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Responding to a Changing Nation: Are Faculty Prepared for Cross-Cultural Conversations and Care?

Lisa K. Rollins, PhD; Elizabeth B. Bradley, PhD; Gregory F. Hayden, MD; Eugene C. Corbett Jr, MD; Steven W. Heim, MD, MSPH; P. Preston Reynolds, MD, PhD

The United States is becoming increasingly diverse.1 Census data cite that over 55 million (19.7%) speak a language other than English, and of these, 24% either speak English “not well” or “not at all.”2 In addition, racial and ethnic health disparities abound,3-5 although the causes are varied and include geographic differences in the quality of care provided,6 different rates of adherence for racial and ethnic minorities,7 and racial stereotyping and bias on the part of health care providers.3,8-10 Cultural competence training has been recognized as a potential solution to closing the gap on health disparities, improving health outcomes, and increasing access to high-quality care for vulnerable populations.11

The need to provide culturally competent care has also been highlighted through national policies,12-13 and 14 states now require proficiency in cultural competence as part of their licensure requirements for physicians.14 Yet, in 2010 the Agency for Health Care Research and Quality found that racial and ethnic groups continued to experience disparate care with little evidence of improvement.5

US medical schools and residency programs have attempted to respond, although there is great variation in the content of the cross-cultural curricula as well as the framework for implementation.15,16 Even among medical schools that are nationally known for their curricula in this area, there were distinct gaps in addressing content related to language and access.16 A recent study also indicated that students perceived their cultural competency skills to be greater than the residents who instruct them and equal with that of their attendings.17 While cultural competence programming has increased in graduate medical education,18 many residents still feel unprepared to address cultural issues with their patients,19 with the exception of residents who received formal curricula and role modeling through Title VII programming.20

The purpose of this study was to determine faculty attitudes, self-perceived comfort and skill, and future knowledge needs pertaining to cultural competence. This study was approved by the Institutional Review Board for Social and Behavioral Sciences.

 

Methods

 
 

In 2009, a Cultural Competence Needs Assessment was adapted, with permission, from two instruments: the Clinical Cultural Competency Questionnaire developed by Robert C. Like, MD, MS, and the Quality and Culture Quiz.21 Face and content validity of the adapted survey were assessed by an expert panel with specific content expertise in health disparities and multicultural health. Two of the panel were external to the University of Virginia (UVA) and included Alexander Green, MD, MPH, from Harvard University, associate director of the Disparities Solutions Center in Boston, MA, and a national expert in sociocultural barriers to care; and Tawara Goode, MA, director of the National Center for Cultural Competence in Washington, DC. The two internal UVA experts included Fern Hauck, MD, MS, medical director of the UVA International Family Medical Clinic and Cultural Competency program director for the UVA School of Medicine; and Preston Reynolds, MD, PhD, who is internationally known for her work in medical professionalism. The panel also included two PhD evaluators from UVA and three UVA MD educators, one of whom received the Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award, a national award for excellence in medical student education.

The survey was administered on-line via Survey Suite™ to all clinical faculty (n=752), with a reminder sent 2 weeks after the initial request. All responses were anonymous. Descriptive statistics and content analyses of open-ended questions were conducted by the project evaluator and verified by a secondary evaluator.

 

Results

 
 

The response rate was 38% (n=287), of whom 62% were male and 38% female. In addition, 84% were specialists and 16% generalists, 25% reported being fluent in a language other than English, and 85% reported Caucasian as their ethnic/racial affiliation (Table 1).

Rollins1

The great majority (93%) of respondents felt that it was either “very important” or “somewhat important” for health professionals to receive training in cultural competence. However, 76% reported having received little or no such training as a faculty member, 80% received little or no training during residency, and 76% received little or no training during medical school.

