Approaching Cultural Competency Education - Professional

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					Approaching Cultural Competency
in Medical Education

• Family physician, suburban practice
• Director, Division of Global Health (Family
• MD Undergraduate Program Global Heath
• Faculty Advisor, Global Health Initiative
    Defining cultural competency
• Culture matters
• Cultural context matters more
• Culture is not static
• Cultural factors impact diagnosis, treatment, and
• Cultural factors impact professional
• Does cultural knowledge improve clinical
• What is the role of political correctness in
  cultural competency?
        A call for cultural competency
    • LCME directive: the need for medical
      students “to recognize and appropriately
      address gender and cultural biases in
      health care delivery.”
    • FMEC recommendations for prioritizing
      social accountability and responsibility

    •   Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Functions and Structure of
        a Medical School. Washington, DC: Liaison Committee on Medical Education; 2007.

        What defines cultural competency?
    • knowledge of characteristics, cultural
      beliefs, and practices of different
      nonmajority groups, and skills and
      attitudes of empathy and compassion in
      interviewing and communicating with
      nonmajority groups.
    •    (Kumagai et al, 2009)

        Defining cultural competency?
    • ‘a set of congruent behaviors, attitudes,
      and policies that come together in a
      system, agency, or among professionals
      and enable that system, agency, or those
      professionals to work effectively in cross-
      cultural situations’

    •   Cross, Bazron, Dennis & Isaacs, 1989 or 1999

            Going beyond the concept of
               Cultural Competency
    • involves the fostering of a critical
      awareness—a critical consciousness—of
      the self, others, and the world and a
      commitment to addressing issues of
      societal relevance in health care.

    •   Kumagai et al 2009

         Deconstructing the notion of
            cultural competency
    Cultural competency isn’t an endpoint, but rather a
     ongoing process involving multiple factors

    … is culture.

          Synergistic processes
Cultural awareness   understanding differences and one’s own assumptions,
                     values, and biases

Cultural security    provision of services offered by the health system will
                     not compromise the legitimate cultural rights, values
                     and expectations
Cultural respect     recognition, protection and continued advancement
                     of the inherent rights, cultures and traditions

Cultural safety      undertaking a process of reflection on one’s own
                     cultural identity and recognizes the impact of our own
                     culture on our practice. Unsafe cultural practice is any
                     action which diminishes, demeans or disempowers the
                     cultural identity and well-being of an individual.
                     (Papps, 2005, p. 25)
Cultural humility    lifelong commitment to self-evaluation and critique;
                     addressing the power imbalances between patient-
                     physician (teacher/student) and developing mutually
                     beneficial…partnerships (Tervalon, Murray-Garcia)
         What is the object of knowledge in
               Cultural Competency
     v? learning a series of lists of cultural attributes,
       which can create dehumanizing stereotypes
     v? a skill-set of questions and demeanors we
       should assume when encountering a patient
       (student) who is not like us
     • Development of a critical consciousness of the
       knowledge and awareness to carry out the social
       roles and responsibilities of a physician (and
     •   Kumagai et al, 2009

      Cultural Competency Initiative
             Jaspreet Mangat, Andrew Wong, Aiza Waheed, Sally Ke

     • Introduction to Communications Skills
       INDE 410 – first year medicine
     • Pilot – year one – readings and
       discussion, including a self-assessment
       survey and discussion
     • Pilot – year two – modify readings, add
       video teaching tool – interviews of patients
       and physicians; LEARN / RESPECT

     • Listen with sympathy and understanding to the
       patient's perception of the problem*
     • Explain your perceptions of the problem
     • Acknowledge and discuss the differences and
     • Recommend treatment / plan
     • Negotiate agreement / plan

     •   *Year one focus on FIFE and explanatory model approach

     •   Berlin, E. & Fowkes, W.A.(1983)

     • Respect
     • Explanatory model
     • Social context, including Stressors, Supports,
       Strengths, and Spirituality
     • Power
     • Empathy
     • Concerns
     • Trust/ Therapeutic alliance/ Team.
     •   Welch, M. (1998). Enhancing awareness and improving cultural competence in health care. A
         partnership guide for teaching diversity and cross-cultural concepts in heath professional training.

