Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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6. Interventions: Cross-Cultural Education in the Health Professions
6. Interventions: Cross-Cultural Education in the Health Professions
Pages 199-214
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From page 199... ...
Clinicians aren't shielded from diversity, as patients present varied perspectives, values, beliefs, and behaviors regarding health and well-being. These include variations in patient recognition of symptoms, thresholds for seeking care, ability to communicate symptoms to a provider who understands their meaning, ability to understand the management strategy, expectations of care (including preferences for or against diagnostic 199
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From page 200... ...
Thus, when sociocultural differences between patient and provider aren't appreciated, explored, understood, or communicated in the medical encounter, the result is patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in care (Flores, 2000; Betancourt et al., 1999; Stewart et al., 1999; Morales et al., 1999; Cooper-Patrick et al., 1999; Langer, 1999~. And it is not only the patient's culture that matters; the provider "culture" is equally important (Nunez, 2000; Robins et al., 1998b)
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From page 201... ...
We all are influenced by and belong, to multiple cultures that include, but go beyond, race and ethnicity. Sociocultural factors are critical to the medical encounter, yet crosscultural curricula have been incorporated into undergraduate, graduate and continued health professions education only to a limited degree (Carrillo et al., 1999~.
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From page 202... ...
Although material related to cultural diversity is considered an TABLE 6-1 Cross-Cultural Curricula in Undergraduate Medical Education 1978 (Wyatt) : 20% med schools offered specific "sociocultural courses" 40% covered issues within other courses, 40% offered none 1992(Lum)
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From page 203... ...
As early as 1977, the National League for Nursing required cultural content in nursing curricula and in 1991, the American Nursing Association published standards specifically indicating that culturally and ethnically relevant care should be available to all patients. APPROACHES TO CROSS-CULTURAL EDUCATION Training in cross-cultural medicine can be divided into three conceptual approaches focusing on attitudes, knowledge, and skills.
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From page 204... ...
o Discussion of these factors as they relate to the provider and the patient culture, and what impact they may have on clinical decision-mak~ng o Importance of curiosity, empathy and respect in the medical encounter highlighted · Approach primarily taught In early in medical school and in certain residencies Gonzalez-Lee and Simon, 1987~. The added importance of these attitudes in cross-cultural medical encounters, where the desire to explore and negotiate divergent health beliefs and behaviors is paramount, has given rise to curricula designed to build or shape them within providers.
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From page 205... ...
The second instance of an effective knowledge-based approach is knowledge that has a specific, evidence-based impact on healthcare delivery. Examples include ethnopharmacology; disease incidence, prevalence, and outcomes among distinct populations; the impact of the Tuskegee Syphilis Study and segregation as the cause of mistrust in African Americans; the effect of war and torture on certain refugee populations and how this shapes their interaction with the healthcare system; and the common cultural and spiritual practices that might interfere with prescribed therapies (such as Ramadhan the sunup-to-sundown fast observed by Muslims and how this might affect people with diabetes)
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From page 206... ...
A Focus on Skills: The Cross-Cultural Approach The cross-cultural approach teaches providers skills that meld those of medical interviewing with the ethnographic tools of medical anthropology (Shapiro and Lenahan, 1996; Carrillo et al., 1999~. These framework-based approaches focus on communication skills, and train providers to be aware of certain cross-cutting cultural issues, social issues, and health beliefs, while providing methods to deal with information clinically once it is obtained (Nunez, 2000; Berlin and Fowkes, 1998; Clinton, 1996~.
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From page 207... ...
, roleplay (whereby students or residents practice interviewing techniques using scripted cases) , patient narratives, video interviews of patients, and the use of patients or actors for faculty facilitated, simulated medical encounters (Gonzalez-Lee and Simon, 1987; Rubenstein et al., 1992~.
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From page 208... ...
Similarly, the NaTABLE 6-5 Methods and Opportunities for Cross-Cultural Education Methods Undergrad/Graduate Medical Education Facilitated reflection Didactics Vignettes Individual Cases Problem-Based Learning Videos Simulated Patients - Community Immersion Continuing Education · Didactics · Problem-Based Learning · Case-Based Discussion Opportunities Undergrad/Graduate Medical Education · Orientation · Electives · Retreats · Rounds · Conferences · Introduction to Clinical Sciences · Stand Alone Course Practicing Providers · Continuing Education · Faculty Development · Licensure/Exams
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From page 209... ...
used multiple-choice question methodology to show that an experimental group of students who completed a "Spanish Language and Cultural Competence Curriculum" had greater knowledge of Hispanic health and cultural issues, including disease prevalence, cultural perceptions of illness, and traditional health practices, compared with a control group (Nora, 1994~. In addition, when compared with the control group, the experimental group was found to be less ethnocentric and more comfortable with others after the curricular intervention, based on the "Misanthropy Scale." In the area of graduate medical education, one published study found that family practice residents exposed to a three-year, multi-method cross-cultural curriculum displayed an increase in cultural knowledge and cross-cultural skills via self-report and faculty corroboration (Culhane-Pera et al., 1997~.
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From page 210... ...
Skills can be evaluated in undergraduate and graduate health professions education using techniques such as the objective structured clinical examination, or videotaping actual clinical encounters (Nunez, 2000; Robins et al., 1998a; Robins et al., 2001~. For practicing providers, one might assess patient satisfaction improvements among those who have completed cross-cultural communication courses.
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From page 211... ...
Third, providers feel that they don't have the time needed to explore and negotiate complex sociocultural issues with patients, due to the short length of today's medical encounter. Fourth, there is lack of consensus on fundamental, conceptual approaches and teaching methodologies, and lack of institutional support (both formal and informal)
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From page 212... ...
SUMMARY This chapter reviews evidence that sociocultural differences between patient and provider influence communication and clinical decisionmaking (Eisenberg, 1979~. Evidence suggests that provider-patient communication is directly linked to patient satisfaction, adherence, and subsequently, health outcomes (Stewart et al., 1999~.
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From page 213... ...
Yet in the absence of the capacity to do this, we should be including the teaching of cross-cultural medicine as a stand-alone (Flores, 2000; Nunez, 2000; Like et al., 1996; Bobo et al., 1991; Clinton, 1996~. For practicing providers, continuing medical education as part of licensure, as part of faculty development, and as part of obtaining medical malpractice insurance all remain promising areas of integrating cross-cultural curricula and assessing cross-cultural communication skills.
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From page 214... ...
Finding 6-2: A significant body of literature defines and supports the importance of cross-cultural education in the training of health professionals. Despite several approaches and various opportunities for integration, curricula in this area have been implemented to a limited degree in undergraduate, graduate, and continuing health professions education.
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