Teaching residents to care for culturally diverse populations

A qualitative study to explore experiences of anti-racism teaching in medical residency programs across the United States and subsequent creation of the SPOC (Support - Pipeline - Outcomes - Community) Model to guide future curricula design

BACKGROUND

Racism contributes to health disparities and is a serious threat to public health. Teaching physicians about racism, how to address it in medical practice, and developing high quality and sustainable curricula are essential to combating racism.

OBJECTIVE

This study aimed to (1) describe the experience of racism and anti-racism teaching in residency programs, and elicit recommendations from key informants, and (2) use these data and formative research to develop recommendations for other residencies creating, implementing, and evaluating anti-racism curricula in their own programs.

METHODS

From May to July 2023, 20 faculty and residents were recruited via convenience sampling for key informant interviews conducted via Microsoft Teams. Interviews were audio recorded, transcribed, and coded. An initial list of themes was developed using theoretical frameworks, and then refined using a grounded-theory approach. A brief online optional anonymous demographic survey was sent to participants in August of 2023.  RESULTS: Eighty percent (20/25) of participants approached were interviewed. Seventy-five percent (15/20) answered a brief optional demographic survey. Seven themes emerged: (1) Racism in medicine is ubiquitous; (2) Anti-racism teaching in medicine varies widely; (3) Sustainability strategies should be multifaceted and include recruitment, resource allocation, and outcome measures; (4) Resources are widely available and accessible if one knows where to look; (5) Outcomes and metrics of success should include resident- faculty-, patient- community-, and system-focused outcomes; (6) Curricular strategies should be multilayered, longitudinal, and woven into the curriculum; and (7) Self-reflection and discomfort are necessary parts of the process.  CONCLUSIONS: This study is one of the first to qualitatively examine perspectives of key stakeholders invested in anti-racism teaching for residents. The Support - Pipeline - Outcomes - Community (SPOC) Model, that was developed using information collected during this study, can be used in the future as a guide for others working to design and implement sustainable and high quality anti-racism curricula for residents.

Competency lists for urban general practitioners/family physicians using the modified Delphi method

BACKGROUND

In recent years, the growing global urbanization and urban population have resulted in the emergence of various health problems unique to urban areas. Therefore, training general practitioners and family physicians who can tackle the complex health problems of urban areas and improve the health of urban people is one of the most important issues of our time. However, findings on competencies for urban general practitioners (GP) and family physicians (FP) were limited. This study aimed to identify their comprehensive and content-validated list of competencies.

METHODS

We used the modified Delphi method to develop a content-validated competency list. First, we analyzed and synthesized the competencies extracted from the literature review using qualitative thematic analysis methods to create an initial competency list of 34 items. We then assembled 39 expert panelists in four groups of study participants: physicians, nurses, patients, and medical education specialists. The expert panelists were asked to indicate their level of agreement with the lists and provide revised comments on the description of each competency via a web-based questionnaire. Their responses were analyzed quantitatively and qualitatively by the research team and used to revise the list. These processes were repeated, and the survey was completed when it was determined that consensus had been reached.

RESULTS

Three rounds of Delphi were conducted. 39 responded in the first round, 38 in the second round, and 36 in the third round. The initial list of competencies was revised and consolidated from 34 to 14 items in the first round, bringing the total to 20 items along with six new items proposed by the panelists. In the second round, it was revised and consolidated into a list of 18 items. In the third round, all 18 items were considered to have been agreed upon by the panelists, so the survey was closed.

CONCLUSION

We identified a comprehensive 18-item list of competencies for urban GP/FP in a content-validated manner. Several are newly discovered competencies in this study. The findings of this study will be useful for the future training of urban GP/FP and for solving urban health problems.

