THE ROLE OF CULTURAL COMPETENCY IN MEDICAL EDUCATION

1. THE ROLE OF CULTURAL COMPETENCY IN MEDICAL EDUCATION Maria A. Marzan, MPH, Associate Director, Introduction to Clinical Medicine Program, Albert Einstein College of Medicine

2. CULTURAL COMPETENCY? • Multicultural Society • Multilingual • Importance of physician-patient care • International/public health impact • Racial and ethnic disparities in health care access and health outcomes

3. DISPARITIES IN HEALTH for Minority Populations • Decreased Access • More uninsured and underinsured • Decreased quality of care • Poorer outcomes of care

4. Largest Ethnic Minority Populations in the U.S. AFRICAN AMERICANS HISPANIC/LATINO ASIAN & PACIFIC ISLANDERS AMERICAN INDIANS & ALASKA NATIVES

5. African-American medicare recipients less likely to get renal transplants Latino patients with leg fractures got less pain medication Women and African-American simulated patients were less likely to get cardiac testing Minority lung cancer patients less likely to get surgery RACIAL/ETHNIC DISPARITIES

6. NON-FINANCIAL BARRIERS TO CARE • Health care workforce issues • Patient educational level • Racial bias and discrimination • Immigration issues • Language barriers

7. Socio-cultural Barriers to Health care:Multilevel • Organizational - leadership and workforce issues • Structural - complex, funding issues, language issues, bureaucratic systems • Clinical level – the medical encounter

8. Provider-patient communication and decision making • Evidence suggests that provider-patient communication is directly linked to patient satisfaction, adherence and health outcomes • Ineffective communication in the medical encounter may lead to patient dissatisfaction, non-adherence, poorer health outcomes, and subsequently, racial and ethnic disparities in healthcare.

9. Conceptual Approaches to Cross-Cultural Medical Education • A Focus on Attitudes:Cultural/Sensitivity Awareness Approach • Focus on Knowledge: The Multicultural/Categorical Approach • Cross-Cultural Approach

10. Cross-Cultural Approach • Tools and Skills for providers • Process-oriented instruction (patient’s explanatory model, assess patient’s social context, provider-patient negotiation) • Care of Diverse populations by cross-cultural interviewing • Practical approach for clinical years - undergraduate, graduate and continuing medical education (CME)

11. CROSS-CULTURAL ISSUES IN HEALTH CARE • Language (including illiteracy, health literacy) • Socio-economic barriers to access are greater in minority and immigrant groups • Educational differences • Diverse health and disease belief systems • Alternative and complementary medicine beliefs and practices vs. traditional medicine • Religious differences • Power and privilege

12. ETHNIC: A FRAMEWORK FOR CULTURAL COMPETENCE E: ExplanationWhat do you think may be the reason you have these symptoms? What do friends, family, others say about these symptoms? Do you know anyone else who has had or who has this kind of problem? Have you heard about/read/seen it on TV/radio/newspaper? (If patient cannot offer explanation, ask what most concerns them about their problems). T: TreatmentWhat kinds of medicine, home remedies other treatments have you tried for this illness? Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it. What kind of treatment are you seeking from me? H: Healers Have you sought any advice from alternative/folk healers, friends or other people (non-doctors) for help with your problems? Tell me about it? N: NegotiateNegotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs. I: InterventionDetermine an intervention with your patient. May include incorporation of alternative treatments, spirituality, and healers as well as other cultural practices (e.g. foods eaten or avoided in general, and when sick). C: CollaborationCollaborate with the patient, family members, other health care team members, healers and community resources.

13. Cultural Competency - Current Mandates and the Future • AAMC • LCME • Legislation (NJ, CA - Bills pending) • National Board of Medical Examiners • Professional Licensure • Malpractice Insurers (discounts)

14. Bronx County Total Population ………………………...1,332,650 WHITE………………………………………..398,003 BLACK/AFRICAN AMERICAN……...……475,007 American Indian & Alaskan Native …….…...11,371 ASIAN…………….……………………………40,120 Native Hawaiian/ Other Pacific Islanders…….1,383 HISPANIC or LATINO……………….…….329,724 White Persons, Non-Hispanic/Latino..……....77,042 Source:US Census Bureau 2000

15. CULTURAL COMPETENCE A set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. This requires a willingness and ability to draw on community-based values,traditions,and customs and to work with knowledgeable persons of and from the community in developing targeted interventions, communications and other supports. Source:Office of Minority and Women's Health, HRSA, NIH

16. CULTURE The shared values, traditions, norms, customs, arts, history, folklore, and institutions of a group of people that are unified by race, ethnicity, language, nationality, or religion. Source:Office of Minority and Women's Health, HRSA, NIH

17. CULTURAL DIVERSITY Differences in race, ethnicity, language, nationality, or religion among various groups within a community is said to be culturally diverse if its residents include members of different groups. Source:Office of Minority and Women's Health, HRSA, NIH

18. ETHNIC Belonging to a common group, often linked by race, nationality, and language with a common cultural heritage and/or derivation. Source: Office of Minority and Women's Health, HRSA, NIH

19. Glossary of Key Terms Culture The shared values, traditions, norms, customs, arts, history, folklore, and institutions a group of people that are unified by race, ethnicity, language, nationally or religion. Cultural CompetenceA set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities similarities, among, and between groups. This requires a willingness and ability to draw on community based values, traditions, and customs and to work with knowledgeable persons of and from the community in developing targeted interventions, communications, and other supports. Cultural GroupA group of people who consciously or unconsciously share identifiable values, norms, symbols, and some ways of living that are repeated and transmitted from one generation to another. Source:Office of Minority and Women's Health, HRSA, NIH

20. Glossary of Key Terms - continued Cultural DiversityDifferences in race, ethnicity, language, nationality, or religion among various groups within a community is said to be culturally diverse if its residents include members of different groups. Cultural SensitivityAn awareness of the nuances of one’s own and other cultures. Culturally AppropriateDemonstrating both sensitivity to cultural differences and similarities and effectiveness in using cultural symbols to communicate a message. Ethnic Belonging to a common group, often linked by race, nationally, and language with a common cultural heritage and/or derivation.