Transcript Document

2009
Cultural Competency
Cultural Competency
Curriculum Development
Art Gomez, MD & Arleen Brown MD, PhD
DGSM at UCLA
NIH Grant K07 HL-04-012
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Background
Culture and Medicine
Our increasingly diverse society.
The impact of culture on patient’s health.
Evidence of Health Disparities
Cross-Cultural Curricula needed
No Consensus RE- Educational Objectives
Question of appropriate approach
Patient-Centered Care.
Ethnic and Racial Database
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Purpose
 Develop a set of common learning
objectives for medical students linking
health disparities research to crosscultural medical education.
 Gain MEC approval of these objectives
 Use them in developing curricula
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Methods
 Use an Expert Consensus Panel to
produce a set of objectives
 Delphi Technique
 Faculty members recognized as experts in the
culture and health from Drew, UCLA and UCSF
area of
 Review existing sets of objectives
The California Endowment
 Office of Minority Health
 AAMC
 Review existing UCLA Curriculum
Arthur Gomez MD & Arleen Brown MD PhD
Educational Objectives
2009
Cultural Competency
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
Arthur Gomez MD & Arleen Brown MD PhD
Educational Objectives
2009
Cultural Competency
 The proverbial three-legged stool
“to support any weight not fully supported by the other two”
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
Affective Domain
Cognitive Domain
Psychomotor Domain
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
Affective 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.
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
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
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
Cognitive 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”
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
 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
Arthur Gomez MD & Arleen Brown MD PhD
Learning Objectives
2009
Cultural Competency
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
Arthur Gomez MD & Arleen Brown MD PhD
Our solution
2009
Cultural Competency
We addressed this challenge by introducing a
cultural competence curriculum:

to develop UCLA medical student knowledge, skills, and
attitudes to deliver patient-centered care,
– a) understand culture’s role
in doctor-patient relations
– b) appreciate complexity of
cultural awareness
– c) incorporate a biopsychosocial perspective,
– d) appreciate racial, spiritual,
cultural diversity
– e) interview effectively with
diverse populations
– f) become aware of health
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
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
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Updating current Modules and Module Development Doctoring
Foundations
Clinical Clerkship
process for Future
Arthur Gomez MD & Arleen Brown MD PhD
Faculty Development
2009
Cultural Competency
• Instructors:
– Paula Henderson, Art Gomez, Jacqueline Bowles, Felice Miller. LuAnn
Wilkerson,Kenneth Wolf, Robert Collins, Johanna Shapiro (UC Irvine)
• Participants:
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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
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Evaluation of Faculty Development
FACULTY LEADERS
(* p<= .1; ** p<=.05)
Pre-Curric
Knowledge
Mean
SD
Post-Curric
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
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
Skills
Arthur Gomez MD & Arleen Brown MD PhD
Faculty Fellow Products
2009
Cultural Competency
• 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)
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
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
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Sample Standardized Patients in
Doctoring
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A Homeless Mother
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Communicate with a vulnerable patient
Elicit barriers to care
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A Diabetic
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Address adherence to diet and
medication
Assess a patient with alternative beliefs
on pathophysiology
Convince a patient with no symptoms
An Immigrant Parent and Son
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Trust in Relation to Health and
Adherence
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Cardiac Transplant Candidates
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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
•
Interview a mother of a patient through
an interpreter
Face challenge of the triadic interview
Show sensitivity and respect toward
alternative treatments including herbals
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
Arthur Gomez MD & Arleen Brown MD PhD
Using the Arts to Teach
2009
Cultural Competency
• “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
Arthur Gomez MD & Arleen Brown MD PhD
Using the Arts to Teach
2009
Cultural Competency
• “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
Curricular Activity
A. Theatrical performance: Slice of Rice, Frijoles, & Greens
Year
2009
Cultural
1 Competency
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 Populations
Q. OPTIONAL Immersion Experiences (Aesculapian Mexico/Nicaragua)
R. OPTIONAL Medical Spanish
S. OPTIONAL Primary Care College Discussions on Culture/ Spirituality
1-2
1-2
1-2
4
TOTAL
•
Hours
Over 40 hours complement clinical training with diverse Los Arthur
Angeles
patients
Gomez
MD & Arleen Brown MD PhD
47 hrs
Working with Interpreters:
2009
Cultural Competency
How student behavior affects quality of patient interaction
when using interpreters
• 152 MSIIs
completed the 3hour 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 confidentiality
Introduction of all interview
participants
Proper positioning
Clear communication
Observation of non-verbal cues
Arthur Gomez MD & Arleen Brown MD PhD
Working with Interpreters:
2009
Cultural Competency
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. Preinterview discussion of goals, length, and topics
M
SD
History Taking Overall (12 items)
0.75
0.14
Interview Quality Overall (5 items)
4.60
0.67
Setting the Stage (4 items)
0.62
0.22
Management (5 items)
0.87
0.16
Patient-Centeredness (3 items)
0.73
0.27
Scale Scores
Sub-categories
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
CPX Evaluates Students
28 Items
(3):
(4):
(5):
(5):
(5):
(6):
elicited my explanatory model of my illness
took my perspective into account when negotiating treatment
appropriately explored my perspective
addressed my feelings
met my needs
a 44 year-old African American male hypertensive
investigated my beliefs about my illness and
medications in the history
Discussed the prevalence of HTN among African-American population
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Using OSCEs
Evaluation / Lessons Learned
Student
Quintile
Score
of 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
4th
15.8
5th
16.4
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.
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
Arthur Gomez MD & Arleen Brown MD PhD
Using Script Concordance
2009
Cultural Competency
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Comparing to OSCE determined
Cultural Competence
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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
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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.
Arthur Gomez MD & Arleen Brown MD PhD
Correlation SCT and OSCE
2009
Cultural Competency
Sebastian Uijtdehaage
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Methods
101 students completed OSCE and responded to clinical vignette of the SCT
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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
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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
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
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
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Ethnopharmocology in Diabetes Care
Type II Diabetes
The Roles of Race, Culture,
Genetics, Environment, and
Behavior
Ajay Dharia, MS IV
Arleen Brown, MD, PhD
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Evaluation
Pretest/posttest & the Spector of
questions on Final
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
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
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Sustained cultural competence training to more faculty and students will help
Arthur Gomez MD & Arleen Brown MD PhD
Future Directions
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2009
Cultural Competency
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????
Arthur Gomez MD & Arleen Brown MD PhD
2009
Cultural Competency
Art Gomez, MD
Arleen Brown, MD PhD
[email protected]
[email protected]
Arthur Gomez MD & Arleen Brown MD PhD