The Role of Culture in the Training of Health Care Professionals: A Multidisciplinary Panel

1. The Role of Culture in the Training of Health Care Professionals: A Multidisciplinary Panel Danny M. Takanishi, Jr., MD, FACS Professor and Chair Department of Surgery University of Hawaii October 7, 2011

2. DISCLOSURE • No Disclosures • The content of this presentation reflects my perspectives, and not the Organizations I have the honor to serve • ACGME Transitional Year Residency Review Committee, Chair • ACGME Council of Review Committees • ACGME Common Program Requirements Committee, Chair • National Board of Medical Examiners/USMLE Step II Surgery Test Material Development Committee, Chair • Hawaii Medical Board, Chair

3. Learning Objectives • At the end of this session the Learner will be able to: • Discuss the salient role of cultural competency in medical education; • Describe how accreditation requirements ensure curricular integration of cultural competency initiatives; • Demonstrate an understanding of how the Milestones Project serves to further enhance competency-based medical education.

4. What is Cultural Competency? • Set of Congruent Behaviors, Knowledge, Attitudes, and Policies • Involve a System or Organization • Enables effective work in cross-cultural situations

5. What is Cultural Competency? • “Culture” = integrated patterns of human behavior • Language, Thoughts, Actions, Customs, Beliefs • Institutions of Racial, Ethnic, Social, Religious Groups • “Competence” = having the capacity to function effectively • Cultural beliefs, Practices, Needs presented by Patients

6. What is Cultural Competency? • Patient/Family-centered Care • Social and Cultural Influences • Quality of Medical Services and Therapy

7. LCME 2011 (IS-16) The LCME and the CACMS believe that aspiring future physicians will be best prepared for medical practice in a diverse society if they learn in an environment characterized by, and supportive of, diversity and inclusion. Such an environment will facilitate physician training in: • Basic principles of culturally competent health care. • Recognition of health care disparities and the development of solutions to such burdens. • The importance of meeting the health care needs of medically underserved populations. • The development of core professional attributes (e.g., altruism, social accountability) needed to provide effective care in a multidimensionally diverse society.

8. LCME 2011 (ED-21) The faculty and medical students of a medical education program 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. Instruction in the medical education program should stress the need for medical students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on patients’ health. To demonstrate compliance with this standard, the medical education program should be able to document objectives relating to the development of skills in cultural competence, indicate the location in the curriculum where medical students are exposed to such material, and demonstrate the extent to which the objectives are being achieved.

9. LCME 2011 (ED-22) Medical students in a medical education program must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery. The objectives for instruction in the medical education program should include medical student understanding of demographic influences on health care quality and effectiveness (e.g., racial and ethnic disparities in the diagnosis and treatment of diseases). The objectives should also address the need for self-awareness among medical students regarding any personal biases in their approach to health care delivery.

10. THE ACGME • Founded in 1981 • Mission: To improve health care by assessing and advancing the quality of resident physicians’ education through exemplary accreditation • 28 Review Committees • 8,734 accredited Residencies • 130 Specialties and Subspecialties • Approximately 111,000 active Residents

11. THE ACGME

12. THE FOCUS OF GRADUATE MEDICAL EDUCATION HAS CHANGED • The Past Process oriented with focus on “what is covered” • The Past Then focus was on “what residents are able to do as a result of their training” • The Present Focus is on patient outcome

13. The Six Competencies • Medical Knowledge • Patient Care • Practice Based Learning and Improvement • Systems Based Practice • Interpersonal and Communications Skills • Professionalism

14. Medical Knowledge • Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and how to apply this knowledge to patient care. • Acquisition • Analysis • Application

15. Patient Care • Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. • Gathering information • Synthesis • Partnering with patients/families

16. Practice Based Learning and Improvement • Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. • Life-long learning • Evidence based medicine • Quality improvement • Teaching skills

17. Systems-based Practice • Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care • Health care delivery system • Cost effective practice • Patient safety and advocacy/Systems causes of error

18. Professionalism • Residents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population • Professional behavior • Ethical principles • Cultural competence

19. Teaching Professionalism Content • Cultural Competence Setting • Clinical teaching • Case based teaching • Interactive Workshops • Lecture/Conference/Seminar • Institutional Initiatives • Role modeling • Mentoring

20. Interpersonal and Communication Skills • Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. • Communicating with patients and families • Communicating with team members • Scholarly Communication

21. QUALITY CARE AND PROFESSIONALISM TASK FORCE • Proposed New Standards directed at: • Resident Duty Hours • Fatigue Mitigation • Resident Supervision • Transitions of Care • Clinical Responsibilities • Patient Safety • Quality Improvement Systems • Interdisciplinary Teams

22. JCAHO LOOKS TO ACGME FOR MEDICAL STAFF STANDARDS • EFFECTIVE = OUTCOMES (e.g., mortality rates) • APPROPRIATE = PROCESSES (i.e., core measures) • COMPASSIONATE = COMMUNICATION WITH PATIENTS AND FAMILIES (e.g., informed consent)

23. Milestones Project • Milestone “Behavior, attitude, or outcome related to general competency domains that describe a significant accomplishment expected of a Resident by a particular point in time.” Susan Swing, PhD Vice-President, Outcome Assessment ACGME

24. Milestones

25. Core Principles • The ACGME Competencies provide the framework • Context is Patient Care • Medical Education is a continuum • UME GME CPD/MOC • Behavioral descriptors provide developmental model • Concept of “Stop Points”

26. NOVICE ADVANCED BEGINNER COMPETENT EXPERT PROFICIENT

27. NRMP Match ENTRY TESTING SKILLS TESTING INITIAL TRAINING SUMMATIVE EXAMINATION MILESTONES INDEPENDENCE MOC FINAL EXAMINATION CONDITIONAL INDEPENDENCE

29. Assessment and Reporting Report to ACGME 1 – Global Scores 2 – Scored Assessments Faculty Global Evaluations Resident Evaluation and Promotion Committee Scored Milestones (e.g., ABSITE, FLS) Semi-Annual Feedback Meeting

30. Benefits • Refines/Reframes the Competencies • Provides for development of national benchmarks for outcomes assessment • Provides for improved reporting (“national accountability”) • Improves Transparency (Resident expectations) • Improves Resident Feedback • Earlier identification of deficits

31. Benefits • Provides gap analysis to Programs • Informs Curriculum development process • Promotes patient safety • Improves confidence with decision making