Participatory approaches, local stakeholders and cultural relevance facilitate an impactful community-based project in Uganda

Sanitation is a major global challenge that is often addressed at national and international levels, while community opinions and beliefs are neglected. To promote water, sanitation and hygiene (WASH) we organized a cross-cultural knowledge exchange workshop to assess participatory methods for engaging local stakeholders. The workshop included 22 participants from all sectors of society. Practical solutions to sanitation challenges were identified and later shared with a local community. Qualitative and quantitative analyses were used to assess impact and showed participatory methods were highly valued to encourage information sharing among widely varied stakeholders, and that video was a particularly successful approach when engaging with local communities. An 8-month follow-up survey of village members revealed excellent information recall, positive behaviour changes and a desire for future visits. Our evidence suggests that community-based participation helped identify solutions to WASH issues affecting rural communities in resource-poor settings. Engaging in a multicultural knowledge-share was particularly valuable as it enabled participants to recognize they have common challenges and allowed them to share low-cost solutions from their different communities. Our use of video was widely viewed as an ideal means of circulating findings, as it communicated information to people with a wide variety of community roles and to all age groups. Its relevance was increased by adopting a culturally appropriate context by involving local communities in workshop activities. We recommend that research in low- and middle-income countries should be mindful of the environmental context in which WASH is implemented, and encourage acceptance by engaging with communities through the use of varied participatory methods.

Perceptions of intercultural competence and institutional intercultural inclusiveness among first year medical students: a 4-year study

BACKGROUND

This study sought to examine the awareness/perception of intercultural competence and institutional intercultural inclusiveness among first year students at an Australian medical school over four consecutive years (2014-2017); to identify existing gaps in the curriculum and proffer recommendations.

METHODS

The study employed an adapted 20-item questionnaire for data collection. The reliability and interrelations of the survey items were examined. Descriptive statistics was used to examine students' perceptions, while Mann-U Whitney and Kruskal-Wallis tests were used to assess items scores in relation to participant characteristics.

RESULTS

Over the 4 years of study, there were 520 respondents with between 53 to 69% response rates per year. Cronbach's alpha for the instrument was 0.88 and factor analysis showed all items loading strongly on two components. Participants' mean score on self-reported intercultural competence levels ranged from 3.8-4.6 out of 5; indicating relatively high awareness, valuing and understanding of cultural differences among this group of students. However, their mean scores (3.4-4.2) for institutional intercultural inclusiveness were slightly lower.

CONCLUSION

The instrument used in this study is effective in assessing level of intercultural competence among medical students. However, the results highlight the need for increased institutional support and professional development for faculty members to foster institutional intercultural inclusiveness.

Health Disparities in Patients with Pulmonary Arterial Hypertension: A Blueprint for Action. An Official American Thoracic Society Statement

BACKGROUND

Health disparities have a major impact in the quality of life and clinical care received by minorities in the United States. Pulmonary arterial hypertension (PAH) is a rare cardiopulmonary disorder that affects children and adults and that, if untreated, results in premature death. The impact of health disparities in the diagnosis, treatment, and clinical outcome of patients with PAH has not been systematically investigated.

OBJECTIVES

The specific goals of this research statement were to conduct a critical review of the literature concerning health disparities in PAH, identify major research gaps and prioritize direction for future research.

METHODS

Literature searches from multiple reference databases were performed using medical subject headings and text words for pulmonary hypertension and health disparities. Members of the committee discussed the evidence and provided recommendations for future research.

RESULTS

Few studies were found discussing the impact of health disparities in PAH. Using recent research statements focused on health disparities, the group identified six major study topics that would help address the contribution of health disparities to PAH. Representative studies in each topic were discussed and specific recommendations were made by the group concerning the most urgent questions to address in future research studies.

CONCLUSIONS

At present, there are few studies that address health disparities in PAH. Given the potential adverse impact of health disparities, we recommend that research efforts be undertaken to address the topics discussed in the document. Awareness of health disparities will likely improve advocacy efforts, public health policy and the quality of care of vulnerable populations with PAH.

Welcome to cultural competency: surgery's efforts to acknowledge diversity in residency training

BACKGROUND

Although cultural competency is not a new concept in healthcare, it has only recently been formally embraced as important in the field of surgery. All physicians, including and especially surgeons, must acknowledge the potential influence of culture in order to provide effective and equitable care for patients of all backgrounds. The Accreditation Council for Graduate Medical Education (ACGME) recognizes cultural competency as a component of "patient care," "professionalism," and "interpersonal and communication skills."

