Transcript Slide 1
Cultural Competence and Health
Disparities— Resources, Context, and
Curricular Development
Harry Pomeranz MS, PA-C
PAEA October 30th, 2008
KNOWLEDGE
Race,
ethnicity, culture
Historical mistrust/prejudice,
Health disparities and inequities
KNOWLEDGE
Traditions
and customs relevant to
health care (sexual/gender issues, age,
disabilities..) without stereotyping
Health beliefs/explanatory model
Styles of communication,
Autonomy vs. family decision-making,
Patients’ access to resources
Health literacy
Definition of cultural competence
Cultural self-identity
Discussion of the culture of medicine
Integrated into interviewing,
communication, PA Seminar classes
Socio-cultural classification of race
Taught using case-based module, lecture
Taught in ethics, professionalism, genetics,
public health, pathology, pharmacology,
impact on health care delivery
Rationale and evidence for teaching CC
The Diversity Research Forum“Tools for
Assessing and Measuring Diversity in Medical
Education” AAMC
“Cultural Competence Education” AAMC
“Recommendations for Teaching about
Racial and Ethnic Disparities in Health and
Health Care”, Wally R. Smith, MD; Joseph R.
Betancourt, MD, MPH; position paper, Annals of
Internal Medicine
Development of cultural competency curriculum
Betancourt, J.R. (2003). Cross-cultural Medical
Education: Conceptual Approaches and
Frameworks for Evaluation. Acad Med, 78(6),
560-569.
Tervalon, M. (2003). Components of Culture
in Health for Medical Students’ Education.
Acad Med, 78(6), 570-576.
Kagawa-Singer, M. & Kassim-Lakha, S. (2003). A
Strategy to Reduce Crosscultural
Miscommunication and Increase the
Likelihood of Improving Health Outcomes.
Acad Med, 78(6), 577-587.
Evaluation
Pretest-Posttests
Approach to Unknown Clinical Cases
Presentation of Clinical Cases
Objective Structured Clinical Exams
ATTITUDES
Has the student learned the particular
importance of humility, empathy, and
respect in cross-cultural encounters?
Does the student reflect on his/her own
bias and prejudice?
Has the student developed flexibility in
making decisions and negotiating?
Clinician self-assessment and reflection
tools
Implicit Association Test is a tool to allow
individuals to gain greater awareness about their
own unconscious preferences and beliefs.
https://implicit.harvard.edu/implicit/demo/select
atest.html
National Center for Cultural Competence has
self-assessment tools for organizations and
practicing physicians:
http://gucchd.georgetown.edu/nccc/selfassessm
ent.html
Stereotyping and Medical Decision-Making
• The Commonwealth Fund http://www.cmwf.org
Excellent article describing the levels of racism:
Jones CP. Levels of racism: A theoretic
framework and a gardener's tale. American
Journal of Public Health; Aug 2000; 90, 8; 12121215.http://www.cahealthadvocates.org/_docs/n
ewsletter/2005/Levels-Of-Racism.pdf
interactive exercise (Bafa Bafa)
http://www.simulationtrainingsystems.com/schools
charities/bafa.html
Self-assessment and reflection
Taught as case-based, on-line
Taught in interviewing, professionalism,
ethics, clinical rotations
Evaluation
Standard Surveying
Structured Interviewing
Self-Awareness Assessment
Presentation of Clinical Cases
Objective Structured Clinical Exam
Videotaped/Audio-taped Clinical
Encounters
SKILLS
Has the student learned how to explore
core cross-cultural issues and the
explanatory model?
Has the student learned how to effectively
negotiate with a patient?
Has the student demonstrated respect for
the beliefs of others?
Has the student demonstrated selfreflection?
Cultural and Linguistic competence
L-E-A-R-N model
Kleinman’s Questions
Integrated into interviewing, health-care
delivery, epidemiology, public health,
genetics, pharmacology classes, medicine
Taught using case-based modules
Cultural Conflicts discussed as part of
ethics, professionalism, medicine
Cross-Cultural Skills
• L-E-A-R-N Model of Cross Cultural Encounter Guidelines
for Health Practitioners. On the Diversity Rx website.
