An Educational Curriculum in Cultural Humility: Framework for Actionable Goals and Objectives

An Educational Curriculum in Cultural Humility: Framework for Actionable Goals and Objectives Monica Yepes-Rios, Kathy Walsh, Tina Kumra Alliance Skills and Leadership Conference, October 21, 2017

Melanie Tervalon, Children ss Hospital Oakland Jann Murray Garcia, UCSF https://youtu.be/_mbu8bvkb_u?list=pl879555abcced8b50 Cultural Humility Principles Lifelong Learning and Critical Self-Reflection Recognize and Challenge Power Imbalances for Respectful Partnerships Institutional Accountability Organizational life-long learning and reflection Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.

Cultural Humility & Health Disparities Melanie Tervalon, Children s Hospital Oakland Jann Murray Garcia, UCSF https://youtu.be/_mbu8bvkb_u?list=pl879555abcced8b50

Health Disparities Socioeconomic Factors Non-Socioeconomic Factors Unconscious Bias Stereotyping Racism Gender Bias Limited English Proficiency or Health Literacy White, A.A. & Stubblefield-Tave, B. J. Some Advice for Physicians and Other Clinicians Treating Minorities, Women, and Other Patients at Risk of Receiving Health Care Disparities. Racial and Ethnic Health Disparities (2017) 4: 472. https://doi.org/10.1007/s40615-016-0248-6 Non Socioeconomic Factors Unconscious Bias (Smedley 2003 ) Greater under stress, and/or multi-tasking Stereotyping (Schulman et al) Simulated patients with identical cardiac symptoms & referral for cath Race and Gender bias (Chiaramonte 2006, Cannon 2009) Labeling (stress vs heart disease), Delay in care, Sub-optimal post ACS meds Racism (Jones 2000, Johnson 2004) Differential access to care or opportunities Internalized: acceptance of stigmatized races about their own abilities

Non Socioeconomic Factors Sexual Orientation (Cruz 2010, Ard 2012) Inferior care of Gay and Lesbian; Bisexuals worse health outcomes. Limited Health Literacy (Wasserman 2014) Limited English Proficiency Cross Cultural Challenges Educational Objectives Understand the evolving terminology that embraces beyond competency, the demonstration of skills and attitudes in a clinical environment. Review the ACGME milestones and EPAs as they relate to Cultural Competency and Humility in Internal Medicine. Discuss a resident/patient encounter and practice giving feedback on the resident s skills in cultural humility. 12

Evolving Terminology Cultural competence: A health care system that is culturally competent acknowledges the significance of sociocultural factors that impact the acceptance and delivery of care and adapts its services in such a way to meet these specific needs. Clinical cultural competence interventions: Educational initiatives that aim to enhance physician knowledge of the relationship between sociocultural factors and health beliefs/behaviors and to teach providers the tools and skills to manage these factors. (Betancourt JR et al 2003) 13 Evolving Terminology Cultural Competence implies it is possible to attain mastery over a finite body of knowledge. Cultural Humility relates to the knowledge, skills and attitudes that must be taught and nurtured in our learners. Patient-centered communication is important for engendering trust and negotiating adequate management plans that take into account the patients health beliefs, customs and specific needs. There is no endpoint to cultural humility it is continual and requires self-reflection. (Prasad 2016) 14

Evolving Terminology It is critical that learners do not use their skills in cultural competence to jump to conclusions about patients simply because they come from a specific cultural group Learners should remain open to their patients unique life experiences When a learner is said to lack cultural competence, the deficit is not usually in knowledge, but instead identifying that the learner needs to adjust his or her attitudes toward a diverse group of patients. 15 EPAs and Milestones: Brief Review Entrustable Professional Activity (EPA): Tasks or responsibilities that trainees are entrusted to perform unsupervised once they have attained sufficient specific competence. EPAs are independently executable, observable, and measurable. 5 of the current EPAs have language that relates to cultural humility. Milestone: A behavioral descriptor that marks a level of performance for a given competency. 6 of the current Milestones have language that relate to cultural humility. 16

