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Park CM, Sison SDM, McCarthy EP, Shi S, Gouskova N, Lin KJ, Kim DH. Claims-Based Frailty Index as a Measure of Dementia Severity in Medicare Claims Data. J Gerontol A Biol Sci Med Sci 2023; 78:2145-2151. [PMID: 37428879 PMCID: PMC10613007 DOI: 10.1093/gerona/glad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Dementia severity is unavailable in administrative claims data. We examined whether a claims-based frailty index (CFI) can measure dementia severity in Medicare claims. METHODS This cross-sectional study included the National Health and Aging Trends Study Round 5 participants with possible or probable dementia whose Medicare claims were available. We estimated the Functional Assessment Staging Test (FAST) scale (range: 3 [mild cognitive impairment] to 7 [severe dementia]) using information from the survey. We calculated CFI (range: 0-1, higher scores indicating greater frailty) using Medicare claims 12 months prior to the participants' interview date. We examined C-statistics to evaluate the ability of the CFI in identifying moderate-to-severe dementia (FAST stage 5-7) and determined the optimal CFI cut-point that maximized both sensitivity and specificity. RESULTS Of the 814 participants with possible or probable dementia and measurable CFI, 686 (72.2%) patients were ≥75 years old, 448 (50.8%) were female, and 244 (25.9%) had FAST stage 5-7. The C-statistic of CFI to identify FAST stage 5-7 was 0.78 (95% confidence interval: 0.72-0.83), with a CFI cut-point of 0.280, achieving the maximum sensitivity of 76.9% and specificity of 62.8%. Participants with CFI ≥0.280 had a higher prevalence of disability (19.4% vs 58.3%) and dementia medication use (6.0% vs 22.8%) and higher risk of mortality (10.7% vs 26.3%) and nursing home admission (4.5% vs 10.6%) over 2 years than those with CFI <0.280. CONCLUSIONS Our study suggests that CFI can be useful in identifying moderate-to-severe dementia from administrative claims among older adults with dementia.
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Affiliation(s)
- Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Denise M Sison
- Division of General Internal Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandra Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia Gouskova
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Merchant AAH, Shaikh NQ, Afzal N, Noorali AA, Abdul Rahim K, Ahmad R, Ahmer A, Khan AA, Bakhshi SK, Mahmood SBZ, Lakhdir MPA, Khan MR, Tariq M, Haider AH. Disparities in patient-resident physician communication and counseling: A multi-perspective exploratory qualitative study. PLoS One 2023; 18:e0288549. [PMID: 37871016 PMCID: PMC10593213 DOI: 10.1371/journal.pone.0288549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 06/29/2023] [Indexed: 10/25/2023] Open
Abstract
Effective communication between physicians and patients plays an integral role in clinical care. Gaps in a physician's ability to ensure effective communication, especially with patients from diverse backgrounds, are known causes of medical errors. This study explores the potential biases and disparities in patient-resident communication, which may influence a patient's quality of care. This exploratory qualitative study was conducted at the largest academic medical center in Pakistan. Purposive sampling was used to approach participants from surgery, medicine, obstetrics and gynecology, pediatrics and family medicine. Faculty, fellows and residents working in these departments and medical students in their fourth and fifth years of undergraduate education with prior experience of at least one month in these specialties during their clinical rotations were included. Focus group discussions (FGDs) lasting 45-60 minutes were conducted with each cohort of healthcare professionals separately, using a semi-structured interview guide. Sixty participants (19 males and 41 females, mean age: 32.9, SD: 10.9) took part in the study. Thematic analysis revealed five major themes. Four themes focused on residents' biases and patient disparities hindering patient-resident communication: (1) patient-resident gender discordance (2) ethnicity and language barriers, (3) differing social class of the patient, and (4) challenging patient-resident interactions (patients resistant to treatment, exceedingly inquisitive and those with multiple attendants, etc.). The fifth theme identified the need for a communication skills curriculum in postgraduate medical education. Opposite gender and discordant socioeconomic/cultural backgrounds of patients pose a challenge to effective patient-physician communication. Self-identification and awareness of residents' biases when interacting with patients can ensure their active elimination and improve their communication skills. Integrating these components in a standardized curriculum within postgraduate programs can enable resident-physicians to provide the same level of care and communicate more efficiently with patients of all backgrounds.
