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Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation
Abstract
Given that understanding the sociocultural dimensions underlying a patient's health values, beliefs, and behaviors is critical to a successful clinical encounter, cross-cultural curricula have been incorporated into undergraduate medical education. The goal of these curricula is to prepare students to care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, and gender biases in health care delivery. Despite progress in the field of cross-cultural medical education, several challenges exist. Foremost among these is the need to develop strategies to evaluate the impact of these curricular interventions. This article provides conceptual approaches for cross-cultural medical education, and describes a framework for student evaluation that focuses on strategies to assess attitudes, knowledge, and skills, and the impact of curricular interventions on health outcomes.
... [12] All these planned teaching activities must be supplemented with assessment methods (targeting assessment of cultural competencies among trauma patients), so that students remain motivated to learn, and feedback must be given to students about their performance to ensure continuous improvement. [19] To summarize, all these training activities related to cultural competency pertaining to trauma patients must be spread across all professional years of training to enable continuous learning. [6,7,[11][12][13][14][15][16][17][18][19] ...
... [19] To summarize, all these training activities related to cultural competency pertaining to trauma patients must be spread across all professional years of training to enable continuous learning. [6,7,[11][12][13][14][15][16][17][18][19] ...
... Like any other domain, medical educators must plan for the assessment of cultural competencies while delivering trauma education, as it will provide insights into the readiness of the students to deliver culturally sensitive and effective care to trauma patients. [19] There is a wide range of assessment methods that can be employed, namely the use of pre-and post-tests (Kirkpatrick Level 2), especially during workshops to measure changes in the level of knowledge among medical students. [13] Objective Structured Clinical Examinations can merge cultural competencies into trauma care scenarios in one or more of the planned stations. ...
A BSTRACT
In the field of health care, cultural competency refers to the ability of healthcare professionals to acknowledge, respect, and accordingly respond to the varied needs, beliefs, values, and practices followed by persons and the communities they serve. The purpose of the current review is to explore the role of cultural factors and trauma experience, and identify the strategies that can be employed to train and assess medical students in cultural competency pertaining to trauma patients. An extensive search of all materials related to the topic was carried out on the PubMed and Google Scholar search engines and a total of 21 articles were selected based on their suitability with the current review objectives. Cultural factors play a defining role in determining the experiences of trauma patients, and how these patients and family members perceive, cope, and recover from such traumatic events. To meet the diverse needs of the community, the medical curriculum has to be flexible and must include the component of cultural competency. Like any other domain, medical educators must plan for the assessment of cultural competencies while delivering trauma education, as it will provide insights into the readiness of the students to deliver culturally sensitive and effective care to trauma patients. In conclusion, the inclusion of cultural competency training within trauma care in the medical curriculum carries immense utility as it can help healthcare professionals to effectively communicate and respond to the varied needs of trauma patients, regardless of their cultural backgrounds. This calls for the adoption of a combination of teaching–learning methods and assessment methods by medical educators so that medical students can be empowered to deliver culturally sensitive medical care to trauma patients.
... This study provides valuable data that builds upon recent attention focused upon the role of early training and medical education in improving care for diverse patient populations [18]. In the age of development of cross-cultural diversity curricula in both pre-medical and medical education [19,20], as well as narrative medicine that acknowledges the relevance of sociocultural contexts along with patients' physical symptoms [21], progress is being made to prepare students to care for patients from diverse backgrounds. ...
... Accrediting bodies such as the LCME and the Accreditation Council for Graduate Medical Education have also updated cultural humility requirements for medical training, specifically the acknowledgement of language barriers as a root cause of health disparities and skillful training of interpreter services to address these barriers [3,22,23]. Existing literature has noticed the lack of strategies to evaluate the impact of these curricular intervention [18], so surveys like the one conducted in this study provide one framework for evaluation that assess attitudes of students, preceptors, and interpreters. ...
Background
The increasing linguistic and cultural diversity in the United States underscores the necessity of enhancing healthcare professionals' cross-cultural communication skills. This study focuses on incorporating interpreter and limited-English proficiency (LEP) patient training into the medical and physician assistant student curriculum. This aims to improve equitable care provision, addressing the vulnerability of LEP patients to healthcare disparities, including errors and reduced access. Though training is recognized as crucial, opportunities in medical curricula remain limited.
Methods
To bridge this gap, a novel initiative was introduced in a medical school, involving second-year students in clinical sessions with actual LEP patients and interpreters. These sessions featured interpreter input, patient interactions, and feedback from interpreters and clinical preceptors. A survey assessed the perspectives of students, preceptors, and interpreters.
Results
Outcomes revealed positive reception of interpreter and LEP patient integration. Students gained confidence in working with interpreters and valued interpreter feedback. Preceptors recognized the sessions' value in preparing students for future clinical interactions.
Conclusions
This study underscores the importance of involving experienced interpreters in training students for real-world interactions with LEP patients. Early interpreter training enhances students' communication skills and ability to serve linguistically diverse populations. Further exploration could expand languages and interpretation modes and assess long-term effects on students' clinical performance. By effectively training future healthcare professionals to navigate language barriers and cultural diversity, this research contributes to equitable patient care in diverse communities.
... Cross-cultural medical education has been proposed as a means of training students to care for diverse patient populations and recognizing and addressing cultural biases in healthcare. 1,2 Understanding the process of adapting medical education across cultures can also help physicians and medical educators by promoting research collaborations and welcoming exchange students. ...
... American medical students who rotate internationally may improve their care for patients of different cultures. 1,2 Third, exposure to different systems can inspire reform at partner institutions. NCKU changed its admissions and curricular policies using AMS as a model; AMS and NCKU have taken steps to de-emphasize exams for accreditation and admissions, and both have focused on supporting humanistic-oriented medical education. ...
Cross-cultural medical education has been suggested to train students to care for diverse patient populations and reform medical education systems. In this article, the authors conduct a cross-cultural comparison between two medical schools with a long-standing relationship - the Warren Alpert Medical School of Brown University in the United States and the School of Medicine of National Cheng Kung University in Taiwan - focusing on history, admissions, and curriculum.
... The inextricable link between culture and health has been widely recognized (Betancourt, 2003;Bhui et al., 2007;Napier, 2015). Culture plays a significant role in shaping individuals' health-related views by determining their perceptions of diseases, experiences in consultations, ways of reporting symptoms, and adhering to treatment (Srivastava, 2006). ...
... The World Health Organisation (WHO) called upon medical schools to "direct their education, research and service activities towards addressing the priority health concerns of the community, religion, and/ or nation they have a mandate to serve" (Boelen et al., 1995, p. 3). Regulatory and accreditation bodies in many western countries stipulate medical graduates are required to provide culturally sensitive and appropriate care (Betancourt, 2003), such as the standards or graduate outcomes published by the Liaison Council on Medical Education in the United States (US) and Canada, the General Medical Council in the United Kingdom (UK), and the Australian Medical Council. In response, medical education at all levels has started to incorporate cultural competence education into its curriculum development. ...
As a result of an increased understanding of culture’s impact on health and healthcare, cultural competence and diversity curricula have been incorporated into many medical programs. However, little is known about how students develop their cultural competence during their training. This ethnographic case study combined participant observation with interviews and focus group to understand students’ views and experiences in developing their cultural competence during clinical placements. The results show that students’ development of cultural competence is an individually varied process via four distinctive yet interrelated learning avenues. Immersion in a diverse healthcare environment contributes to students’ development of cultural awareness and knowledge. Observation of culturally appropriate or inappropriate practices allows students to enhance their practical skills and critical reflection. Interaction with other clinical professionals, patients, and their family members, enables students’ engagement within the busy clinical practice. Reflection helps students to actively think about culture’s impact on health and internalize the importance of cultural competence. Students’ learning via each avenue is interrelated and constantly interacting with their learning environment, which collectively contributes to their development. Integrating the results allowed the authors to generate a theoretical model that conceptualizes medical students’ cultural competence development in clinical placements, which unearths students’ cultural learning within the informal and hidden curriculum. This study provides a rare view of students’ development of cultural competence in clinical placements, which may inform the pedagogic development of cultural competence and diversity education in medicine and healthcare.
... [31] Furthermore, there is a clearer understanding of the role of culture on health care and health inequalities. [32] Cultural norms influence health-seeking behaviour. [33] Some patients may put off seeking treatment because of a sense of cultural insensitivity, apprehension that they will get worse care, or the belief that they have been handled unjustly because of their ethnic or race origin. ...
... [82] • Teach practical skills Traditionally, cultural competency programmes have taken a knowledge-based approach. [32] Lists of recommended phrases, pictures, or ways for handling minority groups are often included in such courses, depicting for every single group as having distinct beliefs, values, and behaviours depend on culture. As mentioned in Table 2 this simplistic approach ignores variation within groups while emphasising contrasts between them, thereby perpetuating stereotyping. ...
Cultural competency is a wide notion with a variety of academic bases and differing perspectives on how it should be implemented. While it is widely acknowledged that cultural competency should be an element of general practise, there is a paucity of literature in this area. It has been commonly claimed that cultural competency is a fundamental prerequisite for working well with persons from different cultural backgrounds. Medical students must learn how to connect successfully with patients from all walks of life, regardless of culture, gender, or financial background. Hence, National Medical Council (NMC) has included cultural competence as a course subject in the curriculum of medical education. The opportunities and concept of Competency Based Medical Education, the inclusion of cultural competency in medical course by NMC, various models and practice skill of cultural competence in medical education are discussed in this paper. This study will be useful to researchers who are looking at cultural competency as a research variable that influences study result.
... Social accountability in medical education provides a compelling and promising case-by-case learning approach to disadvantaged populations [7]. However, medical students will require training opportunities in an interdisciplinary way to develop knowledge, skills and attitudes to address health inequities related to trauma, racism, culture and language differences, access to health systems, tropical infectious disease, vaccination, chronic disease and global mental health [8][9][10]. ...
... Of the learning objectives identified, the 'communicator' competency emerged as a fundamental skill that every student requires to be able to provide effective care for refugees and migrants [9,47]. Cross-cultural communication in refugee health goes beyond the basic communication skills needed to provide care to Canadian-born patients. ...
Background
International migration, especially forced migration, highlights important medical training needs including cross-cultural communication, human rights, as well as global health competencies for physical and mental healthcare. This paper responds to the call for a ‘trauma informed’ refugee health curriculum framework from medical students and global health faculty.
Methods
We used a mixed-methods approach to develop a guiding medical undergraduate refugee and migrant health curriculum framework. We conducted a scoping review, key informant interviews with global health faculty with follow-up e-surveys, and then, integrated our results into a competency-based curriculum framework with values and principles, learning objectives and curriculum delivery methods and evaluation.
Results
The majority of our Canadian medical faculty respondents reported some refugee health learning objectives within their undergraduate medical curriculum. The most prevalent learning objective topics included access to care barriers, social determinants of health for refugees, cross-cultural communication skills, global health epidemiology, challenges and pitfalls of providing care and mental health. We proposed a curriculum framework that incorporates values and principles, competency-based learning objectives, curriculum delivery (i.e., community service learning), and evaluation methods.
