Graduate and Undergraduate Cultural Competence Education

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Graduate and Undergraduate
Cultural Competence Education

Robert C. Like, MD, MS

Professor and Director

Center for Healthy Families and Cultural
Diversity
Department of Family Medicine

UMDNJ-Robert Wood Johnson Medical School
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OBJECTIVES

• Describe a model for cultural competence
  education that can help guide curriculum
  development
• Describe content and strategies related to
  cultural awareness, knowledge, skills,
  encounters, and desire for inclusion in cultural
  competence curricula
• Discuss challenges related to developing,
  implementing, evaluating, and sustaining cultural
  competence curricula in academic medical centers
  and health care organizations

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• Institute of Medicine Reports
• Crossing the Quality Chasm A New Health
• System for the 21st Century (2001)
• Health care should be safe, effective,
• patient-centered, timely, efficient, and
  equitable.
• Unequal Treatment Confronting Racial
• and Ethnic Disparities in Health Care (2002)
• Healthcare providers should be made aware of
• racial and ethnic disparities in healthcare .
• In addition, all current and future healthcare
• providers can benefit from cross-cultural
  education.

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Educating Physicians and Other Health
Professionals to Provide Culturally Competent
Patient-Centered Care

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What is Patient-Centered Care?
Providing care that is respectful of and
responsive to individual patient preferences,
needs and values, ensuring that patient values
guide all clinical decisions
IOM Report,
Cross the Quality Chasm, 2001. Quality
healthcare achieved through a partnership between
informed and respected patients and their
families, and a coordinated healthcare
team National Health Council --
http//www.nationalhealthcouncil.org/initiatives/p
utting_patients.htm
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Patient-Centered Care
Based on The Picker Institutes Video, Through
the Patients Eyes. Volume I Hospital, 1998
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Patient- and Family-Centered Care
Movements

• Picker Institute Picker/Commonwealth Program
  for Patient-Centered Care
• http//www.pickerinstitute.org
• Planetree Health Alliance
• http//www.planetree.org
• Institute for Family-Centered Care
• http//www.familycenteredcare.org

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Cultural Competency
the knowledge and interpersonal skills that
allow providers to understand, appreciate, and
work with individuals from cultures other than
their own. It involves an awareness and
acceptance of cultural differences
self-awareness knowledge of the patients
culture and adaptation of skills.
Culturally Competent Health Care for
Adolescents, AMA, 1994
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Cultural Humility

• A lifelong commitment to self-evaluation and
  self-critique
• Redressing power imbalances
• Developing mutually beneficial partnerships
  with communities on behalf of individuals
  and defined populations

Tervalon M, Murray-Garcia J Cultural humility
versus cultural competence a critical
distinction in defining physician training
outcomes in multicultural education, Journal of
Health Care for the Poor and Underserved 1998
9(2)117-124.
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Mental Health
Nursing
Medicine

CULTURAL COMPETENCE EDUCATION
Oral Health
Pharmacy
Allied Health
Public Health
Social Work
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Principles and Recommended Standards for
Cultural Competence Education
of Health Care Professionals - 2003


Cultures in the Clinic Project

Jean Gilbert, PhD, Chair and Editor
Julia
Puebla Fortier, Co-Chair and Expert
Consultant http//www.calendow.org/Collection_Pu
blications.aspx?coll_id26ItemID316 Funded by
the California Endowment


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Recommended Standards for Cultural Competency in
Professional Training and Development for Health
Care Providers Prepared by the Working Group on
Professional Training Development, The WHO-HPH
International Task Force on
Migrant-Friendly and Culturally Competent
Hospitals, May 2006 Coordinated by Gurwinder
Gill, Trillium Health Centre, Canada Lead
Coordinator, Working Group on Professional
Training Development
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Professional
Medical Organizations

• The following are some of the specialty groups
  that have published guidelines and/or policies
  relating to the care of culturally diverse
  populations
  
  
  
• Society of Teachers of Family Medicine
• American Academy of Family Physicians
• American Osteopathic Association
• American Academy of Pediatrics
• American College of Physicians
• American Psychiatric Association
• American College of Obstetrics and Gynecology
• American College of Emergency Physicians
• American Academy of Orthopaedic Surgeons

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Accreditation Council for Graduate Medical
Education (ACGME) Outcomes Project General
Competencies

• Medical Knowledge
• Patient Care
• Interpersonal and Communications Skills
• Professionalism
• Practice Based Learning and Improvement
• Systems Based Practice

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ACGME OUTCOMES PROJECT GENERAL
COMPETENCIES

• Professionalism
• A commitment to carrying out professional
• responsibilities, adherence to ethical principles
  
• and sensitivity to a diverse population.
• Sensitivity and responsiveness to patients
• culture, age, gender, and disabilities.