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Affiliation(s)
| | | | - Noreen Afzal
- Dean’s Office, Aga Khan University, Karachi, Pakistan
| | | | - Komal Abdul Rahim
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rida Ahmad
- Dean’s Office, Aga Khan University, Karachi, Pakistan
| | - Areesha Ahmer
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | - Muhammad Tariq
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Adil H. Haider
- Dean’s Office, Aga Khan University, Karachi, Pakistan
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
- Department of Surgery, Aga Khan University, Karachi, Pakistan
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Haggins A, Clery M, Ahn J, Hogikyan E, Heron S, Johnson R, Hopson LR. Untold stories: Emergency medicine residents' experiences caring for diverse patient populations. AEM Educ Train 2021; 5:S19-S27. [PMID: 34616969 PMCID: PMC8480494 DOI: 10.1002/aet2.10678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/22/2021] [Accepted: 04/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The Accreditation Council for Graduate Medical Education expects specialties to teach and assess proficiency in culturally competent care. However, little guidance has emerged to achieve these goals. Clinical training within socioeconomically disparate settings may provide an experiential learning opportunity. We sought to qualitatively explore resident experiences working in the generic clinical learning environments (i.e., exposure to socioeconomically diverse patients across different training sites) and how it shapes cultural competency-related skill development. METHODS Residents were recruited from emergency medicine (EM) programs. We used purposeful sampling across all postgraduate years and elicited experiences related to working at the different sites related to cultural identity, frustrating patient encounters, vulnerable populations, and development of health disparities/social determinants of health knowledge. Individual structured interviews were conducted via phone between May and December 2016. Interviews were audiotaped, transcribed, anonymized, and analyzed using systematic and iterative coding methods. RESULTS Twenty-four interviews revealed three main themes. EM residents' experiences caring for patients across sites shaped their understanding of: (1) potential patient attributes that affected the clinical encounter, (2) difficulties in building rapport had adverse effect on the clinical evaluation, and (3) residency program and training experiences shaped their clinical preparedness and willingness to work in underserved areas. CONCLUSION Assessing the impact disparate clinical setting exposures have on trainees' preparedness to care for socioeconomically diverse patients can provide valuable insight for medical educators into barriers and facilitators to delivering optimal learning and patient care. Participants provided a breadth of stories illuminating their real-world consciousness and competency with meeting the needs of diverse populations and their access to varied educational outlets to grapple with the disparities they observed. More research is needed to uncover effective strategies to help residents thrive and feel more prepared to care for diverse populations.
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Affiliation(s)
- Adrianne Haggins
- Department of Emergency Medicine at Michigan MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Michael Clery
- Department of Emergency MedicineEmory School of MedicineAtlantaGeorgiaUSA
| | - James Ahn
- Section of Emergency MedicineDepartment of Internal Medicine, and Program Director of Emergency MedicineUniversity of Chicago Pritzker School of MedicineChicagoIllinoisUSA
| | - Emily Hogikyan
- Department of Pediatrics at NorthwesternFeinberg School of MedicineChicagoIllinoisUSA
| | - Sheryl Heron
- Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
| | - Renee Johnson
- Department of Emergency MedicineUniversity of Texas Health Science Center at Houston McGovern School of MedicineHoustonTexasUSA
| | - Laura R. Hopson
- Department of Emergency Medicine at Michigan MedicineUniversity of MichiganAnn ArborMichiganUSA
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Abrahams S, Kim EJ, Marrast L, Uwemedimo O, Conigliaro J, Martinez J. Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care. BMC Med Educ 2021; 21:218. [PMID: 33874946 PMCID: PMC8056670 DOI: 10.1186/s12909-021-02669-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.
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Affiliation(s)
- Sara Abrahams
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.
| | - Eun Ji Kim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Lyndonna Marrast
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Omolara Uwemedimo
- Occupational Medicine, Epidemiology, and Prevention at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Joseph Conigliaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Johanna Martinez
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
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Roncoroni J, Frank M, Hudson A, Whitaker S, Edelman A, Garcia P, Leeper E, Carrasco V, Melendez D, Ratchford J. Latinx Patients' Perceptions of Culturally Sensitive Health Care and their Association with Patient Satisfaction, Patient-Provider Communication, and Therapeutic Alliance. J Racial Ethn Health Disparities 2021; 9:620-629. [PMID: 33721290 DOI: 10.1007/s40615-021-00994-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 11/25/2022]
Abstract
Latinx in the USA experience disparities in morbidity and mortality when compared to their non-Hispanic White counterparts. Patient-centered culturally sensitive health care (PC-CSHC) has been deemed a best practice approach to alleviate and eliminate these disparities. However, literature on how Latinx patients perceive their care and what indicators of PC-CSHC may be most related to treatment outcomes is limited. This study collected data from 81 adult Latinx participants who had been admitted to an inpatient care unit to understand the following: (a) their perception of their providers' PC-CSHC in three different areas: Competence/Confidence, Sensitivity/Interpersonal, and Respect/Communication; (b) whether there are differences between English- and Spanish-speaking Latinx patients in their perception of their providers' PC-CSHC; and (c) whether these PC-CSHC indicators were associated to patient satisfaction, patient-provider communication, and therapeutic alliance. Participants were mostly male, older than 55 years of age, and working or lower class, with English as their primary language. Results showed that patients rated their providers' Competence (M = 3.57, SD = .46) higher than both Sensitivity, t(68) = .04, p = .04, (M = 3.49, SD =.54), and Respect, t(53) = 2.765, p = .008, (M = 3.38, SD = .57). English-speaking Latinx were overall less satisfied with their providers than Spanish-speaking Latinx, in particular in their communication. Finally, higher provider cultural sensitivity appears to be a predictor of patient satisfaction, patient-provider communication, and working alliance. Implications for refining provider trainings to treat this vulnerable and understudied (i.e., Latinx) population are discussed.
