The Need for Cultural and Linguistic Competence Training in Medical Education Preparing Physicians to Meet the Needs of a Changing Society Mobeen Rathore, MD Heidi Saliba, BA Nicole Brunner Professor and Associate Chairman, UF Jacksonville Division of Pediatric Infectious Diseases and Immunology; Director, UF Center for HIV/AIDS Research, Education & Service (UF CARES) Coordinator of Research Programs, Ped-I-Care & General Pediatrics Volunteer Research Coordinator, General Pediatrics
Overview Section 1: Background and Definitions Section 2: Current and Pending Requirements Section 3: Strategies for the Future of Medical Education Photo credit: Amanda Mills/CDC
Section 1: Background and Definitions Take-Home Message #1: Cultural and Linguistic Competence (CLC) is now considered the core and foundation of professional behavior. Medical education programs must build CLC into all aspects of their learning requirements.
Background Traditional medical education programs have focused on history collection, physical examination, differential diagnosis, and appropriate courses of treatment Little attention to formalized training and development of communication skills, customer service, human relations Last 25 years has ushered in new expectations to meet the needs of an increasingly diverse population 1 1 Shaya F and Gbarayor CM. The Case for Cultural Competence in Health Professions Education. American Journal of Pharamaceutical Education: Volume 70, Issue 6, Article 124. 2006.
Fundamental Concepts Definitions CLC = Cultural and Linguistic Competence Coined by Terry Cross, et al in 1989 monograph: a developmental process that evolves over an extended period. Both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. 2 2 Cross et al. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. 1989
Fundamental Concepts Definitions PCC = Patient-Centered Communication or Patient-Centered Care Not a new concept: The secret of the care of the patient is in caring for the patient Peabody, 1927 3 Focus on the person with the disease rather than the disease itself Kleinman, 1978 4 Patient-Centered Care: Informs and involves patients in medical decision-making and self-management; physical comfort and emotional support; understands cultural beliefs IOM, 2001 5 3 Peabody FW. The Care of the Patient. Journal of the American Medical Association. 1927;88:877-882. 4 Kleinman A, Eisenberg L, and Good B. Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. Annals of Internal Medicine. 1978; 88: 251:258. 5 Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC: National Academy Press.
Sentinel Events in the Development Of Expectations for CLC Care 1927 1978 1989 2009 2014 2050 Peabody: Patient-specific care argument in JAMA Kleinman: Focus on the person as opposed to the disease Terry Cross, et al definition of CLC HP 2010 calls for complete elimination of disparities in care 6 Full implementation of healthcare reform requires CLC care 7 US minority population expected at 62% 8 6 Healthy People 2010. Available at http://www.cdc.gov/nchs/healthy_people.htm. 7 Office of the Legislative Counsel for the Use of the US House of Representatives. Compilation of Patient Protection and Affordable Care Act. Sec. 10410\520B PHSA, p. 895. Available at http://housedocs.house.gov/energycommerce/ppacacon.pdf. 2010. 8 US Census Bureau. An Older and More Diverse Nation by Midcentury. August 2008. Available at http://www.census.gov/newsroom/releases/archives/population/cb08-123.html.
Fundamental Concepts Ped-I-Care s Model of Cultural Competence 9 Professionalism What you have Skills, knowledge, education How you use it Communication, Chosen Behaviors Attitude Cultural and Linguistic Competence 9 Saliba H, Osakwe O, and Giunta N. Cultural Competency in the Healthcare Setting: Navigating the Now, Negotiating What s Next. Poster presentation at Southern Group on Educational Affairs annual meeting in Lexington, Kentucky. 2012.
Primary topics within CLC Specific topics of interest within cultural competency include, but are not limited to: Language and health literacy Age, class, and gender Race, ethnicity, and country of origin Sexual orientation Religion and spirituality Photo of public artwork in Shands Hospital, Gainesville, Florida Disability Education and perceptions of intelligence Technology and the Internet Workplace behaviors
Section 2: Current and Pending Requirements Take-Home Message #2: Providers are expected and legally required to provide services in a culturally and linguistically competent manner. There is much work to be done in meeting these expectations.
ACGME & IOM Expectations Effective communication is an American College of Graduate Medical Education (ACGME) requires CLC as an element of professionalism, among others 11 Effective communication an attribute of physician qualities providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. 5 Care-process level is 1 of at least 4 disparity sources, others being clinical uncertainty, stereotyping, and provider prejudice 12 11 Swing SR. The ACGME Outcome Project: Retrospective and Prospective. Medical Teacher, 2007; 29: 648-654. 12 Balsa AI and McGuire TG. Prejudice, Clinical Uncertainty and Stereotyping as Sources of Health Disparities. Journal of Health Economics 22 (2003) 89-116.
