Cultural Competence and Health Disparities— Resources, Context, and Curricular Development

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 • Historical mistrust/prejudice, • Health disparities and inequities

3. KNOWLEDGE • Traditions and customs relevant to health care (sexual/gender issues, age, disabilities..) without stereotyping • Health beliefs/explanatory model • Styles of communication, • Autonomy vs. family decision-making, • Patients’ access to resources • Health literacy

4. Definition of cultural competence • Cultural self-identity • Discussion of the culture of medicine • Integrated into interviewing, communication, PA Seminar classes

5. Socio-cultural classification of race • Taught using case-based module, lecture • 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 • “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

7. 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. • 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). AStrategy to Reduce Crosscultural Miscommunication and Increase the Likelihood of Improving Health Outcomes. Acad Med, 78(6), 577-587.

8. Evaluation • Pretest-Posttests • Approach to Unknown Clinical Cases • Presentation of Clinical Cases • Objective Structured Clinical Exams

9. ATTITUDES • 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? • 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/selectatest.html • National Center for Cultural Competence has self-assessment tools for organizations and practicing physicians: • http://gucchd.georgetown.edu/nccc/selfassessment.html

11. Stereotyping and Medical Decision-Making • 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 • interactive exercise (Bafa Bafa) http://www.simulationtrainingsystems.com/schoolscharities/bafa.html

12. Self-assessment and reflection • Taught as case-based, on-line • Taught in interviewing, professionalism, ethics, clinical rotations

13. Evaluation • Standard Surveying • Structured Interviewing • Self-Awareness Assessment • Presentation of Clinical Cases • Objective Structured Clinical Exam • 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 effectively negotiate with a patient? • Has the student demonstrated respect for the beliefs of others? • Has the student demonstrated self-reflection?

15. Cultural and Linguistic competence • L-E-A-R-N model • Kleinman’s Questions • Integrated into interviewing, health-care delivery, epidemiology, public health, genetics, pharmacology classes, medicine • Taught using case-based modules • 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. Accessed at: http://www.diversityrx.org/HTML/MOCPT2.htm • Multicultural Health Best Practices Overview. Includes the Kleinman questions. On the Diversity Rx website. Accessed at: 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. http://futurehealth.ucsf.edu/cnetwork/resources/curricula/diversity.html

17. Evaluation • Presentation of Clinical Cases • Objective Structured Clinical Exam • Videotaped/Audio-taped Clinical Encounter • Role-playing in interviews • Standardized patient (or faculty member) • Observation in clinical rotations

18. Health disparities • 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.aspx • Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care , Institute of Medicine, 2002http://www.nap.edu/books/030908265X/html • Initiative to Eliminate Racial and Ethnic Disparities in HealthU.S. Department of Health and Human Services 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

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 • 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

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

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

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/ Slide sets are also available on the Institute of Medicine website: http://www.iom.edu/?id=4475&redirect=0 • 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/ • 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.