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Affiliation(s)
- J Roncoroni
- Department of Counseling Psychology, University of Denver, Denver, CO, USA.
| | - Maria Frank
- Department of Medicine, Denver Health Hospital Authority, Denver, CO, USA
| | - Amy Hudson
- Department of Counseling Psychology, University of Denver, Denver, CO, USA
| | - S Whitaker
- Department of Research Methods and Statistics, University of Denver, Denver, CO, USA
| | - A Edelman
- Department of Counseling Psychology, University of Denver, Denver, CO, USA
| | - P Garcia
- Discovering Greatness, LLC, Rio Rancho, NM, USA
| | - E Leeper
- Pathways Transtion Programs, Inc., Decatur, GA, USA
| | - V Carrasco
- Department of Counseling Psychology, University of Denver, Denver, CO, USA
| | - D Melendez
- First Year Advising Center, Utah Valley University, Orem, UT, USA
| | - J Ratchford
- Department of Counseling Psychology, University of Denver, Denver, CO, USA
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Krystallidou D, Devisch I, Van de Velde D, Pype P. Understanding patient needs without understanding the patient: the need for complementary use of professional interpreters in end-of-life care. Med Health Care Philos 2017; 20:477-481. [PMID: 28374104 DOI: 10.1007/s11019-017-9769-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: (i) how to safeguard patient autonomy against paternalistic interventions by family members, (ii) how to respect the relational context in which patient autonomy can be realized, and (iii) how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended.
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Affiliation(s)
- Demi Krystallidou
- Faculty of Arts, University of Leuven, Sint-Andries Campus Antwerp, Sint-Andriesstraat 2, 2000, Antwerp, Belgium.
| | - Ignaas Devisch
- Department of Primary Care and Family Medicine, Faculty of Medicine and Health Sciences, Ghent University, Campus UZ - 6K3, De Pintelaan 185, 9000, Ghent, Belgium
| | - Dominique Van de Velde
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Campus UZ- 2B3, De Pintelaan 185, 9000, Ghent, Belgium
| | - Peter Pype
- Department of Primary Care and Family Medicine, Faculty of Medicine and Health Sciences, Ghent University, Campus UZ - 6K3, De Pintelaan 185, 9000, Ghent, Belgium
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Thackwell N, Swartz L, Dlamini S, Phahladira L, Muloiwa R, Chiliza B. Race trouble: experiences of Black medical specialist trainees in South Africa. BMC Int Health Hum Rights 2016; 16:31. [PMID: 27914479 PMCID: PMC5135758 DOI: 10.1186/s12914-016-0108-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 11/25/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND This research aimed to identify and explore the experiences of Black registrars in their training in the Western Cape's academic hospitals in order to identify structures, practices, attitudes and ideologies that may promote or impede the advancement of Black doctors into specialist medicine. This is justified by the requirement for universities to work towards monitoring and evaluating efforts to create non-discriminatory and inclusive training environments. METHODS This study employed qualitative research methods. Ten Black African medical specialists were interviewed about their training experiences in two university training hospitals in the Western Cape Province, South Africa. Interview data was collected using open-ended questions and coded and analysed using thematic and critical discursive analysis techniques. RESULTS Four experiential themes emerged from the interview data, they included: 1) experiences of everyday racism during work hours, 2) the physical and psychological effects of tokenism and an increased need to perform, 3) institutional racism as a result of inconsistent and unclear methods of promotion and clinical competence building, and 4) an organisational culture that was experienced as having a race and gender bias. CONCLUSION This is a pilot study and there are limits on the generalizability of the data due to the small sample. What is clear from our participants, though, is the strong experiential component of finding it challenging to be a Black trainee in a White-dominated profession. We are undertaking further research to explore the issues raised in more detail.