Conclusions
The results of this study informed the development of a curriculum framework that integrates cross-cultural communication skills, exploration of barriers towards accessing care for newcomers, and system approaches to improve refugee and migrant healthcare. Programs should also consider social determinants of health, community service learning and the development of links to community resettlement and refugee organizations.
... This requires attaining new types of knowledge and developing new skills, which will make health care professionals cross-culturally competent and in high demand globally. [1][2][3][4][5][6][7], etc. Revised curricula have been proposed and their effectiveness assessed. However, amendments made in the syllabi of Russian medical schools to train experts in cross-cultural care still remain uncharted. ...
... Due to rising numbers of overseas students from a variety of ethnic and cultural backgrounds across the world as well as across Russia, cross-cultural competence has become essential in a great many of professional areas, including clinical settings. A number of scholars doing research into crosscultural competence have identified its key components [3] and behaviours that foster cross-cultural competence in medical education [7], reviewed curricular effectiveness in cross-cultural competence training in medical education [5,2]. Furthermore, the domains and skills embraced by cross-cultural competence including knowledge, values, biases, and skills have been elucidated [25,26]. ...
... Furthermore, the effect of these cultural differences on education, especially in the learning strategies of eastern and western dental students was emphasized (Chuenjitwongsa et al., 2018a). To facilitate a good student learning outcome, an emphasis was placed on the understanding of the regional and global cultural traits and differences (Betancourt, 2003). Furthermore, especially when present internet distance education effortlessly allows an amalgamation of various cultures, the issue of national cultural differences may require even more attention (Sangkapreecha and Sangkapreecha, 2012;Wu, 2006). ...
... Moreover, it is possibly due to the equivocality of aiming at a happiness investigation. This model has been used by other studies in fields of medicine and dentistry (Betancourt, 2003;Chuenjitwongsa et al., 2018a;Itaya et al., 2008;Morrow et al., 2013). However, the Hofstede values survey model (VSM) was designed specifically for international culture comparison; it was not intended for comparing between groups. ...
This cross-sectional descriptive survey determined cultural dimensions among dental students. First, questionnaires based on Hofstede's cultural dimension theory were distributed to all accessible students at the Faculty of Dentistry, Mahidol University, of whom 265 participants responded. In general, they showed high scores in uncertainty avoidance (UA), femininity and collectivism and focused on the long-term goal. However, they had low power distance (PD). In addition, the construct validity was evaluated using principal components factor analysis. The results of the 10-item questionnaire offered insights into the most relevant aspects of three culture dimensions: UA, male-female (MF) and long-term versus short-term goals (LS). These components were revealed logically with UA as the main component explaining 24% of the culture dimension, followed by MF and LS. To reinforce the mainstream learning theories, this study advocates that lessons with high learning barriers required instructional design and should be well-structured with a humanistic approach to address the high UA and femininity. Lessons must also respect the traditions and norms (long-term orientation). In conclusion, Hofstede's cultural dimension revealed the dental students' learning style. Further, educators are encouraged to embrace cultural traits as humanistic and heuristic learning.
... However, preparing students to work with interpreters is only part of the educational equation and such interventions must be firmly situated within a cross-cultural curriculum. As Betancourt (2003) states, the goal of such curricula is to prepare students to care for patients from diverse backgrounds, and to recognize and address social, racial, cultural, and gender biases in health care delivery. ...
... With regards to interpreter education, developing in-house interpreters is seen as a viable solution (Larrison, Velez-Ortiz, Hernandez, Piedra, & Goldberg, 2010) and offers institutions the opportunity to provide bespoke interpreter training programs. However, the effective preparation of students and interpreters is only part of the solution and it is important that such educational interventions are situated within a cross cultural curriculum aimed at strengthening the learner's ability to care for patients from diverse backgrounds (Betancourt, 2003). The third cornerstone points to the need for clear governance procedures that reflect the specific educational, linguistic and cultural contexts in which the language interpreting process is situated. ...
Linguistic differences between patients and clinicians can result in ineffective and inequitable healthcare delivery. Medical students should therefore be facilitated to develop the requisite knowledge and skills to work effectively within language discordant clinical situations. This paper explores language interpreting processes in an undergraduate medical education programme. The study utilizes a constructivist paradigm incorporating an action research approach. Action Research Cycle 1 (ARC1) examines the use of interpreters during clinical examinations while Action Research Cycle 2 (ARC2) focuses on language translation technology. In Action Research Cycle 3 the data that was generated in ARC 1 and ARC 2 is reviewed in association with international literature to develop a framework for practice. This study demonstrates that language interpreting procedures should be based within a collaborative framework with students, interpreters and educators receiving appropriate educational preparation, predicated on a cross cultural approach to care.
... 31 Cultural competence has varied definitions but seems to require the acquisition, integration and application of awareness, knowledge, skills and attitudes regarding cultural differences in order to effectively deliver expert care that meets the unique cultural needs of patients; to manage and reduce cross-cultural misunderstanding in discordant medical encounters; and to successfully negotiate mutual treatment goals with patients and families from different cultural backgrounds. 15,[33][34][35][36][37][38][39][40][41] The guideline first specifies generic aspects such as the awareness, knowledge, skills and provider attitudes required for culturally competent communication as well as the type of healthcare systems that can support and cultivate such communication. The guideline then details specific recommendations for communicating the diagnosis, treatment and prognosis of osteosarcoma to Zulu patients. ...
... Evidence-based rationale: Generic requirements for engaging in culturally competent communication include the development of awareness, the acquisition of knowledge, the acquisition and implementation of skills and strategies, and fostering certain attitudes. 15,33,34 The development and practice of culturally competent communication by individual practitioners and multidisciplinary teams is best fostered in the context of culturally competent healthcare systems. Culturally competent healthcare systems provide linguistically and culturally appropriate services and supportive policies, strategies and resources that promote culturally competent communication. ...
Background
This guideline was developed as a response to patients with osteosarcoma presenting late for
treatment thereby significantly affecting their prognoses. Healthcare providers recognised the
role of culture and the importance of culturally competent communication in addressing this
problem.
The aim of this guideline is to present healthcare providers treating Zulu patients diagnosed with
osteosarcoma with evidence-based recommendations that can facilitate culturally competent
communication regarding the diagnosis, treatment and prognosis of osteosarcoma.
Methods
The AGREE II (Appraisal of Guidelines, Research and Evaluation) appraisal instrument was
used as a guide for developing the evidence-based practice guideline. An integrative literature
review, focus groups with healthcare providers, and in-depth interviews with Zulu patients were
conducted to gather the evidence for the evidence-based practice guideline. The guideline was
reviewed by four content and methodological experts using the AGREE II tool.
Results
The guideline specifies generic aspects such as the awareness, knowledge, skills and provider
attitudes required for culturally competent communication as well as the type of healthcare
system that can support and cultivate such communication. Specific recommendations for
communicating the diagnosis, treatment and prognosis of osteosarcoma to Zulu patients were
also included.
Conclusion
Healthcare providers will require cultural competence and communication training in order to
facilitate the implementation of the guideline. Some of the challenges identified in the focus
group interviews are not addressed in this guideline, leaving room for further development
of the guideline. Evidence-based practice can contribute to improving culturally competent
communication
... Physicians encounter patients from diverse cultural and socioeconomic backgrounds and those patients have various beliefs, values and behaviours regarding health. Research into patient ethnicity has shown ethnical disparities in health, with minority groups suffering disproportionally from cancer and other serious medical conditions [3] [4] [5]. ...
... Additionally, members of minority ethnic groups often have lower levels of education, work in jobs that have greater occupational hazards, live in areas with more environmental hazards and come from lower socioeconomic backgrounds than the majority population [5]. Ethnic differences and socioeconomic influences play a major role in cancer diagnosis and treatment as different cultures have different belief systems and socioeconomic influences. ...
... In response to systematic injustices and inequalities experienced by minoritized groups (a definition based on power and fairness, not numbers) [1], actions to redress these issues have gained momentum, often under the banner of equality, diversity, and inclusion (EDI) in European settings [2,3], with related but distinct nomenclature (diversity, equity and inclusion, DEI) in use in other geographical settings [4,5]. Recommendations for addressing EDI issues in curricula and training acknowledge that factors underpinning inequitable and exclusionary practices are regularly subtle, in the form of microaggressions [6] and other artefacts of hidden curricula [7][8][9]. Practices may be structurally ingrained via policy, reflecting norms of dominant groups [10]. Poorer assessment outcomes experienced by racially minoritized students compared to white counterparts are not accounted for by differences in ability, but instead differences in relationships with peers and trainers, and differences in the learning environment [11][12][13]. ...
Background
Issues relating to equality, diversity, and inclusion (EDI) significantly impact on medical student achievement and wellbeing. Interventions have been introduced at curricular and organisational levels, yet progress in addressing these issues remains limited. Timely evaluation is needed to assess effectiveness of interventions, and to explore issues and interactions in learning environments impacting on student experience. We introduced an anonymous question concerning students’ experiences of EDI into routine online student feedback questionnaires, to scope the nature of ongoing issues and develop greater understanding of students’ experiences in our programme environment. Ecological systems theory, which conceptualizes learning as a function of complex social interactions, determined by characteristics of individual learners and their environment, provides a framework for understanding.
Methods
Free-text responses regarding experiences of EDI gathered over 20 months from all programme years (n = 760) were pooled for analysis, providing a holistic overview of experiences in the learning environment. A counting exercise identified broad categories reported by students. Content analysis of the qualitative dataset was undertaken. Bronfenbrenner’s ecological systems theory was applied as a framework to demonstrate interdependencies between respondents’ experiences and environments, and associated impacts.
Results
Three hundred and seventy-six responses were received relating to wide-ranging EDI issues, most frequently gender or ethnicity. Responses mapped onto all areas of the ecological systems model, with frequent links between subsystems, indicating considerable complexity and interdependencies. Interpersonal interactions and associated impacts like exclusion were frequently discussed. Differential experiences of EDI-related issues in medical school compared to clinical settings were reported. Impacts of institutional leadership and wider societal norms were considered by respondents. Respondents discussed their need for awareness of EDI with reference to future professional practice.
Conclusions
Implementation of a regular free-text evaluation question allowed data-gathering across cohorts and throughout several stages of the curriculum, illuminating student experience. Connections established demonstrated intersectionality, and how environment and other factors interact, impacting on student experiences. Students experience EDI-related issues on multiple levels within the educational environment, with consequent impacts on learning. Any successful approach towards tackling issues and promoting equity of opportunity for all requires multi-level actions and widespread culture change. Students can offer fresh and distinct perspectives regarding change needed, to complement and diversify perspectives provided by staff and organisational leadership. Student voice should be enabled to shape change.