EPAs and Cultural Humility EPA 1: Gather a history and perform a physical exam Patient-centered skills: Demonstrates patient-centered interview skills: For example, being attentive to patient verbal and nonverbal cues, patient/ family culture, social determinants of health, need for interpretive or adaptive services Demonstrates patient-centered examination techniques that reflect respect for patient privacy, comfort, and safety For example, explaining physical exam maneuvers, telling the patient what the physician is doing at each step, and keeping patients covered during the examination 17 EPAs and Cultural Humility EPA 4: Enter and discuss orders and prescriptions Considers patient s preferences in placing orders. Communicates recommendations to patients, families, and the health care team Considers the costs of their orders and the patient s ability and willingness to proceed with the plan Can adapt plan based on the patient s unique demographic, cognitive, physical, cultural, socioeconomic, or situational needs Engages in bidirectional communication with patients, their families, and members of the health care team 18

EPAs and Cultural Humility EPA 8: Give or receive a patient handover to transition care responsibility Can adapt based on patient, audience, setting, or context, including patient disabilities or language barriers EPA 10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management Understands and recognizes personal limitations, emotions, and personal biases and seeks help when needed Demonstrates bidirectional communication with health care team and family regarding goals of care and treatment plan that leads to shared decision making 19 EPAs and Cultural Humility EPA 12: Perform general procedures of a physician: Demonstrates patient-centered skills in performing procedures: Avoids medical jargon such that patients are able to verbalize understanding of the procedure Participates in shared decision making with patients about procedures Has confidence commensurate with level of knowledge and skill that puts patients at ease Simultaneously pays attention to both the procedure and the patient s emotional response 20

Milestones and Cultural Humility Patient Care 2 (PC2): Develops and achieves comprehensive management plan for each patient Ready for unsupervised practice: Appropriately modifies care plans based on patient preferences Aspirational: Role models and teaches complex and patient-centered care Medical Knowledge 1 (MK1): Clinical Knowledge Possesses the scientific, socioeconomic, and behavioral knowledge required to provide patient care 21 Milestones and Cultural Humility System Based Practice 3 (SBP3): Identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care Recognizes that external factors influence a patient s utilization of health care and may act as barriers (socioeconomic, cultural, literacy, insurance status) Ready for unsupervised practice: Addresses patient specific barriers Aspirational: Teaches other to recognize and address patient specific barriers 22

Milestones and Cultural Humility Professionalism (PROF): Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (PROF1) Ready for unsupervised practice: Empathy, compassion, and respect for patients in all situations Aspirational: Role model Responds to each patient s unique characteristics and needs [culture, ethnicity, gender, religion, and personal preference] (PROF3) Ready for unsupervised practice: Modifies plan to account for patient s unique characteristics Aspirational: Role model 23 Milestones and Cultural Humility Interpersonal and Communication Skills 1 (ICS1): Communicates effectively with patients and caregivers Ready for unsupervised practice: Quickly establishes relationships with patients and caregivers, including persons of different socioeconomic and cultural backgrounds Incorporates patient preferences in shared decision making and into plans of care Aspirational: Models cross-cultural communication and establishes therapeutic relationships with persons of diverse socioeconomic backgrounds 24

Case Scenario In the primary care clinic, we are precepting an intern and will be directly observing her during a patient interview to give feedback on cultural humility. After watching the short video, we will work in small groups to formulate positive and constructive feedback based on the ACGME IM milestones (handout provided). 25 Level 1 Level 2 Level 3 Level 4 Level 5 26

27 Worlds Apart: A Four-Part Series on Cross-Cultural Health Care http://www.commonwealthfund.org/publications/resources/2004/feb/worlds-apart---a-film-series-on-crosscultural-health-care Group Discussion Positive feedback for the intern? Constructive feedback for the intern? Thoughts about how our current evaluation forms capture cultural humility? Any additions or changes to suggest? 28