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Affiliation(s)
- Nicola Thackwell
- Department of Psychology, Stellenbosch University, Private Bag X1, Stellenbosch, 7602 South Africa
| | - Leslie Swartz
- Department of Psychology, Stellenbosch University, Private Bag X1, Stellenbosch, 7602 South Africa
| | - Sipho Dlamini
- Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lebogang Phahladira
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rudzani Muloiwa
- Faculty of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bonginkosi Chiliza
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Sherrill WW, Mayo RM, Truong KD, Pribonic AP, Schalkoff CA. Assessing medical student cultural competence: what really matters. Int J Med Educ 2016; 7:248-54. [PMID: 27474895 PMCID: PMC4983182 DOI: 10.5116/ijme.578b.687c] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/17/2016] [Indexed: 05/21/2023]
Abstract
OBJECTIVES The study aimed to explore medical students' attitudes and beliefs toward Latino patients, specifically: to assess students' levels of knowledge, cultural competence, and comfort with Latinos; to determine students' exposure to and previous experience with Latinos; and to evaluate whether factors such as study abroad, living abroad, previous clinical experience with Latinos, and language proficiency predict Latino knowledge, cultural competence, and comfort with Latinos. METHODS This study utilized a cross-sectional survey design. Participants were third and fourth year medical students at three medical schools in the Southeastern United States. Three composite measures: Latino knowledge, Cultural competence, and Comfort with Latino patients, were predicted in a multivariate regression model including individual sociodemographic characteristics and past clinical or social experience with Latinos. RESULTS A total of 170 medical students completed the survey (43% response rate). Spanish language proficiency was a statistically significant predictor (t(131)=2.72, p<0.05) of Latino knowledge. Social interaction with Latinos in the past year (t(126)=3.09, p<0.01), ever having lived in a Spanish-speaking country (t(126)=2.86, p<0.01), and Spanish language proficiency (t(126)=3.28, p<0.01) independently predicted cultural competence. Previous clinical experience with Latinos was not significantly associated with the three composite dependent variables, and comfort with Latino patients was not significantly predicted by any of the six Latino-related explanatory variables. CONCLUSIONS Factors prior to medical school matriculation and during medical education may contribute to increased cultural competence and comfort with multicultural patients. Cultural patient-partner programs may be an effective way to increase cultural competence within the confines of medical school curricula.
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Affiliation(s)
| | - Rachel M. Mayo
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Khoa D. Truong
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Anne P. Pribonic
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
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Alpern JD, Davey CS, Song J. Perceived barriers to success for resident physicians interested in immigrant and refugee health. BMC Med Educ 2016; 16:178. [PMID: 27421774 PMCID: PMC4946089 DOI: 10.1186/s12909-016-0696-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/16/2016] [Indexed: 05/21/2023]
Abstract
BACKGROUND Cross-cultural care is recognized by the ACGME as an important aspect of US residency training. Resident physicians' preparedness to deliver cross-cultural care has been well studied, while preparedness to provide care specifically to immigrant and refugee populations has not been. METHODS We administered a survey in October 2013 to 199 residents in Internal Medicine, Pediatrics, and Medicine/Pediatrics at the University of Minnesota, assessing perceived knowledge, attitudes, and experience with immigrant and refugee patients. RESULTS Eighty-three of 199 residents enrolled in Internal Medicine, Pediatrics and Medicine/Pediatrics programs at the University of Minnesota completed the survey (42 %). Most (n = 68, 82 %) enjoyed caring for immigrants and refugees. 54 (65 %) planned to care for this population after residency, though 45 (54 %) were not comfortable with their knowledge regarding immigrant and refugee health. Specific challenges were language (n = 81, 98 %), cultural barriers (n = 76, 92 %), time constraints (n = 60, 72 %), and limited knowledge of tropical medicine (n = 57, 69 %). 67 (82 %) wanted more training in refugee and immigrant health. CONCLUSIONS The majority of residents enjoyed caring for immigrant and refugee patients and planned to continue after residency. Despite favorable attitudes, residents identified many barriers to providing good care. Some involved cultural and language barriers, while others were structural. Finally, most respondents felt they needed more education, did not feel comfortable with their knowledge, and wanted more training during residency. These data suggest that residency programs consider increasing training in these specific areas of concern.