... In response to systematic injustices and inequalities experienced by minoritized groups (a de nition based on power and fairness, not numbers) (1), actions to redress these issues have gained momentum, often under the banner of equality, diversity, and inclusion (EDI) in European settings (2,3), with related but distinct nomenclature (diversity, equity and inclusion, DEI) in use in other geographical settings (4,5). Recommendations for addressing EDI issues in curricula and training acknowledge that factors underpinning inequitable and exclusionary practices are regularly subtle, in the form of microaggressions (6) and other artefacts of hidden curricula (7)(8)(9). Practices may be structurally ingrained via policy re ecting norms of dominant groups (10). Poorer assessment outcomes experienced by racially minoritized students compared to white counterparts are not accounted for by differences in ability, but instead differences in relationships with peers and trainers, and differences in the learning environment (11)(12)(13). ...
Background
Issues relating to equality, diversity, and inclusion (EDI) significantly impact on medical student achievement and wellbeing. Interventions have been introduced at curricular and organizational levels, yet progress in addressing these issues remains limited. Timely evaluation is needed to assess effectiveness of interventions, and to explore issues and interactions in learning environments impacting on student experience. We introduced an anonymous question concerning students’ experiences of EDI into routine online student feedback questionnaires, to scope the nature of ongoing issues and develop greater understanding of students’ experiences in our programme environment. Ecological systems theory, which conceptualizes learning as a function of complex social interactions, determined by characteristics of individual learners and their environment, provides a framework for understanding.
Methods
Free-text responses regarding experiences of EDI gathered over 20 months from all programme years (n = 760) were pooled for analysis, providing a holistic overview of experiences in the learning environment. Content analysis of the qualitative dataset was undertaken. Bronfenbrenner’s ecological systems model was applied as a framework to demonstrate interdependencies between respondents’ experiences and environments, and associated impacts.
Results
Three hundred and seventy-six responses were received relating to wide-ranging EDI issues, most frequently gender or ethnicity. Responses mapped onto all areas of the ecological systems model, with frequent links between subsystems, indicating considerable complexity and interdependencies. Interpersonal interactions and associated impacts like exclusion were frequently discussed. Differential experiences of EDI-related issues in medical school compared to clinical settings were reported. Impacts of institutional leadership and wider societal norms were considered by respondents. Respondents discussed their need for awareness of EDI with reference to future professional practice.
Conclusions
Implementation of a regular free-text evaluation question allowed data-gathering across cohorts and throughout several stages of the curriculum, illuminating student experience. Connections established demonstrated intersectionality and how environment and other factors interact, impacting on student experiences. Students experience EDI-related issues on multiple levels within the educational environment, with consequent impacts on learning. Any successful approach towards tackling issues and promoting equity of opportunity for all requires multi-level actions and widespread culture change. Students may better understand change needed than staff. Student voice should be enabled to shape change.
... For this study, we chose the following definition of culture: "An integrated pattern of learned beliefs and behaviours that can be shared among groups and include thoughts, styles of communicating, ways of interacting, views of roles and relationships, values, practices and customs" [17]. The latter can also refer to what has been called "habits of mind", as described in Transformative Learning Theory (TLT) [18,19]. ...
Introduction:
Research on international faculty development programs (IFDPs) has demonstrated many positive outcomes; however, participants' cultural backgrounds, beliefs, and behaviors have often been overlooked in these investigations. The goal of this study was to explore the influences of culture on teaching and learning in an IFDP.
Method:
Using interpretive description as the qualitative methodology, the authors conducted semi-structured interviews with 15 Fellows and 5 Faculty of a US-based IFDP. The authors iteratively performed a constant comparative analysis to identify similar patterns and themes. Transformative Learning Theory informed the analysis and interpretation of the results.
Results:
This research identified three themes related to the influences of culture on teaching and learning. First, cultural differences were not seen as a barrier to learning; instead, they tended to act as a bridge to cultural awareness and network building. Second, some cultural differences produced a sense of unease and uncertainty, which led to adaptations, modifications, or mediation. Third, context mattered, as participants' perspectives were also influenced by the program culture and their professional backgrounds and experiences.
Discussion:
The cultural diversity of health professions educators in an IFDP did not impede learning. A commitment to future action, together with the ability to reflect critically and engage in dialectical discourse, enabled participants to find constructive solutions to subtle challenges. Implications for faculty development included the value of enhanced cultural awareness and respect, explicit communication about norms and expectations, and building on shared professional goals and experiences.
... [4][5][6][7][8] Many of these initiatives have been targeted toward trainees, most of whom have had some formal training on these topics during medical school compared to previous generations that may not have received similar training. 9 Although these advances exist, it is unclear how many programs use the curricula, and there are no longitudinal health disparities curricula for EM. Therefore, education on health disparities can be variable across institutions, and past surveys of residents across different specialties have reported low preparedness to deliver cross-cultural care. ...
... Shared decision-making is based on the interaction between physician and patient, while the patient's treat-ment choices are influenced by different factors such as age, socioeconomic status, educational level, language, country-specific data such as geographic area, urban or rural context, spirituality, gender, sexual orientation, occupation, and disability defined culture [39,40]. Cultural factors shape patients' perceptions of disease and their responses to treatments [41,42]. ...
Aims: Providing information in line with patients’
needs is an important determinant for patient satisfaction
and might also affect, distress, anxiety and depression
levels of cancer survivors. Humanity Assurance Protocol
in interventional radiotheraPY (brachytherapy)- HAPPYdefined
the needs of patients undergoing interventional
radiotherapy (IRT, also called brachytherapy) for gynecological
cancer. This work evaluated as these series of
recommendations/interventions may improve the psychological
well-being of the patient during IRT.
Methods: Patients with gynecological cancer (endometrial
and cervix cancer) undergoing IRT-HDR were
analyzed. Patients filled three questionnaires during pre-
IRT visit (T0) and at the end of IRT (T1): Distress
Thermometer (DT, a self-reported international standardized
tool using a 0-to-10 rating scale); a numerical rating
scale for IRT procedure distress (NRS, where the patients
indicate the intensity of the perceived pain assigning a
number included between 0 to 10); Hospital Anxiety and
Depression Scale (HADS, a well validated and reliable
self-reported measure designed to identify the presence
and severity of anxiety and depression in cancer patients).
Results: Fifty-five patients affected by gynecological
cancer (42 endometrial, 13 cervix) and treated with highdose-
rate (HDR)-IRT were selected from January to May
2022. The median age was 64 (range, 35-84) years.
According to the International Federation of Gynecology
and Obstetrics the most of patients have Stage I for endometrial
cancer (29/42) and for cervix cancer all patients
presented locally advanced stage (IB-IVA). Most of
patients have high education (51 patients, 92.7%) and are
married or living with partner (38 patients, 69%). Only 14
patients (25.45%) are currently working. The HADS, DT
and NRS average before IRT were 13.14, 4.58 and 5,
respectively. The HADS, DT and NRS average after IRT
were 12.31, 3.87 and 3.25, respectively. A Wilcoxon
signed rank test analysis comparing T0 vs T1 scores
showed a significant improvement in DT (p=0.251), NRS
(p< 0.00001) and HADS (p=0.034).
Conclusions: Interventional radiotherapy can be perceived
as a stressful experience causing anxiety and
distress for most women. Following clear interventions/
recommendations, which are effective and inexpensive
adjuncts, with the cooperation of an integrated, multidisciplinary
team can 1) improve the emotional state of
patients undergoing IRT and 2) be positive predictors for
psychological outcome.
... Schulman et al [19] reported that the culture to which a patient belongs influences the clinical judgment of health care providers. Betancourt [20] reported that medical professionals need "cultural competence" so as to provide culturally appropriate medical care to patients of different cultures. Cultural competence refers to the ability to be sensitive to the culture of the recipients of health care and to respond accordingly. ...
The difficulty of life scale (DLS) instrument is used to measure specific life problems in patients with ulcerative colitis (UC). Importantly, health care providers should consider the characteristics of the country in which they support patients with UC. This cross-cultural comparison study investigated DLS among patients with UC in Japan and the United Kingdom (UK). Outpatients attending one hospital in London and one in Osaka were included. We collected patient information using the DLS questionnaire, which comprises 18 items in three domains. Mean differences between Japan and the UK were compared for the total score and each domain of the DLS. Variables with P < .05 in univariate analysis were entered into a multiple regression model. We included 142 patients from Japan and 100 patients from the UK in the analysis. Univariate results showed that UK patients had more difficulties than Japanese patients in all three domains. Multivariate results showed that only “decline of vitality or vigor” showed significantly lower difficulty scores in Japanese patients. Having four or more bowel movements per day, visible bleeding, and being a homemaker or unemployed were significantly associated with greater difficulty according to the DLS total score. The level of daily life difficulties assessed using the DLS was greater among patients in the UK than among Japanese patients. This comparative study between patients with UC in Japan and the UK demonstrated certain country-related features for domain 3, “decline of vitality or vigor,” of the DLS. The reasons why UK patients felt greater decline in vitality or vigor may be that these patients may have symptoms other than bowel symptoms; also, Japanese patients are more hesitant to express discomfort. The findings of this study might lead to a better understanding of culturally sensitive perceptions of daily life difficulties in UC.
... This study was conducted at a single, communitybased residency program limited to a very small sample size of only 18 residents, even with 100% participation. Furthermore, survey data, especially data obtained from residents, is prone to observer bias and social desirability bias as residents know they are being studied and may select the responses they believe to be desired by the investigators [25,26]. ...
Objectives
Our program implemented East EMWars, a year-long, longitudinal game that added competition to our existing curricular content. We surveyed residents to investigate the impact of gamification in emergency medicine residency training. We hypothesized that residents would report higher levels of motivation, engagement, and challenge with gamification compared to traditional didactics. Furthermore, we hypothesized that residents would exhibit generally positive perceptions about gamification as a learning tool and that it would translate to improved performance on the annual in-training examination.
Methods
This was a single-center, prospective pre- and post-intervention survey study at a community-based emergency medicine residency program. Given the multiplicity of research questions and inherent nature of educational research, a mixed methods approach was utilized. We utilized nonparametric testing for quantitative data with paired responses pre- and post-intervention. We solicited comments on the post-intervention that were categorized under thematic approach and presented in complete and unedited form in the results.
Results
Eighteen (100%) of eligible residents in our program participated in both surveys. There were statistically significant increases in reported levels of motivation, engagement, and challenge with gamification compared to traditional didactic methods. Residents also reported overwhelmingly positive general perceptions about gamification and its broader generalizability and applicability. We did not reach statistical significance in determining if in-training exam scores were associated with our gamification initiative.
Conclusions
This study was a first-of-its-kind look into a longitudinal game in an emergency medicine residency program. Although our results are encouraging, medical educators need further research to determine if this increase in motivation, engagement, and challenge will be associated with an increase in examination scores or, more importantly, healthcare outcomes. Theory-based, broader-scale, prospective studies are needed to further explore and help establish these associations and outcomes.
... Effective communication skills in healthcare practices help professionals better understand a patient as a whole person, the impact disease may have on their life, and how best to manage the patient's ill health (Lu & Corbett, 2012). Evidence suggests that healthcare provider-patient communication is directly linked to patient satisfaction, adherence to treatment and subsequent health outcomes (Betancourt, 2003). Integrating language and culture in teaching medicine and healthcare thus moves language beyond a narrow focus on linguistic competence, and even beyond a concern for communicative skills and strategies, towards a wider conception of language ability that draws upon a knowledge and appreciation of different value systems (Corbett, 2011, pp. ...
