Understanding the Role of Diversity in Faculty Development

1. Understanding the Role of Diversity in Faculty Development Joan Y. Reede, MD, MPH, MS Harvard Medical School Office for Faculty Development and Diversity December 4, 1999

2. A Time of Change

3. Understanding the Role of Diversity in Faculty Develoment The Diversity Imperative

4. Projected “Minority” Percentage By Year 2056, whites will probably by a “non-dominating” group.

5. Facts… % of Population Foreign-Born

6. There is variation by Race, Ethnicity, and Gender in the health care services individuals receive.

7. Hypotheses to Explain this Variation • Physiologic differences including variations in the natural history of disease. • Failure to account for externalities such as availability of services. • Patient preferences for procedures varies by sub-population • Physicians are biased toward certain groups. • Poor doctor-patient communication

8. Cultural Variation – Biological • Risk of genetically inherited disorders such as thalassemia • Biologic variations such as lactose tolerance • Physiologic or metabolic differences that may affect the administration of medications • Mortality and morbidity rates which may vary

9. Cultural Variation – Attitudes & Values • Importance of individual or community • Roles for women, men, and children • Preferred family structure – nuclear, extended, one generation, multigenerational • Importance of folk wisdom • How time is used and valued • Role of religious life, spirituality, and secular life • Body language

10. Culture • “Culture refers to the dominant set of symbolic codes (linguistic, moral, aesthetic) and material practices (dietary/behavioral) that characterize a group.”Pierce, Earls, Kleinman, 1999 • Culture is a body of beliefs and customs that define a group of people as being connected and that determines their identity.

11. Health Care is a Cultural Construct • Culture of the Biomedical Model • Culture of Individual Professions – allopathic & osteopathic medicine, nursing, social work… • Culture of Individual Discipline – pediatrics, internal medicine, surgery, cardiac surgery… • Culture of Academic Medical Center • Culture of Community Health Center • Culture of Managed Care Organization • Patient’s Culture

12. Perceptions of Disease and Illness • Invasion of microorganism • Deterioration of body due to age, accident • Body imbalance • Punishment by God • Result of offending ancestors

13. Perceptions of Healing and Curing • Fighting an intruder • Putting the body back in balance • Making atonement to God for wrongdoing • Making peace with ancestors

14. Healer Expert/miracle worker God’s worker Shaman Pill dispenser Confidant or friend of family Authority figure Last resort for healing Someone who inflicts pain Perceptions of Doctors

15. Impact of Culture on Physician-Patient Relationships • Patient • Level of comfort with physician • Understanding of the health care system • Fear of rejection of personal health beliefs • Expectation of physician and health providers • Physician • Socialized in Western bio-medical context • Disclosure • Authority • Communication

16. Communication Barriers Patient-Related Barriers Physician-Related Barriers Communication Barriers in Providing Quality Health Care Insurer-Related Barriers Institutional Barriers

17. What is Cultural Competence? • “Cultural competence is the ability to deliver effective medical care to people from different cultures. By understanding, valuing, and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health providers deliver more effective and cost-efficient care.” HRSA 1998

18. Cultural Competency An integration and Interaction of… Health-related beliefs and cultural values Disease-incidence and prevalence Treatment efficacy

19. Improve quality of care Improve health outcomes Increase customer satisfaction Improve acceptance, salience, and efficacy of interventions Social justice Reduce potential liability Satisfy accreditation standards Gain and maintain market share Gain community support Satisfy payor demands Increase productivity Improve recruitment Increase commitment Decrease turnover Increase creativity in problem solving Case for Cultural Competence

20. Understanding the Role of Diversity in Faculty Development Academic Medicine’s Response

21. The Challenge

22. Philosophy • Most physicians are committed to providing culturally competent, high quality care. • Cultural competency encompasses more than race and gender. • Prejudice, fears, and stereotyping are learned behavior that can interfere with communication and trust. • Cultural competency workshops and electives alone will not change long-held attitudes. • Cultural competency and diversity should be seen as part of a continuous learning process

23. Underrepresented Minority Participation in Medical Education

24. Recruitment Issues? • Location defense • Pipeline defense • Budgetary defense • Market forces • No raid policy • Turnover problem

25. Diversity “Taxes” • Assumptions and stereotyping • Chilly climate • Excessive student/resident demands • Excessive committee assignments • Undervaluing scholarship on minority issues • “Token Hire” misconception • Cumulative professional disadvantage

26. Retention Steps • Make commitment to diversity explicit • Prepare department for change • Establish a mentoring process • Involve senior faculty • Networks • Collaboration • Chair/division chief assume responsibility for protection from committee assignments • Provide orientation before and after hire

27. Where? Rewards and Recognition Research Clinical care Teaching Public service Administration

28. Diversity and Promotion • Clinical Service • Marketing, Time constraints • Research • Definition of merit • Administration • Service burden, “Typecasting syndrome” • Teaching • Non-traditional courses • Collegiality • Subjectivity, “Hairsplitting concept”

29. 3P’s – Pro-active, Persistent, Positive • A Time of Change • Training extending into diverse communities with diverse populations • Cultural competence training integrated into • Faculty development training programs • Continuing education • Student and resident education and training • Increasing representation of faculty of color • Recruitment • Retention • Promotion