METHODS

A systematic literature search was conducted using the MEDLINE, EBSCOhost, Web of Science, and Google Scholar databases. All publications focusing on surgical residents and the assessment of patient care, professionalism, interpersonal and communication skills, or specifically cultural competency and/or were considered. This initial search resulted in 12 articles. To further refine the review, publications discussing curricula in residencies other than surgery, the assessment of technical, or clinical skills and/or without any explicit focus on cultural competency were excluded.

RESULTS

Based on the specified inclusion and exclusion criteria, 5 articles were selected. These studies utilized various methods to improve surgical residents' cultural competency, including lectures, Objective Structural Clinical Examinations (OSCE), and written exercises and evaluations.

CONCLUSIONS

A number of surgical residency programs have made promising strides in training culturally competent surgeons. Ultimately, in order to maximize our collective efforts to improve the quality of health care, the development of cultural competency curricula must be made a priority and such training should be a requirement for all trainees in surgical residency programs.

When asides become central: small talk and big talk in interpreted health interactions

OBJECTIVE

In health interactions which require an interpreter, there are occasions when there are uninterpreted asides between participants. These are often construed to be features which hinder the interpreting process. However they have potential to yield critical information in certain health care contexts.

METHODS

This paper examines 17 instances of asides in interpreted interactions which took place in 3 intercultural health care contexts in South Africa. The asides were transcribed, translated and analysed based on conversation analysis principles.

RESULTS

The topics of the asides as well as who initiates them appear highly dependent on contextual features. There is evidence for the emergence of 'small talk' which serves the purpose of framing comfort levels, aligning the interpreter and patient or offering guidance for example, and the emergence of 'big talk' or engagement on topics which for cultural and historical reasons and power imbalances between the health practitioner and patient may be too difficult to raise directly. Such information also yields critical diagnostic and therapeutic information.

CONCLUSION

Our findings suggest evidence for the presence of multiple patterns and roles that the interpreter may assume in such interactions.

PRACTICE IMPLICATIONS

Implications for team training and practice are provided.

Missed appointments in resident continuity clinic: patient characteristics and health care outcomes

BACKGROUND

Frequent missed patient appointments in resident continuity clinic is a well-documented problem, but whether rates of missed appointments are disproportionate to standard academic practice, what patient factors contribute to these differences, and health care outcomes of patients who frequently miss appointments are unclear.

METHODS

The overall population for the study was composed of patients in an academic internal medicine continuity clinic with 5 or more office visits between January 2006 and December 2008. We randomly selected 325 patients seen by resident physicians and 325 patients cared for by faculty. Multivariate linear regression was used to examine the relationship between patient factors and missed appointments. Health outcomes were compared between patients with frequent missed appointments and the remainder of the study sample, using Cox regression analysis.

RESULTS

Resident patients demonstrated significantly higher rates of missed appointments than faculty patients, but this difference was explained by patient factors. Factors associated with more missed appointments included use of a medical interpreter, Medicaid insurance, more frequent emergency department visits, less time impanelled in the practice, and lower proportion of office visits with the primary care provider. Patients with frequent missed appointments were less likely to be up to date with preventive health services and more likely to have poorly controlled blood pressure and diabetes.

CONCLUSIONS

We found that the disproportionate frequency of missed appointments in resident continuity clinic is explained by patient factors and practice discontinuity, and that patients with frequent missed appointments demonstrated worse health care outcomes.

Cultural aspects of communication in cancer care

Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care. Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world. Cultural competence always presupposes oncology professionals' awareness of their own cultural beliefs and values. To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice. Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other. Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.

See one, do one, teach one: developing professionalism across the generations

Individuals develop their professional values and identity as they progress through the hierarchical career stages of medicine. At the same time, the collective values of the profession evolve with changes in the wider society. This leads to recurring small but significant generation gaps in professional values. For the past half century, this gap has centered on the concept of altruism and quality of life. In order for professionalism to develop at the individual level as well as for the community of physicians, the generational differences must be bridged and negotiations for change must build on common ground. This requires a long-term developmental approach including teaching strategies which are career stage appropriate and adapt to the different learning styles of the younger generation.

