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Workshop
B-7: Incorporating physician views into the design and implementation
of cultural competence training
Locally defining
cultural competence: A qualitative study of residents’ experiences
and training needs
It is generally accepted that clinical cultural competence is something
that can be taught and learned. However, for cultural competence training
to be effective, it should be context-specific and learner-centered. Prior
assessment of physicians' experiences and difficulties can help to adapt
the content and methods of cultural competency training programs to learners'
specific needs.
Most of the available literature and training materials on clinical
cultural competence come from the U.S. and reflect the specific context
and concerns of health providers working in the U.S. While the general
concepts and approaches of clinical cultural competence appear to be broadly
relevant across contexts, the specific content of cultural competence
training must be adapted to the specific needs and challenges of clinicians
in their local reality.
In this session, results will be presented from a qualitative study
conducted in the general medicine outpatient clinic at the Geneva University
Hospital (Switzerland). The study explored the difficulties encountered
by residents working with socially and culturally diverse patients in
a hospital outpatient clinic in Geneva, Switzerland, with the aim of situating
cross-cultural communication issues within residents’ practice context.
We will discuss the general context of cross-cultural medicine in Geneva,
and how results from this study have informed the development of cultural
competence training activities for medical students and residents. We
will also describe plans for a follow-on study aimed at developing instruments
for measuring clinicians’ clinical cultural competence.
Patricia Hudelson is a medical anthropologist with 15 years experience
in international health. Her work has focused mainly on research and training
aimed at the development of culturally appropriate health programs and
services. Formerly with the World Health Organization, for the past 3
years she has been working in the Department of Community Medicine at
the at the Geneva University Hospital. In addition to conducting research
in the area of cultural competence, she is currently developing courses
for medical students on cross cultural communication, drawing on the concepts
and methods of medical anthropology.
Patricia Hudelson, PhD
Medical Anthropologist
Department of Community Medicine
Geneva University Hospital
Geneva, Switzerland
Patricia.Hudelson@hcuge.ch
Tel: (41 22 ) 372 9669
http://www.hcuge.ch/dmc/
Are Resident
Physicians Prepared to Deliver Quality Care to Diverse Population?
Context: The Institute of Medicine Report “Unequal Treatment”
cited cross-cultural training as a mechanism to address racial and ethnic
disparities in health care, but little is known about residents' preparedness
to provide quality care to diverse populations or the barriers they face
in practice.
Objective: This study explores residents' perceptions of 1) their
preparedness to deliver care to diverse patients; 2) the barriers they
face in delivering such care; and 3) the educational climate for cross-cultural
training at their institution.
Study Design: National survey of over 2000 residents in seven
specialties in their final year of training.
Principal Findings: 97% of residents felt that it is “moderately”
or “very important” for physicians in their specialty “to
consider the patient’s culture when providing care”. Residents
reported that cross-cultural patient issues “often” resulted
in longer than average visits (41% of residents), non-compliance with
treatment (20%), and delays obtaining consent (18%). Although only 8%
of respondents felt unprepared to care for different cultures generally,
many felt unprepared to deliver specific components of cross-cultural
care, including caring for patients with health beliefs at odds w/ western
medicine (25%), who were new immigrants (25%), or whose religious beliefs
affect treatment (19%). In addition, 24% felt they lacked the skills to
identify relevant cultural customs. Major barriers to delivering cross-cultural
care included lack of time (56% saying it was a moderate or big problem),
inadequate training (31%), and lack of role models (31%). 1/3 to 1/2 of
Residents received little or no instruction in specific areas of cross-cultural
care beyond what was learned in med school, and 41% (family medicine)
to 83% (surgery and OB/GYN) received little or no evaluation on cross-cultural
issues during their residencies.
Conclusions: There is room for improvement in the cross-cultural
education of residents. Many residents’ self-assessment points to
a lack of skills and low preparedness to deliver key components of cross-cultural
care. From an educational perspective, they received mixed messages. Cross-cultural
care was perceived to be important and to have implications for quality,
but there was little clinical time to address cultural issues, little
training, and little to no evaluation.
Authors:
Joel S. Weissman, Ph.D.
Joseph Betancourt, M.D., M.P.H.
Elyse Park, Ph.D.
Minah Kim, Ph.D.
Eric G. Campbell, Ph.D.
Brian Clarridge, Ph.D.
Karen Lee, M.D.
Angela Maina, B.S.
Presenter:
Joel S. Weissman, Ph.D., is an Associate Professor of Health
Policy at the Institute for Health Policy at the Massachusetts General
Hospital and Harvard Medical School. Dr. Weissman's main research interests
lie in the areas of health care financing, access to care, and measurement
issues associated with access, quality of care, and risk adjustment. He
has written extensively on the health care disparities, including studies
of delays in care, uncompensated hospital care, and avoidable hospitalizations.
In 1994 he published a book (co-authored by Arnold M. Epstein, M.D.) entitled,
"Falling Through the Safety Net: Insurance Status and Access to Care,"
under Johns Hopkins University Press. The book, with a forward by Hillary
Rodham Clinton, examined how the availability and type of health insurance
affect the amount, location, and quality of health care received.