Educational Objectives 1. Define Cultural Humility and its relation to health disparities 2. Understand the evolving terminology that embraces beyond competency, the demonstration of skills and attitudes in a clinical environment. 3. Review the ACGME milestones and EPAS as they relate to Cultural Competency and Humility in Internal Medicine. 4. Learn existing educational strategies 5. Develop strategies to educate learners QIAN: Integrating the Humbleness Curriculum Question Immersion Active Listening Negotiation Chang, E. S., Simon, M., & Dong, X. (2012). Integrating cultural humility into health care professional education and training. Advances in health sciences education, 17(2), 269 278.

Michigan Medical School: A Woven Cultural Humility Curriculum Clinical Skills Course: Home Visits Longitudinal Case Studies Course: Clinical cases are introduced during a two to three week period in conjunction with the students' core lecture series Small group setting issues of unequal treatment, problems with health care access, and health care disparities, as well as other issues in medical ethics, patient safety, health care economics, and death and dying Kumagai, A. K., & Lypson, M. L. (2009). Beyond cultural competence: critical consciousness, social justice, and multicultural education. Academic Medicine, 84(6), 782 787. Family Practice Residency Curriculum in Cultural Humility Participatory Learning Activities Panel Presentations Home Visits Book/Video Discussion Relationship centered Interview Training Simulated Patients Culture of Local Seniors Teaching With Humanities Juarez, J. A., Marvel, K., Brezinski, K. L., Glazner, C., Towbin, M. M., & Lawton, S. (2006). Bridging the gap: A curriculum to teach residents cultural humility. FAMILY MEDICINE KANSAS CITY, 38(2), 97.

Auburn University School of Nursing: Reflective Journaling Partnership with the local housing authority, a low income public housing provider Community based curriculum Reflective journaling as a tool to internalize and develop cultural humility in nursing students Schuessler, J. B., Wilder, B., & Byrd, L. W. (2012). Reflective journaling and development of cultural humility in students. Nursing education perspectives, 33(2), 96 99. Institutional Consistency: Systems Level Reflections Johns Hopkins Community Physicians Integration with safety Mechanisms for reporting and evaluation

Small Group Discussions Case scenarios from participant s institutions References 1. https://youtu.be/_mbu8bvkb_u?list=pl879555abcced8b50. Cultural Humility: People, Principles and Practices 1. Yeager KA, Bauer-Wu S. Cultural Humility: Essential foundation for clinical researchers. Appl Nurs Res. 2013 Nov; 26(4): 10.1016/j.apnr.2013.06.008. 2. https://culturallyconnected.ca/ 3. Toolkits, Guides & Videos (referenced in culturally connected.ca) 4. Cultural Humility: People, Principles and Practices (Chávez, V., 2012) 5. A thirty minute documentary that explains what cultural humility is and why it is needed. 6. Culturally Sensitive Care Practice Guidelines (College of Nurses of Ontario, 2009) 7. Practice guidelines which outline elements of providing culturally sensitive care, including self-reflection, exploring culture and beliefs, and working with interpreters. 8. Cultural and Spiritual Sensitivity: A Learning Module for Health Care Professionals (HealthCare Chaplaincy, 2009) 9. Includes self-assessment tools to help reflect on one s own cultural and spiritual beliefs, and practical approaches to develop the ability to provide culturally sensitive approaches to care. 10. Enhancing Cultural Competency: A Resource Kit for Health Care Professionals (Alberta Health Services, 2009) 11. Includes information and tools for health care professionals to enhance their skills in providing culturally competent care to individuals and families from diverse cultural backgrounds.

