not the Organizations I have the honor to servethe honor to serve• ACGME Transitional Year Residency Review

Committee, Chair• ACGME Council of Review Committees• ACGME Common Program Requirements Committee,

Chair• National Board of Medical Examiners/USMLE Step II

Surgery Test Material Development Committee, Chair• Hawaii Medical Board, Chair

Learning ObjectivesLearning Objectives

• At the end of this session the Learner will be At the end of this session the Learner will be able to:able to:• Discuss the salient role of cultural competency in Discuss the salient role of cultural competency in

medical education;medical education;

• Describe how accreditation requirements ensure Describe how accreditation requirements ensure curricular integration of cultural competency curricular integration of cultural competency initiatives;initiatives;

• Demonstrate an understanding of how the Demonstrate an understanding of how the Milestones Project serves to further enhance Milestones Project serves to further enhance competency-based medical education.competency-based medical education.

What is Cultural Competency?What is Cultural Competency?

• Set of Congruent Behaviors, Knowledge, Set of Congruent Behaviors, Knowledge, Attitudes, and PoliciesAttitudes, and Policies

• Involve a System or OrganizationInvolve a System or Organization• Enables effective work in cross-cultural Enables effective work in cross-cultural

situationssituations

What is Cultural Competency?What is Cultural Competency?

• ““CultureCulture” = integrated patterns of human ” = integrated patterns of human behaviorbehavior– Language, Thoughts, Actions, Customs, BeliefsLanguage, Thoughts, Actions, Customs, Beliefs– Institutions of Racial, Ethnic, Social, Religious Institutions of Racial, Ethnic, Social, Religious

GroupsGroups

• ““CompetenceCompetence” = having the capacity to ” = having the capacity to function effectivelyfunction effectively– Cultural beliefs, Practices, Needs presented by Cultural beliefs, Practices, Needs presented by

PatientsPatients

What is Cultural Competency?What is Cultural Competency?

• Patient/Family-centered CarePatient/Family-centered Care• Social and Cultural InfluencesSocial and Cultural Influences• Quality of Medical Services and TherapyQuality of Medical Services and Therapy

LCME 2011LCME 2011(IS-16) The LCME and the CACMS believe that aspiring (IS-16) The LCME and the CACMS believe that aspiring future physicians will be best prepared for medical practice in future physicians will be best prepared for medical practice in a diverse society if they learn in an environment characterized a diverse society if they learn in an environment characterized by, and supportive of, diversity and inclusion. Such an by, and supportive of, diversity and inclusion. Such an environment will facilitate physician training in:environment will facilitate physician training in:• Basic principles of culturally competent health care.Basic principles of culturally competent health care.

• Recognition of health care disparities and the development of solutions to Recognition of health care disparities and the development of solutions to such burdens.such burdens.

• The importance of meeting the health care needs of medically The importance of meeting the health care needs of medically underserved populations.underserved populations.

• The development of core professional attributes (e.g., altruism, social The development of core professional attributes (e.g., altruism, social accountability) needed to provide effective care in a multidimensionally accountability) needed to provide effective care in a multidimensionally diverse society.diverse society.

LCME 2011LCME 2011

(ED-21) The faculty and medical students of a medical (ED-21) The faculty and medical students of a medical education program must demonstrate an understanding of education program must demonstrate an understanding of the manner in which people of diverse cultures and belief the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various systems perceive health and illness and respond to various symptoms, diseases, and treatments.symptoms, diseases, and treatments.

Instruction in the medical education program should stress the need Instruction in the medical education program should stress the need for for medical students to be concerned with the total medical needs of medical students to be concerned with the total medical needs of their their patients and the effects that social and cultural circumstances have patients and the effects that social and cultural circumstances have on on patients’ health. To demonstrate compliance with this standard, the patients’ health. To demonstrate compliance with this standard, the

medical education program should be able to document objectives medical education program should be able to document objectives relating to the development of skills in cultural competence, indicate relating to the development of skills in cultural competence, indicate

the the location in the curriculum where medical students are exposed to location in the curriculum where medical students are exposed to such such material, and demonstrate the extent to which the objectives are material, and demonstrate the extent to which the objectives are being being achieved.achieved.

LCME 2011LCME 2011

(ED-22) Medical students in a medical education program (ED-22) Medical students in a medical education program must learn to recognize and appropriately address gender must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the and cultural biases in themselves, in others, and in the process of health care delivery.process of health care delivery.

The objectives for instruction in the medical education program The objectives for instruction in the medical education program should include medical student understanding of demographic should include medical student understanding of demographic influences on health care quality and effectiveness (e.g., racial influences on health care quality and effectiveness (e.g., racial

and and ethnic disparities in the diagnosis and treatment of diseases). ethnic disparities in the diagnosis and treatment of diseases). The The objectives should also address the need for self-awareness objectives should also address the need for self-awareness among among medical students regarding any personal biases in their medical students regarding any personal biases in their approach approach to health care delivery.to health care delivery.

THE ACGMETHE ACGME

• Founded in 1981Founded in 1981• Mission: To improve health care by assessing Mission: To improve health care by assessing

and advancing the quality of resident and advancing the quality of resident physicians’ education through exemplary physicians’ education through exemplary accreditationaccreditation

• 28 Review Committees28 Review Committees• 8,734 accredited Residencies8,734 accredited Residencies• 130 Specialties and Subspecialties130 Specialties and Subspecialties• Approximately 111,000 active ResidentsApproximately 111,000 active Residents

THE ACGMETHE ACGME

AMA AAMC CMSS AHA ABMS

ACGME BOARD OF DIRECTORS

ACGME

26 RESIDENCY REVIEW COMMITTEESTRANSITIONAL YEAR REVIEW COMMITTEE

INSTITUTIONAL REVIEW COMMITTEE

COUNCIL OF REVIEW COMMITTEE CHAIRS

COUNCIL OF REVIEW COMMITTEE RESIDENTS

THE FOCUS OF GRADUATE MEDICAL THE FOCUS OF GRADUATE MEDICAL EDUCATION HAS CHANGEDEDUCATION HAS CHANGED

• The PastThe Past Process oriented with focus on Process oriented with focus on “what is covered”“what is covered”

• The PastThe Past Then focus was on “what Then focus was on “what residents are able to do as a result of their residents are able to do as a result of their training”training”

• The PresentThe Present Focus is on patient outcome Focus is on patient outcome

The Six CompetenciesThe Six Competencies

– Medical KnowledgeMedical Knowledge

– Patient CarePatient Care

– Practice Based Learning and Practice Based Learning and ImprovementImprovement

– Systems Based PracticeSystems Based Practice

– Interpersonal and Communications SkillsInterpersonal and Communications Skills

– ProfessionalismProfessionalism

Medical KnowledgeMedical Knowledge

• Residents must demonstrate knowledge about Residents must demonstrate knowledge about established and evolving biomedical, clinical, established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-and cognate (e.g. epidemiological and social-behavioral) sciences and how to apply this behavioral) sciences and how to apply this knowledge to patient care. knowledge to patient care.

– AcquisitionAcquisition

– AnalysisAnalysis

– ApplicationApplication

Patient CarePatient Care

• Residents must be able to provide patient care Residents must be able to provide patient care that is compassionate, appropriate, and that is compassionate, appropriate, and effective for the treatment of health problems effective for the treatment of health problems and the promotion of health.and the promotion of health.– Gathering informationGathering information– SynthesisSynthesis– Partnering with patients/familiesPartnering with patients/families

Practice Based Learning and Practice Based Learning and ImprovementImprovement

• Residents must be able to investigate and Residents must be able to investigate and evaluate their patient care practices, appraise evaluate their patient care practices, appraise and assimilate scientific evidence, and improve and assimilate scientific evidence, and improve their patient care practices. their patient care practices. – Life-long learningLife-long learning– Evidence based medicineEvidence based medicine– Quality improvementQuality improvement– Teaching skillsTeaching skills

Systems-based PracticeSystems-based Practice

• Residents must demonstrate an awareness of Residents must demonstrate an awareness of and responsiveness to the larger context and and responsiveness to the larger context and system of health care and the ability to system of health care and the ability to effectively call on system resources to provide effectively call on system resources to provide optimal health careoptimal health care– Health care delivery systemHealth care delivery system– Cost effective practiceCost effective practice– Patient safety and advocacy/Systems causes Patient safety and advocacy/Systems causes

of errorof error

ProfessionalismProfessionalism

• Residents must demonstrate professionalism, as Residents must demonstrate professionalism, as manifested through a commitment to carrying manifested through a commitment to carrying out professional responsibilities, adherence to out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse ethical principles, and sensitivity to a diverse patient population patient population – Professional behaviorProfessional behavior– Ethical principlesEthical principles– Cultural competenceCultural competence

Teaching ProfessionalismTeaching Professionalism

ContentContent• Cultural CompetenceCultural Competence

SettingSetting• Clinical teachingClinical teaching• Case based teachingCase based teaching• Interactive WorkshopsInteractive Workshops• Lecture/Conference/SeminarLecture/Conference/Seminar• Institutional InitiativesInstitutional Initiatives• Role modelingRole modeling• MentoringMentoring

Interpersonal and Interpersonal and Communication SkillsCommunication Skills

• Residents must be able to demonstrate Residents must be able to demonstrate interpersonal and communication skills that interpersonal and communication skills that result in effective information exchange and result in effective information exchange and teaming with patients, their patients families, teaming with patients, their patients families, and professional associates. and professional associates.

Communicating with patients and familiesCommunicating with patients and familiesCommunicating with team membersCommunicating with team membersScholarly CommunicationScholarly Communication

QUALITY CARE AND QUALITY CARE AND PROFESSIONALISM TASK FORCEPROFESSIONALISM TASK FORCE

• Proposed New Standards directed at:Proposed New Standards directed at:– Resident Duty HoursResident Duty Hours– Fatigue MitigationFatigue Mitigation– Resident SupervisionResident Supervision– Transitions of CareTransitions of Care– Clinical ResponsibilitiesClinical Responsibilities– Patient SafetyPatient Safety– Quality Improvement SystemsQuality Improvement Systems– Interdisciplinary Teams Interdisciplinary Teams

JCAHO LOOKS TO ACGME FOR JCAHO LOOKS TO ACGME FOR MEDICAL STAFF STANDARDSMEDICAL STAFF STANDARDS

• EFFECTIVEEFFECTIVE = OUTCOMES = OUTCOMES (e.g., mortality rates)(e.g., mortality rates)

• APPROPRIATEAPPROPRIATE = PROCESSES = PROCESSES(i.e., core measures)(i.e., core measures)

• COMPASSIONATECOMPASSIONATE = = COMMUNICATION WITH PATIENTS COMMUNICATION WITH PATIENTS AND FAMILIES AND FAMILIES (e.g., informed consent) (e.g., informed consent)

Milestones ProjectMilestones Project

• MilestoneMilestone““Behavior, attitude, or outcome Behavior, attitude, or outcome related to general related to general

competency domains competency domains that describe a significant that describe a significant accomplishment expected of a Resident accomplishment expected of a Resident by a by a particular point in time.”particular point in time.”

Susan Swing, PhDSusan Swing, PhD

Vice-President, Outcome AssessmentVice-President, Outcome Assessment

ACGME ACGME

MilestonesMilestones

Core PrinciplesCore Principles

• The ACGME Competencies provide the The ACGME Competencies provide the frameworkframework

• Context is Context is Patient CarePatient Care• Medical Education is a continuumMedical Education is a continuum

– UMEUME GMEGME CPD/MOCCPD/MOC

• Behavioral descriptors provide developmental Behavioral descriptors provide developmental modelmodel

• Concept of “Stop Points” Concept of “Stop Points”

PROFICIENT EXPERT

NOVICE ADVANCED BEGINNER COMPETENT

NRMP Match ENTRY TESTING

INITIAL TRAININGSKILLS TESTING

MILESTONESSUMMATIVE

EXAMINATION

CONDITIONALINDEPENDENCE

FINAL EXAMINATION

INDEPENDENCEMOC

Assessment and ReportingAssessment and Reporting

Resident Evaluation

and Promotion Committee

Semi-Annual Feedback Meeting

Report to ACGME

1 – Global Scores

2 – Scored Assessments

BenefitsBenefits

• Refines/Reframes the CompetenciesRefines/Reframes the Competencies• Provides for development of national benchmarks Provides for development of national benchmarks

for outcomes assessmentfor outcomes assessment• Provides for improved reporting (“national Provides for improved reporting (“national

accountability”)accountability”)• Improves Transparency (Resident expectations)Improves Transparency (Resident expectations)• Improves Resident FeedbackImproves Resident Feedback

– Earlier identification of deficitsEarlier identification of deficits

BenefitsBenefits

• Provides gap analysis to ProgramsProvides gap analysis to Programs• Informs Curriculum development processInforms Curriculum development process• Promotes patient safetyPromotes patient safety• Improves confidence with decision makingImproves confidence with decision making