This article offers insights into the knowledge, skills and attitudes medical educators need to teach effectively to culturally diverse cohorts of medical students. “CLIL in Medical Education: Reaching for Tools to Teach Effectively in English in a Multicultural and Multilingual Learning Space” (CLILMED), an Erasmus+ Strategic Partnership, designed a profile to assist medical educators in the process of intentional goal-setting and self-reflection around their pedagogy, language and culture. It is the pluricultural outcomes of education that will be addressed here, since favouring the development of knowledge, attitudes and skills related to otherness, plurality and diversity have a direct impact on the quality of healthcare provision (Bradshaw, 2019; Corbett, 2011; Tiwary et al., 2019). Understanding what competences medical educators need in an intercultural classroom greatly influences their ability to intentionally design, implement and develop their teaching. The CLILMED Glocal Competence Profile for Medical Educators, centred around the intended pluricultural outcomes of Content and Language Integrated Learning (CLIL), is intended to clarify and support lifelong learning for helping medical professionals interact effectively and appropriately with students from other linguistic and cultural backgrounds.
... The teaching of clinical communication has been extensively explored in the field of medical education in the West, including with regard to curricula, assessment, learning outcomes, and educator training [1][2][3][4][5][6][7]. The recent expansion of this research area has been reflected in the increased emphasis on communication skills in many medical education programmes worldwide. ...
Background
In the absence of a well-rounded syllabus that emphasises both interpersonal and medical dimensions in clinical communication, medical students in the early stages of their career may find it challenging to effectively communicate with patients, especially when dealing with perceived priorities and challenges across different disciplines.
Methods
To explore the priorities, challenges, and scope of clinical communication teaching as perceived by clinicians from different clinical disciplines, we recruited nine medical educators, all experienced frontline clinicians, from eight disciplines across seven hospitals and two medical schools in Hong Kong. They were interviewed on their clinical communication teaching in the Hong Kong context, specifically its priorities, challenges, and scope. We then performed interpretative phenomenological analysis of the interview data.
Results
The interview data revealed five themes related to the priorities, challenges, and scope of clinical communication teaching across a wide range of disciplines in the Hong Kong context, namely (1) empathising with patients; (2) using technology to teach both the medical and interpersonal dimensions of clinical communication; (3) shared decision-making with patients and their families: the influence of Chinese collectivism and cultural attitudes towards death; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician–patient communication.
Conclusions
Coming from different clinical disciplines, the clinicians in this study approached the complex nature of clinical communication teaching in the Hong Kong context differently. The findings illustrate the need to teach clinical communication both specifically for a discipline as well as generically. This is particularly important in the intensive care unit, where clinicians from different departments frequently cooperate. This study also highlights how communication strategies, non-verbal social cues, and the understanding of clinical communication in the Hong Kong Chinese context operate differently from those in the West, because of differences in sociocultural factors such as family dynamics and hierarchical social structures. We recommend a dynamic teaching approach that uses role-playing tasks, scenario-based exercises, and similar activities to help medical students establish well-rounded clinical communication skills in preparation for their future clinical practice.
... Though cultural competency allows for somewhat more accessible and adequate health care (Kirmayer, 2012), racism and inequities are still prevalent in Indigenous health users' experiences (Allan & Smylie, 2015). Cultural competency means providing competent cross-cultural care and responding to diverse values and needs (Betancourt, 2003;Ruben, 1989). Nevertheless, even the most basic necessity for mental health care, psychological measurement, is lacking. ...
Emotion regulation is reflected in the reactions of the body: phenotypical patterns of autonomic nervous system (ANS) arousal like cardiac and electrodermal activity. Some data would propose that individuals who have difficulties with emotion regulation (or disorders characterized by emotion dysregulation) have a generalized over-reactivity and dysregulated recovery even after some non-trauma-related cues. Thus, psychophysiological reactivity to height could be used as a paradigm to test the dysregulation of the ANS and provide an objective measure to characterize some aspects of emotion dysregulation. This paradigm could be useful in complementing psychometric measures of mental well-being and illness, especially in populations where reliability or safety of psychometric measurement is limited due to linguistic or cultural factors. For Inuit in Quebec, the concept of emotion regulation ties closely to their ability to adapt to the environment while recognizing limited control over it and keeping hopeful for the future (e.g., resilience). Inuit have indicated that common rating scales for psychopathology are not culturally sensitive. in this case, psychophysiological measurement could be useful for both momentary assessment and in treatment (e.g., biofeedback), and could relatively easily and inexpensively be implemented through the use of virtual reality (VR) and photoplethysmography (PPG) devices. In this thesis, I describe the integration, evaluation, and testing of a reactivity testing paradigm, which aims to be a more culturally sensitive measurement. I provide both qualitative and quantitative data towards this non-trauma psychophysiological reactivity testing paradigm that uses heights to evoke both subjective (self-reported) and objective (skin conductance response and heart rate) arousal. I describe the initial results of the usefulness and feasibility of the paradigm in a sample (n=16) of healthy participants. I also outline the protocol for a future randomized controlled trial, which will test the reactivity paradigm as a complementary outcome. This work is part of a larger co-design project with an Inuit advisory committee towards culturally sensitive methods in mental health services using digital technology.
... A new set of skills in cultural competency has been developed as an effort to improve health outcomes. 31 Cultural competence for the physician would involve learning about the patient's preferences and ethnic background. However, this is easier said than done. ...
... Third, patient-provider interactions could be improved with cultural humility training. An understanding of cultural humility may enhance the quality of patient-provider communication, increase rates of utilization as well as encourage patient-centered care, understanding, and trust (Betancourt et al., 2003;Thom & Tirado, 2006;Parisi et al., 2012;Sim et al., 2014;Fontil et al., 2018). Cultural competence helps to build skills for working and interacting with patients to improve the overall health of different racial and ethnic populations (Thom & Tirado, 2006). ...
The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009–2017 were used to study the association between patient-provider social distance as measured by “racial/ethnic concordance” and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.
... (7) However, if medical students are to lead the post COVID-19 generation of healthcare providers, they will need training opportunities to develop knowledge, skills and attitudes to address health inequities related to trauma, racism, culture and language differences, access to health systems, tropical infectious disease, vaccination, chronic disease and global mental health. (8)(9)(10) Refugee and migrant or newcomer health is a eld of study that focuses on the health of forcibly displaced and migrating populations. (11) The International Organization of Migration estimates there are 272 million international migrants worldwide, 80 million of whom were forcibly displaced in 2019. ...
Background: International migration, especially forced migration, highlights important medical training needs including cross-cultural communication, human rights, as well as global health competencies for physical and mental healthcare. This paper responds to the call for a ‘trauma informed’ refugee health curriculum framework from medical students and global health faculty.
Methods: We used a mixed-methods approach to develop a guiding medical undergraduate refugee and migrant health curriculum framework. We conducted a scoping review, key informant faculty interviews and e-surveys, and then, integrated our results into a competency-based curriculum framework with values and principles, learning objectives and curriculum delivery methods and evaluation.
Results: The majority of our Canadian medical faculty respondents reported some refugee health learning objectives within their undergraduate medical curriculum. The most prevalent learning objective topics included access to care barriers, social determinants of health for refugees, cross-cultural communication skills, global health epidemiology, challenges and pitfalls of providing care and mental health. We report competency-based learning objectives and primary and secondary topics. We also discuss curriculum delivery and evaluation methods such as community service learning with reflection exercises.
Conclusions: This guiding undergraduate medical education curriculum suggests integrating cross-cultural communication skills, exploration of access to care barriers for newcomers, and system approaches to improve refugee and migrant healthcare. Programs should also consider social determinants of health, community service learning and the development of links to community resettlement and refugee organizations.
... Cultural competence education has become more widespread as a result of a shift in demographics globally. While the available literature initially focused on strategies to improve the quality of care across racial and ethnic groups, 46,47 cultural competence education has more recently expanded to include other marginalized populations, such as the lesbian, gay, bisexual, ...
There is a need for culturally competent health care providers (HCPs) to provide care to deaf signers, who are members of a linguistic and cultural minority group. Many deaf signers have lower health literacy levels due to deprivation of incidental learning opportunities and inaccessibility of health-related materials, increasing their risk for poorer health outcomes. Communication barriers arise because HCPs are ill-prepared to serve this population, with deaf signers reporting poor-quality interactions. This has translated to errors in diagnosis, patient nonadherence, and ineffective health information, resulting in mistrust of the health care system and reluctance to seek treatment. Sign language interpreters have often not received in-depth medical training, compounding the dynamic process of medical interpreting. HCPs should thus become more culturally competent, empowering them to provide cultural- and language-concordant services to deaf signers. HCPs who received training in cultural competency showed increased knowledge and confidence in interacting with deaf signers. Similarly, deaf signers reported more positive experiences when interacting with medically certified interpreters, HCPs with sign language skills, and practitioners who made an effort to improve communication. However, cultural competency programs within health care education remain inconsistent. Caring for deaf signers requires complex, integrated competencies that need explicit attention and practice repeatedly in realistic, authentic learning tasks ordered from simple to complex. Attention to the needs of deaf signers can start early in the curriculum, using examples of deaf signers in lectures and case discussions, followed by explicit discussions of Deaf cultural norms and the potential risks of low written and spoken language literacy. Students can subsequently engage in role plays with each other or representatives of the local signing deaf community. This would likely ensure that future HCPs are equipped with the knowledge and skills necessary to provide appropriate care and ensure equitable health care access for deaf signers.
... For many medical workers it can be difficult to find common language with patients, resulting in a growing mistrust of the healthcare professional, dissatisfaction with health services provided to patients, declining confidence in the health system, and, consequently, low efficacy of treatment. These issues are widely studied by scientists Betancourt J., Green A., Carillo E. [10]. Nevertheless, the discourse about training a highly qualified professional, responding to the labour market needs, is under close attention. ...
Due to growing health disparities in underserved communities, a comprehensive approach is needed to train physicians to work effectively with patients who have cultures and belief systems different from their own. To address these complex healthcare inequities, Rowan-Virtua SOM implemented a new curriculum, The Tensegrity Curriculum, designed to expand beyond just teaching skills of cultural competence to include trainees’ exploration of cultural humility. The hypothesis is that this component of the curriculum will mitigate health inequity by training physicians to recognize and interrupt the bias within themselves and within systems. Early outcomes of this curricular renewal process reveal increased student satisfaction as measured by course evaluations. Ongoing course assessments examine deeper understanding of the concepts of implicit bias, social determinants of health, systemic discrimination and oppression as measured by performance on graded course content, and greater commitment to continual self-evaluation and critique throughout their careers as measured by course feedback. Structured research is needed to understand the relationship between this longitudinal and integrated curricular design, and retainment or enhancement of empathy during medical training, along with its impact on health disparities and community-based outcomes.