Health-care outcomes in ethnoculturally discordant medical encounters: the role of physician transnational competence in consultations with asylum seekers

In this mobility-upheaval era, many health outcomes are shaped by transnational interactions among care-providers and recipients who meet in settings where nationality/ethnic match is a diminishing option. This exploratory study compares health-care outcomes in ethnoculturally discordant medical encounters according to patient national/ethnic identity, frequency (intensity) of medical consultation, and physician transnational competence (TC). Analysis is based on interviews with 35 political-asylum seekers and their ethnoculturally discordant clinicians at five reception centres in Finland. The three medical-encounter outcomes considered are patient-reported adherence with medication instructions, satisfaction, and confidence in the principal attending physician's recommendations. The intersubjectively assessed overall transnational competence of the attending physician provided the strongest association with all three outcome measures. The results of exploratory study suggest that preparing medical students with skills that can be applied effectively in variable transnational-encounter contexts would help close disparities in certain health-care outcomes.

Medical education for a changing world: moving beyond cultural competence into transnational competence

Given rapidly changing global demographic dynamics and the unimpressive evidence regarding health outcomes attributable to cultural competence (CC) education, it is time to consider a fresh and unencumbered approach to preparing physicians to reduce health disparities and care for ethnoculturally and socially diverse patients, including migrants. Transnational competence (TC) education offers a comprehensive set of core skills derived from international relations, cross-cultural psychology, and intercultural communication that are also applicable for medical education. The authors discuss five limitations (conceptual, vision, action, alliance, and pedagogical) of current CC approaches and explain how an educational model based on TC would address each problem area.The authors then identify and discuss the skill domains, core principles, and reinforcing pedagogy of TC education. The five skill domains of TC are analytic, emotional, creative, communicative, and functional; core principles include a comprehensive and consistent framework, patient-centered learning, and competency assessment. A central component of TC pedagogy is having students prepare a "miniethnography" for each patient that addresses not only issues related to physical and mental health, but also experiences related to dislocation and adaptation to unfamiliar settings. The TC approach promotes advances in preparing medical students to reduce health disparities among patients with multiple and diverse backgrounds, health conditions, and health care beliefs and practices. Perhaps most important, TC consistently directs attention to the policy and social factors, as well as the individual considerations, that can alleviate suffering and enhance health and well-being in a globalizing world.

Internal medicine residents' perceptions of cross-cultural training. Barriers, needs, and educational recommendations

BACKGROUND

Physicians increasingly face the challenge of managing clinical encounters with patients from a range of cultural backgrounds. Despite widespread interest in cross-cultural care, little is known about resident physicians' perceptions of what will best enable them to provide quality care to diverse patient populations.

OBJECTIVES

To assess medicine residents' (1) perceptions of cross-cultural care, (2) barriers to care, and (3) training experiences and recommendations.

DESIGN, SETTING, AND PATIENTS

Qualitative individual interviews were conducted with 26 third-year medicine residents at Massachusetts General Hospital in Boston (response rate=87%). Interviews were recorded, transcribed, and analyzed.

RESULTS

Despite significant interest in cross-cultural care, almost all of the residents reported very little training during residency. Most had gained cross-cultural skills through informal learning. A few were skeptical about formal training, and some expressed concern that it is impossible to understand every culture. Challenges to the delivery of cross-cultural care included managing patients with limited English proficiency, who involve family in critical decision making, and who have beliefs about disease that vary from the biomedical model. Residents cited many implications to these barriers, ranging from negatively impacting the patient-physician relationship to compromised care. Training recommendations included making changes to the educational climate and informal and formal training mechanisms.

CONCLUSIONS

If cross-cultural education is to be successful, it must take into account residents' perspectives and be focused on overcoming residents' cited barriers. It is important to convey that cross-cultural education is a set of skills that can be taught and applied, in a time-efficient manner, rather than requiring an insurmountable knowledge base.