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Affiliation(s)
- Jonathan D Alpern
- Department of Infectious Disease, University of Minnesota, 800 North 3rd St. Apt 520, Minneapolis, MN, 55401, USA.
| | - Cynthia S Davey
- University of Minnesota, Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, Minneapolis, MN, USA
| | - John Song
- Department of Medicine, University of Minnesota, Center for Bioethics, Minneapolis, MN, USA
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Watt K, Abbott P, Reath J. Cross-cultural training of general practitioner registrars: how does it happen? Aust J Prim Health 2016; 22:349-353. [DOI: 10.1071/py14165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 04/11/2015] [Indexed: 11/23/2022]
Abstract
An equitable multicultural society requires general practitioners (GPs) to be proficient in providing health care to patients from diverse backgrounds. GPs are required to have a certain attitudes, knowledge and skills known as cultural competence. Given its importance to registrar training, the aim of this study was to explore ways in which GP registrars are currently developing cultural competence. This study employed a survey design for GP registrars in Western Sydney. Training approaches to cultural competence that are relevant to the Australian General Practice setting include exposure to diversity, attitudes, knowledge and skills development. The 43 GP registrar respondents in Western Sydney are exposed to a culturally diverse patient load during training. Registrars report a variety of teachings related to cross-cultural training, but there is little consistency, with the most common approach entailing listening to patients’ personal stories. Exposure to cultural diversity appears to be an important way in which cultural competency is developed. However, guidance and facilitation of skills development throughout this exposure is required and currently may occur opportunistically rather than consistently.
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Jernigan VBB, Hearod JB, Tran K, Norris KC, Buchwald D. An Examination of Cultural Competence Training in US Medical Education Guided by the Tool for Assessing Cultural Competence Training. J Health Dispar Res Pract 2016; 9:150-167. [PMID: 27818848 PMCID: PMC5091804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In the United States, medical students must demonstrate a standard level of "cultural competence," upon graduation. Cultural competence is most often defined as a set of congruent behaviors, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations. The Association of American Medical Colleges developed the Tool for Assessing Cultural Competence Training (TACCT) to assist schools in developing and evaluating cultural competence curricula to meet these requirements. This review uses the TACCT as a guideline to describe and assess pedagogical approaches to cultural competence training in US medical education and identify content gaps and opportunities for curriculum improvement. A total of 18 programs are assessed. Findings support previous research that cultural competence training can improve the knowledge, attitudes, and skills of medical trainees. However, wide variation in the conceptualization, implementation, and evaluation of cultural competence training programs exists, leading to differences in training quality and outcomes. More research is needed to establish optimal approaches to implementing and evaluating cultural competence training that incorporate cultural humility, the social determinants of health, and broader structural competency within the medical system.
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Affiliation(s)
| | | | - Kim Tran
- University of Texas Southwestern
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Paternotte E, van Dulmen S, van der Lee N, Scherpbier AJJA, Scheele F. Factors influencing intercultural doctor-patient communication: a realist review. Patient Educ Couns 2015; 98:420-45. [PMID: 25535014 DOI: 10.1016/j.pec.2014.11.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/23/2014] [Accepted: 11/17/2014] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Due to migration, doctors see patients from different ethnic backgrounds. This causes challenges for the communication. To develop training programs for doctors in intercultural communication (ICC), it is important to know which barriers and facilitators determine the quality of ICC. This study aimed to provide an overview of the literature and to explore how ICC works. METHODS A systematic search was performed to find literature published before October 2012. The search terms used were cultural, communication, healthcare worker. A realist synthesis allowed us to use an explanatory focus to understand the interplay of communication. RESULTS In total, 145 articles met the inclusion criteria. We found ICC challenges due to language, cultural and social differences, and doctors' assumptions. The mechanisms were described as factors influencing the process of ICC and divided into objectives, core skills and specific skills. The results were synthesized in a framework for the development of training. CONCLUSION The quality of ICC is influenced by the context and by the mechanisms. These mechanisms translate into practical points for training, which seem to have similarities with patient-centered communication. PRACTICE IMPLICATIONS Training for improving ICC can be developed as an extension of the existing training for patient-centered communication.
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Affiliation(s)
- Emma Paternotte
- Department of Healthcare Education, Sint Lucas Andreas hospital, Amsterdam, The Netherlands.
| | - Sandra van Dulmen
- NIVEL (Netherlands Institute for Health Services Research), Utrecht, The Netherlands; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands; Faculty of Health Sciences, Buskerud and Vestfold University College, Drammen, Norway.
| | - Nadine van der Lee
- Department of Healthcare Education, Sint Lucas Andreas hospital, Amsterdam, The Netherlands.
| | - Albert J J A Scherpbier
- Institute for Medical Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Fedde Scheele
- Medical School of Sciences, Vu University Medical Center, Amsterdam, The Netherlands.
