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Development of a Multifaceted Health Disparities Curriculum for Medical Residents

Ashley H. Noriea, MD, MAPP; Nicole Redmond, MD, PhD, MPH; Rebekah A. Weil, MD; William A. Curry, MD; Monica E. Peek, MD, MPH, MSc; Lisa L. Willett, MD, MACM

Background and Objectives: Health disparities education is required during residency training. However, residency program directors cite numerous barriers to implementing disparities curricula, and few publications describing successful disparities curricula exist in the literature. In this report, we describe the development, implementation, and early evaluation of a longitudinal health disparities curriculum for resident physicians. We provide resource references, process, and didactic toolkits to facilitate use by other residency programs.

Methods: We used a standard, six-step model for curricular design, implementation, and evaluation. We assessed feasibility of curricular development including practicality (program cost and time requirements) and demand (resident engagement). We also assessed program and learner outcomes, including number of didactic and clinic sessions delivered and resident preparedness, attitudes, and skill in caring for vulnerable patients.

Results: We designed, implemented, and evaluated our curriculum in less than 1 year, with no external funding. Time costs included 100 chief resident and 20 faculty hours for curricular development, followed by 20 chief resident and 16 faculty hours for implementation. In the first year of our curriculum, 21% of residents (16 of 75) participated. We created eight didactic sessions and delivered four as intended. Residents provided 84 free clinic sessions for uninsured patients and reported increased preparedness and skill caring for vulnerable patients in 15 of 20 measured domains. Residents also reported 20 commitments to change on themes that comprehensively reflected the content of our first curricular year.

Conclusions: It is possible to design a disparities curriculum, overcome cited barriers, and improve educational outcomes related to the care of vulnerable patients.

(Fam Med. 2017;49(10):796-802.)

Health disparities are a significant problem in the United States.1 To ensure that future physicians are prepared to address health disparities, accreditation councils have mandated disparities education during residency training.2-4 Disparities education is particularly important for future primary care physicians (PCPs), as the lack of PCPs skilled in caring for diverse populations is thought to contribute to disparities.5 Unfortunately, residency program directors cite numerous barriers to implementing disparities curricula,6 and a recent review notes few publications available to assist in developing this important aspect of training.7 In this report, we describe the design, implementation, and early evaluation of a multifaceted disparities curriculum for medical residents.

 

Methods

 
 

We developed the Health Disparities Track (HDT) within the Tinsley Harrison Internal Medicine Residency Program at the University of Alabama at Birmingham (UAB). All postgraduate year (PGY) 2 and 3 residents were invited to participate. We began curriculum planning in April 2014 and implemented the HDT in July 2014. We used Kern’s six-step model for curriculum design8 as described below (Table 1). This study was exempt by the UAB Institutional Review Board.

 

Table 1

 

 

We considered curricular, learner, and patient needs in our general needs assessment, which was conducted prior to curriculum implementation (Table 1). We asked all PGY2 and 3 residents to rate the usefulness of five educational tools in learning to care for patients of cultures other than their own. All five tools were considered “useful or very useful”. Thus, we took a multidimensional approach to curricular design. We used publicly available resources created by experts in health disparities9 and curricular design10 to inform our goals, objectives, and educational strategies (Table 1).

Implementation

Two chief medical residents (AN, RW) and one faculty member (NR) created HDT didactic sessions using publicly available resources.10-13 Didactics were delivered quarterly from 5 to 7:00 pm (Table 2). To offer residents clinical experience, we partnered with a neighborhood clinic for uninsured patients, MPower Ministries Health Center (MPower).14 Based on availability, we were able to assign nine residents to MPower for one-quarter of their continuity clinic time; the remaining three-quarters were completed at a previously assigned UAB clinic site. For experiential learning, we assigned videos,15,16 structured community exploration, and critical reflection.10 We tasked HDT residents with dissemination of information on health disparities to their peers through development of a 1-hour lecture and community resource guide for clinical and social services available to low-income patients.