In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.
The domain of cultural competency in medical education deals with the varied cultural backgrounds and specific needs of different patients who are accessing health-care delivery services. The training in cultural competency imparted to medical students augments their knowledge and makes them aware of the presence and role of cultural, ethnic, and socioeconomic diversity in heterogeneous population groups. It is quite essential that training of medical students to become culturally competent must be conducted across all professional years of training in a longitudinal manner. Even though there are multiple benefits of training medical students in the domain of cultural competency, once we plan and implement such training, there can be multiple challenges. In conclusion, as medical education continues to evolve to meet the health-related needs of diverse population groups, cultural competency has to be acknowledged as one of the foundational pillars in empowering future cohorts of health-care professionals to deliver inclusive and culturally sensitive patient-centered medical care. The need of the hour is to identify the potential challenges in its successful implementation and then adopt a multipronged approach to effectively respond to them.
Background
Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.
Sources of Data
In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.
Areas of Agreement
The unjustness of health care disparities is universally accepted.
Areas of Controversy
Whether the outcome of CCT justifies the cost has not been effectively answered.
Growing Points
These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.
Areas timely for developing Research
Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.
Background Despite increasing endeavours to incorporate teaching material on healthcare for minority groups into medical school curricula, including cultural competency, there is a lack of research exploring medical students' comprehension of this. With age and gender as the only demographic information routinely provided in undergraduate single best answer (SBA) questions, the diversity of patients encountered by doctors in clinical practice is not fairly represented in assessments. This study examined the impact of not declaring gender or explicitly indicating LGBT+ identities and ethnicity, on how medical students evaluate clinical scenarios through SBA questions. Methods 200 medical students across clinical years completed 15 SBA questions in an online simulated exam. Participants were randomised to control and test groups testing different types of patient demographic information in question stems. Results Linear regression modelling demonstrated overall statistically nonsignificant differences between groups. The largest effect size was seen in the LGBT+ question intervention group, which had the fewest white and postgraduate participants. Older and more senior medical students performed better generally. White participants overall significantly outperformed non-white participants; this difference was eliminated when answering a mix of question styles. Using a mix of question styles produced statistically significant differences, with participants scoring worse on LGBT+ and ethnicity style questions. Conclusion Increased depth and breadth of clinical experience enables medical students to approach clinical scenarios with more flexibility. Unfamiliarity with minority patient groups may have impacted their performance in this study. For medical education to remain contemporary in preparing future clinicians to interact with diverse patient groups, assessments need to normalise the presence of these patients.
Objective:
To assess the cultural competence (CC) of GP trainees and GP trainers.Design and setting: A cross-sectional survey study was conducted at the GP Training Institute of Amsterdam UMC.
Subjects:
We included 92 GP trainees and 186 GP trainers.
Main outcome measures:
We measured the three domains of cultural competency: 1) knowledge, 2) culturally competent attitudes and 3) culturally competent skills. Regression models were used to identify factors associated with levels of CC. Participants rated their self-perceived CC at the beginning and end of the survey, and the correlation between self-perceived and measured CC was assessed.
Results:
Approximately 94% of the GP trainees and 81% of the GP trainers scored low on knowledge; 45% and 42%, respectively, scored low on culturally competent attitudes. The level of culturally competent skills was moderate (54.3%) or low (48.4%) for most GP trainees and GP trainers. The year of residency and the GP training institute were significantly associated with one or more (sub-)domains of CC in GP trainees. Having >10% migrant patients and experience as a GP trainer were positively associated with one or more (sub-) domains of cultural competence in GP trainers. The correlation between measured and self-perceived CC was positive overall but very weak (Spearman correlation coefficient ranging from -0.1-0.3).
Conclusion:
The level of cultural competence was low in both groups, especially in the knowledge scores. Cultural competence increased with experience and exposure to an ethnically diverse patient population. Our study highlights the need for cultural competence training in the GP training curricula.
Introduction
Effective cross-cultural care is foundational for mitigating health inequities and providing high-quality care to diverse populations. However, medical school teaching practices vary widely, and learners have limited opportunities to develop these critical skills. To understand the current state of cross-cultural education and to identify potential opportunities for improvement, we disseminated a validated survey instrument among medical students at a single institution.
Methods
Learners across 4 years of medical school participated in the cross-cultural care assessment, using a tool previously validated with resident physicians and modified for medical students. The survey assessed medical student perspectives on (1) preparedness, (2) skillfulness, and (3) educational curriculum and learning environment. Cross-sectional data were analyzed by class year, comparing trends between school years.
Results
Of 700 possible survey responses, we received 260 (37% response rate). Fourth-year students had significantly higher scores than first-year students (p<0.05) for 7 of 12 preparedness items and 4 of 9 skillfulness items. Less than 50% of students indicated readiness to deliver cross-cultural care by their fourth year in 9 of 12 preparedness items and 6 of 9 skillfulness items. Respondents identified inadequate cross-cultural education as the primary barrier.
Discussion
Medical students reported a lack of readiness to provide cross-cultural care, with self-assessed deficiencies persisting through the fourth year of medical school. Medical educators can use data from the cross-cultural care survey to longitudinally assess students and enhance curricular exposures where deficiencies exist. Optimizing cross-cultural education has the potential to improve the learning environment and overall patient care.
Introduction
Providing care for refugees and asylum seekers requires special knowledge and training. Refugees and asylum seekers often have unique health needs that require specialized care.
Purpose
This research focused on the need and relevance of incorporation of refugee and asylum seekers’ health in undergraduate medical curriculum teaching at King’s College London GKT Medical School.
Methods
A mixed method approach was adopted involving review of available literature on refugee health in the medical curriculum, followed by interview and e-survey on the perspectives of tutors and students, respectively.
Discussion
The research points to an overwhelming agreement on the need, learning outcomes and challenges of integrating refugee and asylum seeker health into undergraduate medical and dental education both from the perspectives of clinical teachers and medical students.
Conclusion
A collaborative approach involving students, teachers and refugee stakeholders will help in developing an effective refugee curriculum to provide equitable healthcare in the UK.
Background
Although the word culture is frequently mentioned in research on faculty development (FD), the concept is rarely explored. This research aimed to examine the culture of FD in Canada, through the eyes of leaders of FD in the health professions. Studying culture can help reveal the practices and implicit systems of beliefs and values that, when made explicit, could enhance programming.
Method
FD leaders from all Canadian medical schools were invited to participate in semi-structured telephone interviews between November 2016 and March 2017. The researchers used a constructivist methodology and theoretical framework located within cultural studies, borrowing from phenomenological inquiry to move beyond descriptions to interpretations of participants’ perceptions. Constant comparison was used to conduct a thematic analysis within and across participants’ interview transcripts.
Results
Fifteen FD leaders, representing 88% of medical schools (15/17) in Canada, participated in this study. Four themes characterized the culture of FD: balancing competing voices and priorities; cultivating relationships and networks; promoting active, practice-based learning; and negotiating recognition.
Conclusion
Although the culture of FD may vary from context to context, this study revealed shared values, practices, and beliefs, focused on the continuous improvement of individual and collective abilities and the attainment of excellence.
Cancer diagnoses expose patients to traumatic stress, sudden changes in daily life, changes in the body and autonomy, with even long-term consequences, and in some cases, to come to terms with the end-of-life. Furthermore, rising survival rates underline that the need for interventions for emotional wellbeing is in growing demand by patients and survivors. Cancer patients frequently have compliance problems, difficulties during treatment, stress, or challenges in implementing healthy behaviors. This scenario was highlighted during the COVID-19 emergency. These issues often do not reach the clinical attention of dedicated professionals and could also become a source of stress or burnout for professionals. So, these consequences are evident on individual, interpersonal, and health system levels. Oncology services have increasingly sought to provide value-based health care, considering resources invested, with implications for service delivery and related financing mechanisms. Value-based health care can improve patient outcomes, often revealed by patient outcome measures while seeking balance with economical budgets. The paper aims to show the Gemelli Advanced Radiation Therapy (ART) experience of personalizing the patients' care pathway through interventions based on technologies and art, the personalized approach to cancer patients and their role as “co-stars” in treatment care. The paper describes the vision, experiences, and evidence that have guided clinical choices involving patients and professionals in a co-constructed therapeutic pathway. We will explore this approach by describing: the various initiatives already implemented and prospects, with particular attention to the economic sustainability of the paths proposed to patients; the several pathways of personalized care, both from the patient's and healthcare professional perspective, that put the person's experience at the Gemelli ART Center. The patient's satisfaction with the treatment and economic outcomes have been considered. The experiences and future perspectives described in the manuscript will focus on the value of people's experiences and patient satisfaction indicators, patients, staff, and the healthcare organization.
The COVID-19 pandemic and the escalation of the Black Lives Matter Movement worldwide have foregrounded the long-standing inequality in society and healthcare. The provision of culturally competent care has become more necessary than at any other time. However, cultural competence (CC) education remains inconsistent across medical schools, and little is known about how students develop their CC through campus-based classroom teaching. We took an ethnographic approach to study students’ development of CC in campus-based formal classroom teaching. This study was conducted in a large London medical school in England. We triangulated data collected from 6-month participant observation, 25 individual interviews, and three focus groups to generate reliable accounts of students’ CC developmental experience. Thick descriptions were developed through iterative, inductive, interactive, and reflexive review and interpretation of data using NVivo 11. The results show that students undergo staged cultural learning throughout their undergraduate medical curriculum through bespoke CC lectures, workshops, clinical/research projects, and integrated clinical simulations that incorporate CC and other clinical subjects. The early learning mainly takes place in the pre-clinical year of the curriculum, among which a range of valued-based sessions is observed as conducive to students’ development of CC. As they progress, students develop their CC by attending clinical sessions with embedded cultural content. The curriculum in senior years presents reduced mandatory teaching, but more clinical exposure and opportunities to reach out to other subjects and disciplines. It means students start to have more diverse and dispersed learning experiences based on their individual choices, some of which may contribute to their development of CC. This study provides a rare insight into medical students’ CC development through participation in campus-based classroom teaching. Various learning opportunities contribute to different aspects of CC development and cater to different learning preferences of the diverse student population. To support students’ comprehensive development of CC, educators need to work collaboratively and use overt signposting to related disciplines and subjects. There needs to be recognition of students’ learning not only in the formal curriculum but also in the informal and hidden curricula.
Background and purpose
Health professional programs, including pharmacy, have increased Indigenization efforts through cultural safety learning. The objective of this paper is to describe student and alumni interest, impact, and perceptions for improvement of an undergraduate elective course on Indigenous health.
Educational activity and setting
A three-credit elective course was developed with an Indigenous advisory committee and a two-phase mixed-methods design incorporating pre- and post-course surveys and interviews for pharmacy students was implemented from 2013 to 2016. In 2019, all previous students enrolled in the course, now alumni and practicing pharmacists were invited to participate in an online survey and follow-up interview.