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Casillas A, Paroz S, Green AR, Wolff H, Weber O, Faucherre F, Ninane F, Bodenmann P. Is the Front Line Prepared for the Changing Faces of Patients? Predictors of Cross-Cultural Preparedness Among Clinical Nurses and Resident Physicians in Lausanne, Switzerland. Teach Learn Med 2015; 27:379-386. [PMID: 26507995 DOI: 10.1080/10401334.2015.1077127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED PHENOMENON: Assuring quality medical care for all persons requires that healthcare providers understand how sociocultural factors affect a patient's health beliefs/behaviors. Switzerland's changing demographics highlight the importance of provider cross-cultural preparedness for all patients-especially those at risk for social/health precarity. We evaluated healthcare provider cross-cultural preparedness for commonly encountered vulnerable patient profiles. APPROACH A survey on cross-cultural care was mailed to Lausanne University hospital's "front-line healthcare providers": clinical nurses and resident physicians at our institution. Preparedness items asked "How prepared do you feel to care for … ?" (referring to example patient profiles) on an ascending 5-point Likert scale. We examined proportions of "4 - well/5 - very well prepared" and the mean composite score for preparedness. We used linear regression to examine the adjusted effect of demographics, work context, cultural-competence training, and cross-cultural care problem awareness, on preparedness. FINDINGS Of 885 questionnaires, 368 (41.2%) were returned: 124 (33.6%) physicians and 244 (66.4%) nurses. Mean preparedness composite was 3.30 (SD = 0.70), with the lowest proportion of healthcare providers feeling prepared for patients "whose religious beliefs affect treatment" (22%). After adjustment, working in a sensitized department (β = 0.21, p = .01), training on the history/culture of a specific group (β = 0.25, p = .03), and awareness regarding (a) a lack of practical experience caring for diverse populations (β = 0.25, p = .004) and (b) inadequate cross-cultural training (β = 0.18, p = .04) were associated with higher preparedness. Speaking French as a dominant language and physician role (vs. nurse) were negatively associated with preparedness (β = -0.26, p = .01; β = -0.22, p = .01). INSIGHTS: The state of cross-cultural care preparedness among Lausanne's front-line healthcare providers leaves room for improvement. Our study points toward institutional strategies to improve preparedness: notably, making sure departments are sensitized to cross-cultural care resources and increasing provider diversity to reflect the changing Swiss demographic.
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Affiliation(s)
- Alejandra Casillas
- a Department of Ambulatory Care and Community Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Sophie Paroz
- b Department of Community Medicine and Public Health , Lausanne University Hospital , Lausanne , Switzerland
| | - Alexander R Green
- c Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School , Boston , Massachusetts , USA
| | - Hans Wolff
- d Department of Primary Care, Community Medicine, and Emergencies , Geneva University Hospitals , Geneva , Switzerland
| | - Orest Weber
- e Department of Psychiatry , Lausanne University Hospital , Lausanne , Switzerland
| | - Florence Faucherre
- e Department of Psychiatry , Lausanne University Hospital , Lausanne , Switzerland
| | - Françoise Ninane
- a Department of Ambulatory Care and Community Medicine , Lausanne University Hospital , Lausanne , Switzerland
| | - Patrick Bodenmann
- a Department of Ambulatory Care and Community Medicine , Lausanne University Hospital , Lausanne , Switzerland
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Paternotte E, Fokkema JPI, van Loon KA, van Dulmen S, Scheele F. Cultural diversity: blind spot in medical curriculum documents, a document analysis. BMC Med Educ 2014; 14:176. [PMID: 25150546 PMCID: PMC4236597 DOI: 10.1186/1472-6920-14-176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/18/2014] [Indexed: 05/10/2023]
Abstract
BACKGROUND Cultural diversity among patients presents specific challenges to physicians. Therefore, cultural diversity training is needed in medical education. In cases where strategic curriculum documents form the basis of medical training it is expected that the topic of cultural diversity is included in these documents, especially if these have been recently updated. The aim of this study was to assess the current formal status of cultural diversity training in the Netherlands, which is a multi-ethnic country with recently updated medical curriculum documents. METHODS In February and March 2013, a document analysis was performed of strategic curriculum documents for undergraduate and postgraduate medical education in the Netherlands. All text phrases that referred to cultural diversity were extracted from these documents. Subsequently, these phrases were sorted into objectives, training methods or evaluation tools to assess how they contributed to adequate curriculum design. RESULTS Of a total of 52 documents, 33 documents contained phrases with information about cultural diversity training. Cultural diversity aspects were more prominently described in the curriculum documents for undergraduate education than in those for postgraduate education. The most specific information about cultural diversity was found in the blueprint for undergraduate medical education. In the postgraduate curriculum documents, attention to cultural diversity differed among specialties and was mainly superficial. CONCLUSIONS Cultural diversity is an underrepresented topic in the Dutch documents that form the basis for actual medical training, although the documents have been updated recently. Attention to the topic is thus unwarranted. This situation does not fit the demand of a multi-ethnic society for doctors with cultural diversity competences. Multi-ethnic countries should be critical on the content of the bases for their medical educational curricula.
