A prescription for cultural competence in medical education

Artificial Intelligence and Workforce Diversity in Nuclear Medicine

Artificial intelligence (AI) has rapidly reshaped the global practice of nuclear medicine. Through this shift, the integration of AI into nuclear medicine education, clinical practice, and research has a significant impact on workforce diversity. While AI in nuclear medicine has the potential to be a powerful tool to improve clinical, research and educational practice, and to enhance patient care, careful examination of the impact of each AI tool needs to be undertaken with respect to the impact on, among other factors, diversity in the nuclear medicine workforce. Some AI tools can be used to specifically drive inclusivity and diversity of the workforce by supporting women and underrepresented minorities. Other tools, however, have the potential to negatively impact minority groups, leading to a widening of the diversity gap. This manuscript explores how various AI solutions have the potential to both negatively and positively affect diversity in the nuclear medicine workforce.

Understanding the Psychology of Practical Wisdom

The longstanding view of doctors as scientists has been an emphasis in the MCAT and medical school training. However, the AAMC recommended recognizing the importance of social and behavioral science for medicine. There is also a growing realization that being a smart problem solver and the physician as scientist model emphasizes a cold cognitive problem-solving paradigm that overlooks other human capacities that may be critical to medical reasoning and decision-making. Considering a smart physician versus a wise physician, intelligence and problem-solving are important, but a wise physician can use other important capacities beyond intelligence and rationality. This could benefit patients by introducing patient and family perspective taking, as well as compassion in doctor-patient interaction. By reconceptualizing professions from the perspective of practical wisdom, this may increase resilience to problems such as burnout. I outline some psychological capacities viewed as important in wise reasoning that are not about traditional views of intelligence. I argue that wise reasoning is not a native talent but a skill that can be developed. I argue that different kinds of experiences can increase aspects of empathy, epistemic humility, perspective taking, and wise reasoning and I examine evidence that wise reasoning may increase resilience.

Supporting Educational Excellence in Diversity (SEED): faculty development and allyship

INTRODUCTION

Bias, privilege, microaggressions, and other forms of mistreatment negatively impact students' learning, professional development, wellness, and identity. Supporting Educational Excellence in Diversity (SEED) is an innovative faculty development curriculum co-founded and co-designed by medical students/trainees. SEED is unique given it provides vital yet practical communication tools and strategies to support cultural humility when navigating critical conversations related to diversity, inclusion, and harm.

OBJECTIVE

This curriculum helps faculty to identify, redress, and prevent mistreatment within clinical and non-clinical learning environments while cultivating cultural humility.

METHODS

SEED incorporated a sequential hybrid model approach through the use of interactive online modules, virtual asynchronous self-reflection assignments, followed by in-person discussions with role-play opportunities. Using novel tools, it taught faculty core knowledge and strategies to facilitate discussions in navigating harms related to diversity and inclusion. Authors measured impact via self-reported, de-identified pre-and-post questionnaires.

RESULTS

An idependent t-test analysis pre-post-test study of 67 faculty participants revealed statistically significant (P < .001) differences from pre to post on all items with one item statistically significant at a p < .05. The overall effect size was 1.65 showing significant improvement in participants' self-perceived ability to identify and address microaggressions, privilege, sources of bias, and related harm in the clinical and learning environments. These improvements were identified within themselves, faculty peers, teaching curricula, and teaching modalities. SEED was adopted health system-wide through customized departmental faculty offerings given the statistically and practically significant change in learning, awareness, and attitudes for respondents. SEED is currently under consideration as a maintenance of certification self-assessment course by a national board.

CONCLUSION

The innovative SEED faculty development curriculum was co-created and designed by students/trainees. SEED shows promising results in improving participants' foundational learning in promoting inclusive change to enhance learning environments for healthcare trainees. SEED is unique in providing vital yet practical communication tools and strategies to support cultural humility when navigating critical conversations related to diversity, inclusion, and harm.

Supporting minority cultures during initial engagements with body donors in the dissecting room: A pilot study exploring perspectives of Pasifika medical students around culture and cultural safety

The first experience of medical students in the dissecting room (DR) is a challenging event. Few data exist around whether or how culturally appropriate support is required in the DR for students from ethnic minorities. This pilot study explored Pasifika (peoples with heritage from the Pacific Islands) students' first experience of the DR and exposure to body donors to explore cultural perspectives around this event. Participants were second year Pasifika medical students with no prior engagement with body donors. Following a first exposure to body donors, semi-structured face-to-face interviews were conducted. Questioning explored how Pasifika students experienced initial DR engagement in regard to Pasifika culture and cultural safety. Interviews were recorded, transcribed, and analyzed thematically. Eight Pasifika students were interviewed (ages 18-32 years, mean 21.3 years, five females); mean interview duration 24.5 min. Four themes were identified: cultural observations, student behaviors, cultural safety, and cultural comfort. Dominant messages included the cultural challenges presented by this event, conformity of cultural behavior, identification of cultural safety being appropriate, and illumination of potential cultural support strategies. Current mechanisms supporting cultural safety were identified as adequate, which juxtaposed against behavior where students could not act in a culturally authentic manner. Suggestions were made around improving cultural comfort, such as the presence of elders or Christian-focused elements such as prayer. Enhanced cultural support could increase cultural comfort for the initial DR and body donor experience of Pasifika students, which may facilitate increased cultural knowledge and promote cultural diversity within the medical student cohort.

Exploring cultural competence barriers in the primary care sexual and reproductive health centres in Catalonia, Spain: perspectives from immigrant women and healthcare providers

BACKGROUND

Immigrant populations, especially women, continue facing challenges in accessing quality healthcare, particularly sexual and reproductive health services (SRH). Poor cultural competent health systems contribute to communication challenges between immigrant women and healthcare providers perpetuating health disparities. This exploratory study describes these communication barriers from the perspective of Moroccan and Pakistani immigrant women and healthcare providers within the Catalan health system and its implications to ensure an equitable provision of SRH services.

METHODS

An exploratory-descriptive qualitative study was conducted in various municipalities of Barcelona with high concentration of immigrants. Eight focus groups (N = 51) and semi-structured interviews (N = 22) with Moroccan and Pakistani immigrant women were combined with key informant interviews (N = 13) with healthcare professionals. Thematic analysis and data triangulation were performed primarily using an inductive approach.

RESULTS

Language barriers and cultural differences in health needs, expectations, care-seeking behaviours and understanding of quality healthcare provision hindered the ability of immigrant women and providers to interact effectively. Limited availability of intercultural mediators and inadequate cultural competence training opportunities for health staff were also identified. Findings suggest a lack of minority representation in the Catalan health workforce and leadership roles.

CONCLUSION

This study reinforces the evidence of persistent inequities in accessing healthcare among immigrant populations by focusing on the cultural competence barriers of the Catalan health system in the provision and access to SRH services. The regularization of adequately trained intercultural mediators, quality training in cultural competence for health staff and a commitment to increase workforce diversity would contribute to improve intercultural communication between immigrant patients and providers. An urgent call to action in this direction is needed to ensure an equitable access to SRH services among immigrant women.

Improving cultural humility in physical therapy students: What is faculty's role?

BACKGROUND

Clinician bias contributes to health disparities; therefore, educational standards and professional expectations incorporate cultural humility. Vague standards and numerous pedagogical methods make implementing an effective and uniform curriculum challenging. Classroom and clinical faculty's attitudes and behaviors are pivotal; however, evidence on roles beyond instruction is lacking.