Globalization, migration health, and educational preparation for transnational medical encounters

Unprecedented migration, a core dimension of contemporary globalization, challenges population health. In a world of increasing human mobility, many health outcomes are shaped by transnational interactions among care providers and care recipients who meet in settings where nationality/ethnic match is not an option. This review article explores the value of transnational competence (TC) education as preparation for ethnically and socially discordant clinical encounters. The relevance of TC's five core skill domains (analytic, emotional, creative, communicative, and functional) for migration health and the medical-school curriculum is elaborated. A pedagogical approach that prepares for the transnational health-care consultation is presented, with a focus on clinical-clerkship learning experiences. Educational preparation for contemporary medical encounters needs to include a comprehensive set of patient-focused interpersonal skills, be adaptable to a wide variety of service users and global practice sites, and possess utility in addressing both the quality of patient care and socio-political constraints on migration health.

Cultural aspects of communication in cancer care

Cancer is increasing in incidence and prevalence worldwide, and the WHO has recently included cancer and its treatments as a health priority in developed and developing countries. The cultural diversity of oncology patients is bound to increase, and cultural sensitivity and competence are now required of all oncology professionals. A culturally competent cancer care leads to improved therapeutic outcome and it may decrease disparities in medical care. Cultural competence in medicine is a complex multilayered accomplishment, requiring knowledge, skills and attitudes whose acquisition is needed for effective cross-cultural negotiation in the clinical setting. Effective cultural competence is based on knowledge of the notion of culture; on awareness of possible biases and prejudices related to stereotyping, racism, classism, sexism; on nurturing appreciation for differences in health care values; and on fostering the attitudes of humility, empathy, curiosity, respect, sensitivity and awareness. Cultural competence in healthcare relates to individual professionals, but also to organizations and systems. A culturally competent healthcare system must consider in their separateness and yet in there reciprocal influences social, racial and cultural factors. By providing a framework of reference to interpret the external world and relate to it, culture affects patients' perceptions of disease, disability and suffering; degrees and expressions of concern about them; their responses to treatments and their relationship to individual physicians and to the healthcare system. Culture also influences the interpretation of ethical norms and principles, and especially of individual autonomy, which can be perceived either as synonymous with freedom or with isolation depending on the cultural context. This, in turn, determines the variability of truth-telling attitudes and practices worldwide as well as the different roles of family in the information and decision-making process of the cancer patient. Finally, culture affects individual views of the patient-doctor relationship in different contexts.

Mixed messages: residents' experiences learning cross-cultural care

PURPOSE

An Institute of Medicine report issued in 2002 cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents' training and capabilities to provide quality care to diverse populations. This article explores a select group of residents' perceptions of their preparedness to deliver quality care to diverse populations.

METHOD

Seven focus groups and ten individual interviews were conducted with 68 residents in locations nationwide. Qualitative analysis of focus-group and individual interview transcripts was performed to assess residents' perceptions of (1) preparedness to deliver care to diverse patients; (2) educational climate; and (3) training experiences.

RESULTS

Most residents in this study noted the importance of cross-cultural care yet reported little formal training in this area. Residents wanted more formal training yet expressed concern that culture-specific training could lead to stereotyping. Most residents had developed ad hoc, informal skills to care for diverse patients. Although residents perceived institutional endorsement, they sensed it was a low priority due to lack of time and resources.

CONCLUSIONS

Residents in this study reported receiving mixed messages about cross-cultural care. They were told it is important, yet they received little formal training and did not have time to treat diverse patients in a culturally sensitive manner. As a result, many developed coping behaviors rather than skills based on formally taught best practices. Training environments need to increase training to enhance residents' preparedness to deliver high-quality cross-cultural care if the medical profession is to achieve the goals set by the Institute of Medicine.

Neonatology research for the 21st century: executive summary of the National Institute of Child Health and Human Development-American Academy of Pediatrics workshop. Part II: training issues

This is the second part of the executive summary based on the presentations and discussions at a workshop on research in neonatology sponsored by the National Institute of Child Health and Human Development and the American Academy of Pediatrics held in January 2004. In this article, neonatology fellowship training requirements and workforce issues are addressed, and the reasons for the shortage of physician-scientists, particularly of the underrepresented minority ethnic groups, are highlighted. Full-length articles from the presented topics are yet to be published.

