Cultural Competency – The Evolution of Early, Integrated Education For Medical Students, Residents and Faculty at One Institution Maria L. Soto-Greene, M.D. Vice President, Hispanic Serving Health Professions Schools, Inc. Senior Associate Dean for Education Director, Hispanic Center of Excellence New Jersey Medical School Newark, New Jersey

Overview Developing, integrating, and evaluating a cultural competency curriculum for:  Medical students  Medical residents  Faculty  Hospital interpreters

Overall Goal Adapted from the Promoting, Reinforcing, and Improving Medical Education (PRIME) project by the American Medical Student Association (AMSA) and HRSA with expectation that: Students will learn about culture and diversity’s role in medicine Students will learn about culture and diversity’s role in medicine Students will learn the importance of being culturally competent Students will learn the importance of being culturally competent Students will develop cultural and linguistic competency through participation in a variety of clinical experiences while completing a community learning experience Students will develop cultural and linguistic competency through participation in a variety of clinical experiences while completing a community learning experience

Comprehensive Curriculum 1 st year 1 st year  Art of Medicine Course  History & Physical Exam Course  Administration of the Health BELIEF Attitude Survey 2 nd year 2 nd year  Communications exercise during the Introduction to Clinical Medicine course  Teach students how to conduct a triadic interview

Comprehensive Curriculum (cont’d) 3 rd year 3 rd year  Expansion of training into third year clerkships with concomitant faculty training. 4 th year 4 th year  Graduation Objective Structured Clinical Examination (OSCE) that assesses our graduate’s cultural and linguistic competency skills.  Re-administering the Health BELIEF Attitude Survey.

“The Art of Medicine begins with the communication between a physician and the patient.” Introduced new components to the history Introduced new components to the history Trained H & P faculty on these additional components Trained H & P faculty on these additional components Introduced the appropriate use of an interpreter Introduced the appropriate use of an interpreter Integrated these components into the ambulatory preceptorships in the community Integrated these components into the ambulatory preceptorships in the community

Students’ Views The Health BELIEF Attitude Survey is an instrument used to assess how important students consider obtaining a patients health care view points. The Health BELIEF Attitude Survey is an instrument used to assess how important students consider obtaining a patients health care view points. This survey was developed and piloted at UTHSC at San Antonio by their HCOE, a HSHPS member, and Society of Teachers of Family Medicine Foundation. This survey was developed and piloted at UTHSC at San Antonio by their HCOE, a HSHPS member, and Society of Teachers of Family Medicine Foundation.

ETHNIC: A Framework for Culturally Competent Clinical Practice E: Explanation What do you think may be the reason you have these symptoms? What do friends, family, and others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on TV/radio/newspaper? (If the patient cannot offer an explanation, ask what most concerns them about their problems). Developed by:Steven J. Levin, M.D. Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H. Department of Family Medicine UMDNJ-Robert Wood Johnson Medical School

ETHNIC: Cont’d T: TreatmentWhat kinds of medicines, home remedies or other treatments have you tried for this illness? Is there anything you eat, drink or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatment are you seeking from me? H: HealersHave you sought any advice from alternative/folk healers, friends or other people (non-doctors) for help with your problems? Tell me about it. Developed by:Steven J. Levin, M.D. Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H. Department of Family Medicine UMDNJ-Robert Wood Johnson Medical School

ETHNIC: Cont’d N: NegotiateNegotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs. I: InterventionDetermine an intervention with your patient. May include incorporation of alternative treatments, spirituality, and healers as well as other cultural practices (e.g. food eaten or avoided in general and when sick). C: CollaborationCollaborate with the patient, family members, other health care team members, healers and community resources. Developed by:Steven J. Levin, M.D. Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H. Department of Family Medicine UMDNJ-Robert Wood Johnson Medical School

Introduction of Culture Glossary of Cultural Terms Glossary of Cultural Terms Case studies from the AMSA project Case studies from the AMSA project Cultural and Spiritual Beliefs Cultural and Spiritual Beliefs Complementary and Alternative Medicine (CAM) Complementary and Alternative Medicine (CAM)

Definition of Culture We adopted, with some modification, the broader definition of cultural and linguistic competency recommended by HRSA in its publication: “Cultural Competence Works Cultural & Linguistic is: “…a set of congruent behaviors, attitudes, policies and procedures that come together in a system, agency or among professionals which enable they system, agency, or those professionals to work effectively and efficiently in cross-cultural and diverse linguistic situations on a continuous basis.”

INTERPRET I:Prior to session, introductions take place. Interpreter introduces her/himself to provider. Provider introduces interpreter to patient. N:Interpreter tells provider if patient says she/he is a non-citizen or an illegal immigrant. T:The provider and interpreter should develop trust between themselves and with the patient. E:To achieve effectiveness, provider talks directly to patient in the first person; speaks in small segment; and clarifies technical terms. Interpreter is linguistically competent; speaks simply and clearly in the first person; explains cultural and linguistic topics; interprets everything said without adding or deleting; stops provider and patient if they are speaking too long; and refrains from offering advice.