PURPOSE

This study explored physical therapy (PT) students' perceptions of faculty's role in improving their cultural humility.

METHODS

This study was rooted in a phenomenological approach that incorporated elements of both descriptive and interpretive phenomenology. Thirteen first-year PT students participated in one-on-one interviews which underwent reflexive thematic analysis.

RESULTS

Reflexive thematic analysis generated two hundred-ninety codes, six categories, and one overarching theme. Dissonance emerged between students' perceptions of faculty's role and the explicit and implicit curriculum.

CONCLUSION

Explicit messaging from classroom instruction and implicit messaging from clinical encounters and unspoken attitudes, values, and behaviors were disparate. Faculty role modeling, diversity, cultural awareness, and perceived comfort interacting with a diverse patient population improved students' self-confidence and cultural humility. Professional development including field experience with a cognitive apprenticeship approach, and standardized, discipline-specific cultural humility competencies may provide uniform and clear guidelines.

Cultural Competence in Ophthalmic Dispensing Education: A Qualitative Study

Purpose

Understanding and acknowledging cultural diversity in healthcare is essential in providing culturally competent care. Higher education institutions are critical to providing students with the necessary knowledge, attitudes, and skills to respond to cultural diversity in various contexts. Cultural competence teaching in ophthalmic dispensing education has emerged as an essential concept that needs to be included in the curriculum. This study explored ophthalmic dispensing lecturers' understandings, experiences, and attitudes in teaching cultural competence.

Methods

This study used a qualitative approach within an interpretivist paradigm by conducting semi-structured interviews with lecturers (n = 7) in the ophthalmic dispensing program. Braun and Clarke's framework for thematic analysis was utilized. The research was conducted at an ophthalmic dispensing department at a South African university.

Results

The analysis of the semi-structured interviews indicated three main themes of importance regarding factors influencing cultural competence education in the ophthalmic dispensing curriculum: the interplay between experiences and understandings of cultural competence, cross-cultural exposure and teaching practices, and inclusion of cultural competence into the curriculum. The participants recognized that cultural competence was not explicitly included in the curriculum. Including culture in education was rather unsystematic and, in most cases, unplanned.

Conclusion

Further training of lecturers on cultural competence skills and evidence-based teaching and assessment strategies are required to assist in developing curricula that include cultural competence.

The role of cultural competency training to address health disparities in surgical settings

BACKGROUND

Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

SOURCES OF DATA

In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

AREAS OF AGREEMENT

The unjustness of health care disparities is universally accepted.

AREAS OF CONTROVERSY

Whether the outcome of CCT justifies the cost has not been effectively answered.

GROWING POINTS

These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Effectively teaching cultural competence in a pre-professional healthcare curriculum

BACKGROUND

There has been research documenting the rising numbers of racial and ethnic minority groups in the United States. With this rise, there is increasing concern over the health disparities that often affect these populations. Attention has turned to how clinicians can improve health outcomes and how the need exists to educate healthcare professionals on the practice of cultural competence. Here we present one successful approach for teaching cultural competence in the healthcare curriculum with the development of an educational session on cultural competence consisting of case-based, role-play exercises, class group discussions, online discussion boards, and a lecture PowerPoint presentation.

METHODS

Cultural competence sessions were delivered in a pre-dental master's program to 178 students between 2017 and 2020. From 2017 to 2019, the sessions were implemented as in-person, case-based, role-play exercises. In 2020, due to in-person limitations caused by the COVID-19 pandemic, students were asked to read the role-play cases and provide a reflection response using the online Blackboard Learn discussion board platform. Evaluation of each session was performed using post-session survey data.

RESULTS

Self-reported results from 2017 to 2020 revealed that the role-play exercises improved participant's understanding of components of cultural competence such as communication in patient encounters (95%), building rapport with patients (94%), improving patient interview skills (95%), and recognition of students own cultural biases when working with patients (93%).

CONCLUSIONS

Students were able to expand their cultural awareness and humility after completion of both iterations of the course session from 2017 to 2019 and 2020. This session can be an effective method for training healthcare professionals on cultural competence.

Interpreter and limited-English proficiency patient training helps develop medical and physician assistant students' cross-cultural communication skills

BACKGROUND

The increasing linguistic and cultural diversity in the United States underscores the necessity of enhancing healthcare professionals' cross-cultural communication skills. This study focuses on incorporating interpreter and limited-English proficiency (LEP) patient training into the medical and physician assistant student curriculum. This aims to improve equitable care provision, addressing the vulnerability of LEP patients to healthcare disparities, including errors and reduced access. Though training is recognized as crucial, opportunities in medical curricula remain limited.

METHODS

To bridge this gap, a novel initiative was introduced in a medical school, involving second-year students in clinical sessions with actual LEP patients and interpreters. These sessions featured interpreter input, patient interactions, and feedback from interpreters and clinical preceptors. A survey assessed the perspectives of students, preceptors, and interpreters.

RESULTS

Outcomes revealed positive reception of interpreter and LEP patient integration. Students gained confidence in working with interpreters and valued interpreter feedback. Preceptors recognized the sessions' value in preparing students for future clinical interactions.

CONCLUSIONS

This study underscores the importance of involving experienced interpreters in training students for real-world interactions with LEP patients. Early interpreter training enhances students' communication skills and ability to serve linguistically diverse populations. Further exploration could expand languages and interpretation modes and assess long-term effects on students' clinical performance. By effectively training future healthcare professionals to navigate language barriers and cultural diversity, this research contributes to equitable patient care in diverse communities.

Examining the pedagogical practices that support cultural proficiency development in graduate health science students

BACKGROUND

Health disparities are often a function of systemic discrimination and healthcare providers' biases. In recognition of this, health science programs have begun to offer training to foster cultural proficiency (CP) in future professionals. However, there is not yet consensus about the best ways to integrate CP into didactic and clinical education, and little is known about the role of clinical rotations in fostering CP.

METHODS

Here, a mixed-methods approach was used to survey students (n = 131) from a private all-graduate level osteopathic health sciences university to gain insight into the training approaches students encountered related to CP and how these may vary as a function of academic progression. The research survey included instruments designed to quantify students' implicit associations, beliefs, and experiences related to the CP training they encountered through the use of validated instruments, including Implicit Association Tests and the Ethnocultural Empathy Inventory, and custom-designed questions.

RESULTS

The data revealed that most students (73%) had received CP training during graduate school which primarily occurred via discussions, lectures, and readings; however, the duration and students' perception of the training varied substantially (e.g., training range = 1-100 hours). In addition, while students largely indicated that they valued CP and sought to provide empathetic care to their patients, they also expressed personal understandings of CP that often fell short of advocacy and addressing personal and societal biases. The results further suggested that clinical rotations may help students attenuate implicit biases but did not appear to be synergistic with pre-clinical courses in fostering other CP knowledge, skills, and attitudes.

CONCLUSIONS

These findings highlight the need to utilize evidence-based pedagogical practices to design intentional, integrated, and holistic CP training throughout health science programs that employ an intersectional lens and empowers learners to serve as advocates for their patients and address systemic challenges.

Storied reflections: Development of a longitudinal interdisciplinary curriculum to improve patient-provider communication

Objective

This article details the development of an interdisciplinary graduate medical education (GME) narrative curriculum.