Ensuring culturally effective pediatric care: implications for education and health policy

This policy statement defines culturally effective health care and describes its importance for pediatrics and the health of children. The statement also defines cultural effectiveness, cultural sensitivity, and cultural competence and describes the importance of these concepts for training in medical school, residency, and continuing medical education. The statement is based on the conviction that culturally effective health care is vital and a critical social value and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through focused curricula throughout the spectrum of lifelong learning, from premedical education and medical school through residency and continuing medical education. The American Academy of Pediatrics also believes that these educational efforts must be supported through health policy and advocacy activities that promote the delivery of culturally effective pediatric care.

Public Health Nursing in Ireland: A Critical Overview*

The World Health Organization have stressed the importance of nurses and midwives as a "force for health" in society's efforts to tackle the public health challenges of our time. The public health challenges are both diverse and complex. Principally, they emanate from a social model of health that takes cognizance of our behavior, our environment, and the historical, political, and cultural structures that facilitate health or militate against it. This paper provides a critical overview of public health nursing in Ireland, toward situating both our contribution to public health and some of the challenges that lie ahead of us. Specifically, it looks at nonquantifiable practice, where, through the presentation of stories, the wealth of public health nursing work is demonstrated in the ordinary voices of public health nurses. The potential risk of ignoring and minimizing the contribution of public health nursing in future developments in primary care in Ireland is discussed. Finally, it is proposed that public health nurses need to get political.

Racial and ethnic differences in patient perceptions of bias and cultural competence in health care

OBJECTIVES

To determine: 1) whether racial and ethnic differences exist in patients' perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables.

DESIGN

Cross-sectional telephone survey.

SETTING

The Commonwealth Fund 2001 Health Care Quality Survey.

SUBJECTS

A total of 6,299 white, African-American, Hispanic, and Asian adults.

MEASUREMENTS AND MAIN RESULTS

Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents' perceptions of their PCPs' and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P <.001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively).

CONCLUSION

While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.

Effect of race on ratings of hypothetical candidates for a research scholarship/research assistant position

BACKGROUND

Study of the racial-ethnic biases of medical students is necessary to further understand health disparities. The objectives of this study were to (a) determine if medical students exhibit racial biases, (b) assess whether there are differences in racial biases among medical students who have and have not received a curriculum in cultural sensitivity, and (c) determine if these findings vary by student race-ethnicity.

DESCRIPTION

We evaluated medical students' preferences in hiring hypothetical candidates for a research scholarship and a research assistant position. Each student received a packet containing four curricula vitae (CVs) with attached photographs. Three CVs and photographs were identical. The fourth CV was identical, but in half the packets the photograph was of an African American man and in the other half of a White man. Students were asked to provide ratings of suitability.

EVALUATION

The African American candidate received better ratings than the White candidate. There were no differences in the ratings by student curriculum receipt or race-ethnicity.

CONCLUSION

We found no evidence that an African American candidate was discriminated against by medical students.

Serving as a physician role model for a diverse population of medical learners

PURPOSE

Medical learners look to role models to better understand the values, attitudes, behaviors, and ethics of the medical profession. This study examined issues related to physicians serving as role models for diverse medical learners.

METHOD

Between September and November 2000, in-depth semi-structured 30-minute interviews were conducted with 29 highly regarded role models, as judged by medical house officers at two large teaching hospitals in Baltimore, Maryland. Interview transcripts were independently coded and compared for agreement. Content analysis identified several major categories of themes that were examined and conceptually organized.

RESULTS

The informants identified issues that relate to role modeling for diverse medical learners. Subcategories under the domain of similarity facilitates role modeling included learners prefer role models similar to them, role modeling is easier when the learner resembles the teacher, and minority physicians may be better role models for minority learners. Under the domain role modeling when physician-teachers and learners are different were the subcategories extra effort may be necessary, success promotes and inspires confidence, and role modeling across diversity is an achievable objective that should be pursued. The final domain, approaches to differences between physician-teachers and learners, encompassed embrace diversity, act as a consultant and refer when necessary, and minimize and disregard all differences.

CONCLUSIONS

The results of this study should draw attention to these issues and may serve as a stimulus for teaching physicians to consider a broader range of options for successful interactions with medical learners who are different from them.

