1. An Online Approach to Teach Sociocultural Aspects of Hyperlipidemia to Third Year Medical Students Pablo Joo MD, Sharon Krackov EdD, Deborah Jones MD, Richard Younge MD, Michelle V. Hall MA, Edgar Figueroa MD MPH 36 th Annual Predoctoral Education Conference 2010 Society of Teachers of Family Medicine Jacksonville, FL Columbia P&S New York, New York Contact E-mail: pablo.joo@einstein.yu.edu Albert Einstein College of Medicine

2. Session goals 1. Illustrate a web-based approach to teaching national standards of diagnosis and management of hyperlipidemia (ATP III) to medical students. 2. Demonstrate a dynamic and interactive learning intervention for teaching sociocultural aspects of health and illness to medical students.

3. Background A competent physician today must care for multicultural patients with diverse: 1 – –languages – –socioeconomic status – –education levels – –varying degrees of “assimilation” – –health literacy levels – –and unique ways of understanding and experiencing illness and health Patient explanatory model Biomedical model Negotiation 1. Carrillo JE, Green A, Betancourt J. 1. Carrillo JE, Green A, Betancourt J. Cross-Cultural Primary Care: A Patient-Based Approach Ann Intern Med. 1999;130:829-834.

4. Health Disparities in the United States 2 Patient / Provider – –Communication – –Conscious / unconscious discrimination – –Individual / community mistrust of the medical establishment Health Care System – –Institutional racism – –System obstacles – –Fractured health care delivery system Lack of Access –Lack of financial resources –Health insurance issues –Lack of regular source of care –Legal obstacles –Scarcity of health providers –Lack of a diverse health care force Lack of Advocacy –Disadvantaged populations have less political representation and less health advocacy 2. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002

5. Benefits of Improved Communication Effectiveness of communication and the physician– patient relationship are closely related to rates of patient satisfaction and adherence with medical regimens. 3 Effectiveness of communication and the physician– patient relationship are closely related to rates of patient satisfaction and adherence with medical regimens. 3 Acquiring effective interview skills should: 1 Acquiring effective interview skills should: 1 –improve clinical diagnosis and management –promote culturally responsive health education –avoid unnecessary medical testing –lead to better understanding between physicians and patients 3. Novack D. 3. Novack D. Therapeutic aspects of the clinical encounter. In: Lipkin M Jr, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag; 1995:32- 49. 1. Carrillo JE, Green A, Betancourt J. 1. Carrillo JE, Green A, Betancourt J. Cross-Cultural Primary Care: A Patient-Based Approach Ann Intern Med. 1999;130:829-834.

6. LCME Requirement ED-21. The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments ED-21. The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments

7. Cross-Cultural Primary Care: A Patient-Based Approach 1 Framework for analysis of the individual patient’s social context and cultural health beliefs and behaviors. Provides practical cultural competence skills. Avoids stereotypes of patients of similar cultures clustered into group “characteristic” values, customs, and beliefs. Meaning of Illness –Explanatory model –Patient’s agenda –Illness and health behavior Social Context –Economic –Literacy and language –Change in environment –Social stressors and supports –Spiritual and religious Negotiation –Explanatory model –Biomedical model –Negotiation of management options 1. Carrillo JE, Green A, Betancourt J. 1. Carrillo JE, Green A, Betancourt J. Cross-Cultural Primary Care: A Patient-Based Approach Ann Intern Med. 1999;130:829-834.

8. Our Clerkship Setting In our third year primary care clerkship, 150 students spend five weeks at one of 18 diverse clinical practices across the United States. In our third year primary care clerkship, 150 students spend five weeks at one of 18 diverse clinical practices across the United States. Whiteriver, Arizona Zuni, New Mexico Shiprock, New Mexico Concord, New Hampshire Cooperstown, NY Stamford, Connecticut New York, NY

9. Our Approach Online module to reach all learners. Online module to reach all learners. Learning intervention links students’ clinical knowledge about hyperlipidemia to new knowledge about cross-cultural care. Sociocultural aspects of hyperlipidemia are integrated into the module. Sociocultural aspects of hyperlipidemia are integrated into the module.

11. Curriculum Design 1) Students learn national hyperlipidemia standards of diagnosis and management (Adult Treatment Panel III) and apply the standards to solve online cases. 2) Final scenario in each case features a sociocultural challenge. 3) Students conduct one interview in clinic exploring patient’s beliefs about cholesterol and its management. 4) Interview tool adapted from the sociocultural curriculum article. 5) Students electronically submit a reflective exercise based on this interview. 6) Essays are electronically shared with two faculty and a fourth year student who give the third year student direct feedback.

12. Level 1: Learners’ reactions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 3: Change in behavior Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Kirkpatrick’s Hierarchy of Outcome Measures Adaptation by Barr H, Freeth D, Hammick M et al., 2000 Kirkpatrick’s Four Levels of Evaluation, 1967 Curriculum assessment

13. Level 1: Learners’ reactions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 3: Change in behavior Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Kirkpatrick’s Hierarchy of Outcome Measures Adaptation by Barr H, Freeth D, Hammick M et al., 2000 Kirkpatrick’s Four Levels of Evaluation, 1967 Curriculum assessment

14. Level 1: Students’ reactions to the hyperlipidemia online module The materials in this web module added to my understanding of hyperlipidemia. n = 429 %

15. Level 1: Learners’ reactions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 3: Change in behavior Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Kirkpatrick’s Hierarchy of Outcome Measures Adaptation by Barr H, Freeth D, Hammick M et al., 2000 Kirkpatrick’s Four Levels of Evaluation, 1967 Curriculum assessment

16. Level 2a: Assessment of third year medical students attitudes and perceptions about sociocultural aspects of health care n=209 % The HYPERLIPIDEMIA - SOCIOCULTURAL ASSESSMENT EXERCISE helped me to reflect on improving communication and cooperation between my patients and me.