Findings
A total of 87 students and 21 alumni participated. The course appeared to have considerable impact on students' interest in course topics, specifically Canadian history of colonialism and impact on health. The course generated an increased interest in both Indigenous-oriented practicums and future practice setting. Self-perceived efficacy in providing care to Indigenous patients increased post-course and was sustained in alumni. Three major themes emerged: course should be mandatory and/or more widely available to all students, incorporate more experiential learning (such as educational field trips), and understanding of Indigenous history and impact on health care was a key learning outcome.
Summary
A lecture-based elective course increased interest in Indigenous health topics, changed current perspectives on Indigenous health needs, and improved self-perceived efficacy in providing care. Students and alumni felt course content should be more widely available and highlighted the importance of increased experiential learning opportunities.
Health care professions, especially physicians and physician candidates should be more competent in culture-specific approach. This study aims to verify the validity and reliability of the “Intercultural Sensitivity Scale” developed by Chen and Starosta (which is the most frequently-used tool while conducting the intercultural sensitivity research) among Turkish medical students. In order to demonstrate the construct validity of the scale, exploratory factor analysis based on polychoric correlation was applied together with the oblique rotation method, and first and second order confirmatory factor analysis based on polychoric correlations was applied to confirm the factor structure of the scale. Cronbach’s alpha and Spearman-Brown coefficients, were calculated to assess the reliability of the scale. Of the participants (n = 667), 52.6% were female and mean age was 24.2 ± 1.4. Cronbach’s alpha coefficient for the whole scale was 0.906. The Spearman-Brown coefficients for the whole scale and its sub-dimensions show that reliability values were also sufficient. According to the results of first and second order confirmatory factor analysis, fit indices demonstrated a very good model fit. These results confirmed that the scale consisting of 23-items and 5-dimensions is a valid and reliable tool and can be used for Grade V and VI Turkish medical students. It is considered that integrating intercultural sensitivity training in undergraduate education of physicians would help to increase the number of physicians who are sensitive to different cultures and thus contribute to reducing disparities in healthcare provision.
Introduction:
Given the increasing impact of the healthcare cost of hypertension on the economy, understanding the control of high blood pressure is warranted, particularly as it pertains to racial/ethnic disparities in hypertension control.
Objective:
To understand the relationship between hypertension control and racial/ethnic concordance, we investigated whether the racial/ethnic concordance between a patient's race/ethnicity and that of the individual's provider is a predictor of high blood pressure control.
Methods:
Data was collected for 612,524 patients from Kaiser Permanente Southern California who were at least 18 year old and received a diagnosis of hypertension between January 1, 2016 and December 31, 2019. A multiple regression analysis was carried out to assess the correlation between hypertension control and patient-provider concordance.
Results:
The independent variables proxying for patient-provider relationship are positive and statistically significant at the 5% level. Out of the 3 types of concordance, language has the highest standardized estimate, followed by gender and race.
Discussion:
We found correlations between racial/ethnic patient-provider concordance and hypertension control. Consistent with previous studies, we found that Asian patients experience more time in hypertension control. By contrast, Black and Hispanic patients have less time in hypertension control. Having the same primary care provider for a longer span of time is also positively correlated with length of hypertension control.
Conclusion:
Correlation between racial/ethnic concordance, length of time under the primary provider's care, and length of time spent in hypertension control suggests that the patient-provider relationship remains a critical component of health outcomes.
Objective. Pharmacists must be equipped with the knowledge, skills, and attitudes necessary to provide culturally intelligent and patient-centered care; however, most are not trained to do so. In order to prepare culturally intelligent pharmacists, standards and curricula for cultural intelligence must be defined and implemented within pharmacy education. The objective of this study was to create a cultural intelligence framework (CIF) for pharmacy education and determine its alignment with Doctor of Pharmacy (PharmD) training.Methods. An extensive literature analysis on current methods of cultural intelligence education was used to construct a CIF, which integrates leading models of cultural intelligence in health care education with Bloom's Taxonomy. Five student focus groups were conducted to explore and map their cultural experiences to the CIF. All focus groups were recorded, transcribed, deidentified and deductively coded using the CIF.Results. The four CIF domains (awareness, knowledge, practice, desire) were observed in all five focus groups; however, not every participant expressed each domain when sharing their experiences. Most students expressed cultural awareness, knowledge, and desire, however, only a few students discussed cultural practice. Participant comments regarding their experiences differed by race and year in the curriculum.Conclusion. This study was a first step toward understanding cultural intelligence education and experiences in pharmacy. The CIF represents an evidence-based approach to cultural intelligence training that can help prepare pharmacy learners to be socially responsible health care practitioners.
Objectives
The Accreditation Council for Graduate Medical Education expects specialties to teach and assess proficiency in culturally competent care. However, little guidance has emerged to achieve these goals. Clinical training within socioeconomically disparate settings may provide an experiential learning opportunity. We sought to qualitatively explore resident experiences working in the generic clinical learning environments (i.e., exposure to socioeconomically diverse patients across different training sites) and how it shapes cultural competency–related skill development.
Methods
Residents were recruited from emergency medicine (EM) programs. We used purposeful sampling across all postgraduate years and elicited experiences related to working at the different sites related to cultural identity, frustrating patient encounters, vulnerable populations, and development of health disparities/social determinants of health knowledge. Individual structured interviews were conducted via phone between May and December 2016. Interviews were audiotaped, transcribed, anonymized, and analyzed using systematic and iterative coding methods.
Results
Twenty-four interviews revealed three main themes. EM residents’ experiences caring for patients across sites shaped their understanding of: (1) potential patient attributes that affected the clinical encounter, (2) difficulties in building rapport had adverse effect on the clinical evaluation, and (3) residency program and training experiences shaped their clinical preparedness and willingness to work in underserved areas.
Conclusion
Assessing the impact disparate clinical setting exposures have on trainees’ preparedness to care for socioeconomically diverse patients can provide valuable insight for medical educators into barriers and facilitators to delivering optimal learning and patient care. Participants provided a breadth of stories illuminating their real-world consciousness and competency with meeting the needs of diverse populations and their access to varied educational outlets to grapple with the disparities they observed. More research is needed to uncover effective strategies to help residents thrive and feel more prepared to care for diverse populations.
Objective
To define clinical empathy from the perspective of healthcare workers and patients from a multicultural setting.
Design
Grounded theory approach using focus group discussions.
Setting
A health cluster in Singapore consisting of an acute hospital, a community hospital, ambulatory care teams, a medical school and a nursing school.
Participants
69 participants including doctors, nurses, medical students, nursing students, patients and allied health workers.
Main outcome measures
A robust definition of clinical empathy.
Results
The construct of clinical empathy is consistent across doctors, nurses, students, allied health and students. Medical empathy consists of an inner sense of empathy (imaginative, affective and cognitive), empathy behaviour (genuine concern and empathic communication) and a sense of connection (trust and rapport). This construct of clinical empathy is similar to definitions by neuroscientists but challenges a common definition of clinical empathy as a cognitive process with emotional detachment.
Conclusions
This paper has defined clinical empathy as ‘a sense of connection between the healthcare worker and the patient as a result of perspective taking arising from imaginative, affective and cognitive processes, which are expressed through behaviours and good communication skills that convey genuine concern’. A clear and multidimensional definition of clinical empathy will improve future education and research efforts in the application and impact of clinical empathy.
Barriers in communication between doctors and patients arise from differences in language, culture, and health literacy. Communication barriers contribute to poor quality of care for patients with limited English proficiency, which can be mitigated with appropriate language assistance. Low health literacy is widespread and associated with difficulty taking medications and with mortality risk. Sociocultural differences between patient and provider can be exacerbated by language discordance or assumptions regarding health literacy, and can create misunderstanding and distrust. Exploring such differences with humility can promote a therapeutic patient–provider relationship. This chapter provides emergency providers with strategies to simplify and clarify medical communication to benefit patients regardless of their primary language, cultural background, or literacy level.
Limited understanding of health information may contribute to an increased risk of adverse maternal outcomes among migrant women. We explored factors associated with migrant women’s understanding of the information provided by maternity staff, and determined which maternal health topics the women had received insufficient coverage of. We included 401 newly migrated women (≤5 years) who gave birth in Oslo, excluding migrants born in high-income countries. Using a modified version of the Migrant Friendly Maternity Care Questionnaire, we face-to-face interviewed the women postnatally. The risk of poor understanding of the information provided by maternity staff was assessed in logistic regression models, presented as adjusted odds ratios (aORs), with 95% confidence intervals (CI). The majority of the 401 women were born in European and Central Asian regions, followed by South Asia and North Africa/the Middle East. One-third (33.4%) reported a poor understanding of the information given to them. Low Norwegian language proficiency, refugee status, no completed education, unemployment, and reported interpreter need were associated with poor understanding. Refugee status (aOR 2.23, 95% CI 1.01–4.91), as well as a reported interpreter need, were independently associated with poor understanding. Women who needed but did not get a professional interpreter were at the highest risk (aOR 2.83, 95% CI 1.59–5.02). Family planning, infant formula feeding, and postpartum mood changes were reported as the most frequent insufficiently covered topics. To achieve optimal understanding, increased awareness of the needs of a growing, linguistically diverse population, and the benefits of interpretation services in health service policies and among healthcare workers, are needed.
Background
Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.
Methods
A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.
Results
109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ “eye opening” content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.
Conclusions
The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.
Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such concepts is described as illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capable of translating concepts from cultural anthropology into clinical language for practical application. The implementation of this approach in medical teaching and practice requires more support, both curricular and financial.
Postulating that a program integrating language skills with other aspects of cultural knowledge could assist in developing medical students' ability to work in cross-cultural situations and that partnership with targeted communities was key to developing an effective program, a medical school and two organizations with strong community ties joined forces to develop a Spanish Language and Hispanic Cultural Competence Project. Medical student participants in the program improved their language skills and knowledge of cultural issues, and a partnership with community organizations provided context and resources to supplement more traditional modes of medical education.
To deliver effective medical care to patients from all cultural backgrounds, family physicians need to be culturally sensitive and culturally competent. Our department implemented and evaluated a 3-year curriculum to increase residents' knowledge, skills, and attitudes in multicultural medicine. Our three curricular goals were to increase self-awareness about cultural influences on physicians, increase awareness about cultural influences on patients, and improve multicultural communication in clinical settings. Curricular objectives were arranged into five levels of cultural competence. Content was presented in didactic sessions, clinical settings, and community medicine projects.
Residents did self-assessments at the beginning of the second year and at the end of the third year of the curriculum about their achievement and their level of cultural competence. Faculty's evaluations of residents' levels of cultural competence correlated significantly with the residents' final self-evaluations. Residents and faculty rated the overall curriculum as 4.26 on a 5-point scale (with 5 as the highest rating).
Family practice residents' cultural knowledge, cross-cultural communication skills, and level of cultural competence increased significantly after participating in a multicultural curriculum.
Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain.
We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test.
The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004).
Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.