References Chang, E., Simon, M. & Dong, X. Integrating cultural humility into health care professional education and training. Adv in Health Sci Educ (2012) 17: 269. https://doi.org/10.1007/s10459-010-9264-1 Butler PD, et al. Integrating Cultural Competency and Humility Training into Clinical Clerkships: Surgery as a Model. Journal of Surgical Education doi:10.1016/j.jsurg.2011.01.002 Implicit Association Test. Project Implicit. https://implicit.harvard.edu/implicit/takeatest.html Accessed September 22, 2015. References Health Disparities White, A.A. & Stubblefield-Tave, B. J. Some Advice for Physicians and Other Clinicians Treating Minorities, Women, and Other Patients at Risk of Receiving Health Care Disparities. Racial and Ethnic Health Disparities (2017) 4: 472. https://doi.org/10.1007/s40615-016-0248-6 References from White et al: Smedley B, Stith A, Nelson A. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington: The National Academies; 2003. Schulman KA, Verlin JA, Harless W, Kemer JF, Sistrunk SS, Gersh BJ, et al. The Effect of Race and Sex on Physicians Recommendations for Cardiac Catheterization. N Engl J Med. 1999;340:618 26. Thomas Cannon, et al. Elapsed Time in Emergency Medical Services for patients with Caridac Complaints Circulation, online, January 13, 2009. Jones PCA. Levels of Racism: A Theoretic Framework and a Gardener s Tale. Am J Public Health. 2000;90(8):1212 5. Ard, KL, Makadon, HJ. Improving the health care of lesbian, gay, bisexual and transgender (LGBT) people: understanding and eliminating health disparities. Boston: The National LGBT Health Education Center, The Fenway Institute, July 2012. http://www.lgbthealtheducation.org/wpcontent/uploads/12-054_lgbthealtharticle_v3_07-09-12.pdf

References Health Disparities Cruz E Study: biphobia puts bisexual men at risk for STIs. The Advocate. http://www.advocate.com/bisexuality/2014/06/26/study-biphobia-putsbisexual-men-risk-stis Wasserman M, Renfrew MR, Green AR, Lopez L, Tan-McGrory A, Brach C, Betancourt JR. Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field. J Healthc Qual. 2014;36:5 16. doi:10.1111/jhq.12065. White A. Some advice for minorities and women on the receiving end of health-care disparities. J Racial and Ethnic Health Disparities. 2014;1:61 6. Like, RC. Powerpoint presentation. Workforce Diversity and Cultural Competency: A Strategy for Eliminating Minority Health Disparities Conference, Office of Minority Health and Health Disparities, Maryland Department of Health and Mental Hygiene. Baltimore, MD, April 24, (2007). http://phpa.dhmh.maryland.gov/cancer/cancerplan/archives/disparities_conf/like_presentation.pdf. Culturally Connected Online resource from BC Mental Health This resource helps health professionals use a cultural humility framework to establish cultural safety for diverse clients. Use this tool to learn health literacy skills and see how they can be applied in practice. https://culturallyconnected.ca/

Kleinman s Explanatory Model It can be challenging to conduct a successful assessment while building a trusting relationship. The Kleinman Explanatory Model guides the interaction between health professional and client through a list of assessment questions and topics. This model takes into account world-view, culture, social context, and spirituality. Explore a client s understanding of their health concern by asking: 1. What do you call your problem? What name do you give it? 2. What do you think has caused it? 3. Why did it start when it did? 4. What does your sickness do to your body? How does it work inside you? 5. How severe is it? Will it get better soon or take longer? 6. What do you fear most about your sickness? 7. What are the chief problems your sickness has caused for you (personally, family, work, etc.)? 8. What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment? Tip: Try and blend the timing and phrasing of these questions into your discussion with your client in an informal manner Printable PDF Reference:Kleinman A Eisenberg L & Good B (1978) Culture illness and care: clinical lessons from anthropological and cross cultural research Ann

Reference: Berlin, E. & Fowkes, W.A. (1983). A teaching framework for cross-cultural health care. Western Journal of Medicine, 139:934 938. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc10 11028/pdf/westjmed00196-0164.pdf