17. Level 2a: Assessment of third year medical students attitudes and perceptions about sociocultural aspects of health care The HYPERLIPIDEMIA - SOCIOCULTURAL ASSESSMENT EXERCISE increased my awareness of the sociocultural factors that affect patient care. n=209 %

18. Level 2a: Assessment of third year medical students attitudes and perceptions about sociocultural aspects of health care % n=209 The HYPERLIPIDEMIA - SOCIOCULTURAL ASSESSMENT EXERCISE allowed me to explore patient's beliefs about health and illness, values, and behaviors.

19. Level 1: Learners’ reactions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 2b: Acquisition of knowledge/skills Level 2a: Modification of attitudes/perceptions Level 3: Change in behavior Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Level 4b: Benefits to patients or clients Level 4a:Change in organizational practice Kirkpatrick’s Hierarchy of Outcome Measures Adaptation by Barr H, Freeth D, Hammick M et al., 2000 Kirkpatrick’s Four Levels of Evaluation, 1967 Curriculum assessment

20. Level 2b: Sociocultural Knowledge Student narrative comments are: – –not direct measures of student knowledge. – –but may predict an early indication of knowledge gain.

21. Level 2b: Sociocultural Knowledge Student narrative statements “I was able to explore matters affecting healthcare which I had previously underestimated. Actually I feel that without this exercise, the patient may have left the clinic with no intention of filling her prescription. In this case, addressing the cost of the prescriptions made a big difference to the patient.” SOCIOECONOMIC ISSUESSOCIOECONOMIC ISSUES

22. Level 2b: Sociocultural Knowledge Student narrative statements “Despite this woman's low educational level and not speaking English, she had a pretty accurate concept of her health problems. This reminded me that you cannot assume one way or the other about how a patient is going to perceive their illness and health care in general. It's important to ask.” AVOIDING ASSUMPTIONSAVOIDING ASSUMPTIONS

23. “The patient was a bit hesitant to start medications due to fear of side effects and preference for conservative management. We offered the combination of fish oil and lifestyle changes. The patient chose this route with no prodding, and agreed to try medications if these approaches did not work alone.” NEGOTATIONNEGOTATION Level 2b: Sociocultural Knowledge Student narrative statements

24. “When asked what the most important thing a doctor could do for her, she responded with, ‘Listen to me carefully and try to understand my problems’.’ It was important to her that doctors understand her medical issues from her perspective and offer appropriate solutions. This had a strong impact on me and my own understanding as to what constitutes successful medical care.” PATIENT’S AGENDAPATIENT’S AGENDA

25. Conclusions Our intervention: Our intervention: –integrates simulated online experiences with real clinical experiences –received positive feedback from most students –increased student self-rated competence on sociocultural awareness –allows students to discuss and apply what they learned from their patients to formulate patient- centered management plans

26. Challenges Balancing the interactive nature of this module with time demands of the students and faculty. Balancing the interactive nature of this module with time demands of the students and faculty. Locating partners in education technology to successfully build and maintain the module. Locating partners in education technology to successfully build and maintain the module. Identifying enthusiastic faculty and fourth year students to give feedback to third year students on their essay. Identifying enthusiastic faculty and fourth year students to give feedback to third year students on their essay. Developing appropriate student assessments that are linked to the cultural competency-based objectives for the module. Developing appropriate student assessments that are linked to the cultural competency-based objectives for the module. Logistic and financial obstacles to the assessment of Kirkpatrick’s Hierarchy of Outcome Measures at Level 3 (change in practice behavior) or Level 4 (change in patient outcomes). Logistic and financial obstacles to the assessment of Kirkpatrick’s Hierarchy of Outcome Measures at Level 3 (change in practice behavior) or Level 4 (change in patient outcomes).

27. Future Directions Columbia P&S – –Transition from group email feedback to wiki communication feedback Albert Einstein College of Medicine – –Team-based Learning Session Phase One: Online Module Phase Two: Readiness Assurance Testing Phase Three: Application of Concepts Coding qualitative data from student essays

28. Acknowledgements Columbia University Center for New Media Teaching and Learning Columbia University Center for New Media Teaching and Learning Columbia University Medical Center / Center for Education Research and Evaluation Columbia University Medical Center / Center for Education Research and Evaluation Columbia P&S / Center for Family and Community Medicine Columbia P&S / Center for Family and Community Medicine Albert Einstein College of Medicine / Department of Family and Social Medicine Albert Einstein College of Medicine / Department of Family and Social Medicine

29. Bibliography 1. Carrillo JE, Green A, Betancourt J. 1. Carrillo JE, Green A, Betancourt J. Cross-Cultural Primary Care: A Patient-Based Approach Ann Intern Med. 1999;130:829-834. 2. 2. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002 3. Novack D. 3. Novack D. Therapeutic aspects of the clinical encounter. In: Lipkin M Jr, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag; 1995:32-49.

30. Thank You! Thank You