In today's multicultural society, assuring quality health care for all persons requires that physicians understand how each patient's sociocultural background affects his or her health beliefs and behaviors. Cross-cultural curricula have been developed to address these issues but are not widely used in medical education. Many curricula take a categorical and potentially stereotypic approach to "cultural competence" that weds patients of certain cultures to a set of specific, unifying characteristics. In addition, curricula frequently overlook the importance of social factors on the cross-cultural encounter. This paper discusses a patient-based cross-cultural curriculum for residents and medical students that teaches a framework for analysis of the individual patient's social context and cultural health beliefs and behaviors. The curriculum consists of five thematic units taught in four 2-hour sessions. The goal is to help physicians avoid cultural generalizations while improving their ability to understand, communicate with, and care for patients from diverse backgrounds.
Many studies have documented race and gender differences in health care received by patients. However, few studies have related differences in the quality of interpersonal care to patient and physician race and gender.
To describe how the race/ethnicity and gender of patients and physicians are associated with physicians' participatory decision-making (PDM) styles.
Telephone survey conducted between November 1996 and June 1998 of 1816 adults aged 18 to 65 years (mean age, 41 years) who had recently attended 1 of 32 primary care practices associated with a large mixed-model managed care organization in an urban setting. Sixty-six percent of patients surveyed were female, 43% were white, and 45% were African American. The physician sample (n = 64) was 63% male, with 56% white, and 25% African American.
Patients' ratings of their physicians' PDM style on a 100-point scale.
African American patients rated their visits as significantly less participatory than whites in models adjusting for patient age, gender, education, marital status, health status, and length of the patient-physician relationship (mean [SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P = .03). Ratings of minority and white physicians did not differ with respect to PDM style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites, 61.7 [3.1]; P = .13). Patients in race-concordant relationships with their physicians rated their visits as significantly more participatory than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P = .02). Patients of female physicians had more participatory visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5 [3.1]; P = .03), but gender concordance between physicians and patients was not significantly related to PDM score (unadjusted mean [SE] PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P = .12). Patient satisfaction was highly associated with PDM score within all race/ethnicity groups.
Our data suggest that African American patients rate their visits with physicians as less participatory than whites. However, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory. Improving cross-cultural communication between primary care physicians and patients and providing patients with access to a diverse group of physicians may lead to more patient involvement in care, higher levels of patient satisfaction, and better health outcomes.
This chapter covers important and well-studied aspects of patient-doctor communication. First the paper describes the lessons learned from studies about patients' satisfactions or dissatisfactions related to patient-doctor communication, making the point that complaints about doctors are usually due to communication problems and not technical competency issues. The next section of the chapter deals with time. It is often assumed that effective communication is inefficient. While this is not necessarily the case, the research results are complex and very interesting. The third part of the chapter covers communication in relation to patient adherence with the management plan recommended by the doctor. There is strong evidence that communication affects patient adherence and that there are four key aspects of communication that can enhance the patients' co-operation with the management plan. The final topic is patients' health. Twenty-two studies indicate the generally positive effect of key dimensions of communication on actual patient health outcomes such as pain, recovery from symptom, anxiety, functional status, and physiologic measures of blood pressure and blood glucose.
Race/ethnicity and socioeconomic status (SES) are associated with the use of Medicare services. In this article, the author juxtaposes disparities in health outcome measures (including death rates for heart disease, cancer, and stroke) with disparities in the use of elective services expected to improve health, and with disparities in the use of non-elective services associated with poor management of chronic disease. This approach is intended to provide information for judging (a) the reasonableness of the explanations offered for disparities in Medicare utilization and (b) the recommendations made to effect change.
Activities relating to “cultural diversity” and “cultural competence” have gained a greater audience with the increase in culturally diverse populations in the United States. In the area of health care, issues range from managing and preparing a more diverse workforce to eliminate disparities in health outcomes to ensuring access and utilization of services by culturally diverse communities. Cultural competence is inextricably tied to quality of care and is a cross-cutting issue affecting all service delivery systems and providers, including health educators. Health educators need to have an awareness of their own cultural values and beliefs with recognition for how they influence attitudes and behaviors (Randall-David, 1989). In addition, agencies and organizations should assess their cross-cultural strengths and weakness in terms of policies, procedures, practice, and structure. Respect for cultural values, traditions, and customs affects the willingness and ability of both individuals and organizations to develop interventions and services that affirm and reflect the value of different cultures. The extent to which interventions and services successfully affirm and reflect these values determines the appropriateness, acceptability, accessibility, and utilization of services (Epstein, 1998).
Internal medicine and medicine-pediatric residents (n = 76) completed a questionnaire that measured variables including sociodemographics, family dynamics, cross-cultural exposure, and exposure to intercultural medicine principles. Questions were answered regarding perceptions of their patients and level of comfort discussing specific cultural variables. Gender, training status, and geographic background did not influence responses, but the responses of European-Americans (71%) vs. ethnic minorities and foreign medical graduates (29%) were significantly different. European-Americans were more likely to be men, less likely to have an urban background (p = .02), and their self-described socioeconomic status was upper-middle to upper class (p = .02). European-Americans vs. all others differed in their perceptions of patients' financial support (p = .001), and reasons for doctor-patient miscommunications (p = .05). The European-Americans had significantly less exposure to friends and classmates (p = .002), and instructors (p = .0001) of ethnic origins different than their own prior to residency training. Our data support the inclusion of intercultural medicine principles in the general internal medicine curriculum.
(C) Copyright 1991 Southern Society for Clinical Investigation
Recent articles on clinical decision-making have proposed sophisticated quantitative methods for improving the physician's clinical judgment. Actual clinical decisions, however, are influenced by interactions between the clinician, the patient, and the sociocultural milieu as well as by biomedical considerations. This paper explores these sociologic influences on the decision-making process. Four types of sociologic factors influence the clinician's judgment: the characteristics of the patient; the characteristics of the clinician; the clinician's interaction with his profession and the health care system; and the clinician's relationship with the patient. To illustrate sociologic influences on clinical decision-making, this paper presents observations from the literature of sociology, clinical psychology, psychiatry, and medicine. Further studies are needed to provide additional empirical information.
Significant demographic changes in patient populations have contributed to an increasing awareness of the impact of cultural diversity on the provision of health care. For this reason methods are being developed to improve the cultural sensitivity of persons responsible for giving health care to patients whose health beliefs may be at variance with biomedical models. Building on methods of elicitation suggested in the literature, we have developed a set of guidelines within a framework called the LEARN model. Health care providers who have been exposed to this educational framework and have incorporated this model into the normal structure of the therapeutic encounter have been able to improve communication, heighten awareness of cultural issues in medical care and obtain better patient acceptance of treatment plans. The emphasis of this teaching model is not on the dissemination of particular cultural information, though this too is helpful. The primary focus is rather on a suggested process for improved communication, which we see as the fundamental need in cross-cultural patient-physician interactions.
Editor's Note: To aid in dissemination of curriculum guidelines created by STFM groups and task forces, Family Medicine will begin publishing such guidelines when deemed to be important to the Society's members. The information that follows are recommendations for helping residency programs train family physicians to provide culturally sensitive and competent health care. These guidelines were developed by the STFM task force and groups listed below and have been endorsed by the Society's Board of Directors and the American Academy of Family Physicians. Family Medicine encourages other STFM groups and task forces to submit similar documents that can serve as curricular models for residency training and medical education. Groups or task forces that submit information to the journal should follow the Instructions for Authors published each year in the January issue of Family Medicine and available on the Internet on STFM's home page (http://stfm.org).
Background:
Using cultural sensitivity in the training of family practice residents generally results in positive consequences for patient care. However, certain potential problems associated with cross-cultural educational efforts deserve examination, including patient stereotyping, assumptive bias, and the confounding of ethnicity with class and socioeconomic status. Even awareness of these pitfalls may not guarantee physician avoidance of other barriers to effective patient care, such as communication difficulties, diagnostic inaccuracies, and unintentional patient exploitation. Despite these complications, future family physicians must continue to participate in educational activities that increase sensitivity toward and understanding of patients of different ethnicities. This article discusses certain features characteristic of the ways in which cultural variables operate in the doctor-patient encounter and identifies specific ways in which residents can successfully elicit and use cultural knowledge to enhance patient care.
The Tuskegee Syphilis Study continues to cast its long shadow on the contemporary relationship between African Americans and the biomedical community. Numerous reports have argued that the Tuskegee Syphilis Study is the most important reason why many African Americans distrust the institutions of medicine and public health. Such an interpretation neglects a critical historical point: the mistrust predated public revelations about the Tuskegee study. This paper places the syphilis study within a broader historical and social context to demonstrate that several factors have influenced--and continue to influence--African American's attitudes toward the biomedical community.
The authors discuss the growing need for primary care residents to learn how to care for patients of many cultural backgrounds. To effectively learn the needed skills, residents must incorporate insights from areas outside medicine. The authors focus on three such areas: cultural competency, public health, and community-oriented primary care. Regarding cultural competency, the authors make clear that on the one hand, physicians must be trained to be sensitive to cultural differences and patterns, but on the other, they cannot be expected to know the many cultures of their patients in depth. They discuss the Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care created by the Society of Teachers of Family Medicine. Regarding community-oriented primary care (COPC), a process introduced from Europe in 1982, the authors state that one of its key elements is to provide accessible care to diverse and often underserved populations. However, various factors have kept COPC, and the federally funded community health centers that address the concerns of COPC, from having the widespread effects they could have. Regarding public health, the authors review the various services and orientations of public health and show how these help foster care for diverse populations. The authors then briefly describe their own residency program and its work with diverse populations. They conclude by emphasizing the importance for residents of learning the principles and practices embodied in cultural competency, public health, and COPC in order to effectively communicate with their patients.
AMERICAN medical practice is strongly influenced by the nation's historically dominant culture. Culturally based presuppositions of biomedical practice and its ethics, long neglected, are now under serious scholarly examination. For example, the primacy of individual patient autonomy is generally accepted as an enlightened perspective, particularly in the wake of earlier paternalism. However, this philosophy is not accepted by many ethnic groups in the United States and elsewhere who hold interpersonal and social responsibility in relatively higher regard.1,2 Assessments of good and harm are culturally mediated. Examples include general acceptance of euthanasia in the Netherlands, common use of fetal sonography for sex selection in India, African practices of female circumcision, and nondisclosure of cancer diagnoses in Italy and Japan.
Medical training has traditionally focused on diagnosis and treatment of disease, with the notion that if these two factors are satisfactorily managed, the desired outcome will inevitably follow. When it does not, failure is often blamed on patient noncompliance. Failure of patients to return for follow-up visits or comply with medication regimens has been shown to be a major barrier to the delivery of effective medical care. However, effective clinical decision making requires that physicians skillfully address not only the biomedical aspects of diseases and their management, but also the sociobehavorial characteristics of patients. The authors maintain that patient participation is necessary for compliance and that a naturally occurring therapeutic alliance between physician and patient incorporates factors such as lifestyle, family, and living circumstances and an awareness of the culturally unique needs of minority patients. Integration of these factors into professional decision making and practical management plans will enhance patient compliance.