Methods

Descriptive statistics were conducted for the narrative session surveys. Two separate qualitative analyses were conducted. First, content and thematic analyses of the open-ended questions in the survey using NVIVO software occurred. Second, an inductive analysis of the participants' 54 stories was performed to identify unique themes not related to the prompt topics.

Results

Quantitative survey results demonstrated that 84% of learners' felt the session benefited their personal or professional sense of wellbeing and resilience, 90% of learners believed the sessions aided in their ability to listen more effectively, and 86% of learners could apply what they practiced or witnessed. Qualitative analysis of survey data showed learners focused on patient care and listening. Thematic analysis of participants' narratives revealed strong feelings and emotions, struggles with time management, increase in self- and other-awareness, and challenges managing job-life balance.

Conclusion

The longitudinal interdisciplinary Write-Read-Reflect narrative exchange curriculum is cost-effective, sustainable, and demonstrably valuable to learners and their program directors across multiple disciplines.

Innovation

The program was designed for 4 graduate programs' learners to simultaneously experience a narrative exchange model to improve patient-provider communication, support professional resilience, and deepen relationship-centered care skills.

Virtual and In-Person Day Camps for the Craniofacial Community

ABSTRACT

Children with congenital craniofacial conditions (CFCs) and their families may stand to benefit from day camps offering tailored psychosocial support and resources. Nonprofit ConnectMed International has held virtual and in-person day camps in San Diego for this community since 2018. We administered surveys before and after a series of day camps to understand the needs of this community and benefits perceived programming offered. Although studies have reported the psychosocial benefits of camps for children with rare diseases, few have examined the specific benefit for children with CFCs and their parents. Herein, we present the findings of our survey study as the first article to report a needs assessments and psychosocial benefits of day camps for children with CFCs and their parents.

Exploring Biologic Treatment Hesitancy Among Black and Indigenous Populations in Canada: a Review

Biologics are becoming an increasingly important part of patient care across Canada. Recent studies from the USA show that Black patients are less likely than White patients to receive biologic treatment for several medical conditions. The relative lack of race-based data in Canada makes it difficult to replicate such studies in Canada. As a result, there is a paucity of literature that explores the association between biologic usage and race in Canada. Our review aims to explore the factors that might be driving racial treatment disparity in Canada that likely parallels the inequalities found in the USA. We provide a summary of the available literature on the factors that contribute to biologic treatment hesitancy among Black and Indigenous populations in Canada. We highlight several solutions that have been proposed in the literature to address biologic treatment hesitancy. Our review found that biologic treatment decision at the individual level can be very complex as patient's decisions are influenced by social inputs from family and trusted community members, biologic-related factors (negative injection experience, fear of needles, formulation, and unfamiliarity), cultural tenets (beliefs, values, perception of illness), and historical and systemic factors (past research injustices, socioeconomic status, patient-physician relationship, clinical trial representation). Some proposed solutions to address biologic treatment hesitancy among Black and Indigenous populations include increasing the number of Black and Indigenous researchers involved in and leading clinical trials, formally training physicians and healthcare workers to deliver culturally competent care, and eliminating financial barriers to accessing medications. Further research is needed to characterize and address race-based new treatment inequalities and hesitancy in Canada.

Cultural Competence Is Everyone's Business: Embedding Cultural Competence in Curriculum Frameworks to Advance Veterinary Education

Cultural competence in professional and research practice is important to effectively deliver animal and One Health services and programs. Veterinarians work with culturally and linguistically diverse teams, clients, and communities. Cultural perspectives on the significance and perceptions of animals and differences in consultation and engagement protocols and strategies can influence client-practitioner and researcher-community relationships, impacting animal health, welfare, and/or research outcomes. Curricula have been proposed to build cultural capacity in graduates, but these have not been reported in veterinary programs, and early attempts to integrate cultural competency into the University of Sydney veterinary curriculum lacked a formal structure and were ad hoc with respect to implementation. To address this, the authors introduced a broad curriculum framework into the University of Sydney veterinary program, which defines cultural competence, perceptions of animals, effective communication, and community engagement in a range of contexts. Cultural competency learning outcomes were described for units of study. These were contextually relevant and aligned to course learning outcomes and University of Sydney graduate qualities. Constructive alignment was achieved by linking learning outcomes to teaching and learning activities and assessment. The continuum of cultural competency underpinned mapping of cultural competency across the curriculum with staged, vertical integration of key principles. Additionally, action to engage staff, students, and stakeholders in a cultural competence agenda assisted in sustaining curriculum change. The result was integration of cultural competency across the curriculum aligning with recommendations from accrediting bodies and with best practice models in medicine, nursing, and allied health programs.

Evaluation of a Virtual Health Equity Training for Mid-Career Primary Healthcare Providers

OBJECTIVES

Providing cultural competence training is recommended as a way to improve patient-centered care and reduce health disparities. Increasing awareness of implicit biases and understanding internal motivations for overcoming these biases can influence provider decisions and communications with patients. This study aims to provide a health equity and implicit bias training to healthcare providers and assess knowledge and attitude gains.

METHODS

Mid-career primary healthcare providers (n = 21) with at least 5 years of primary care experience participated in the training as a prerequisite for providing patient care in a telehealth primary care practice that overwhelmingly serves patients of color.

RESULTS

There was a significant increase in knowledge (p < .001) as well as attitudes (p < .001) in healthcare providers from pretest to posttest. Almost none (4.5%) of the providers were distracted during the training, which may be due to the interactive nature of the training that included group-based reflection discussions.

CONCLUSION

A virtual training for primary healthcare providers on health equity and implicit bias improved knowledge and equitable attitudes and had high satisfaction. Additional research is needed to determine if this type of training can influence providers' ability to actively address known disparities in care.

The priorities, challenges, and scope of clinical communication teaching perceived by clinicians from different disciplines: a Hong Kong case study

Background

In the absence of a well-rounded syllabus that emphasises both interpersonal and medical dimensions in clinical communication, medical students in the early stages of their career may find it challenging to effectively communicate with patients, especially when dealing with perceived priorities and challenges across different disciplines.

Methods

To explore the priorities, challenges, and scope of clinical communication teaching as perceived by clinicians from different clinical disciplines, we recruited nine medical educators, all experienced frontline clinicians, from eight disciplines across seven hospitals and two medical schools in Hong Kong. They were interviewed on their clinical communication teaching in the Hong Kong context, specifically its priorities, challenges, and scope. We then performed interpretative phenomenological analysis of the interview data.

Results

The interview data revealed five themes related to the priorities, challenges, and scope of clinical communication teaching across a wide range of disciplines in the Hong Kong context, namely (1) empathising with patients; (2) using technology to teach both the medical and interpersonal dimensions of clinical communication; (3) shared decision-making with patients and their families: the influence of Chinese collectivism and cultural attitudes towards death; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician–patient communication.

Conclusions

Coming from different clinical disciplines, the clinicians in this study approached the complex nature of clinical communication teaching in the Hong Kong context differently. The findings illustrate the need to teach clinical communication both specifically for a discipline as well as generically. This is particularly important in the intensive care unit, where clinicians from different departments frequently cooperate. This study also highlights how communication strategies, non-verbal social cues, and the understanding of clinical communication in the Hong Kong Chinese context operate differently from those in the West, because of differences in sociocultural factors such as family dynamics and hierarchical social structures. We recommend a dynamic teaching approach that uses role-playing tasks, scenario-based exercises, and similar activities to help medical students establish well-rounded clinical communication skills in preparation for their future clinical practice.

