Cultural Competence and Health Disparities— Resources, Context, and Curricular Development Harry Pomeranz MS, PA-C PAEA October 30th, 2008

KNOWLEDGE Race, ethnicity, culture Race, ethnicity, culture Historical mistrust/prejudice, Historical mistrust/prejudice, Health disparities and inequities Health disparities and inequities

KNOWLEDGE Traditions and customs relevant to health care (sexual/gender issues, age, disabilities..) without stereotyping Traditions and customs relevant to health care (sexual/gender issues, age, disabilities..) without stereotyping Health beliefs/explanatory model Health beliefs/explanatory model Styles of communication, Styles of communication, Autonomy vs. family decision-making, Autonomy vs. family decision-making, Patients’ access to resources Patients’ access to resources Health literacy Health literacy

Definition of cultural competence Cultural self-identity Cultural self-identity Discussion of the culture of medicine Discussion of the culture of medicine Integrated into interviewing, communication, PA Seminar classes Integrated into interviewing, communication, PA Seminar classes

Socio-cultural classification of race Taught using case-based module, lecture Taught using case-based module, lecture Taught in ethics, professionalism, genetics, public health, pathology, pharmacology, impact on health care delivery Taught in ethics, professionalism, genetics, public health, pathology, pharmacology, impact on health care delivery

Rationale and evidence for teaching CC The Diversity Research Forum“Tools for Assessing and Measuring Diversity in Medical Education” AAMC The Diversity Research Forum“Tools for Assessing and Measuring Diversity in Medical Education” AAMC “Cultural Competence Education” AAMC “Cultural Competence Education” AAMC “Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care”, Wally R. Smith, MD; Joseph R. Betancourt, MD, MPH; position paper, Annals of Internal Medicine “Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care”, Wally R. Smith, MD; Joseph R. Betancourt, MD, MPH; position paper, Annals of Internal Medicine

Development of cultural competency curriculum Development of cultural competency curriculum Betancourt, J.R. (2003). Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation. Acad Med, 78(6), Betancourt, J.R. (2003). Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation. Acad Med, 78(6), Tervalon, M. (2003). Components of Culture in Health for Medical Students’ Education. Acad Med, 78(6), Tervalon, M. (2003). Components of Culture in Health for Medical Students’ Education. Acad Med, 78(6), Kagawa-Singer, M. & Kassim-Lakha, S. (2003). A Strategy to Reduce Crosscultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Acad Med, 78(6), Kagawa-Singer, M. & Kassim-Lakha, S. (2003). A Strategy to Reduce Crosscultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Acad Med, 78(6),

Evaluation Pretest-Posttests Pretest-Posttests Approach to Unknown Clinical Cases Approach to Unknown Clinical Cases Presentation of Clinical Cases Presentation of Clinical Cases Objective Structured Clinical Exams Objective Structured Clinical Exams

ATTITUDES Has the student learned the particular importance of humility, empathy, and respect in cross-cultural encounters? Has the student learned the particular importance of humility, empathy, and respect in cross-cultural encounters? Does the student reflect on his/her own bias and prejudice? Does the student reflect on his/her own bias and prejudice? Has the student developed flexibility in making decisions and negotiating? Has the student developed flexibility in making decisions and negotiating?

Clinician self-assessment and reflection tools Implicit Association Test is a tool to allow individuals to gain greater awareness about their own unconscious preferences and beliefs. atest.html Implicit Association Test is a tool to allow individuals to gain greater awareness about their own unconscious preferences and beliefs. atest.html atest.html atest.html National Center for Cultural Competence has self-assessment tools for organizations and practicing physicians: National Center for Cultural Competence has self-assessment tools for organizations and practicing physicians: ent.html ent.html ent.html ent.html

Stereotyping and Medical Decision-Making The Commonwealth Fund The Commonwealth Fund Excellent article describing the levels of racism: Jones CP. Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health; Aug 2000; 90, 8; newsletter/2005/Levels-Of-Racism.pdf Excellent article describing the levels of racism: Jones CP. Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health; Aug 2000; 90, 8; newsletter/2005/Levels-Of-Racism.pdfhttp:// newsletter/2005/Levels-Of-Racism.pdfhttp:// newsletter/2005/Levels-Of-Racism.pdf interactive exercise (Bafa Bafa) interactive exercise (Bafa Bafa) charities/bafa.html charities/bafa.html

Self-assessment and reflection Taught as case-based, on-line Taught as case-based, on-line Taught in interviewing, professionalism, ethics, clinical rotations Taught in interviewing, professionalism, ethics, clinical rotations

Evaluation Standard Surveying Standard Surveying Structured Interviewing Structured Interviewing Self-Awareness Assessment Self-Awareness Assessment Presentation of Clinical Cases Presentation of Clinical Cases Objective Structured Clinical Exam Objective Structured Clinical Exam Videotaped/Audio-taped Clinical Encounters Videotaped/Audio-taped Clinical Encounters

SKILLS Has the student learned how to explore core cross-cultural issues and the explanatory model? Has the student learned how to explore core cross-cultural issues and the explanatory model? Has the student learned how to effectively negotiate with a patient? Has the student learned how to effectively negotiate with a patient? Has the student demonstrated respect for the beliefs of others? Has the student demonstrated respect for the beliefs of others? Has the student demonstrated self- reflection? Has the student demonstrated self- reflection?