Researchers and program developers in medical education presently face the challenge of implementing and evaluating curricula that teach medical students and house staff how to effectively and respectfully deliver health care to the increasingly diverse populations of the United States. Inherent in this challenge is clearly defining educational and training outcomes consistent with this imperative. The traditional notion of competence in clinical training as a detached mastery of a theoretically finite body of knowledge may not be appropriate for this area of physician education. Cultural humility is proposed as a more suitable goal in multicultural medical education. Cultural humility incorporates a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.
To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white).
A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale.
We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this "very poor," "poor," or "fair"; p <.01); (2) answers to their questions (27% vs 16% vs 12%; p <.01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p <.01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p <.01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p <.01).
This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.
Recent attention has focused on whether government health service institutions, particularly in the United Kingdom, reflect cultural sensitivity and competence and whether medical students receive proper guidance in this area.
To systematically identify educational programs for medical students on cultural diversity, in particular, racial and ethnic diversity.
The following databases were searched: MEDLINE (1963-August 1998); Bath International Data Service (BIDS) Institute for Scientific Information science and social science citation indexes (1981-August 1998); BIDS International Bibliography for the Social Sciences (1981-August 1998); and the Educational Resources Information Centre (1981-August 1998). In addition, the following online data sets were searched: Kings Fund; Centre for Ethnic Relations, University of Warwick; Health Education Authority; European Research Centre on Migration and Ethnic Relations, University of Utrecht; International Centre for Intercultural Studies, University of London; the Refugee Studies Programme, University of Oxford. Medical education and academic medicine journals (1994-1998) were searched manually and experts in medical education were contacted.
Studies included in the analysis were articles published in English before August 1998 that described specific programs for medical students on racial and ethnic diversity. Of 1456 studies identified by the literature search, 17 met the criteria. Two of the authors performed the study selection independently.
The following data were extracted: publication year, program setting, student year, whether a program was required or optional, the teaching staff and involvement of minority racial and ethnic communities, program length, content and teaching methods, student assessment, and nature of program evaluation.
Of the 17 selected programs, 13 were conducted in North America. Eleven programs were exclusively for students in years 1 or 2. Fewer than half (n = 7) the programs were part of core teaching. Only 1 required program reported that the students were assessed on the session in cultural diversity.
Our study suggests that there is limited information available on an increasingly important subject in medical education. Further research is needed to identify effective components of educational programs on cultural diversity and valid methods of student assessment and program evaluation.
Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled. The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.
Cardiovascular disease disproportionately affects minority populations, in part because of multiple sociocultural factors that directly affect compliance with antihypertensive medication regimens. Compliance is a complex health behavior determined by a variety of socioeconomic, individual, familial, and cultural factors. In general, provider-patient communication has been shown to be linked to patient satisfaction, compliance, and health outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of linguistic and contextual barriers that preclude effective provider-patient communication. These factors may further limit compliance. The ESFT Model for Communication and Compliance is an individual, patient-based communication tool that allows for screening for barriers to compliance and illustrates strategies for interventions that might improve outcomes for all hypertensive patients.
To prepare students to be effective practitioners in an increasingly diverse United States, medical educators must design cross-cultural curricula, including curricula in women's health. One goal of such education is cultural competence, defined as a set of skills that allow individuals to increase their understanding of cultural differences and similarities within, among, and between groups. In the context of addressing health care needs, including those of women, the author states that it is valid to define cultural groups as those whose members receive different and usually inadequate health care compared with that received by members of the majority culture. The author proposes, however, that cross-cultural efficacy is preferable to cultural competency as a goal of cross-cultural education because it implies that the caregiver is effective in interactions that involve individuals of different cultures and that neither the caregiver's nor the patient's culture offers the preferred view. She then explains why cross-cultural education needs to expand the objectives of women's health education to go beyond the traditional ones, and emphasizes that learners should be trained in the real-world situations they will face when aiding a variety of women patients. There are several challenges involved in both cross-cultural education and women's health education (e.g., resistance to learning; fear of dealing openly with issues of discrimination; lack of teaching tools, knowledge, and time). There is also a need to assess the student's acquisition of cross-cultural efficacy at each milestone in medical education and women's health education. Components of such assessment (e.g., use of various evaluation strategies) and educational objectives and methods are outlined. The author closes with an overview of what must happen to effectively integrate cross-cultural efficacy teaching into the curriculum to produce physicians who can care effectively for all their patients, including their female patients.
Coronary artery disease is the leading cause of death in the United States. Blacks are more likely than whites to experience premature disease, and they have poorer prognosis after acute myocardial infarction. Multiple studies have demonstrated that blacks are less likely to be referred for certain invasive cardiac procedures. Few studies have examined the effect of race on physician and patient decision making in referrals for cardiac procedures. The authors present a framework for the complex series of steps involved in obtaining invasive cardiac care. Patient race can affect each of these steps, and differences in physician and patient race may be a particular impediment to effective communication about symptoms and preferences and to the establishment of a therapeutic partnership. The potential role of communication in race-discordant physician-patient relationships suggests a need for more research in physician decision making and for efforts to promote cultural competency as a core component of medical education.
Even as the importance of improved communication between health professionals and patients grows, the factors making it more difficult continue unabated--everything from expanding medical technology and increased subspecialization to America's ever-increasing cultural diversity. This article looks at some of the ways health care professionals, administrators, accreditors, and educators across the continuum of medical and health-related professions are seeking to increase the cultural competence skills of current and future practitioners. Many of these efforts, however, are still too recent and limited to produce measurable results. Data on the implementation of educational standards and curricula need to be collected, analyzed, and disseminated to begin to identify the degree to which standards and educational materials are being developed and implemented and what, if any, impact they are having on the delivery of culturally effective care.
To assess students' performances on a health-beliefs communication OSCE station to determine whether there were differences in cultural competence based on the students' ethnic backgrounds.
A total of 71 students completed a health-beliefs communication OSCE station in which they were required to address the health beliefs and cultural concerns of a standardized patient (SP) portraying an African American woman with diabetes. The SPs rated students' performances on a ten-item interview assessment checklist. Scores on the station were standardized within SPs to adjust for differences in their use of the rating scale. A factor analysis was performed to determine conceptual constructs on the interview assessment checklist. Subscale means were computed for each student. T-tests of these subscale scores were conducted to investigate gender and ethnic differences between subgroups of students. The underrepresented minority (URM) students (five African Americans and three Mexican Americans) were compared with all other students, and the white students were compared with all others. To assess the magnitudes of the differences between subgroups, effect sizes (ES(m)) were computed for means comparisons.
Factor analysis formed two factors: Disease Beliefs and Management, and Cultural Concerns. Two remaining items loaded on a third factor that had reliability too low to support further analysis. Meaningful differences were found in cultural sensitivity based on students' ethnic backgrounds. The URM students performed better than did all other students in addressing the patient's concerns about altering culturally-based dietary behaviors for diabetes self-care [URM students' mean standardized score (SD) = 0.42 (0.15); all others = -0.01 (0.67); ES(m) = 1.05]. White students performed better than did all other students in assessing the patient's concerns about using insulin to control her blood sugar levels [white students' mean standardized score (SD) = 0.13 (0.40); all others = -0.10 (0.64); ES(m) = 0.4].
Cultural competency deficits and differences were measurable using a health-beliefs communications station, and these differences were meaningful enough to warrant faculty discussion and research about how to ensure that students master this competency.
Racial disparities in medical care should be understood within the context of racial inequities in societal institutions. Systematic discrimination is not the aberrant behavior of a few but is often supported by institutional policies and unconscious bias based on negative stereotypes. Effectively addressing disparities in the quality of care requires improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds. Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.
In this article, the author discusses her many and varied experiences with health care provision. Her insights into the many dimensions of disparity in health care lead to a set of recommendations for further research.
This paper describes the development and psychometric evaluation of an instrument designed to assess medical students' comfort with a range of sociocultural issues and intercultural experiences. Each survey item obliged students to reflect on their own sociocultural identities and academic status in relation to others', and to judge how comfortable they would be interacting across perceived boundaries based on sociocultural identity and academic status. More than 90% of University of Michigan first-year medical students (n=153) completed the survey just before classes began. Principal components analysis of the survey's 26 items identified 7 interpretable factors or subscales; the Cronbach alpha reliability coefficients for the 7 subscales and the total scale ranged from .73 to .92. T-tests were used to investigate differences in average ratings among student subgroups (based on gender and ethnicity). To assess the magnitude of the effect of the differences between groups, effect size was computed for each of the means comparisons. Psychometric analyses indicated that this survey was both reliable and valid for assessing students' cultural attitudes. Further, analyses by gender and ethnic subgroup identified meaningful ratings differences in men's and women's reported comfort levels. Our findings suggest that this instrument is useful for assessing students' openness to developing cultural awareness and competence. Educators at other medical schools may find this instrument useful as a needs assessment tool for planning educational programs designed to increase students' cultural competence.
Culturally competent professionals in therapeutic alliances enhance patient compliance Transforming cultural competence into cross-cultural efficacy in women's health education
- N C Langer
Langer N. Culturally competent professionals in therapeutic alliances enhance patient compliance. J Health Care Poor Underserved. 1999;10(1):19–26. C R O S S – C U L T U R A L E D U C A T I O N C O N C E P T S, C O N T I N U E D A C A D E M I C M E D I C I N E, V O L. 7 8, N O. 6 / J U N E 2 0 0 3 568 18. Nunez AE. Transforming cultural competence into cross-cultural efficacy in women's health education. Acad Med. 2000;75:1071–80.
Teaching Spanish and cross-cultural sensitivity to medical students Culhane A curriculum for multicultural education in family medicine
- Gonzalez
- T Lee
- Hj- Simon
- Pera
- Ka
- C Relf
- E Egil
- Baker
- Nj
- Kassekert
Gonzalez-Lee T, Simon HJ. Teaching Spanish and cross-cultural sensitivity to medical students. West J Med. 1987;146:502–4. 31. Culhane-Pera KA, Relf C, Egil E, Baker NJ, Kassekert R. A curriculum for multicultural education in family medicine. Educ Res Meth. 1997;29:719–23.
A physician’s perspective on minority healthHealth Care Financing Administra-tion)
- Coleman
- Miller
Coleman-Miller B. A physician’s perspective on minority health. Health Care Financing Review (Health Care Financing Administra-tion). 2000;21:45–56
Disparities in Medicare services: potential causes, plausible explanations and recommendations. Health Care Financing Review (Health Care Financing Administration)
- Me Gornick
Gornick ME. Disparities in Medicare services: potential causes,
plausible explanations and recommendations. Health Care Financing
Review (Health Care Financing Administration). 2000;21:23–43.
Available at hhttp://www.census.govi
- U S Census
U.S. Census 2000. Available at hhttp://www.census.govi. Accessed 3/
07/03.
Understanding and addressing racial disparities in health care. Health Care Financing Review (Health Care Financing Administration)
- Dr Williams
- Td Rucker
Williams DR, Rucker TD. Understanding and addressing racial
disparities in health care. Health Care Financing Review (Health
Care Financing Administration). 2000;21:75–90.