A Scoping Review of Published Intimate Partner Violence Curricula for Medical Trainees

Intimate partner violence (IPV) affects many, and health care has the potential to provide a safe space for individuals experiencing IPV. However, physicians cite lack of time and education as barriers. The aim of this study is to complete a review of published IPV curricula in medical school, residency training, and postresidency training. We performed a scoping review to provide a quantitative assessment and summary review of existing IPV curricula. In May 2020, a librarian conducted a search of Ovid MEDLINE, Ovid EMBASE, and Scopus. We evaluated each article for the following curriculum content and structure items: (1) year introduced; (2) delivery method; (3) curriculum type; (4) curriculum content; (5) curriculum effectiveness; and (6) implementation barriers. Fifty-six articles met criteria, most were for medical school learners (n = 32, 57.1%) and short-term (lasting less than one academic year) (n = 41, 73.2%). For residency, IPV curricula were most frequently taught in family medicine, internal medicine, and emergency medicine. Formal lecture and use of standardized patients were the most popular delivery methods. Most curricula taught risk factors for and identification of individuals who have experienced IPV. The most cited implementation barrier was limited time in standard medical education, followed by inability to measure the effectiveness of the curriculum. There was great variation in the methods of assessing effectiveness of IPV curricula. Published IPV curricula are varied, without consistent validated tools for assessing efficacy. Future initiatives to establish a standard of competency for medical students regarding IPV, including a standard curriculum, may better ensure that physicians are capable of identifying and caring for individuals who have experienced IPV.

How school life with international students develops the intercultural competence of domestic dental students

INTRODUCTION

Reflecting multicultural society, the diversity of the healthcare professional students' ethnicities and cultures is promoted around the world. However, most of the healthcare professional education in Japan had been targeted mainly at students who follow the Japanese language and culture. The aim of this study is to clarify what Japanese dental students have culturally experienced and how they developed intercultural competence during their school life with international dental students in Japan.

MATERIALS AND METHODS

We conducted semi-structured interviews with 18 of the sixth-grade students in standard Japanese undergraduate dental programmes who shared required classes in Japan with non-Japanese-speaking international dental students in preclinical programmes. Based on the qualitative analysis of the interviews, we administered a questionnaire survey to 82 dental trainees (the seventh grade) in clinical training programmes who just graduated from various Japanese dental schools. Then, the answers of the questionnaire were statically analysed.

RESULTS

The interview identified a total of 37 constituent elements regarding "students' attitudes and experiences in school days" and "perceptions and motivations." Analysis of the questionnaire showed that the group experiencing a learning environment with international students had various communication with and respect for their various classmates and had the ambition to develop themselves. Especially, the participants who had international experiences both in and out of classrooms showed more active attitude on intercultural communication.

CONCLUSIONS

Overall, for Japanese dental students, daily contact with international students gave direct and indirect cross-cultural experiences and recognitions. In particular, the Japanese students were stimulated active perceptions. The findings of this study can be used for future discussion about the cross-cultural education and collaboration of healthcare professionals not only within Japan but also around the world.

Development and validation of cultural competence assessment tool for healthcare professionals, India

Culture influences an individual's perception of "health" and "sickness". Therefore, cultural competence assessment of healthcare professionals is very important. Existing assessment scales have limited application in India due to the nation's rich cultural diversity and heterogeneous healthcare streams. This study was undertaken to develop and validate a cultural competence assessment tool for healthcare professionals in India. A cross-sectional study using convenience sampling was conducted following all standard steps among 290 healthcare professionals in India. Item reduction was followed by estimation of validity and reliability. Responses were recorded on a five-point Likert scale, ranging from strongly disagree to strongly agree. The resultant tool, named Cultural Competence Assessment Tool-India (CCT-I) showed an acceptable internal consistency (Cronbach's alpha =0.734). Inter-rater agreement was 81.43%. Face, content, and construct validity were demonstrated. There was no statistically significant difference in cultural competence between the healthcare streams based on years of clinical experience. There was statistically significant difference between streams of healthcare (p-value =0.009) and also between dentistry and Ayurveda groups (p-value = 0.003). This comprehensive tool can be used as the first step toward designing cultural competence training of healthcare manpower and the establishment of culturally sensitive healthcare organizations.

Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions

BACKGROUND

The medical case vignette has long been used in medical student education and frequently includes demographic variables such as race, ethnicity and gender. However, inclusion of demographic variables without context may reinforce assumptions and biases. Yet, the absence of race, sexual orientation, and social determinants of health may reinforce a hidden curriculum that reflects cultural blindness. This replication study compared proportions of race, ethnicity, and gender with University of Minnesota (UMN) findings. This study sought to determine if there has been progress in the representation of demographic characteristics in case vignettes.

METHODS

University of North Carolina (UNC) case vignettes from 2015-2016 were analyzed and compared to UMN case vignettes from 1996-1998. Data included mentions of race, ethnicity, gender and social determinants of health.

RESULTS

In the 278 UNC vignettes, white race was noted in 19.7% of cases, black race was in 7.9% cases, and 76.6% of cases were unspecified. In the 983 UMN vignettes, white race was recorded in 2.85% cases, and black race in 0.41% cases. The institutions were significantly different in the proportion of their cases depicting race (0.20; 95% CI (0.15, 0.25)). Males were represented in the majority of vignettes.

DISCUSSION

Comparing case vignettes results from two medical schools suggests that reporting explicit demographic diversity was not significantly different. The findings illustrate that sex was the demographic characteristic consistently described, where males were over-represented. Based on these findings, greater cultural diversity as it intersects with social determinants of health is needed in medical student education.

Structural equation modeling of the association between professional and cultural competencies of nurses in Saudi Arabia

AIM

To determine the influence of Saudi nurses' professional competencies on their cultural competency using the structural equation model (SEM).

BACKGROUND

Nurses are an essential component of the health care delivery system; it is crucial to understand their professional and cultural competencies. However, these concepts remain underreported from a middle eastern perspective.

DESIGN

A correlational, cross-sectional design.

METHODS

Data were collected using two self-report instruments from 587 nurses employed in three government-run tertiary hospitals in Saudi Arabia. Spearman rho and SEM were performed to analyze the relationships of the studied variables.

RESULTS

The emerging model showed acceptable model fit indices. Among the six dimensions of professional competency, only three significantly influence cultural competency. Specifically, both care pedagogics and medical and technical care had a moderate, positive influence on cultural competency. Contrastingly, value-based nursing care had a moderate but negative influence on cultural competency.

CONCLUSIONS

Cultural competency is a complex and underused nursing concept influenced by nurses' professional competencies. The knowledge acquired from the presented model can be used by nurse leaders, administrators and educators in developing appropriate policies, programs and strategies.

Medical Trainees Comfort and Confidence in Providing Care to Arab and Muslim Patients at a Large Academic Medical Center

PHENOMENON

There are currently 3.5 million Americans of Arab descent and 3.45 million Muslims living in the United States. These rapidly growing populations face significant health disparities, which is likely in part due to the lack of culturally competent physicians trained to treat these populations. While the Institute of Medicine calls for cross-cultural training for all providers, it is not clear if this need is being met. The purpose of this study is to examine medical trainees' current level of cultural training and whether this corresponds to confidence in caring for Arab and Muslim patients.

