Resident Physicians’ Preparedness to Provide Cross-Cultural Care

Harvard University, Cambridge, Massachusetts, United States
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2005; 294(9):1058-67. DOI: 10.1001/jama.294.9.1058
Source: PubMed


Two recent reports from the Institute of Medicine cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents' educational experience in this area.
To assess residents' attitudes about cross-cultural care, perceptions of their preparedness to deliver quality care to diverse patient populations, and educational experiences and educational climate regarding cross-cultural training.
A survey was mailed in the winter of 2003 to a stratified random sample of 3435 resident physicians in their final year of training in emergency medicine, family practice, internal medicine, obstetrics/gynecology, pediatrics, psychiatry, or general surgery at US academic health centers.
Responses were obtained from 2047 (60%) of the sample. Virtually all (96%) of the residents indicated that it was moderately or very important to address cultural issues when providing care. The number of respondents who indicated that they believed they were not prepared to care for diverse cultures in a general sense was only 8%. However, a larger percentage of respondents believed they were not prepared to provide specific components of cross-cultural care, including caring for patients with health beliefs at odds with Western medicine (25%), new immigrants (25%), and patients whose religious beliefs affect treatment (20%). In addition, 24% indicated that they lacked the skills to identify relevant cultural customs that impact medical care. In contrast, only a small percentage of respondents (1%-2%) indicated that they were not prepared to treat clinical conditions or perform procedures common in their specialty. Approximately one third to half of the respondents reported receiving little or no instruction in specific areas of cross-cultural care beyond what was learned in medical school. Forty-one percent (family medicine) to 83% (surgery and obstetrics/gynecology) of respondents reported receiving little or no evaluation in cross-cultural care during their residencies. Barriers to delivering cross-cultural care included lack of time (58%) and lack of role models (31%).
Resident physicians' self-reported preparedness to deliver cross-cultural care lags well behind preparedness in other clinical and technical areas. Although cross-cultural care was perceived to be important, there was little clinical time allotted during residency to address cultural issues, and there was little training, formal evaluation, or role modeling. These mixed educational messages indicate the need for significant improvement in cross-cultural education to help eliminate racial and ethnic disparities in health care.

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    • "To achieve this goal, Carpenter-Song et al. [23] recommend that psychiatrists remain open and willing to seek clarification when presented with unusual or unfamiliar complaints . Nevertheless, resident physicians' self-reported preparedness to deliver cross-cultural care lags well behind preparedness in other clinical and technical areas [123]. Clinically competent mental health professionals are interested in the patient's cultural biases and world view, knowing that these are strongly colored by cultural values, and are also aware of their own personal cultural strengths, weaknesses and prejudices which may affect their response to patients [58] [65] [84] [91] [100] [111] [112] [129]. "
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    ABSTRACT: The stress of migration as well as social factors and changes related to the receiving society may lead to the manifestation of psychiatric disorders in vulnerable individuals after migration. The diversity of cultures, ethnicities, races and reasons for migration poses a challenge for those seeking to understand how illness is experienced by immigrants whose backgrounds differ significantly from their clinicians. Cultural competence represents good clinical practice and can be defined as such that a clinician regards each patient in the context of the patient's own culture as well as from the perspective of the clinician's cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. It points out that cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment. To reach these aims, both individual and organizational competence are needed, as well as teaching competence in terms of educational leadership. The WPA Guidance on Mental Health and Mental Health Care for Migrants and the EPA Guidance on Mental Health Care for Migrants list a series of recommendations for policy makers, service providers and clinicians; these are aimed at improving mental health care for immigrants. The authors of this paper would like to underline these recommendations and, focusing on cultural competency and training, believe that they will be of positive value. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    European Psychiatry 02/2015; 30(3). DOI:10.1016/j.eurpsy.2015.01.012 · 3.44 Impact Factor
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    • "Given evidence that medical graduates can feel poorly prepared to deliver cross-cultural care (Weissman et al. 2005), and commentary questioning the effectiveness of cultural competence curricula (Perloff et al. 2006; Pon 2009), there is scope for new ways forward. Critically reviewing cultural competence initiatives informed by our understandings of the formal, informal and hidden curricula, provides an opportunity to reflect on what it is that educators are trying to achieve and the importance of curricular congruence. "
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    ABSTRACT: The concept of cultural competence has become reified by inclusion as an accreditation standard in the US and Canada, in New Zealand it is demanded through an Act of Parliament, and it pervades discussion in Australian medical education discourse. However, there is evidence that medical graduates feel poorly prepared to deliver cross-cultural care (Weissman et al. in J Am Med Assoc 294(9):1058-1067, 2005) and many commentators have questioned the effectiveness of cultural competence curricula. In this paper we apply Hafferty's taxonomy of curricula, the formal, informal and hidden curriculum (Hafferty in Acad Med 73(4):403-407, 1998), to cultural competence. Using an example across each of these curricular domains, we highlight the need for curricular congruence to support cultural competence development among learners. We argue that much of the focus on cultural competence has been in the realm of formal curricula, with existing informal and hidden curricula which may be at odds with the formal curriculum. The focus of the formal, informal and hidden curriculum, we contend, should be to address disparities in health care outcomes. In conclusion, we suggest that without congruence between formal, informal and hidden curricula, approaches to addressing disparity in health care outcomes in medical education may continue to represent reform without change.
    Advances in Health Sciences Education 02/2014; 19(5). DOI:10.1007/s10459-014-9497-5 · 2.12 Impact Factor
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    • "Equally important in the present investigation is the comparison between physicians and nurses. Although there is literature to document differences between medical specialties [11,15,16], there is a paucity of literature examining the cross-cultural competency of nurses and other non-physician health providers [17]; even when cultural competence encompasses a general set of competencies that should be evaluated among all health providers [18,19]. This is contextually relevant in Switzerland, where nurses are increasingly assuming clinical responsibilities for vulnerable patients [20], and driving advocacy efforts in cultural competency training [21-23]. "
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    ABSTRACT: As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital. A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness. Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (beta = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (beta = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (beta = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (beta = -0.34, p < 0.005) was negatively correlated with skillfulness. Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.
    BMC Medical Education 01/2014; 14(1):19. DOI:10.1186/1472-6920-14-19 · 1.22 Impact Factor
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