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MESH Headings
- Community Medicine/education
- Cultural Diversity
- Curriculum/statistics & numerical data
- Documentation/statistics & numerical data
- Education, Medical/methods
- Education, Medical/statistics & numerical data
- Education, Medical, Graduate/methods
- Education, Medical, Graduate/statistics & numerical data
- Education, Medical, Undergraduate/methods
- Education, Medical, Undergraduate/statistics & numerical data
- Humans
- Internship and Residency/statistics & numerical data
- Netherlands
- Occupational Medicine/education
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Affiliation(s)
- Emma Paternotte
- Department of Medical Education, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, P.O. Box 9243, 1061 AE Amsterdam, The Netherlands
| | - Joanne PI Fokkema
- Department of Medical Education, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, P.O. Box 9243, 1061 AE Amsterdam, The Netherlands
| | - Karsten A van Loon
- Department of Medical Education, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, P.O. Box 9243, 1061 AE Amsterdam, The Netherlands
| | - Sandra van Dulmen
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- NIVEL (Netherlands Institute for health services research), Utrecht, The Netherlands
- Department of Health Sciences, Buskerud and Vestfold University College, Drammen, Norway
| | - Fedde Scheele
- Department of Medical Education, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, P.O. Box 9243, 1061 AE Amsterdam, The Netherlands
- Department of Medical Education, VU University Medical Centre, Amsterdam, The Netherlands
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Ghaddar S, Ronnau J, Saladin SP, Martínez G. Innovative approaches to promote a culturally competent, diverse health care workforce in an institution serving Hispanic students. Acad Med 2013; 88:1870-1876. [PMID: 24128616 DOI: 10.1097/acm.0000000000000007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The underrepresentation of minorities among health care providers and researchers is often considered one of the contributing factors to health disparities in these populations. Recent demographic shifts and the higher proportion of minorities anticipated among the newly insured under the Patient Protection and Affordable Care Act make the need for a more diverse and culturally competent health care workforce an urgent national priority.The authors describe current and future strategies that have been developed at the College of Health Sciences and Human Services at the University of Texas-Pan American (an institution with 89% Hispanic students in 2012) to prepare a culturally competent and ethnically diverse health care workforce that can meet the needs of a diverse population, especially in the college's own community. The college graduates approximately 650 students annually for careers in nursing, physician assistant studies, occupational therapy, pharmacy, rehabilitation services, clinical laboratory sciences, dietetics, and social work. The college's approach centers on enriching student education with research, service, and community-based experiences within a social-determinants-of-health framework. The approach is promoted through an interdisciplinary health disparities research center, multiple venues for community-based service learning, and an innovative approach to improve cultural and linguistic competence. Although the different components of the college's approach are at different developmental stages and will benefit from more formal evaluations, the college's overall vision has several strengths that promise to serve as a model for future academic health initiatives.
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Affiliation(s)
- Suad Ghaddar
- Dr. Ghaddar is director, South Texas Border Health Disparities Center, University of Texas-Pan American, Edinburg, Texas. Dr. Ronnau is dean, College of Health Sciences and Human Services, University of Texas-Pan American, Edinburg, Texas. Dr. Saladin is associate dean for research, College of Health Sciences and Human Services, University of Texas-Pan American, Edinburg, Texas. Dr. Martínez is chair and professor, Department of Spanish and Portuguese, Ohio State University, Columbus, Ohio
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Frintner MP, Mendoza FS, Dreyer BP, Cull WL, Laraque D. Resident cross-cultural training, satisfaction, and preparedness. Acad Pediatr 2013; 13:65-71. [PMID: 23312858 DOI: 10.1016/j.acap.2012.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Revised: 10/11/2012] [Accepted: 10/17/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the diversity of pediatric residents and examine relationships of cross-cultural training experiences with training satisfaction, perceived preparedness for providing culturally effective care, and attitudes surrounding care for underserved populations. METHODS A cross-sectional survey was conducted of a national random sample of graduating pediatric residents and an additional sample of minority residents. Using weighted analysis, we used multivariate regression to test for differences in satisfaction, preparedness, and attitudes between residents with more and less cross-cultural experiences during residency, controlling for residents' characteristics and experiences before training. RESULTS The survey response rate was 57%. Eleven percent were Hispanic, 61% white, 21% Asian, 9% African American, 9% other racial/ethnic groups; 34% grew up in a bi- or multilingual family. Ninety-three percent of residents were satisfied with their residency training, 81% with the instruction they received on health and health care disparities, and 54% on global health issues. Ninety-six percent of residents felt they were prepared to care for patients from diverse backgrounds, but fewer felt prepared to care for families with beliefs at odds with Western medicine (49%) and families who receive alternative or complementary care (37%). Residents with more cross-cultural experiences during residency reported being better prepared than those with less experience to care for families with limited English proficiency (adjusted odds ratio [aOR] 2.11; 95% confidence interval [CI] 1.40-3.17), new immigrants (aOR 1.91; 95% CI 1.32-2.75), and with religious beliefs that might affect clinical care (aOR 1.62; 95% CI 1.13-2.32). CONCLUSIONS Pediatric residents begin their training with diverse cross-cultural backgrounds and experiences. Residency experiences in cross-cultural care contribute to feelings of preparedness to care for diverse US children.