Affordable Care Act (ACA) Requirements Standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee to reduce health and health care disparities, including through the use of language services, community outreach, and cultural competency trainings. State is to provide: education programs in the cultural context that is most appropriate for individuals in the particular population group to which they are directed. quality-driven, cost-effective, culturally appropriate, and patient- and family-centered health care 7 7 Office of the Legislative Counsel for the Use of the US House of Representatives. Compilation of Patient Protection and Affordable Care Act. Available at http://housedocs.house.gov/energycommerce/ppacacon.pdf. 2010.
Medical Milestones Expectations Being implemented for evaluation of medical student and resident evaluation for competencies: 13 Interpersonal and communication skills: Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds; demonstrate intercultural sensitivity Professionalism: Several sub-components, including: 1) Respecting the dignity, culture, beliefs, values, and opinions of the patient; 2) Recognizing and addressing disparities in health care. 13 American Board of Internal Medicine. Developmental Milestones for Internal medicine Residency Training, 2007. Available in draft format at http://www.abim.org/pdf/milestones/milestones-framework-draft.pdf.
From the Literature Physician Patient Communication Schwartz Center for Compassionate Healthcare, Mass Gen Hospital: 14 Survey of 72 groups of physicians (with 3 to 244 physicians per group) Reviewed previously completed patient experience survey reports 48% patients felt they played no role in decision making for their care 29% patients did not know which doctor was in charge of their care 81% of patients and 71% of doctors reported that outcomes were better with better communication 14 Friedberg MW, SteelFisher GK, Karp M, Schneider EC.Physician Groups Use of Data from Patient Experience Surveys. J Gen Intern Med. Published on-line: 15 December 2010. doi:10.1007/s11606-010-1597-1.
Training MDs: Technical Items Estimated direct & indirect costs (2003-2006) of racial & ethnic disparities in health care in US $229.6 billion 15 Most common healthcare disparities for minorities: Access to care - System structural and financial barriers prevent from receiving high-quality care Safe care - Experience more medical errors with great clinical consequences Evidence-based - Less evidence-based care; less likely to receive preventive health services. Timely - More likely to wait for same procedure. Efficient - Higher rates of ER utilization, hospital admissions as well as longer inpatient stays. 15 LaVesit TA, Gaskin DJ, and Richard P. The Economic Burden of Health Inequalities in the United States. Johns Hopkins Center for Health Disparities Solutions, Joint Center for Political and Economic Studies. Sept. 2009.
Challenges Overcoming misconceptions about meaning, implications of CLC CLC not just race, ethnicity Overcoming the notion that communication studies, interpersonal skills are fluff work/not really important Issue of technology is often the overlooked in patientprovider relationship, as well as in medical education Need for CLC training with practical, hands-on training w/take-home messages Intricate, comprehensive explanations of anthropological terms and concepts is helpful but should not take center stage in CLC training
Section 3: Strategies for the Future Of Medical Education Take-Home Message #3: Although there is much work to be done, the medical community can and will meet these expectations if it embraces the essence of CLC as providing the most appropriate care to each individual. Those who practice patient-centered communication/care are likely already providing CLC care.
Training MDs: The Essentials Providers need to be trained in: Requirements of law and standards; Definition and nature of CLC, and what it is not. Patient-centered communication/care, and how PCC intersects with CLC Chevannes study: 1, 16 1) Integrate cultural competence into the foundations of health profession education 2) A core curriculum that includes cultural competency training with experience in and understanding of delivering high-quality care to multiethnic populations 16 Chevannes M. Issues in Educating Health Professionals to Meet the Diverse Needs of Patients and Other Service Users from Ethnic Minority Groups. J Adv Nurs. 2002 Aug;39(3):290-8.
Training MDs: Technical Items All MDs need to know: HIPAA requires info made available to patients in the format they request written, electronic, otherwise17 Medicaid requires written communications at 4 th grade or lower level 18 A number of free resources available to help with provider-patient communication, patient health literacy CDC, JAMA patient pages Website must be section 508 compliant 19 Part of Rehabilitation Act of 1973 which requires electronic communications be accessible to people with disabilities Affects structure, design, syntax of web design 17 Office for Civil Rights. The HIPAA Privacy Rule s Right of Access and Health Information Technology. 18 Centers for Medicare & Medicaid Services Special Terms and Conditions. Number 11-W-00206/4. 19 United States Access Board. Questions & Answers about Section 508 of the Rehabilitation Act Amendments of 1998.
Patient-Centered Communication Consider each patient encounter a discussion with a specialist/expert/colleague 20 You are the expert in the disease Patient/family is expert on the patient Patients specialty as Patientist Seek patient s input and perspective Physicians: Correct diagnosis and treatment plan is key Patient: Connecting with physician is key Patient-centered care/communication is an example of CLC in action Photo credit: Dawn Arlotta/CDC 20 Rathore M. Patient-Centered Communication. Grand Rounds presentation at University of Florida Department of Pediatrics, 2012.