APPROACH

The authors created an anonymous survey that was distributed via email to medical students and residents at Michigan Medicine between January and March 2020. Questions included trainees' comfort and confidence level in caring for Arab and Muslim patients, as well education received on this topic.

FINDINGS

Results showed that 41% of respondents were confident in their ability to take a history from an Arab patient immigrated to the U.S. Additionally, 55% of non-Muslim participants reported that they felt comfortable in caring for fasting patients, while only 24% felt confident in their ability to answer patient questions about fasting. Approximately half of respondents felt confident in their ability to examine an Arabic-speaking woman (47%) or woman wearing a hijab (49%). The majority of respondents had not received any training or education in the care of Arab patients (64%) or fasting patients (81%).

INSIGHT

Medical trainees at one large academic medical center in the state with the second largest Arab-American population, and one of the largest populations of Muslim-Americans lack comfort and confidence in providing culturally competent care for Arab and Muslim patients. Education of trainees about Arab and Muslim health should be implemented into the curriculum to optimize care delivered to this patient population.

Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff

BACKGROUND

Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists).

METHODS

Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback.

RESULTS

Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules.

CONCLUSIONS

There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Effects of an internationalization at home (IAH) programme on cultural awareness among medical and nursing students in Hong Kong and Indonesia during the COVID-19 pandemic: a mixed-methods study

BACKGROUND

The COVID-19 pandemic has severely impacted the learning experience of students by limiting their opportunities for face-to-face intercultural exchanges. Given the importance of cultural competence in medical education, there is a need to develop a programme that promotes cultural awareness, but that offers more flexibility in terms of outbound mobility. This study aims to evaluate the effectiveness of an internationalization at home programme and to explore the learning experiences of medical and nursing students from Hong Kong and Indonesia.

METHODS

Students were recruited from two universities in Hong Kong and Indonesia. They attended an online internationalization at home programme designed by members of the research team from both countries. A mixed-methods study was conducted using a concurrent triangulation approach. A pre-test post-test design was used to evaluate the effects of the programme on cultural awareness, and four focus groups were conducted to explore the students' experiences in the programme. Quantitative and qualitative data were analysed by T-test and reflexive thematic analysis, respectively. Data were integrated and triangulated using joint displays by comparing findings from both sources.

RESULTS

One hundred and forty-eight students from Hong Kong and Indonesia participated in the study. After the programme, there was a significant improvement in cultural awareness. Three themes were identified: (1) learning process: enjoyable, but a desire remains for face-to-face cross-cultural communication; (2) learning outcomes: gained cultural awareness, developed cultural sensitivity, had an opportunity to practice language and learn about new learning styles; (3) factors influencing learning outcomes: facilitators (micro-movie and active communication) and barriers (language barrier, inappropriate time arrangement, insufficient prior briefing).

CONCLUSION

This programme achieved the learning outcomes by successfully enhancing the cultural awareness of students during a time of pandemic when outbound student exchanges were not possible. Further adaptations of the programme are required to enhance different learning outcomes.

Institutional Ethnoracial Discrimination and Microaggressions among a Diverse Sample of Undergraduates at a Minority-Serving University: A Gendered Racism Approach

Purpose

Ethnoracial minorities report a variety of discriminatory experiences due to systemic racism. Yet, few studies have examined whether gender and race/ethnicity interact to predict institutional discrimination and racial microaggressions through an intersectional approach.

Design/methodology/approach

A predominantly female (60%), ethnoracial minority (20.8% Black, 31.6% Asian, 30.8% Latina/o, 8.2% White, 6.6% Middle Eastern) sample of 895 undergraduates attending a minority-serving public university in an urban setting completed self-report measures of sociodemographic characteristics, experiences of racial microaggressions, and institutional discrimination.

Findings

Significant (p<.05) gender × race/ethnicity interaction effects were found in several institutional discrimination domains: Males reported more police/court discrimination overall, but gender differences in police/court discrimination were less pronounced for non-Black vs. Black students. While males tended to report more institutional discrimination than females, the reverse was true for the Middle Eastern group: Middle Eastern females reported institutional discrimination in more domains and more discrimination getting hired than their male counterparts. There was a significant race/ethnicity × gender interaction effect for environmental microaggressions: White males reported more environmental microaggressions than White females, but gender differences were not found in the overall sample.

Originality

This study is the first to our knowledge to assess the interactive effects of gender and ethnicity on the type of microaggressions experienced in a diverse sample that includes individuals of Middle Eastern descent. The authors highlight the range of discriminatory events that ethnoracially minoritized undergraduates experience, even at a minority-serving institution.

Understanding undergraduate students’ eHealth usage and views of the patient-provider relationship

eHealth has grown exponentially alongside technology and has become widely accessed by some populations, but little is documented about how undergraduate students use eHealth or perceive their eHealth literacy. As access to online information and non-traditional options for interacting with providers has increased, patient views of the provider-patient relationship may also be changing. This study evaluates how frequently undergraduates use eHealth, how they perceive their ability to use eHealth appropriately, and how they view their patient-provider relationships. A mixed methods approach was used to address the research questions, with quantitative data from a survey and qualitative data from follow-up interviews of twelve of the survey respondents. The survey was distributed to over 650 undergraduate students in introductory biology laboratory courses for students of all fields of interest at one university. Based on 527 survey responses and 12 interviews, students reported commonly using eHealth but being skeptical of telehealth appointments. Although students generally felt capable of finding and interpreting eHealth sources, they were not strongly confident in their ability to do so. Use of eHealth was not seen as altering the patient-provider relationship, but students expressed a desire for their physician to act more as a counselor or advisor than a guardian. Students from minority populations were more likely to use eHealth in comparison to their peers. In addition, student comfort with their provider differed by race and ethnicity, as well as whether they shared the same gender identity as their provider. This research highlights how undergraduate students, who are often making medical decisions for themselves for the first time as adults, access health information and view the patient-provider relationship differently than the traditional guardian or paternalistic model. In addition, having diverse, culturally competent medical providers are critical for students to develop the relationship with their provider that they desire.

Addressing disparities in medicine through medical curriculum change: a student perspective

Cultural competency training has been a focus of medical schools for some time. An essential step in developing culturally competent physicians, effective cultural competency training has previously been researched at medical schools. Before forming a diversity task force to head cultural competency training, one medical school utilized medical student volunteers to review current teaching material and provide suggestions to increase cultural competency training. A study group consisting of three faculty members and 29 medical students was formed on a voluntary basis during the summer of 2020. Based on medical student opinion and reviewed teaching materials, learning tools were created to guide medical curricular updates. This experience resulted in the formation of four teaching tools: a didactic lecture checklist to include more diverse patient populations; case-based learning objectives that focus on social determinants of health; a facilitator question script to encourage group discussion and student feedback on the given clinical cases; and a student reflection form on the effects of race, gender, and socioeconomic status on patients and medical professionals in the clinical setting. Updating the medical school curriculum is a constant and ongoing process. Forming a diversity task force to guide these changes and regularly review medical teaching materials will help train physicians ready to care for a diverse patient population. In addition, the use of the suggested teaching tools may help guide the review process for such committees at other medical schools.