Cultural and Linguistic competence L-E-A-R-N model L-E-A-R-N model Kleinman’s Questions Kleinman’s Questions Integrated into interviewing, health-care delivery, epidemiology, public health, genetics, pharmacology classes, medicine Integrated into interviewing, health-care delivery, epidemiology, public health, genetics, pharmacology classes, medicine Taught using case-based modules Taught using case-based modules Cultural Conflicts discussed as part of ethics, professionalism, medicine Cultural Conflicts discussed as part of ethics, professionalism, medicine

Cross-Cultural Skills L-E-A-R-N Model of Cross Cultural Encounter Guidelines for Health Practitioners. On the Diversity Rx website. L-E-A-R-N Model of Cross Cultural Encounter Guidelines for Health Practitioners. On the Diversity Rx website. Accessed at: Multicultural Health Best Practices Overview. Includes the Kleinman questions. On the Diversity Rx website. Multicultural Health Best Practices Overview. Includes the Kleinman questions. On the Diversity Rx website. Accessed at: Mutha S, Allen C, Welch M. Toward Culturally Competent Care A Toolbox for Teaching Communication Strategies. Center for the Health Professions, UCSF. Mutha S, Allen C, Welch M. Toward Culturally Competent Care A Toolbox for Teaching Communication Strategies. Center for the Health Professions, UCSF. iversity.html iversity.html

Evaluation Presentation of Clinical Cases Presentation of Clinical Cases Objective Structured Clinical Exam Objective Structured Clinical Exam Videotaped/Audio-taped Clinical Encounter Videotaped/Audio-taped Clinical Encounter Role-playing in interviews Role-playing in interviews Standardized patient (or faculty member) Standardized patient (or faculty member) Observation in clinical rotations Observation in clinical rotations

Health disparities Taught in epidemiology, public health, professionalism, ethics, pharmacology, genetics, medicine, interviewing Taught in epidemiology, public health, professionalism, ethics, pharmacology, genetics, medicine, interviewing

Health and Health Care Disparities National Healthcare Disparities Report, spx National Healthcare Disparities Report, spx spx spx Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, Initiative to Eliminate Racial and Ethnic Disparities in Health U.S. Department of Health and Human Services e alth.hhs.gov Initiative to Eliminate Racial and Ethnic Disparities in Health U.S. Department of Health and Human Services e alth.hhs.gov e alth.hhs.gov e alth.hhs.gov Health Disparities Collaboratives: A National Efforts to Improve Health Outcomes for All Medically Underserved People with Chronic Diseases Health Disparities Collaboratives: A National Efforts to Improve Health Outcomes for All Medically Underserved People with Chronic Diseases

factors underlying health and health-care disparities Freeman HP. Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities. CA Cancer J Clin, 2004;54: /72 Freeman HP. Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities. CA Cancer J Clin, 2004;54: /72 /72 /72 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000,JAMA. 2004;291: Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000,JAMA. 2004;291:

Racial/ethnic differences in cardiac care Henry J Kaiser Family Foundation and the American College of Cardiology Foundation. The Commonwealth Fund The Commonwealth Fund

Resources on the intersection of race and genetics social determinants of health, January 2005 American Psychologist special issue on “ Genes, Race, and Psychology in the Genome Era ”: social determinants of health, January 2005 American Psychologist special issue on “ Genes, Race, and Psychology in the Genome Era ”: Department of Energy’s Human Genome Project’s website has linkages to two special journal issues on race and genetics they sponsored (November 2004 Nature Genetics; Spring 2002 Journal for Minority Medical Students supplement), Genome/elsi/minorities.shtml Department of Energy’s Human Genome Project’s website has linkages to two special journal issues on race and genetics they sponsored (November 2004 Nature Genetics; Spring 2002 Journal for Minority Medical Students supplement), Genome/elsi/minorities.shtml Genome/elsi/minorities.shtml Genome/elsi/minorities.shtml

The Impact of Stereotyping on Medical Decision-Making Taught in interviewing, medicine, ethics, professionalism, internal medicine, surgery, evidence-based medicine, public health, clinical rotations Taught in interviewing, medicine, ethics, professionalism, internal medicine, surgery, evidence-based medicine, public health, clinical rotations

Bias, Discrimination and Racism: the Impact of Stereotyping on Medical Decision-Making Unequal Treatment: Confronting Racial & Ethnic Disparities in Health. Smedley BD, Stith AY, Nelson AR. Institute of Medicine Unequal Treatment: Confronting Racial & Ethnic Disparities in Health. Smedley BD, Stith AY, Nelson AR. Institute of Medicine Slide sets are also available on the Institute of Medicine website: The Right to Equal Treatment: An Action Plan to End Racial and Ethnic Disparities The Right to Equal Treatment: An Action Plan to End Racial and Ethnic Disparities in Clinical Diagnosis and Treatment in the United States Physicians for Human Rights.

Stereotyping The University of North Carolina’s minority health project website has slidesets on these topics from Dr. Jack Geiger (2005) and other previous speakers: Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 2000;50: Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 2000;50: