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

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

3. 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

4. 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

5. 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

6. 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

7. 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), 560-569. Betancourt, J.R. (2003). Cross-cultural Medical Education: Conceptual Approaches and Frameworks for Evaluation. Acad Med, 78(6), 560-569. Tervalon, M. (2003). Components of Culture in Health for Medical Students’ Education. Acad Med, 78(6), 570-576. Tervalon, M. (2003). Components of Culture in Health for Medical Students’ Education. Acad Med, 78(6), 570-576. 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), 577-587. 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), 577-587.

8. 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

9. 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?

10. 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. https://implicit.harvard.edu/implicit/demo/select atest.html Implicit Association Test is a tool to allow individuals to gain greater awareness about their own unconscious preferences and beliefs. https://implicit.harvard.edu/implicit/demo/select atest.html https://implicit.harvard.edu/implicit/demo/select atest.html https://implicit.harvard.edu/implicit/demo/select 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: http://gucchd.georgetown.edu/nccc/selfassessm ent.html http://gucchd.georgetown.edu/nccc/selfassessm ent.html http://gucchd.georgetown.edu/nccc/selfassessm ent.html http://gucchd.georgetown.edu/nccc/selfassessm ent.html

11. Stereotyping and Medical Decision-Making The Commonwealth Fund http://www.cmwf.org The Commonwealth Fund http://www.cmwf.org 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; 1212- 1215.http://www.cahealthadvocates.org/_docs/ 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; 1212- 1215.http://www.cahealthadvocates.org/_docs/ newsletter/2005/Levels-Of-Racism.pdfhttp://www.cahealthadvocates.org/_docs/ newsletter/2005/Levels-Of-Racism.pdfhttp://www.cahealthadvocates.org/_docs/ newsletter/2005/Levels-Of-Racism.pdf interactive exercise (Bafa Bafa) interactive exercise (Bafa Bafa) http://www.simulationtrainingsystems.com/schools charities/bafa.html http://www.simulationtrainingsystems.com/schools charities/bafa.html

12. 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

13. 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

14. 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?

15. 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

16. 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: http://www.diversityrx.org/HTML/MOCPT2.htm http://www.diversityrx.org/HTML/MOCPT2.htm 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: http://www.diversityrx.org/best/ http://www.diversityrx.org/best/ 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. http://futurehealth.ucsf.edu/cnetwork/resources/curricula/d iversity.html http://futurehealth.ucsf.edu/cnetwork/resources/curricula/d iversity.html

17. 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

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

19. Health and Health Care Disparities National Healthcare Disparities Report, 2004 http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.a spx National Healthcare Disparities Report, 2004 http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.a spx http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.a spx http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.a spx Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, 2002 http://www.nap.edu/books/030908265X/html Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Institute of Medicine, 2002 http://www.nap.edu/books/030908265X/htmlhttp://www.nap.edu/books/030908265X/html Initiative to Eliminate Racial and Ethnic Disparities in Health U.S. Department of Health and Human Services http://raceandh e alth.hhs.gov Initiative to Eliminate Racial and Ethnic Disparities in Health U.S. Department of Health and Human Services http://raceandh e alth.hhs.gov http://raceandh e alth.hhs.gov http://raceandh e alth.hhs.gov Health Disparities Collaboratives: A National Efforts to Improve Health Outcomes for All Medically Underserved People with Chronic Diseases http://www.healthdisparities.net Health Disparities Collaboratives: A National Efforts to Improve Health Outcomes for All Medically Underserved People with Chronic Diseases http://www.healthdisparities.net http://www.healthdisparities.net

20. factors underlying health and health-care disparities Freeman HP. Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities. CA Cancer J Clin, 2004;54:72-77 http://caonline.amcancersoc.org/cgi/reprint/54/2 /72 Freeman HP. Poverty, Culture, and Social Injustice: Determinants of Cancer Disparities. CA Cancer J Clin, 2004;54:72-77 http://caonline.amcancersoc.org/cgi/reprint/54/2 /72 http://caonline.amcancersoc.org/cgi/reprint/54/2 /72 http://caonline.amcancersoc.org/cgi/reprint/54/2 /72 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000,JAMA. 2004;291:1238-1245. http://www.csdp.org/research/1238.pdf Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000,JAMA. 2004;291:1238-1245. http://www.csdp.org/research/1238.pdf http://www.csdp.org/research/1238.pdf

21. Racial/ethnic differences in cardiac care Henry J Kaiser Family Foundation and the American College of Cardiology Foundation. http://www.kff.org/whythedifference/ http://www.kff.org/whythedifference/ The Commonwealth Fund http://www.cmwf.org The Commonwealth Fund http://www.cmwf.org http://www.cmwf.org

22. 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 ”: http://www.genome.gov/13014159 social determinants of health, January 2005 American Psychologist special issue on “ Genes, Race, and Psychology in the Genome Era ”: http://www.genome.gov/13014159http://www.genome.gov/13014159 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), http://www.ornl.gov/sci/techresources/Human_ 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), http://www.ornl.gov/sci/techresources/Human_ Genome/elsi/minorities.shtml http://www.ornl.gov/sci/techresources/Human_ Genome/elsi/minorities.shtml http://www.ornl.gov/sci/techresources/Human_ Genome/elsi/minorities.shtml

23. 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

24. 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. 2002. http://www.nap.edu/books/030908265X/html/ Unequal Treatment: Confronting Racial & Ethnic Disparities in Health. Smedley BD, Stith AY, Nelson AR. Institute of Medicine. 2002. http://www.nap.edu/books/030908265X/html/ http://www.nap.edu/books/030908265X/html/ Slide sets are also available on the Institute of Medicine website: http://www.iom.edu/?id=4475&redirect=0 http://www.iom.edu/?id=4475&redirect=0 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. 2003.Physicians for Human Rights. http://www.phrusa.org/research/domestic/race/race_report/report.html

25. 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: http://www.minority.unc.edu/ http://www.minority.unc.edu/ Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 2000;50:813-28. Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med 2000;50:813-28.