Cultural Competency

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Cultural Competency The Evolution of Early,
Integrated Education For Medical Students,
Residents and Faculty at One Institution
Maria L. Soto-Greene, M.D. Vice President,
Hispanic Serving Health Professions Schools,
Inc. Senior Associate Dean for Education Director,
Hispanic Center of Excellence New Jersey Medical
School Newark, New Jersey
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Overview

• Developing, integrating, and evaluating a
  cultural competency curriculum for
• Medical students
• Medical residents
• Faculty
• Hospital interpreters

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Overall Goal

• Adapted from the Promoting, Reinforcing, and
  Improving
• Medical Education (PRIME) project by the American
• Medical Student Association (AMSA) and HRSA with
• expectation that
• Students will learn about culture and diversitys
  role in medicine
• Students will learn the importance of being
  culturally competent
• Students will develop cultural and linguistic
  competency through participation in a variety of
  clinical experiences while completing a community
  learning experience

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Comprehensive Curriculum

• 1st year
• Art of Medicine Course
• History Physical Exam Course
• Administration of the Health BELIEF Attitude
  Survey
• 2nd year
• Communications exercise during the Introduction
  to Clinical Medicine course
• Teach students how to conduct a triadic interview

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Comprehensive Curriculum (contd)

• 3rd year
• Expansion of training into third year clerkships
  with concomitant faculty training.
• 4th year
• Graduation Objective Structured Clinical
  Examination (OSCE) that assesses our graduates
  cultural and linguistic competency skills.
• Re-administering the Health BELIEF Attitude
  Survey.

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

• Introduced new components to the history
• Trained H P faculty on these additional
  components
• Introduced the appropriate use of an interpreter
• Integrated these components into the ambulatory
  preceptorships in the community

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Students Views

• The Health BELIEF Attitude Survey is an
  instrument used to assess how important students
  consider obtaining a patients health care view
  points.
• This survey was developed and piloted at UTHSC at
  San Antonio by their HCOE, a HSHPS member, and
  Society of Teachers of Family Medicine
  Foundation.

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ETHNIC A Framework for Culturally Competent
Clinical Practice

• E Explanation
• What do you think may be the reason you have
  these symptoms?
• What do friends, family, and others say about
  these symptoms?
• Do you know anyone else who has had or who has
  this kind of problem?
• Have you heard about/read/seen it on
  TV/radio/newspaper?
• (If the patient cannot offer an explanation,
  ask what most concerns them about their
  problems).
• Developed by Steven J. Levin, M.D.
• Robert C. Like, M.D., M.S., Jan E. Gottlieb,
  M.P.H.
• Department of Family Medicine
• UMDNJ-Robert Wood Johnson Medical School

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ETHNIC Contd

• T Treatment What kinds of medicines, home
  remedies or other treatments have you tried
  for this illness?
• Is there anything you eat, drink or do (or
  avoid) on a regular basis to stay healthy?
  Tell me about it.
• What kind of treatment are you seeking from
  me?
• H Healers Have you sought any advice from
  alternative/folk healers, friends or other
  people (non-doctors) for help with your
  problems? Tell me about it.
• Developed by Steven J. Levin, M.D.
• Robert C. Like, M.D., M.S., Jan E. Gottlieb,
  M.P.H.
• Department of Family Medicine
• UMDNJ-Robert Wood Johnson Medical School

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ETHNIC Contd

• N Negotiate Negotiate options that will be
  mutually acceptable to you and your patient
  and that do not contradict, but rather
  incorporate your patients beliefs.
• I Intervention Determine an intervention with
  your patient. May include incorporation of
  alternative treatments, spirituality, and
  healers as well as other cultural practices
  (e.g. food eaten or avoided in general and when
  sick).
• C Collaboration Collaborate with the patient,
  family members, other health care team
  members, healers and community resources.
• Developed by Steven J. Levin, M.D.
• Robert C. Like, M.D., M.S., Jan E. Gottlieb,
  M.P.H.
• Department of Family Medicine
• UMDNJ-Robert Wood Johnson Medical School

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Introduction of Culture

• Glossary of Cultural Terms
• Case studies from the AMSA project
• Cultural and Spiritual Beliefs
• Complementary and Alternative Medicine (CAM)

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Definition of Culture

• We adopted, with some modification, the broader
  definition
• of cultural and linguistic competency recommended
  by
• HRSA in its publication Cultural Competence
  Works 2001.
• Cultural Linguistic is a set of congruent
  behaviors, attitudes, policies and procedures
  that come together in a system, agency or among
  professionals which enable they system, agency,
  or those professionals to work effectively and
  efficiently in cross-cultural and diverse
  linguistic situations on a continuous basis.