 

table2

 

Program Evaluation

We assessed feasibility of curricular implementation,17 as well as program and learner outcomes.8 For feasibility, we assessed practicality (total time and cost required for curriculum implementation), and demand (resident engagement).17 For program outcomes, we assessed number of didactic and clinic sessions delivered. For learner outcomes, we assessed changes in self-reported preparedness and skill, as well as attitudes regarding the care of vulnerable patients. For preparedness and skill, we used a previously published survey18 asking residents to rate their preparedness in caring for 10 unique patient populations (1=very unprepared, 5=very well-prepared) and skill providing 10 unique aspects of cross-cultural care (1=not at all skillful, 5=very skillful). We administered the survey online in July 2014 (pre) and May 2015 (post). For attitudes, we evaluated resident commitments to change (CTC), which are validated self-assessment tools associated with learner behavior change.19, 20

Data Analysis

We collapsed preparedness and skill survey responses into categories of unprepared/unskillful (Likert answers 1-2) and prepared/skillful (Likert answers 3-5) as done by previous authors.18 We analyzed pre- and posttest differences in preparedness and skill using chi-squared tests on Stata software, version 14. Two authors (AN, LW) independently organized commitments to change into themes.

 

Results

 
 

Feasibility

In the first year of our curriculum, we implemented all curricular activities (Table 1) with no external funding. We provided meals for didactic sessions, yielding an internal funding requirement of $300. Time costs included curricular development (100 chief resident and 20 faculty hours) and implementation (20 chief resident and 16 faculty hours). No UAB curricula were replaced by implementation of this curriculum. One faculty member (WC) provided care at MPower 1 half day each week; no additional funding was required for his supervisory time.

Twenty-one percent of eligible residents participated in the curriculum’s first year (16 of 75), and attended an average of 2.1 (of 4) didactic sessions. HDT resident engagement in curricular activities varied, ranging from 38% (n=6) community explorations to 69% (n=11) critical reflections, 88% (n=14) viewing of assigned videos, and 100% (n=16) participation in dissemination of disparities information to peers.

Program Outcomes

We developed content for eight didactic sessions and delivered four in the first year, as intended. Residents who participated in MPower clinic provided 84 3-hour clinic sessions. Process (Table 1) and didactic (Table 2) toolkits are described here to facilitate external use by other residency programs.

Learner Outcomes

Ten HDT residents (63%) completed pre- and postsurveys. These residents improved in 15 of 20 measured domains, although the small sample size precluded statistical significance. Sixteen HDT residents (100%) made 20 CTC that comprehensively reflected material covered in the first year of didactic sessions (Table 3).

 

table3

 

 

Discussion

 
 

Our study describes the design, implementation, and early evaluation of a longitudinal health disparities track for medical residents. Previous research has cited barriers to development of disparities curricula including lack of faculty expertise, time for curriculum development, and tools for assessing resident cultural competency.6 However, with the help of supportive program leadership, chief resident and faculty champions, a community clinic with aligning priorities, and publicly available resources,8-13, 15-18, 20 we were able to design, implement, and evaluate the HDT in less than 1 year without external funding.

This curriculum was designed in an internal medicine residency; however given the generalized resources used to create this curriculum, we believe that our experience is applicable to all graduate medical education programs. Our small sample size limited the evaluation of our program, as did the lack of control group and potential for social desirability bias and ceiling effects. Next steps include longitudinal evaluation of outcomes and qualitative assessment of key stakeholders’ opinions to determine the best methods of curricular improvement and expansion.

Acknowledgements: We acknowledge the MPower Ministries Health Clinic and UAB School of Nursing for their assistance developing the clinical portion of this curriculum. Special thanks to Laura Washington, Ryan Hankins, Cynthia Selleck, PhD, RN, FAAN, and Jennifer Frank, RN, without whom this curriculum would not have been possible.

Presentations: Content from this manuscript was presented on April 19, 2016 at the Association of Program Directors in Internal Medicine Annual Meeting, and on May 12, 2016 at the National Annual Meeting of the Society of General Internal Medicine.

Conflicts of Interest: Dr Redmond contributed to this article during her time as an employee of the University of Alabama at Birmingham (UAB). The views expressed are her own and do not necessarily represent the views of the National Institutes of Health or the United States Government, for whom she currently works. No authors have any conflicts of interests to report.

Corresponding Author: Address correspondence to Dr Ashley H. Noriea, Section of General Internal Medicine, University of Chicago, 5841 S Maryland Ave, MC2007, Chicago, IL 60637. 773-702-2083. Fax: 773-834-2238.
ashley.noriea@oakstreethealth.com.

 

References

 
 
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From the University of Chicago Section of General Internal Medicine (Drs Noriea and Peek); National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Clinical Applications and Prevention Branch (Dr Redmond); Oregon Health and Science University Division of Internal Medicine and Geriatrics (Dr Weil); and Division of General Internal Medicine, University of Alabama at Birmingham (Drs Curry and Willett).


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