            Translating RESPECT to the
            preceptor-student relationship
     • Empathic listening skills may wither in
       students whose own concerns are
       routinely ignored
     • Incorporating the student’s own values,
       worldview, and experiences
     • Addressing power dynamics in teaching
       relates to the concept of eliminating health
       disparities and a call for social justice and
       respect for social roles and responsibilities
     •   Kumagai et al, 2009

            Precepting with RESPECT
       Adapting patient-care model to preceptor-learner relationship

• Harnessing the
  parallels between
  educational and
  clinical encounters

•   (Carol Mostow et al)
• Doctor - patient         • Preceptor - resident
• A demonstrable           • Approach learner with
  attitude                   respect
  communicating the        • Builds learner
  value and autonomy         confidence and
  of the patient and the     preceptor-resident
  validity of his/her        relationship
  concerns                 • Reduces
          Explanatory Model
• The patient’s         • Elicit the resident’s
  understanding of what   thoughts about the
  causes their illness,   patient and the
  or what will help it    interest in the
                          patient’s perspective
                        • Helps preceptor learn
                          what resident knows
                          and creates starting
                          point for discussion
               Social Context
• Impact of patient's life   • Check re. resident’s
  upon illness and of          well-being and
  illness on his/her life.     context; explore
  Include stressors,           professional and
  supports, strengths,         personal stressors
  spiritual resources        • Builds relationship
  that influence patient,    • Models how to act
  health or care               with patients
• Shared access to         • Find ways to share
  status, control,           power and support
  resources, options,        resident self-efficacy;
  and ability to produce     resist temptation to
  desired outcomes           takeover in face of
• Emphasize                  learner’s uncertainty
  partnership,             • Investment in service
  negotiation or roles       and learning
• Verbal and nonverbal   • Let resident know
  responses that           their frustrations and
  validate patients’       emotions are heard
  emotions and cause     • Observe for decline in
  them to feel             resident’s mood and
  understood.              empathy, as well as
                           any difference in
                           patient’s background
                         • Support resident to
                           engage more
                           effectively with patient
• Worries about symptoms,    • Elicit and address
  diagnosis, or treatment,     resident’s concern about
  often unexpressed            situations they don’t feel
                               confident handling or fear
                               will make the visit to long
                             • Develop strategies to find
                             • Replace anxiety with
                               information to improve
                               quality and efficiency
        Trust, Team-building
• Relationship built on   • Build on the above
  understanding, power      skills to foster trust in
  -sharing and              preceptor-student
  empathy; patient          relationship
  confident that doctor   • Learners may be
  acts on his behalf        more willing to identify
                            areas of challenge
•   Treating and Precepting with RESPECT: A Relational Model Addressing Race,
    Ethnicity, and Culture in Medical Training, Carol Mostow, LICSW,1 Julie Crosson,
    MD,2,9 Sandra Gordon, MD,3,9 Sheila Chapman, MD,3,9 Peter Gonzalez, MD,10,11
    Eric Hardt, MD,6,9 Leyda Delgado, MD,3,8,9 Thea James, MD,7,9 and Michele
    David, MD, MPH, MBA3,4,5,9 ; J General Intern. Med. 2010 May

•   Beyond Cultural Competence: Critical Consciousness, Social Justice, and
    Multicultural Education, Arno K. Kumagai, MD, and Monica L. Lypson, MD; Acad
    Med, 2009; 84:782-787

•   Anthropology in the Clinic: The Problem of Cultural Competency and How to
    Fix It, Arthur Kleinman, Peter Benson, PLoS Medicine, October 2006, Volume 3,
    Issue 10, e294

•   Principles and Practices of Cultural Competency: A Review of the Literature

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