Cross-cultural medical education: conceptual approaches and frameworks for evaluation

Given that understanding the sociocultural dimensions underlying a patient's health values, beliefs, and behaviors is critical to a successful clinical encounter, cross-cultural curricula have been incorporated into undergraduate medical education. The goal of these curricula is to prepare students to care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, and gender biases in health care delivery. Despite progress in the field of cross-cultural medical education, several challenges exist. Foremost among these is the need to develop strategies to evaluate the impact of these curricular interventions. This article provides conceptual approaches for cross-cultural medical education, and describes a framework for student evaluation that focuses on strategies to assess attitudes, knowledge, and skills, and the impact of curricular interventions on health outcomes.

Educational benefits of diversity in medical school: a survey of students

PURPOSE

Many U.S. medical schools have abandoned affirmative action, limiting the recruitment and reducing the admission of underrepresented minority (URM) students even though research supports the premise that the public benefits from an increase in URM physicians and that URM physicians are likely to serve minority, poor, and Medicaid populations. Faculty and students commonly assume they benefit from peer cultural exchange, and the published evidence for the past two decades supports this notion. This research examined the students' perceptions of the educational merits of a diverse student body by surveying medical students at two schools.

METHOD

In 2000, medical students from all four years at Harvard Medical School and the University of California, San Francisco, School of Medicine were enrolled in a telephone survey about the relevance of racial diversity (among students) in their medical education. Students responded to the interviewer's questions on a five-point Likert-type scale.

RESULTS

Of the 55% of students who could be located, 97% responded to the survey. Students reported having little intercultural contact during their formative years but significantly more interactions during higher education years, especially in medical school. Students reported contacts with diverse peers greatly enhanced their educational experience. They strongly supported strengthening or maintaining current affirmative action policies in admissions. The responses and demography of the Harvard and UCSF students did not differ significantly, nor did they differ for majority students and URM students-all groups overwhelmingly thought that racial and ethnic diversity among their peers enhanced their education.

CONCLUSIONS

Diversity in the student body enhanced the educational experiences of students in two U.S. medical schools.

The ETHNIC(S) mnemonic: a clinical tool for ethnogeriatric education

Geriatrics healthcare providers need to be aware of the effect that culture has on establishing treatment priorities, influencing adherence, and addressing end-of-life care issues for older patients and their caregivers. The mnemonic ETHNIC(S) (Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, Spirituality/Seniors) presented in this article provides a framework that practitioners can use in providing culturally appropriate geriatric care. ETHNIC(S) can serve as a clinically applicable tool for eliciting and negotiating cultural issues during healthcare encounters and as a new instructional strategy to be incorporated into ethnogeriatric curricula for all healthcare disciplines.

Wrestling with ethnic diversity: toward empowering health educators

The importance of training health professionals for work in an ethnically diverse society is increasingly recognized. However, health educators may lack confidence or experience in delivering such teaching, contributing to a self-perpetuating inertia.

OBJECTIVES

To identify current experience and challenges perceived by educators of different health professionals, and to facilitate and debate the development of teaching in this field.

METHODS

Educators (n=61) from 42 different organizations, participated in facilitated workshops in three different UK settings. They included clinician teachers of medical undergraduates and postgraduates, and educators of nurses, primary care and hospital physicians, physiotherapists, occupational therapists and paramedical staff. Opportunities were provided for educators to discuss experiences; to participate as "learners" in examples of interactive training exercises; to anticipate challenges they might encounter in developing and providing training themselves; and to discuss ways of negotiating them. Qualitative data generated from the workshops were analysed for common themes.

RESULTS

Participants had received little relevant training themselves. For many, the workshops provided a first formal opportunity to consider their own responses to ethnic diversity in health care. Current provision of such training in their institutions was limited. Educators lacked specific training to facilitate the learning of others in this field. They wrestled with a wide range of issues: from critical dilemmas about the philosophy of teaching, through to the practicalities and personal challenges of face to face teaching. Strategies to address these were generated that may merit consideration.

CONCLUSION

Educators will need help to overcome their uncertainty in approaching this topic and be empowered to develop training. Developing teachers' own awareness and skills, followed by appropriate support, are likely to be prerequisites for successful training.