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INTERPRET

• I Prior to session, introductions take place.
  Interpreter introduces her/himself to provider.
  Provider introduces interpreter to patient.
• N Interpreter tells provider if patient says
  she/he is a non-citizen or an illegal immigrant.
• T The provider and interpreter should develop
  trust between themselves
• and with the patient.
• E To achieve effectiveness, provider talks
  directly to patient in the first person speaks
  in small segment and clarifies technical terms.
  Interpreter is linguistically competent speaks
  simply and clearly in the first person explains
  cultural and linguistic topics interprets
  everything said without adding or deleting
  stops provider and patient if they are speaking
  too long and refrains from offering advice.

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INTERPRET (contd)

• R The provider has the lead role. When working
  with an untrained interpreter, the provider is
  also responsible for explaining the
  interpreters roles and duties as outlined on
  this card to the interpreter.
• P Proper positioning is crucial. Provider
  faces patient. Interpreter sits beside and
  slightly behind patient. Avoid triangular
  dynamics.
• R Useful resources include the following
• Diversity Rx http//www.DiversityRX.org
• Bilingual Dictionaries http//www.ibdltd.com
• MA Medical Interpreter Assoc.
  http//www.mmia.org
• E The provider and interpreter put ethics into
  practice. They exercise confidentiality and a
  non-judgmental attitude.
• T A culturally competent triadic interview
  involves an ample timeframe. Learn to work
  effectively and efficiently.

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Third year medical students

• Began by pilot testing a cross cultural
  curriculum with 40 third year medical students
  during their medicine clerkship.
• Assessed level of competency at baseline and
  after the curriculum using 2 modalities.

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Medical Student Objective Structured Clinical
Examination
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Results

• Students in the cross cultural curriculum had
  higher exam scores and higher levels of
  confidence and satisfaction. All 40 students had
  the same level of interest in cross cultural
  issues.
• Goal to develop an integrated third year medical
  student curriculum that emphasis sociocultural
  issues throughout their rotations.

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Graduation Objective Structured Clinical
Examination (OSCE)

• At the core of this examination is the
  doctor-patient communication.
• OSCEs are used to assess the core skills,
  knowledge and attitudes of tomorrows physicians
  including more recently in licensure.
• Specifically, our OSCE will test a students
  ability to communicate using cross cultural
  principles.

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Cultural Competency Training Medical Residents

• Assess level of need and competency at
  baseline.
• Assess effectiveness of curriculum with the goal
  of implementing a formal cultural competency
  residency training program.
• A determinant of success is whether the medical
  resident trained receives increased patient
  satisfaction when working with diverse cultural
  groups.

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Medical Residents
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Medical Interpreter Training

• Pilot project funded by the State of NJ to train
  volunteer hospital medical interpreters.
• 16 interpreters participated in a one day medical
  interpreting and cultural competency training
  program.
• curriculum focused on attitudes, knowledge, and
  skills

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Medical Interpreter Training Program Results
and Outcomes

• Trained interpreters received high patient and
  physician satisfaction scores in the clinical
  setting.
• Trained interpreters found that physicians do not
  know how to use an interpreter appropriately.
• An Interpreter Training Curriculum was submitted
  to the State of NJ.
• University Hospital now funds a program to train
  all interpreters.

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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.
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Every clinical encounter is cross-cultural

• No one way to treat a racial or ethnic group
  given the great sociocultural diversity
• Need to have a Framework of interventions that
  can be individualized
• A one size fits all health care system cannot
  meet the needs of an increasingly diverse
  American population

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Organizational and Health Care Policies

• Develop a mission statement that articulates
  principles, rationale, and values for culturally
  and linguistically competent health care service
  delivery
• Ensure consumer and community participation

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Organizational and Health Care Policies (contd)

• Implement processes that review policies and
  procedures to assess relevance of initiatives
  launched
• Implement legislation that provides resources
  (i.e. funding from Titles VII VIII, NIH,
  private sector, etc.) that supports ongoing
  professional development and in-service training
  for culturally and linguistically diverse
  communities

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Cultural Competency Training and Education

• To succeed, we must have
• Research Agendas
• Evaluation Tools
• Uniformity at all levels - both state and
  federal
• Legislation with appropriate levels of funding
  to ensure that there is the level of training
  that ensures equal access and care for all
  Americans.