Introduction
Cultural competence has been defined as “the ability to understand and respond effectively to the cultural and linguistic needs of patients in the health care encounter” or “a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.” Cultural competency training recognizes both the individual patient-doctor relationship and population-based perspectives.
Despite published reports of disparities in health care for the uninsured, African American, and Hispanic population relative to Caucasians and those with private insurance, most graduates of U.S. internal residency programs have not received adequate training in culture competency at the start of their careers. Two specific accreditation standards (ED-21 and ED-22) now require the teaching of cross-cultural issues in medical schools, and states have begun to legislate inclusion of this teaching in continuing medical education (CME) for physicians to better address health care needs of the diverse U.S. population. An integrated, rather than stand alone, curricular strategy is considered the most effective way to deliver this training across the continuum of medical education. The Association of American Medical Colleges (AAMC) has provided a framework to isolate key domains and learning objectives that recognize under addressed issues within cultural competency teaching and to guide faculty. The AAMC recently revised six domains identified as: health disparities, bias and stereotyping, community strategies, cross-cultural communication skills, working with interpreters, and the culture of medicine, with the first three being least addressed by most schools. Attending faculty, fellows, or residents should integrate teaching in the 6 domains, take steps to assess teaching impact and improve future self-directed learning.
Most educational research supports the case-based, precepting approach as more effective than the formal lecture-based didactic method during clinical training. Despite limited time to provide didactic teaching, frequent direct contact with learners presents informal or hidden opportunities for “teachable moments” that inevitably occur throughout the workday. This chapter will focus on ways to integrate teaching into direct patient care activities and identify “teachable moments” that build on learners’ existing knowledge and skills. Case studies will be used to (1) provide a framework to address cultural competency teaching, (2) identify potential missed opportunities for teaching, (3) demonstrate learner- and patient-centered strategies to integrate the teaching of cultural competence into the hospitalist rotation, (4) review methods for assessing and giving feedback to learners, and (5) provide resources to help faculty to improve the teaching of cross-cultural medicine.
Case 1: Addressing Health Disparities
Health disparities are differences in the prevalence, etiology, presentation of disease, and access to care that result in unequal outcomes for different groups of people. They can be attributed to the patient (attitudes, adherence, education, beliefs, and health literacy), the physician (lack of knowledge, bias, poor cultural skills) and the health system (insurance, hospitals, neighborhoods, access to care, bias). Disparities resulting in adverse outcomes affect many patient groups including ethnic minorities, rural populations, the elderly, the young and those with disabilities, different sexual orientation, or religious beliefs. Recent research has uncovered a myriad of ethnic and gender disparities in the process and outcomes of care by physicians and hospitals. Physicians can reduce disparities in their own practices and communities by recognizing vulnerable populations and seeking opportunities to improve screening and diagnosis, patient education, and access to care for the underserved. See Chapter 3, Health Care Disparities.
TWO PATIENTS, SAME MEDICAL PROBLEM Student SS presents a 45-year-old African American single mother with left ventricular dysfunction secondary to severe hypertension unresponsive to multiple drug regimens. Increasing shortness of breath and recurrent left chest pain brought her to the emergency department, where she was noted to have a blood pressure on admission of 210/98 mm Hg. Student WM presents a 60-year-old white male smoker on a prepaid health plan. With history of multiple cardiovascular risk factors, he developed congestive heart failure 2 years ago. He is now functionally limited, lives alone, and receives disability income. His primary care physician’s office directly admits him to the hospital for worsening dyspnea on exertion, progressive orthopnea, and bilateral leg edema. Both patients had physical exam findings, chest x-rays, and B-type natriuretic peptide (BNP) levels consistent with acute heart failure. Acute myocardial infarction was successfully ruled out for both patients and both patients received loop diuretics. The attending recommends medication changes to optimize their heart failure management. The attending then moves on to the third admission of the night. Five Minute precepting model What are the missed teaching opportunities for culturally competent patient care here? How else could the attending have responded to the students? What teaching strategies can be used to facilitate learning about health disparities? Evidence based assignment Before the next morning’s rounds both students present a summary of one systematic review and one randomized trial addressing the black-white disparity in heart failure but report that they could not find a clinical practice guideline that addressed race. |
- What are the missed teaching opportunities for culturally competent patient care?
- How else could the attending have responded to the students?
- What teaching strategies can be used to facilitate learning about health disparities?
This attending failed to use the example of two patients with a similar problem as an opportunity to teach about potential sources of disparity in heart failure outcomes. Using Socratic questioning to engage the students’ interest in the topic, the attending might have framed specific questions as follows:
- (Asking for information): “Do you know if there are differences in risk for heart failure between African American and white patients? Are you aware of differences between Latinos, Native Americans, and Asians?”
- (Open-ended questions): “What are your thoughts about the long-term prognosis for these 2 patients?” “Are there differences in patient satisfaction between hospitalized African American and white patients? What factors might influence patient satisfaction?”
- (Combination questions): “What are some management strategies to ensure the best outcome for these two patients? Are they different because of the patient’s race or insurance status?”
- (Prediction questions): “What is the impact of health insurance or the lack of insurance on their health?” “What is the data relating to neighborhood dimensions that may affect health? What if one of these patients was homeless?”
- (Extension questions): “What else can you do to improve care for these 2 patients?” “If you were given a grant to conduct cardiovascular research in health disparities, what would be your hypothesis for a new study? If you were a health policy maker how would you distribute funding to reduce this disparity?”
- (Action question): “What would you do if you were their primary care doctor?”
- (Summarizing questions): “What inferences can we make about health disparities and their causes from these two cases? How would you summarize what we have learned from this discussion?”
Knowledge gaps or inability to answer questions could generate learning using an evidence-based assignment. The attending might ask a search question, such as “Does race affect long-term outcomes of myocardial infarction, hospitalization, or mortality for patients hospitalized with their first episode of heart failure?” In preparation for the next morning’s rounds the students would perform a focused literature search for the best and most recent practice guidelines or studies to present as practice pearls for reducing racial disparities in heart failure care. The students may be asked to define neighborhoods and report back on specific data about neighborhoods and homelessness in their city and how different boundaries carry different risks related to hepatitis, diabetes, and other diseases. The attending might explore the ethics of distributive justice, a discussion of how insurance coverage impacts health, and how physicians can address social determinants of health. This attending has now planted the seed of scientific inquiry into health disparities as a legitimate health outcomes research topic and an important health policy issue.
Case 2: Recognizing and Addressing Bias and Stereotyping
First noted in a study comparing the likelihood of referral of African American versus white, and male versus female patients, for angiography and more recently observed for thrombolysis decision-making, unconscious physician bias can potentially negatively impact clinical decision making despite evidence for best practice. Implicit bias against “fat people” among health care providers has been well documented and recognizing unconscious bias is one way to prevent the bias from adversely affecting outcomes of care.
After assigning a few obese patients to the student, the attending observes a 10-minute counseling session by the student at the bedside of a patient before discharge. At the end he turned and asked the patient “So, how do you feel about losing weight? What will you do differently now?” The patient replies, “No doctor here has asked me about what I am willing to give up and what I cannot give up and shown such understanding about my emotional struggles with food. Maxwell has visited me every day and knows every detail about my diet and lifestyle now. Can I follow up with him?” The student smiles and says “Of course. I am in ambulatory medicine the next 6 weeks. Let me help you make an appointment.” Thus, by being nonjudgmental and giving the student permission to recognize his own bias, the attending has also improved the student’s skills in motivational counseling and given him new confidence in caring for obese patients. The likelihood of future self-directed learning in the student may also have increased.