INTERPRET (cont’d) R:The provider has the lead role. When working with an untrained interpreter, the provider is also responsible for explaining the interpreter’s roles and duties as outlined on this card to the interpreter. P:Proper positioning is crucial. Provider faces patient. Interpreter sits beside and slightly behind patient. Avoid triangular dynamics. R:Useful resources include the following: Diversity Rx Bilingual Dictionaries MA Medical Interpreter Assoc. E:The provider and interpreter put ethics into practice. They exercise confidentiality and a non-judgmental attitude. T:A culturally competent triadic interview involves an ample timeframe. Learn to work effectively and efficiently.

Third year medical students Began by pilot testing a cross cultural curriculum with 40 third year medical students during their medicine clerkship. Began by pilot testing a cross cultural curriculum with 40 third year medical students during their medicine clerkship. Assessed level of competency at baseline and after the curriculum using 2 modalities. Assessed level of competency at baseline and after the curriculum using 2 modalities.

Medical Student Objective Structured Clinical Examination

Results Students in the cross cultural curriculum had higher exam scores and higher levels of confidence and satisfaction. All 40 students had the same level of interest in cross cultural issues. Students in the cross cultural curriculum had higher exam scores and higher levels of confidence and satisfaction. All 40 students had the same level of interest in cross cultural issues. Goal: to develop an integrated third year medical student curriculum that emphasis sociocultural issues throughout their rotations. Goal: to develop an integrated third year medical student curriculum that emphasis sociocultural issues throughout their rotations.

Graduation Objective Structured Clinical Examination (OSCE) At the core of this examination is the doctor- patient communication. At the core of this examination is the doctor- patient communication. OSCE’s are used to assess the core skills, knowledge and attitudes of tomorrow’s physicians including more recently in licensure. OSCE’s are used to assess the core skills, knowledge and attitudes of tomorrow’s physicians including more recently in licensure. Specifically, our OSCE will test a student’s ability to communicate using cross cultural principles. Specifically, our OSCE will test a student’s ability to communicate using cross cultural principles.

Cultural Competency Training: Medical Residents Assess level of need and competency at baseline. Assess level of need and competency at baseline. Assess effectiveness of curriculum with the goal of implementing a formal cultural competency residency training program. Assess effectiveness of curriculum with the goal of implementing a formal cultural competency residency training program. A determinant of success is whether the medical resident trained receives increased patient satisfaction when working with diverse cultural groups. A determinant of success is whether the medical resident trained receives increased patient satisfaction when working with diverse cultural groups.

Medical Residents

Medical Interpreter Training Pilot project funded by the State of NJ to train volunteer hospital medical interpreters. Pilot project funded by the State of NJ to train volunteer hospital medical interpreters. 16 interpreters participated in a one day medical interpreting and cultural competency training program. 16 interpreters participated in a one day medical interpreting and cultural competency training program. curriculum focused on attitudes, knowledge, and skills curriculum focused on attitudes, knowledge, and skills

Medical Interpreter Training Program: Results and Outcomes Trained interpreters received high patient and physician satisfaction scores in the clinical setting. Trained interpreters received high patient and physician satisfaction scores in the clinical setting. Trained interpreters found that physicians do not know how to use an interpreter appropriately. Trained interpreters found that physicians do not know how to use an interpreter appropriately. An Interpreter Training Curriculum was submitted to the State of NJ. An Interpreter Training Curriculum was submitted to the State of NJ. University Hospital now funds a program to train all interpreters. University Hospital now funds a program to train all interpreters.

Clinicians must “check their own pulse” and become aware of personal attitudes, beliefs, biases, and behaviors that may influence (consciously or unconsciously) the care of their patients.

Every clinical encounter is cross-cultural No “one” way to treat a racial or ethnic group given the great “sociocultural” diversity No “one” way to treat a racial or ethnic group given the great “sociocultural” diversity Need to have a “Framework” of interventions that can be individualized Need to have a “Framework” of interventions that can be individualized A “one size fits all” health care system cannot meet the needs of an increasingly diverse American population A “one size fits all” health care system cannot meet the needs of an increasingly diverse American population

Organizational and Health Care Policies Develop a mission statement that articulates principles, rationale, and values for culturally and linguistically competent health care service delivery Develop a mission statement that articulates principles, rationale, and values for culturally and linguistically competent health care service delivery Ensure consumer and community participation Ensure consumer and community participation

Organizational and Health Care Policies (cont’d) Implement processes that review policies and procedures to assess relevance of initiatives launched Implement processes that review policies and procedures to assess relevance of initiatives launched Implement legislation that provides resources (i.e. funding from Titles VII & VIII, NIH, private sector, etc.) that supports ongoing professional development and in-service training for culturally and linguistically diverse communities Implement legislation that provides resources (i.e. funding from Titles VII & VIII, NIH, private sector, etc.) that supports ongoing professional development and in-service training for culturally and linguistically diverse communities

Cultural Competency Training and Education To succeed, we must have: To succeed, we must have:  Research Agendas  Evaluation Tools  Uniformity at all levels - both state and federal  Legislation with appropriate levels of funding to ensure that there is the level of training that ensures equal access and care for all Americans.