• http//www.acgme.org/outcome/
  comp/compFull.asp5

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Cultural Competency Education
in Residency Programs
Weissman JS, Betancourt JR, et al. Resident
Physicians Preparedness to Provide
Cross-Cultural Care, Journal of the American
Medical Association 2005 1058-1067. Zweifler
J, Gonzalez AM. "Teaching Residents to Care for
Culturally Diverse Populations," Academic
Medicine 1998 73(10)1056-1061. Culhane-Pera
KA, Like RC, Lebensohn-Chialvo P, Loewe R.
"Multicultural Curricula in Family Practice
Residencies," Family Medicine 2000
32(3)167-173. Like RC, Steiner RP, Rubel AJ.
"Recommended Core Curriculum Guidelines on
Culturally Sensitive and Competent Health Care,"
Family Medicine 1996 28291-297.
http//www.stfm.org/corep.html
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(No Transcript)
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Key Findings and Recommendations
for Clinical Care and
Medical Education Policy
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LIAISON COMMITTEE ON MEDICAL EDUCATION
Faculty students must demonstrate an
understanding of the manner in which people of
diverse cultures belief systems perceive health
illness respond to various symptoms,
diseases, treatments. Medical students
should learn to recognize appropriately address
gender cultural biases in health care delivery,
while considering first the health of the
patient.
LCME Accreditation Standards (from Functions
Structure of a Medical School, Part
2) www.lcme.org
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Tool for Assessing Cultural
Competency Training (TACCT)

Association of American
Medical Colleges http//www.aamc.org/meded/tacct/s
tart.htm
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TACCT DOMAINS

• I. Cultural Competence Rationale,
  Context and Definition
• II. Key Aspects of Cultural Competence
• III. Impact of Stereotyping on
  Medical Decision-Making
• IV. Health Disparities and Factors
  Influencing Health
• V. Cross-Cultural Clinical Skills

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Cultural Competency Education
in Medical Schools
Flores G, Gee D, Kastner B. "The Teaching of
Cultural Issues in U.S and Canadian Medical
Schools," Academic Medicine 2000
75(5)451-455. Cultural Competency in Medical
Education A Guidebook for Schools, HRSA
Bureau of Health Professions and AMSA Foundation,
September 2004 http//www.ask.hrsa.gov/downloads/C
ulturalCompBHP00208.pdf Dolhun EP.
"Cross-Cultural Education in U.S. Medical
Schools Development of an Assessment Tool,
Academic Medicine 2003 78(6)615-622. Betancourt
JR. "Cross-Cultural Medical Education
Conceptual Approaches and Frameworks for
Evaluation," Academic Medicine 2003
78(6)560-569.
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Core Curriculum Development The
ASKED Acronym
A - Awareness S - Skill K -
Knowledge E - Encounters D - Desire
Campinha-Bacote J. Cultural Competence in
Psychiatric Nursing Have you ASKED the Right
Questions? 2002.
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Cultural Awareness
Cultural awareness is the deliberate, cognitive
process in which health care providers become
appreciative and sensitive to the values,
beliefs, lifeways, practices, and problem solving
strategies of clients cultures . This awareness
process must involve examination of ones own
prejudices and biases toward other cultures and
in-depth exploration of ones own cultural
background.



Campinha-Bacote J. A Model and Instrument
for Addressing Cultural Competence in Health
Care,
Journal of Nursing Education 1999 38204.
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Cultural Skills
Cultural skill is the ability to collect
relevant cultural data regarding the clients
health histories and presenting problems as well
as accurately performing a culturally specific
physical assessment.



Campinha-Bacote J. A Model and
Instrument for Addressing Cultural Competence in
Health Care,
Journal of Nursing Education 1999 38204.
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Cultural Knowledge
Cultural knowledge is the process of seeking and
obtaining a sound educational foundation
concerning the various world views of different
cultures . The process
... also involves obtaining knowledge regarding
specific physical, biological, and physiological
variations among ethnic groups.



Campinha-Bacote J. A
Model and Instrument for Addressing Cultural
Competence in Health Care,
Journal of Nursing Education
1999 38204.
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Cultural Encounters
Cultural encounter is the process which
encourages health care providers to engage
directly in cross-cultural interactions with
clients from culturally diverse backgrounds.




Campinha-Bacote J. A Model and Instrument for
Addressing Cultural Competence in Health Care,
Journal of
Nursing Education 1999 38205.
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Cultural Desire
Cultural desire is the motivation of health care
providers to want to engage in the process of
cultural competence.



Campinha-Bacote J. A Model and
Instrument for Addressing Cultural Competence in
Health Care,
Journal of Nursing Education 1999 38205.
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Developmental Model of Ethnosensitivity
(Adapted from Bennett )
General Specific
ETHNOCENTRIC ETHNOSENSITIVE
FEAR DENIAL SUPERIORITY MINIMIZATION RELATIVISM E
MPATHY INTEGRATION
Irrelevancy Categorization
Denigration Reversal
Reductionism Marginalization Universalism
Adaptation Pluralism
Ethics Contextual Evaluation
Borkan JM, Neher JO A Developmental Model of
Ethnosensitivity in Family Practice Training,
Family Medicine 1991 23212-217
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Key Points

• Need to create a learning environment that
  fosters safety, trust, and respect
• Within-group diversity is often greater than
  between-group diversity
• There is no cookbook approach to treating
  patients
• Avoid stereotyping and overgeneralization
• An assets and strengths-based perspective is
  important to maintain
• Every encounter is a cross-cultural encounter

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Becoming a Culturally Competent Academic Medical
Center and
Health Care Organization
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Cultural Competency Training

• What is the Current Status?
• No Talk and No Walk
  
• Talking the Talk
  
• Walking the Talk
• Talking and Walking

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Which Curriculum is Being Transformed?