Dr. Weissman currently divides his time between work on patient safety
and projects aimed at understanding and documenting the social determinants
of health care. He is principal or co-investigator on investigations examining
hospital crowding, weekend care, e-prescribing, patient safety culture,
and the reporting and disclosure of medical errors in hospitals, as well
as studies exploring the socio-cultural determinants of mammography re-screening,
differences in quality of care by racial and ethnicity, and the preparedness
of medical residents to provide cross-cultural care (co-PI with Joe Betancourt,
MD).
Associate Professor, The Institute for Health Policy, Massachusetts
General Hospital/Partners HealthCare System, Inc., and
Lecturer, the Department of Health Care Policy, Harvard Medical School.
Massachusetts General Hospital,
50 Staniford Street, 9th floor,
Boston, MA 02114.
Phone: 617-724-4731,
FAX:617-724-4738,
jweissman@partners.org
Assessing
the impact of a cultural competency training program for family physicians:
results and lessons learned
Providing culturally competent care has been proposed by the Institute
of Medicine as a key strategy for helping to reduce racial and ethnic
health disparities and to ensure diversity in the health care workforce.
Cross-cultural training for physicians and other health care professionals
is one of the specific interventions that has attracted increased interest
and attention. This has led to a growing number of cultural competency
curricula, educational programs, and materials being developed and implemented
in various predoctoral, postdoctoral, and continuing education settings.
An Agency for Healthcare Research and Quality-funded comprehensive review
of the literature carried out by the Johns Hopkins University Evidence-Based
Practice Center found “excellent or good evidence that cultural competence
training can improve provider knowledge, attitudes, and skills and patient
satisfaction,” but “poor or no evidence that cultural competence
training can improve patient adherence or health outcomes.” A recommendation
was made for “more comprehensive and rigorous studies … to guide
education in cultural competence” (Beach MC, et al. Strategies for
Improving Minority Healthcare Quality. File Inventory, Evidence Report/Technology
Assessment Number 90. AHRQ Publication No. 04-E008-02, January 2004. Agency
for Healthcare Research and Quality, Rockville, MD – http://www.ahrq.gov/clinic/minquinv.htm).
In this workshop, we discuss the Center for Healthy Families and Cultural
Diversity’s recently completed Aetna Foundation-funded research project,
"Assessing the Impact of Cultural Competency Training Using Participatory
Quality Improvement Methods." The primary aim of this two-year study
was to assess whether integrating a cultural competency training program
into ongoing quality improvement activities at two large urban family
practice centers affiliated with a medical school would result in: 1)
improved physician knowledge, skills, attitudes, and comfort levels relating
to the care of patients from diverse backgrounds; and 2) increased patient
satisfaction with cross-cultural primary care clinical encounters. A secondary
aim was to learn more from physicians, staff, and patients about the challenges
involved in meeting the USDHSS Office of Minority Health's National Standards
for Culturally and Linguistically Appropriate Services (CLAS) in Health
Care.
We share our project experiences, and selected qualitative findings
derived from depth interviews with the medical directors and office managers,
and focus group interviews with faculty physicians, support staff, and
patients at the two family practice centers. The Cultural Competency
for Health Care Providers Training Program, a series of five, 1.5
hour interactive seminars (total = 7.5 hours), is described. Pre- and
post-training quantitative changes in physician self-perceived knowledge,
skills, attitudes, and comfort levels as measured by a newly-developed
Clinical Cultural Competency Questionnaire are also presented.
We examine challenges in assessing clinical cultural competence, as
well as barriers and facilitators to teaching about cultural competence.
Implications for the future of the “cultural competency movement”
both in the United States and abroad are also explored.
Robert C. Like (M.D., '79, Harvard; M.S., '84, Case Western Reserve)
is a practicing family physician with a background in medical anthropology
who is nationally known for his work in the area of cultural competence
and health professions education. Dr. Like has served as co-chair of the
Society of Teachers of Family Medicine's Group on Multicultural Health
Care and Education, and as a member of the DHHS Office of Minority Health's
CLAS Standards National Project Advisory Committee. He was principal investigator
on an Aetna Foundation-funded study entitled, "Assessing the Impact
of Cultural Competency Training Using Participatory Quality Improvement
Methods," and is consulting to the European Union’s Migrant
Friendly Hospitals initiative. Dr. Like is a 2004 Pfizer/American Academy
of Family Physicians Foundation Visiting Professor in Family Medicine,
and is actively involved in providing training and technical assistance
relating to the delivery of culturally responsive, patient-centered care
to diverse populations.
Robert C. Like, M.D., M.S.
Associate Professor and Director
Center for Healthy Families and Cultural Diversity
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
1 Robert Wood Johnson Place
New Brunswick, N.J. 08904
phone: 732-235-7662
fax: 732-246-8084
like@umdnj.edu
http://www2.umdnj.edu/fmedweb/chfcd/index.htm
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