PCC Continued: Respect Demonstrate appreciation/value for patient s choices, behaviors, special qualities You have obviously worked hard on this That was tough; You handled it well You have obviously researched this problem Let s see if I can add to your knowledge Shared decision making Empowering the patient/family Listening to their concerns: non-judgmental Not blowing off concerns Respectful of everyone s time
Training MDs: Communicating Effectively GRUSK: 21 Gentle, Respectful, Understanding, Sympathetic, Kind OARS: Open-ended questions, Affirmations, Reflective Listening, Summaries Four Habits Model Kalamazoo Consensus Statement Relationship PEARLS: Partnership, Empathy, Apology/ Acknowledgement, Respect, Legitimization, Support Photo credit: Amanda Mills/CDC 21 Dr. Robert McKay, AAP President 1970-71.
References 1. Shaya F and Gbarayor CM. The Case for Cultural Competence in Health Professions Education. American Journal of Pharamaceutical Education: Volume 70, Issue 6, Article 124. 2006. 2. Cross et al. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. 1989. 3. Peabody FW. The Care of the Patient. Journal of the American Medical Association. 1927;88:877-882 4. Kleinman A, Eisenberg L, and Good B. Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross- Cultural Research. Annals of Internal Medicine. 1978; 88: 251:258. 5. Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21 st Century. Washington DC: National Academy Press. 6. Healthy People 2010. Available at http://www.cdc.gov/nchs/healthy_people.htm. 7. Office of the Legislative Counsel for the Use of the US House of Representatives. Compilation of Patient Protection and Affordable Care Act. Available at http://housedocs.house.gov/energycommerce/ppacacon.pdf. 2010. 8. US Census Bureau. An Older and More Diverse Nation by Midcentury. August 2008. Available at http://www.census.gov/newsroom/releases/archives/population/cb08-123.html. 9. Saliba H, Osakwe O, and Giunta N. Cultural Competency in the Healthcare Setting: Navigating the Now, Negotiating What s Next. Poster presentation at Southern Group on Educational Affairs annual meeting in Lexington, Kentucky. 2012. Saliba H. Photo of ceiling tile artwork on public display in Shands Hospital, Gainesville, Florida. 2010. 10. Saliba H. Photo of ceiling tile artwork on public display in Shands Hospital, Gainesville, Florida. 2010. 11. Swing SR. The ACGME Outcome Project: Retrospective and Prospective. Medical Teacher, 2007; 29: 648-654. 12. Balsa AI and McGuire TG. Prejudice, Clinical Uncertainty and Stereotyping as Sources of Health Disparities. Journal of Health Economics 22 (2003) 89-116. 13. American Board of Internal Medicine. Developmental Milestones for Internal medicine Residency Training, 2007. Available in draft format at http://www.abim.org/pdf/milestones/milestones-framework-draft.pdf. 14. Friedberg MW, SteelFisher GK, Karp M, Schneider EC. Physician Groups Use of Data from Patient Experience Surveys. J Gen Intern Med. Published on-line: 15 December 2010. doi:10.1007/s11606-010-1597-1.
References 15. LaVesit TA, Gaskin DJ, and Richard P. The Economic Burden of Health Inequalities in the United States. Johns Hopkins Center for Health Disparities Solutions, Joint Center for Political and Economic Studies. Sept. 2009. Available at http://www.jointcenter.org/sites/default/files/upload/research/files/the%20economic%20burden%20of%20heal th%20inequalities%20in%20the%20united%20states.pdf. 16. Chevannes M. Issues in Educating Health Professionals to Meet the Diverse Needs of Patients and Other Service Users from Ethnic Minority Groups. J Adv Nurs. 2002 Aug;39(3):290-8. 17. Office for Civil Rights. The HIPAA Privacy Rule s Right of Access and Health Information Technology. Available at http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/healthit/eaccess.pdf. 18. Centers for Medicare & Medicaid Services Special Terms and Conditions. Number 11-W-00206/4. Available at http://www.fdhc.state.fl.us/medicaid/medicaid_reform/lip/docs/cms_stc.pdf. 19. United States Access Board. Questions & Answers about Section 508 of the Rehabilitation Act Amendments of 1998. Available at http://www.access-board.gov/sec508/faq.htm. 20. Rathore M. Patient-Centered Communication. Grand Rounds presentation at University of Florida Department of Pediatrics, 2012. 21. Dr. Robert McKay, AAP President 1970-71. 22. Photos from the Centers for Disease Control s Public Health Image Library: 13746, 13475, and 11582. Available at http://phil.cdc.gov.