1. Saint Louis University Family Medicine Residency
Training in Healthcare Disparities Using a Longitudinal Underserved Community Curriculum
Christine Jacobs, MD
Jay Brieler, MD
Saint Louis University Family Medicine Residency
St. Louis MO

2. Disclosures No financial conflicts of interests
No off-label uses of curriculum
No live animals harmed other than interns

3. Objectives Describe a dedicated curriculum in underserved care.
Describe curricular methods that impart multiple perspectives of cultural difference.
List teaching activity characteristics that maximize resident engagement in cultural topics.
Characterize experiences, successes, and challenges in teaching cross-cultural care and health care disparities.

4. What Predicts Preparedness for Cross-Cultural Care?
Role models
Greater cross-cultural case mix during residency
More instructional opportunities for learning cross-cultural care.
GreerJA et al. Primary care resident perceived preparedness to deliver cross-cultural care: an examination of training and specialty differences. J Gen Intern Med Aug;22(8):
Mail Survey of 1150 residents (family medicine, internal medicine, pediatrics and OB/gyne) in 2004:

5. Saint Louis University Family Medicine Residency
Opened in 2011 to train family physicians to care for underserved patients.
Ambulatory care in an FQHC with:
Diverse ethnic population
High behavioral health burden
High prevalence of tobacco, obesity
Significant rates of incarceration and homelessness

6. Objectives of the Curriculum
Increase resident understanding of the social determinants of health and cultural competency.
Engage and empower residents in the care of underserved patients
To help residents integrate sociocultural and behavioral health considerations into practice.
To promote resident wellness while serving a challenging population.

7. Attitudes Essential To Underserved Care
Understanding of community
Appreciation of challenges of special populations
Underrepresented Minorities
Immigrants
LGBTQ
Recognition of challenge of living in poverty
Exposure to cultural traditions and beliefs
Recognition of Bias

8. Four E’s of Resident Training in Underserved Care
Engage residents
Empower residents
Help residents Execute underserved care
Ensure resident wellness

9. Engage Interest residents in underserved and cross-cultural care
Increase resident understanding of the social determinants of health and cultural competency.
How?
Exposure to culture in a nonmedical setting
Create low-stakes immersive experiences
Model joy in caring for populations at need
Lack of understanding causes:
Patient dissatisfaction
Inefficient care
Resident overwhelm and burnout

10. Empower Basic understanding of cultural determinants
Residents have tools for cross-cultural care
How?
Screening tools
Best practices for community health (nutrition, addiction, chronic disease)
Behavioral techniques
Connections with community providers
Resource lists

11. Execute
Residents apply sociocultural and behavioral health considerations to practice
How?
Practice at FQHC
Precepting by faculty who led sessions
Office observation by BH

12. Ensure Resident Wellness
Residents feel supported
Residents part of community of care providers
How?
Quality time with faculty at workshops
Medical humanism workshop

13. Longitudinal Underserved Community Curriculum
PGY1 orientation and Community Medicine rotation
Monthly Community-Focused lectures
12 one-day PGY2 Community Health Workshops
Physician mentoring
Recruiting for diversity

14. Community Orientation
Clinic and resource introduction
Windshield survey
Poverty or domestic violence simulation
Community nurse visits- newborns & elders
Career introduction by Primary Care Association
Personal & Professional Identity Sessions

15. Community Medicine Rotation
Correctional facility
High School health education
Asthma Coalition
Immigrant clinic
Travel clinic at health department
STI clinic
TB clinic- DOT
Integrated behavioral health

16. Community- Focused Lectures
Cultural Competency (Bosnian, Albanian, Somali, and Hispanic populations; Use of interpreters; Citizenship and naturalization)
Health Disparities (Understanding Poverty, Health Outcomes in the Region, LGBT, health literacy)
Behavioral (addictions, adolescent risky behavior, SBIRT)
Violence (intimate partner violence, human trafficking)
Policy (State healthcare policy, Affordable Care Act)

17. LUCC Workshops Pediatric Child Abuse and Family Dynamics
Developmental and Education Issues
Environment and Nutrition
Adult
Chronic Disease- Obesity and COPD
Homelessness and Addiction
Living with Disabilities
Effects of Incarceration
Senior Safety Net
Community
Immigrant and Refugee Health
Neighborhood Resources
State Health Policy and Advocacy
Wellness
Medical Humanism
Activities
Patient conversations, learning sessions, site visits, interdisciplinary provider talks

18. Workshop 1 – Immigrant and Refugee Health
Learning session- Culture-specific refugee and immigrant experiences
Site visit – International Institute
Patient Speakers- Somali, Bosnian, Albanian refugees
II - , learn about citizenship process, role of medical providers

19. Workshop 2- Living with Disabilities
Implicit Bias Test
Agency Tour- Independent Living Agency that supports disabled in community
Agency Tour- Disabled Program Agency, conversation re. disability etiquette
Tour of DME provider

20. Workshop 3 – Education and Child Development
Learning session on IEPs, learning disabilties
Speaker from area independent school
Simulation- dyslexia and other learning disabilities
Immigrant parent/patient discussing challenges with children’s educational disabilities and medical diagnoses
MPACT / Missouri Parent ACT
Churchill – simulation of learning disability
City Academy
Child advocacy attorney
Parent as in slide

21. Workshop 4- Chronic Disease
Half day diabetes/half day COPD focus
Conversation with COPD patient
Guideline reviews
Hands-on spirometry/ inhaler training
Management discussions
Visit bariatric surgery office

22. Workshop 5- Homelessness and Addiction
Learning session: Detox and addiction treatment
Agency visit: Places for People – focus on homelessness and chronic mental illness
Community visit: Immunizing homeless clients
provider of housing, employment and health opportunities for people who are homeless or at risk of becoming homeless

23. Breadth of Cultural Differences Explored in the LUCC
Emphasize recognition of own culture
Think beyond ethnic and SES lines
Awareness of medical culture
Literacy and numeracy
Effects of addiction and incarceration on relationships with social safety nets

24. Key elements of the LUCC
Teachers from other cultures from the medical field.
Direct, experiential learning about community resources.
Residents gain resources
Taking residents out of usual role of performance and obligation.
Explicit prioritization of underserved care within the entire residency culture

25. 1. LUCC Teachers Non physicians Culturally diverse
Patients and parents
Health care workers with feet in both worlds
The playing field is leveled as they teach the residents

26. 2. Experiential Learning
Conversations with engaging people
Going to sites in community

27. 3. Residents gain Resources
Knowledge of community agencies
Colleagues to call
Written materials or tools for patient care
Residents understand and connect with resources, don’t just get a list

28. 4. Resident physicians in learning role/mode
Residents as learners with open ears and curiosity
No obligation to make judgements or fix problems
Allows residents to be vulnerable and honest in asking questions

29. 5. Prioritization Protected time away from clinical responsibility.
The different space also strengthens the group
Mentorship by faculty who moderate the workshops

30. Discussion Points
Other programs’ experience teaching underserved and cross-cultural care
Obstacles to successful learning
Engagement of residents