1. The Hidden Curriculum in IMG Education: An Anthropological Approach Edward J. Rohn, MA James P. Meza, MD, MSA Department of Family Medicine Residency Program Henry Ford Health System Detroit, MI

2. Session Goals 1.Understand that socio-cultural factors impact individual behaviors and interaction among members of the health care team. 2.Learn specific skills to apply to your own program and educational activities. 3.View setting as a socially-dynamic system of interactions vs. individual personalities.

3. Session Objectives 1.Report out a successful intervention using anthropological analysis and methodology. 2.Practice specific qualitative data gathering tools. 3.Review specific known issues related to IMG education.

4. Case Study – Need Analysis Needs analysis provoked by impending closure of Family Medicine in-patient service. Press-Ganey scores in Family Medicine lowest in the hospital. Hospital politics in nursing administration actively considering closing the in-patient unit, threatening the viability of the residency.

5. Case Study – An Anthropological Analysis Pierre Bourdieu – practice theory –Cultural capital is acquired by individuals over time; it is the knowledge, skills, and abilities recognized by others (grades, promotion, and increasing competence are all markers). –Habitus is a person’s character and way of thinking, developed by prolonged exposure in a social setting (such as medical practice). –Field is a particular structure of social power relationships (such as the hierarchy inherent in medical education).

6. Case Study – Medical Educator’s View Hospital in-patient setting –Field is the hierarchy in medical education, including the attendings, nurses, senior residents, and others, and the relationships between each. –Habitus is the natural ways of behaving based on example from others in the field, typically top down (Here? There?). –Cultural capital is the accrued power based on demonstrated knowledge, skills, and other valued attributes.

7. Case Study – Methods Ethnographic interviewing –Informal questioning to understand “emic” viewpoint. Participant-observation –Observing social patterns while participating. Textual analysis –Reviewing documents for larger understanding.

8. Case Study – Methods Ethnographic interviewing –Listening to nurse administrator, nurses, residents, customer-service reps, attendings, students Participant-observation –Watching social interactions on the floor and departmental retreat related to the crisis. Textual analysis –Actions plans generated by nurses, department directors, Press-Ganey.

9. Case Study - Observations Authoritarian attending (trained in India, practiced as surgeon, graduate of the program). Formal, hierarchical style of teaching (cultural capital) Reinforced social position of nursing staff (bottom) Resentment of nursing staff – dissonance of IMG field vs. US. IMG residents recognize the habitus of a medical education appropriate in India. Residents replicated interactions with nurses (cultural replication, habitus).

10. Case Study Summary Residents recognized and duplicated an inappropriate social field and habitus creating conflicts over cultural capital that spilled over into patient care. Patterns of behavior endured 24 hours a day. Medical educators call this the “hidden curriculum”.

11. Case Study – Intervention Aligned between behavioral science curriculum, Press-Ganey language, and clarifying and revaluing roles of each team member. Social interactions such as pot lucks, posters, conversation, etc. Increased dialogue and establishing new expectations of the residents and attendings.

12. Case Study – Outcomes

13. Case Study – Reactions from stakeholders Prior to the intervention, not a single nurse wanted to be assigned to Family Medicine. Following the intervention, a waiting list of nurses are requesting assignment to Family Medicine. The Family Medicine service remains open, and is a vibrant and thriving part of our residency.

14. Observational Exercise

15. Take-Aways Describe, don’t evaluate. –Watch for adjectives, value statements, judgments, assumptions. Different people see different things. –Our experiences/interests form our filters. Self-reflect on observational filters. –We have them. Account for them in data.

16. Interviewing Exercise “How do you evaluate residents?”

17. Interviewing Exercise Hallmarks of an ethnographic interview –Only open-ended questions –Tracking the agenda of the respondent, not yours –Seeking “emic” point of view –Don’t assume shared meaning of critical terms –Be willing to let go your “need to know” – the absence of content is equally important. –Acquire data, seek deeper understanding; don’t evaluate (cultural relativism).

18. Textual Analysis Comparison of behavioral science curriculum to Press-Ganey recommendations. Document used to realign the behaviors and values of our in-patient service with the needs of the institution and educational commitments.

19. What we’ve learned about IMG experiences It is imperative to explore residents’ own culture of origin together so that the attendings and residents understand how to adjust to the new social field. This is the antithesis to “Now they’re in the United States, they have to act like us.”

20. What we’ve learned about IMG experiences “Being a foreigner, I may be punished if I make a small mistake” Not knowing on rounds is unacceptable Idiomatic phrases often go unheard Individual patient autonomy vs. family decision-making Coping through silence at the cost of internal anguish Medical language vs. vernacular English Roles in work setting vs. roles in family life Overt expectation to “act like an American” doesn’t work. Cross multiple cultural barriers – medical culture, culture of origin, subspecialty cultures.

21. Curriculum Development Authoritarian attending has undergone self- initiated professional development to improve teaching style (habitus adapting to new social field). Increased presence of behavioral scientist on in- patient service, continuing methodology outlined above (continuity of new social field). Reflect on cultural differences and similarities; identify strengths from home and new cultures (contextualize genograms and cultural discussions as cultural capital).

22. Curriculum Development Role modeling of new habitus during case study translated to patient care by the residents Orientation activities with new residents geared to maintain new work values and behaviors. Use of ethnographic interviewing and its clinical equivalent, unstructured listening. Unstructured listening activity

23. “WE ARE A TEAM” (Poster) We, the physicians, nursing and support staff on I-2 are a TEAM. We are equal partners in our work together to achieve our common goal of BEST PATIENT CARE. We RESPECT each other and LEARN from each other. We also support each other and work to make our unit THE BEST! Signed (All nurses, residents, & attendings)

24. Taking it home… Questions about applications for this approach in your own educational setting. ?