Accessed at:
http://www.diversityrx.org/HTML/MOCPT2.htm
• Multicultural Health Best Practices Overview. Includes the
Kleinman questions. On the Diversity Rx website.
Accessed at: http://www.diversityrx.org/best/
• Mutha S, Allen C, Welch M. Toward Culturally
Competent Care A Toolbox for Teaching
Communication Strategies. Center for the Health
Professions, UCSF.
http://futurehealth.ucsf.edu/cnetwork/resources/curricula/d
iversity.html
Evaluation
Presentation of Clinical Cases
Objective Structured Clinical Exam
Videotaped/Audio-taped Clinical Encounter
Role-playing in interviews
Standardized patient (or faculty member)
Observation in clinical rotations
Health disparities
Taught in epidemiology, public health,
professionalism, ethics, pharmacology,
genetics, medicine, interviewing
Health and Health Care Disparities
National Healthcare Disparities Report, 2004
http://www.qualitytools.ahrq.gov/disparitiesreport/browse/browse.a
spx
Smedley BD, Stith AY, Nelson AR, eds. Unequal
Treatment: Confronting Racial and Ethnic
Disparities in Health Care , Institute of Medicine,
2002 http://www.nap.edu/books/030908265X/html
Initiative to Eliminate Racial and Ethnic
Disparities in Health
U.S. Department of Health and Human Services
http://raceandh e alth.hhs.gov
Health Disparities Collaboratives: A National
Efforts to Improve Health Outcomes for All
Medically Underserved People with Chronic
Diseases
http://www.healthdisparities.net
factors underlying health and
health-care disparities
• Freeman HP. Poverty, Culture, and Social
Injustice: Determinants of Cancer
Disparities. CA Cancer J Clin, 2004;54:72-77
http://caonline.amcancersoc.org/cgi/reprint/54/2
/72
• Mokdad AH, Marks JS, Stroup DF, Gerberding JL.
Actual Causes of Death in the United
States, 2000,JAMA. 2004;291:1238-1245.
http://www.csdp.org/research/1238.pdf
Racial/ethnic differences in cardiac care
Henry J Kaiser Family Foundation and the
American College of Cardiology
Foundation.
http://www.kff.org/whythedifference/
• The Commonwealth Fund
http://www.cmwf.org
Resources on the intersection of
race and genetics
• social determinants of health, January 2005
American Psychologist special issue on “Genes,
Race, and Psychology in the Genome
Era”: http://www.genome.gov/13014159
Department of Energy’s Human Genome
Project’s website has linkages to two special
journal issues on race and genetics they
sponsored (November 2004 Nature Genetics;
Spring 2002 Journal for Minority Medical
Students supplement),
http://www.ornl.gov/sci/techresources/Human_
Genome/elsi/minorities.shtml
The Impact of Stereotyping on Medical
Decision-Making
Taught in interviewing, medicine, ethics,
professionalism, internal medicine,
surgery, evidence-based medicine, public
health, clinical rotations
Bias, Discrimination and Racism: the
Impact of Stereotyping on Medical
Decision-Making
Unequal Treatment: Confronting Racial &
Ethnic Disparities in Health. Smedley BD, Stith AY,
Nelson AR. Institute of Medicine. 2002.
http://www.nap.edu/books/030908265X/html/
Slide sets are also available on the Institute of Medicine website:
http://www.iom.edu/?id=4475&redirect=0
The Right to Equal Treatment: An Action
Plan to End Racial and Ethnic Disparities
in Clinical Diagnosis and Treatment in the
United States. 2003.Physicians for Human Rights.
http://www.phrusa.org/research/domestic/race/race_report/report.html
Stereotyping
The University of North Carolina’s minority health
project website has slidesets on these topics
from Dr. Jack Geiger (2005) and other
previous speakers:
http://www.minority.unc.edu/
Van Ryn M, Burke J. The effect of patient
race and socio-economic status on
physicians’ perceptions of patients. Soc Sci
Med 2000;50:813-28.