• Explicit Curriculum
  formal, co-, or
  extra-curricular activities
• Implicit Curriculum
  hidden curriculum
• Null Curriculum
  what is left out of the
  curriculum
• Adapted from Elliott Eisner (http//www.teachersmi
  nd.com/eisner.htm)

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Cultural and Linguistic Competency Educational
Resources

• Monographs/Articles
• Seminars/Workshops/Courses
• Grand Rounds/Conferences
• Curricular Materials/Simulations
• Community Immersion Experiences
• Multimedia - Videos/CD-ROMs/DVDs
• Websites/E-Learning/Blended Learning

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Cultural Competency Distance Learning Programs
Office of Minority Health - A Physicians
Practical Guide to
Culturally Competent Care http//cccm.thinkcul
turalhealth.org Office of Minority Health -
Culturally Competent Nursing Care
A Cornerstone of Caring https//ccnm.thinkcultura
lhealth.org Health Resources and Services
Administration - Unified Health Communication
Unified Health Communication Addressing Health
Literacy, Cultural Competency, and Limited
English Proficiency http//www.hrsa.gov/cultural
competence (to be posted) Manhattan Cross
Cultural Group - Quality Interactions
A Patient-Based Approach to
Cross-Cultural Care http//www.qualityinteractio
ns.org
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What is the Evidence Base for
Cultural
Competency Training
A Methodologic Review of Studies Evaluating
Cultural Competence Training of Health
Professionals.
Price EG, et al.
Academic Medicine 2005 80(6)578-586 Cultural
Competence A Systematic Review of Health Care
Provider Educational Interventions

Beach MC, et al.
Medical Care 2005 43(4)356-373.
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• Clinical Cultural Competency
• Assessment Tools
• Weissman JS, Betancourt JR, et al. Resident
  Physicians Preparedness to Provide
  Cross-Cultural Care, Journal of the American
  Medical Association 2005 2941058-1067.
• Thom DH, Tirado MD. Development and Validation
  of a Patient-Reported Measure of Physician
  Cultural Competency, Medical Care Research and
  Review 2006 63(5)636-655.
• Campinha-Bacote J Inventory for Assessing the
  Process of Cultural Competence Among
  Healthcare Professionals-Revised (IAPCC-R)
  http//www.transculturalcare.net
• Georgetown National Center for Cultural
  Competence
• Cultural Competence Health Practitioner
  Assessment (CCHPA)
• http//gucchd.georgetown.edu/nccc/pa.htm
• Like RC Clinical Cultural Competency
  Questionnaire (CCCQ)
• http//www2.umdnj.edu/fmedweb/chfcd/aetna_foundat
  ion.htm
• Krajic K, Straßmayr C, et al. "Improving ethno-cul
  tural competence of hospital  staff by training
  Experiences from the European Migrant Friendly
  Hospitals project, Diversity in Health and Social
   Care, 2005 2279-290.

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Transforming the Face of Health Professions
Through Cultural Linguistic Competence
Education The Role of the HRSA
Centers of Excellence http//www.hrsa.gov/cultur
alcompetence/curriculumguide


Funded by the Health Resources and
Services Administration
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Second Language and Cultural Competency Training
for Continuing Medical Education (CME) Credit
http//www.calendow.org/Collection_publications
.aspx?coll_id26ItemID316
Funded by the
California Endowment
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• Integrating Cultural Competence into
  a Medical School Curriculum
• Top Down and Bottom Up Support
• A Needs Assessment from the Faculty
  
• Format Work Groups
• Maximum Use of Resources
• Identify Power Base of Change (Internal and
  External)
• Integrate Change Within the Current System
• Adapted from Nunez AE. Incorporating womens
  health and cultural competence in medical
  education. Proceedings, National Conference on
  Cultural Competence and Womens Health Curricula
  in Medical Education. Washington, DC USDHSS
  1998II-23.

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ONGOING CHALLENGES

• How do we generate interest, deal with
  resistance, and support the desire to become
  more culturally competent?
• How do we measure cultural competence and
  cultural humility?
• How do we evaluate the effectiveness of clinical
  cultural competency educational programs?

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ONGOING CHALLENGES

• How do we deal with hot button and cold
  button issues, and prevent burnout?
• How do we partner with communities in developing,
  implementing, and assessing the impact of
  cultural competency training?
• How do we provide high quality cultural
  competency training within a budget?

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Adding wings to caterpillars does not create
butterflies -- it creates awkward and
dysfunctional caterpillars. Butterflies are
created through transformation.
Stephanie Pace Marshall
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Worlds Apart. A Four-Part Series on
Cross-Cultural Healthcare

Mohammed Kochis Story


Maren Grainger-Monsen, MD and Julia Haslett
Stanford University,
Center for Biomedical Ethics Fanlight
Productions (www.fanlight.com)

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DISCUSSION