A Qualitative Analysis of Clinical Year Veterinary Student Journal Entries for a Shelter Medicine Rotation

Veterinary medical schools are tasked with not only providing experiences necessary to graduate veterinarians proficient in the skills and knowledge used most frequently in private practice, but also develop expertise in animal behavior, welfare, ethics, veterinary forensics, and cultural competency. Integrating all these knowledge areas into the curriculum can be challenging. Shelter medicine is increasingly identified by educators as an optimal learning environment to offer exposure to these topics. It can not only meet learning objectives in veterinary medical curriculum, but also provide students with authentic learning experiences to engage in and gain a deeper understanding of cultural humility, implicit bias, diversity, and inclusion. This includes documentation of international learning outcomes for shelter medicine in veterinary medical curriculum. There have been no studies evaluating authentic learning experiences specific to shelter medicine programs and their impacts on students. The aim of this study was to determine the individual activities and thematic categories on which veterinary students chose to reflect on and their potential impacts during a clinical rotation in shelter medicine at Penn Vet through qualitative content analysis of their journal entries. In our study, students found experiences on the shelter medicine rotation to be beneficial to their growth as a future veterinarian, provided them with takeaways that they found applicable and practical, helped them self-identify knowledge gaps, and changed their perspectives on several important topics related to collective human and animal welfare. These results speak to the value perceived by students of the rotation and suggest an authentic learning experience through a shelter medicine program can help cultivate more practice-ready and culturally competent veterinary graduates.

Cultural Competence in Healthcare Leadership Education and Development

Cultural competence is a phenomenon that straddles many disciplines and fields of study. There is no settled definition of the term, and it is argued that this is not necessary to explore or discuss the phenomenon as it is context-dependent across diverse societies. Explorations of cultural competence in clinical education and training are well-established, but there has been less attention towards its expression in the field of developing healthcare leaders. There is a debate about whether cultural competence is best achieved primarily through training-based educational inputs or by being infused in all areas of curriculum development. Using an exploration of selected literature followed by the case of an ambitious set of leadership development programmes in the English National Health Service, this paper explores the balance and interdependencies of cultural competence in healthcare leadership development as knowledge, skills and attitudes. The paper concludes that it is important for educators in this field to provide space for reflection, develop skills of reflexivity and facilitate sensitive discussions of sometimes contested ideas and concepts. A further evaluation of the impact of teaching and learning interventions, while mapping developments in perceptions of knowledge, skill and attitudes would be an area ripe for future research.

Strategies for Incorporating Health Disparities and Cultural Competency Training into the Pharmacy Curriculum and Co-curriculum

Objective. To identify and review strategies reported in the literature for strengthening instruction about both health disparities and cultural competency (HDCC) within various portions of the Doctor of Pharmacy curriculum and co-curriculum.Findings. The classroom strategies reported in the literature for incorporating HDCC into the PharmD curriculum involved teaching a single course or series of courses in HDCC. Activities found to be effective in teaching HDCC were those that involved case-based and community engagement exercises. Recommendations for incorporating HDCC into the experiential education included preceptor development in areas of HDCC to assess student understanding of health disparities concepts, increasing student engagement with diverse patient populations, and implementation of cross-cultural communication models at clinical sites. Co-curricular and interprofessional (IPE) portions of pharmacy training were found to permit greater methodological flexibility for incorporating training in HDCC, as they often confronted fewer time or space constraints than classroom endeavors. Documented methods for teaching HDCC within co-curricular and IPE experiences included service learning, study abroad, symposia, and forums.Summary. There is a paucity of literature describing processes for incorporation of health disparities and cultural competency education and training into the PharmD program. Findings suggest that conceptual frameworks for HDCC should be used throughout the pharmacy curriculum, with learning activities mapped to relevant pharmacy education standards to ensure coverage of important practice competencies. Best practices also involve the use of contemporary tools, strategies, and resources from a cross-section of disciplines that provide opportunities for learners to correct misconceptions and biases through active situational problem-solving.

Gender and Racial Disparities among US Psychiatry Residents: A Review of Trends

Diversity provides better patient outcomes, reduces physician burnout, and therefore lessens the burden of the healthcare system. In this study, we explore the gender and racial trends in the recruitment of medical graduates into US psychiatry residency programs. Retrospective data analysis was performed utilizing the data from the Accreditation Council for Graduate Medical Education (ACGME) Data's annual Resource Books from the year 2007 to 2018. Demographic data, including gender and race, were extracted for psychiatry residents. Gender was categorized as Male, Female, and Not Reported. Race/ethnicity was categorized as White (Non-Hispanic), Asian/Pacific Islander, Hispanic, Black/African-American (Non-Hispanic), Native American/Alaskan, Others (not in the aforementioned categories), and Unknown. Female psychiatry residents relatively decreased by 2.6% whereas male psychiatry residents relatively increased by 15.5% from 2007 to 2018. Between the years 2011 and 2018, there was a relative increase in African American/Black and Native American/Alaskan psychiatry residents by 5.5% and 1%, respectively, whereas the Asian/Pacific Islanders, White (Non-Hispanic), and Hispanic/Latino psychiatry residents relatively decreased by 5.1%, 2.3%, and 1.7%, respectively. Despite the overall increase of women and ethnic minorities in US medical schools, women and racial minorities remain significantly under-represented in psychiatry residency programs in the US.

Development of a 1-Week Intensive Course on Diversity and Equity in Veterinary Medicine

While colleges of veterinary medicine continually strive to promote diversity and inclusion on their campuses, few offer dedicated diversity courses within their curriculums. This article provides details on the development and implementation of a 1-week intensive course on equity and diversity in veterinary medicine, discusses the strengths and challenges encountered, and provides suggestions for those seeking to develop similar learning experiences into their curriculum. This selective course was developed to introduce students to the principles of social justice and provide them with the opportunity to examine systems of power, privilege, and oppression within the context of veterinary medicine.

A Framework for Developing Antiracist Medical Educators and Practitioner-Scholars

With an increasing awareness of the disparate impact of COVID-19 on historically marginalized populations and acts of violence on Black communities in 2020, academic health centers across the United States have been prioritizing antiracism strategies. Often, medical students and residents have been educated in the concepts of equity and antiracism and are ready to tackle these issues in practice. However, faculty are not prepared to respond to or integrate antiracism topics into the curriculum. Leaders in faculty affairs, education, diversity, and other departments are seeking tools, frameworks, expertise, and programs that are best suited to meet this imminent faculty development need. In response to these demands for guidance, the authors came together to explore best practices, common competencies, and frameworks related to antiracism education. The focus of their work was preparing faculty to foster antiracist learning environments at traditionally predominantly White medical schools. In this Scholarly Perspective, the authors describe their collaborative work to define racism and antiracism education; propose a framework for antiracism education for faculty development; and outline key elements to successfully build faculty capacity in providing antiracism education. The proposed framework highlights the interplay between individual learning and growth and the systemic and institutional changes needed to advance antiracist policies and practices. The key elements of the framework include building foundational awareness, expanding foundational knowledge on antiracism, embedding antiracism education into practice, and dismantling oppressive structures and measuring progress. The authors list considerations for program planning and provide examples of current work from their institutions. The proposed strategies aim to support all faculty and enable them to learn, work, and educate others in an antiracist learning environment.

Description of a novel curriculum on equity, diversity and inclusion for pediatric residents

BACKGROUND

Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.

METHODS

A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.

RESULTS

109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ "eye opening" content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.

CONCLUSIONS

The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.