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Affiliation(s)
- Mary Pat Frintner
- Department of Research, American Academy of Pediatrics, Elk Grove Village, IL, USA
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Abstract
An extensive body of literature has documented significant racial and ethnic disparities in health and health care. Cultural competency interventions, including the training of physicians and other health care professionals, have been proposed as a key strategy for helping to reduce these disparities. The continuing medical education (CME) profession can play an important role in addressing this need by improving the quality and assessing the outcomes of multicultural education programs. This article provides an overview of health care policy, legislative, accreditation, and professional initiatives relating to these subjects. The status of CME offerings on cultural competence/disparities is reviewed, with examples provided of available curricular resources and online courses. Critiques of cultural competence training and selected studies of its effectiveness are discussed. The need for the CME profession to become more culturally competent in its development, implementation, and evaluation of education programs is examined. Future challenges and opportunities are described, and a call for leadership and action is issued.
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Affiliation(s)
- Robert C Like
- Center for Healthy Families and Cultural Diversity, Department of Family Medicine and Community Health, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA.
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Yamada AM, Brekke JS. Addressing mental health disparities through clinical competence not just cultural competence: the need for assessment of sociocultural issues in the delivery of evidence-based psychosocial rehabilitation services. Clin Psychol Rev 2008; 28:1386-99. [PMID: 18778881 PMCID: PMC2659411 DOI: 10.1016/j.cpr.2008.07.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Revised: 07/16/2008] [Accepted: 07/24/2008] [Indexed: 11/15/2022]
Abstract
Recognition of ethnic/racial disparities in mental health services has not directly resulted in the development of culturally responsive psychosocial interventions. There remains a fundamental need for assessment of sociocultural issues that have been linked with the expectations, needs, and goals of culturally diverse consumers with severe and persistent mental illness. The authors posit that embedding the assessment of sociocultural issues into psychosocial rehabilitation practice is one step in designing culturally relevant empirically supported practices. It becomes a foundation on which practitioners can examine the relevance of their interventions to the diversity encountered in everyday practice. This paper provides an overview of the need for culturally and clinically relevant assessment practices and asserts that by improving the assessment of sociocultural issues the clinical competence of service providers is enhanced. The authors offer a conceptual framework for linking clinical assessment of sociocultural issues to consumer outcomes and introduce an assessment tool adapted to facilitate the process in psychosocial rehabilitation settings. Emphasizing competent clinical assessment skills will ultimately offer a strategy to address disparities in treatment outcomes for understudied populations of culturally diverse consumers with severe and persistent mental illness.
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Affiliation(s)
- Ann-Marie Yamada
- University of Southern California, School of Social Work, 669 W. 34th St., MRF 102C, Los Angeles, CA 90089-0411
| | - John S Brekke
- University of Southern California, School of Social Work, 669 W. 34th St., Los Angeles, CA 90089-0411
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Greer JA, Park ER, Green AR, Betancourt JR, Weissman JS. Primary care resident perceived preparedness to deliver cross-cultural care: an examination of training and specialty differences. J Gen Intern Med 2007; 22:1107-13. [PMID: 17516107 PMCID: PMC2305746 DOI: 10.1007/s11606-007-0229-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Revised: 03/28/2007] [Accepted: 04/02/2007] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents' perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties. DESIGN Cross-sectional, national mail survey of resident physicians in their last year of training. PARTICIPANTS Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%). RESULTS Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty. CONCLUSIONS Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents' preparedness to provide cross-cultural care.
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Affiliation(s)
- Joseph A Greer
- Harvard Medical School, Massachusetts General Hospital, Boston, Mass, USA.
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