Self-reported ratings of comfort reflected that 58% of the respondents felt “very comfortable” caring for patients from culturally diverse backgrounds, although this percentage dropped to 30% when specifying patients with limited English proficiency. Of the situations presented, respondents felt the least comfortable breaking “bad news” to a patient’s family first rather than to the patient if this is more culturally appropriate (47% either “not particularly” or “not at all” comfortable).

Activities in which the highest proportion of respondents reported feeling “very skilled” included: working with medical interpreters (41%), apologizing for cross-cultural misunderstandings or errors (33%), and eliciting the patients’ perspectives about health and illness (31%). Activities in which the highest proportion of respondents reported feeling “not at all skilled” included: providing culturally sensitive end-of-life care (33%); dealing with cross-cultural conflicts relating to diagnosis or treatment (30%), ethical issues (30%), and adherence/compliance (25%); providing culturally sensitive preventive services (28%) and patient education counseling (27%); performing a culturally sensitive physical exam (27%); and eliciting information about the use of folk healers and/or other alternative practitioners (27%).

 

Discussion

 
 

When considering each phase along the medical education continuum (medical school, residency, CME), fewer than 25% of the respondents reported receiving formal instruction in cultural competency in any given phase, and many felt significantly limited in their ability to conduct a culturally appropriate physical examination, counsel a patient and family about end-of-life care in a culturally sensitive manner, elicit information about alternative and complementary health practices, and address adherence to medication and treatment plans from ethnically, racially, and socioeconomically diverse patients. While the greatest percentage of respondents reported feeling very skilled in working with medical interpreters, apologizing for cross-cultural misunderstandings, and eliciting patients’ perspectives about health and illness, these percentages still only ranged from 31%–41% self identifying as “very skilled,” reflecting percentages that have much room for improvement. These limitations, paired with the discomfort in addressing cross-cultural ethical issues, provide additional insight into the ongoing national challenge to address health disparities and quality-of-care indices among minority patient populations. Until clinical faculty become more comfortable addressing these issues and are able to model these behaviors to learners, positive responses to national policies and standards in culturally competent care are likely to be limited. In addition, these faculty noted challenges in breaking bad news to a family first instead of a patient. With the change in US demographics that now include 13% of residents as immigrants,22 many of whom come with significantly different cultural traditions, skills in cross-cultural communication and reasoning within a broader ethical framework will be essential to providing high-quality care.

New models for medical education have been proposed to meet changing models of care in the workplace.23 These are consistent with the methodological preferences for continuing education expressed by these study participants, including personal examples, case-based interactive sessions, skills-based sessions, and open discussion and sharing of ideas among culturally diverse health care providers or other relevant individuals. To teach cultural communication skills, it will be important to utilize methodologies that are engaging, expand a repertoire of responses, and incorporate activities across multiple levels within an institutional administration.24

There are several limitations of this study. The response rate was 38% and, as a result, those who responded may not have been representative and/or the data may reflect a response bias; the study relies on self-report; due to limited cell sizes, we did not identify variables associated with level of comfort; and while the composition of these respondents is similar to many academic medical centers,25 the study was performed at a single institution and may not be generalizable to institutions with a substantially different faculty composition.

Acknowledgements: This project was funded through a Primary Care Predoctoral Training grant from the US Department of Health and Human Services, Health Resources and Services Administration (1 D5DHP19233-01-00). We would also like to acknowledge the contributions of three of our expert panel reviewers: Alexander Green, MD, MPH; Tawara Goode, MA, and Fern Hauck, MD, MS.

Corresponding Author: Address correspondence to Dr Rollins, University of Virginia, Department of Family Medicine, PO Box 800729, Charlottesville, VA 22908. 434-982-4474. Fax: 434-243-4800. lkr2h@virginia.edu.

 

 

References

 
 

 

 

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From the Department of Family Medicine (Drs Rollins and Heim), Department of Medicine (Drs Bradley, Corbett, and Reynolds), Department of Pediatrics (Dr Hayden), and School of Nursing (Dr Corbett), University of Virginia.


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