Attitudes Toward Euthanasia: A Longitudinal Analysis of the Role of Economic, Cultural, and Health-Related Factors

CONTEXT

It is crucial that physicians understand differing attitudes toward euthanasia and which factors to consider when discussing end-of-life decisions with patients and families from diverse backgrounds.

OBJECTIVES

To investigate how attitudes toward euthanasia differ among countries, how they change, and how economic, religious, and health-related factors affect these attitudes.

METHODS

We analyzed attitudes toward euthanasia and economic, religious, and health-related indicators using longitudinal (1981-2018) World Values Survey (WVS) data. They included 62 countries with at least a 15-year, three-wave, time series (total n = 389,243 participants). Each national survey interviewed representative samples of adults (mean = 1405).

RESULTS

In the latest wave, The Netherlands had the most favorable views of euthanasia (10-point scale with 1 = least justifiable: mean = 7.47) and Jordan the least (mean = 1.50). Residents of 23 of 24 high-income countries came to view euthanasia as more justifiable, while residents of 12 of 38 middle- and low-income countries came to view it as less justifiable over time. The higher GDP per-capita at the time of survey, the more euthanasia was accepted (r = 0.703; P< 0.0001); the more important respondents viewed religion as being, the less euthanasia was accepted (r = -0.834; P< 0.0001); the higher life expectancy and the lower infant mortality were, the more euthanasia was accepted (r = 0.669; P< 0.0001/r = -0.716; P< 0.0001).

CONCLUSION

Euthanasia-related attitudes differ widely depending on the cultural context; changes over time varied in both directions; euthanasia-related attitudes were associated with economic, religious and health-related factors. With globalization increasing cultural diversity, these findings can inform physicians' communication about end-of-life decisions with patients and families from diverse backgrounds.

Interventions to improve the well-being of medical learners in Canada: a scoping review

BACKGROUND

Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada.

METHODS

We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels.

RESULTS

Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes.

INTERPRETATION

Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

Simulated Patient-Based Communication Skills Training for Undergraduate Medical Students at a University in Ethiopia

BACKGROUND

Educational strategies following interactive methods of teaching enhance communication skill acquisition of medical students. However, which method of interactivity results in the most compelling communication skill improvement is the prime question yet unanswered.

MATERIALS AND METHODS

In this study, experimental study design was employed among pre-clerkship II medical students of Jimma University, in the 2017/18 academic year. Accordingly, study participants were grouped in to two arms randomly. Arm 1 students were trained using simulated patients in a skill development lab and arm 2 students were trained using case-based role-plays. Both forms of training lasted for 20 hours and focused on 7 important communication skill dimensions key to patient care tasks, as adapted from the Kalamazoo II Report. An objective structured clinical examination (OSCE) form of assessment with a standardized checklist was utilized to investigate communication skill acquisition.

RESULTS

In this study a total of 60 medical students was assessed for communication skills via 12 SP-based OSCE stations. This study discerned that, out of the total students, 21 (35.0%) were found to be poor at listening effectively. Similarly, 19 (31.7%), 18 (30.0%) and 16 (26.7%) were rated as poor at demonstrating caring and respectful behaviors, building and maintaining a therapeutic relationship and making informed judgments based on client data and preferences, respectively. Furthermore, the modalities of communication skill training are associated with key communication skill competencies except for eliciting information with effective questioning skills and counseling and educating patients. Thus, the SP-based training approach was found to be significantly associated with communication skill acquisition as compared to the case-based role-play approach, with AOR 21.696 at a p-value of <0.001.

CONCLUSION

In this study, it was concluded that an SP-based communication skill training approach is superior to a case-based role-play approach.

Assessing Asian Medical Students' Readiness for Diversity: Localizing Measures of Cross-Cultural Care Competence

Phenomenon: There is now broad acceptance that the development of cross-cultural competence (CCC) supports the delivery of appropriate care to diverse groups and is an essential component in medical education worldwide. CCC training in East Asian contexts has been constrained by the fact that "cultural diversity" training globally has focused primarily on the needs of racial and ethnic communities, to the relative neglect of other groups. The present study explores Taiwanese students' perceptions of CCC provision to identify gaps in local medical education and thus facilitate a more systematic delivery of CCC. Approach: Using an adapted and translated version of the Cross-Cultural Care Survey developed by Harvard Medical School, we collected 1567 student responses from four geographically-distributed Taiwanese medical schools between 2015 and 2017. In addition to student responses, we also collected 122 clinical teacher responses from two of the four medical schools that were surveyed to cross-examine the students' self-perceived competence. The data were analyzed with SPSS and ANOVA was employed with student data to compare the differences among different stages. The analysis focuses on CCC in 4 stages of training: general education, basic pre-clinical and integrated clinical sciences, clerkship, and internship. Findings: The findings show that students felt unprepared to deal with health disparities and the needs of diverse groups and there was no evidence of an increased sense of preparedness in the development of relevant skills in the analyses of the pre-clinical to clinical stages of the curriculum. Similarly, teachers also perceived students across the different stages of training to be unprepared in dealing with the health disparities and needs of diverse groups. However, although findings from teachers' responses parallel those from students, teachers tend to perceive students to be even more unprepared than they perceive themselves to be. The training for CCC appeared inadequate from both set of data and students perceive CCC training to be less explicitly evident in the medical program as it advances from the foundation stage to the pre-clinical stage. Insights: The study raises some crucial issues in terms of diversity and CCC training in medical education programs. The fact that increased awareness of health disparities and the needs of diverse groups fails to be aligned with a sense of preparedness and skillfulness confirms that CCC has not been explicitly and sufficiently addressed in the medical curriculum, particularly in the pre-clinical stage when the focus is on acquiring scientific and technical knowledge. This study shows how a questionnaire designed by and for an American medical institution situated in a highly diverse society can be adapted so that its findings serve as a baseline for medical education programs in Taiwan, and perhaps in other countries that are beginning to acknowledge hitherto "hidden" diversity. This study also has implications which indicate that CCC is crucial in the delivery of appropriate care by members of the medical profession to diverse patients.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

PURPOSE

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

METHOD

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

RESULTS

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

CONCLUSIONS

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Cultural Sensitivity and Learning About Healthcare Equity for the Underserved: Experiential Learning in a Student-Run Free Clinic

With increased diversity in the USA comes a growing need to educate medical students on how best to manage diverse patient populations. Medical students on the board of a student-run free clinic (SRFC) were surveyed to determine how such a leadership experience might alter students' cultural sensitivity as it relates to healthcare equity. Forty-six students (42.2% response) reported their experiences helped them better understand patient's needs (4.37, 0.64; mean, SD), cultural barriers (4.44, 0.55), and racial/ethnic disparities (4.27, 0.70). Thus, service on the board of a SRFC improves cultural sensitivity.

Knowledge and attitudes of U.S. medical students regarding the care of Asian American patients: a cross-sectional survey study

BACKGROUND

Asian Americans (AsAm) are a rapidly growing population in the U.S. With this growing population, U.S. healthcare providers must be equipped to provide culturally competent care for AsAm patients. This project surveyed U.S. medical students on their knowledge of and attitudes towards AsAm to assess predictors of readiness to care for AsAm patients.

METHOD

This cross-sectional study surveyed medical students who had completed at least one clinical rotation. The survey was distributed online to nine medical schools throughout the U.S. The survey measured self-rated knowledge of, comfort with, cultural competency (CC) towards, and explicit biases towards AsAm patients. The first three domains were analyzed in a multivariate regression model including sociodemographic characteristics and past clinical, curricular, and social experiences with AsAm. Explicit bias questions were reported descriptively.

RESULTS

There were 688 respondents. Asian race, AsAm-prevalent hometown, AsAm-related extracurricular activities, Asian language knowledge, and having taken a population health course predicted increased AsAm knowledge. Social interactions with AsAm increased comfort with AsAm patients. Increasing year in medical school, more frequent exposure to AsAm patients on rotations, and prior travel to an Asian country were predictors of increased CC toward AsAm. Importantly, having completed a CC course was a significant predictor in all domains. In terms of explicit bias, students felt that AsAm patients were more compliant than Caucasian patients. Students also believed that Caucasian patients were generally more likely to receive self-perceived "preferred" versus "acceptable" care, but that in their own clinical experiences neither group received preferred care.

CONCLUSION

Experience with and exposure to AsAm prior to and during medical school and CC courses may increase medical student knowledge, comfort, and CC with AsAm patients. Standardized and longitudinal CC training, increased simulations with AsAm patients, diverse student recruitment, and support for students to engage in AsAm-related activities and interact with AsAm may improve CC of future physicians towards AsAm patients and possibly other minority populations.

Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients

Bias toward historically marginalized patients affects patient-provider interactions and can lead to lower quality of care and poor health outcomes for patients who are Black, Indigenous, People of Color (BIPOC) and Lesbian, Gay, Bisexual, Transgender and Gender Diverse (LGBTQ+). We gathered experiences with biased healthcare interactions and suggested solutions from 25 BIPOC and LGBTQ+ people. Through qualitative thematic analysis of interviews, we identified ten themes. Eight themes reflect the experience of bias: Transactional Care, Power Inequity, Communication Casualties, Bias-Embedded Medicine, System-level problems, Bigotry in Disguise, Fight or Flight, and The Aftermath. The remaining two themes reflect strategies for improving those experiences: Solutions and Good Experiences. Characterizing these themes and their interconnections is crucial to design effective informatics solutions that can address biases operating in clinical interactions with BIPOC and LGBTQ+ patients, improve the quality of patient-provider interactions, and ultimately promote health equity.

Just in TIME: Trauma-Informed Medical Education

Numerous organizations implement a trauma-informed approach. This model assists institutions in providing care and education that delivers support to members who have undergone traumatic experiences, and many institutions apply the principles as a universal precaution. Student and trainee experiences in medical education reveal a hidden curriculum that may deliver conflicting messages about the values of an institution, in which equity is promoted, but biased and discriminatory practices are commonplace. Implicit racial bias has been identified in the patient-provider interaction and may also extend its impact on the learner experience. Bias and discrimination inflict trauma on its targets via emotional injury. Applying the principles of the trauma-informed approach, we advocate for trauma-informed medical education (TIME). TIME fosters awareness that students and trainees can experience trauma from a biased system and culture and advocates for the establishment of policies and practices that support learners to prevent further re-traumatization. TIME will serve as a means to deliver just and equitable education.

Integrating Cultural Awareness into Medical Gross Anatomy Instruction

Medical students need to understand how culture and patient management relate in order to provide optimal care to a diverse society. Multiple studies call for more cultural training in medical education. Some studies show that well-intentioned cultural competency curriculum can reinforce stereotypes, yet it is essential for educators to discuss varying identities with our students in their training in order to avoid the implication that white is the default patient identity. Our study evaluates a pilot, novel approach for integrating cultural content into the biomedical sciences, specifically gross anatomy. Clinical vignette practice questions were developed as tools to help students expand their anatomical knowledge and cultural and socioeconomic awareness, taking special consideration to avoid stereotypical presentations. We evaluated class of 2021 students' self-reported cultural awareness and ability to utilize culturally relevant information through completion of a survey in fall 2017 (pre) and winter 2017 (post). The students were surveyed on their ability to recognize and/or integrate culturally relevant information. Twenty-one students (n = 21) participated. There was significant improvement in the overall cultural awareness score between the pre- and post-surveys (pre mean = 3.54, while post mean = 3.81; p = 0.016). The most dramatic domains that students became aware of included incorporating culturally relevant information into a treatment plan and communicating with sensitivity and respect when caring for patients. Culturally informed curriculum does not need to be limited to the humanities courses in medical education. Direct integration into biomedical sciences is a novel approach to help students gain exposure to biomedical and cultural content simultaneously.

Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature

PURPOSE

To explore best practices for increasing cultural competency and reducing health disparities, the authors conducted a scoping review of the existing literature.

METHOD

The review was guided by 2 questions: (1) Are health care professionals and medical students learning about implicit bias, health disparities, advocacy, and the needs of diverse patient populations? (2) What educational strategies are being used to increase student and educator cultural competency? In August 2016 and July 2018, the authors searched 10 databases (including Ovid MEDLINE, Embase, and Scopus) and MedEdPORTAL, respectively, using keywords related to multiple health professions and cultural competency or diversity and inclusion education and training. Publications from 2005 to August 2016 were included. Results were screened using a 2-phase process (title and abstract review followed by full-text review) to determine if articles met the inclusion or exclusion criteria.

RESULTS

The search identified 89 articles that specifically related to cultural competency or diversity and inclusion education and training within health care. Interventions ranged from single-day workshops to a 10-year curriculum. Eleven educational strategies used to teach cultural competency and about health disparities were identified. Many studies recommended using multiple educational strategies to develop knowledge, awareness, attitudes, and skills. Less than half of the studies reported favorable outcomes. Multiple studies highlighted the difficulty of implementing curricula without trained and knowledgeable faculty.

CONCLUSIONS

For the field to progress in supporting a culturally diverse patient population, comprehensive training of trainers, longitudinal evaluations of interventions, and the identification and establishment of best practices will be imperative.

Building a Tool Kit for Medical and Dental Students: Addressing Microaggressions and Discrimination on the Wards

INTRODUCTION

Microaggressions, subtle slights related to characteristics such as race, gender, or sexual orientation, in a clinical setting can sabotage the therapeutic alliance. Curricula tailored specifically towards medical students that raise awareness of microaggressions and aim to change behavior are absent.

METHODS

We created a 2-hour workshop to prepare preclinical medical and dental students to recognize and respond to microaggressions in clinical practice. The workshop consisted of a didactic portion describing microaggressions and strategies for responding to them and a case-based small-group portion to practice strategies. Participants completed electronic pre- and postworkshop surveys.

RESULTS

Of 163 students participating in the workshop, 121 (74%) completed the preworkshop survey, 105 (64%) completed the postworkshop survey, and 81 (50%) completed both. Preworkshop, 48% reported female gender, and 36% reported underrepresented in medicine status. The majority (77%) had witnessed or experienced microaggressions in the clinical setting, and 69% reported very good or excellent familiarity with the concept of microaggressions. The curriculum appeared to significantly mitigate challenges associated with microaggressions, including reductions in perceived difficulty in identifying microaggressions (p < .001), being unsure what to do or say (p < .001), improvements in familiarity with institutional support systems (p < .001), and awareness of the clinical relevance of microaggressions (p < .001).

DISCUSSION

Given the high self-reported prevalence of microaggressions in the clinical setting, students need the skills to respond. This innovative session improves readiness to address microaggressions by helping participants build and practice these skills in a supportive environment.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.