Approaching Cultural Competency
in Medical Education
Videsh
Kapoor
• Family physician, suburban practice
• Director, Division of Global Health (Family
Practice)
• MD Undergraduate Program Global Heath
Coordinator
• Faculty Advisor, Global Health Initiative
Defining cultural competency
•
•
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Culture matters
Cultural context matters more
Culture is not static
Cultural factors impact diagnosis, treatment, and
care.
• Cultural factors impact professional
communication
• Does cultural knowledge improve clinical
outcomes?
• What is the role of political correctness in
cultural competency?
A call for cultural competency
• LCME directive: the need for medical
students “to recognize and appropriately
address gender and cultural biases in
health care delivery.”
• FMEC recommendations for prioritizing
social accountability and responsibility
•
5
Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Functions and Structure of
a Medical School. Washington, DC: Liaison Committee on Medical Education; 2007.
What defines cultural competency?
• knowledge of characteristics, cultural
beliefs, and practices of different
nonmajority groups, and skills and
attitudes of empathy and compassion in
interviewing and communicating with
nonmajority groups.
•
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(Kumagai et al, 2009)
Defining cultural competency?
• ‘a set of congruent behaviors, attitudes,
and policies that come together in a
system, agency, or among professionals
and enable that system, agency, or those
professionals to work effectively in crosscultural situations’
•
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Cross, Bazron, Dennis & Isaacs, 1989 or 1999
Going beyond the concept of
Cultural Competency
• involves the fostering of a critical
awareness—a critical consciousness—of
the self, others, and the world and a
commitment to addressing issues of
societal relevance in health care.
•
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Kumagai et al 2009
Deconstructing the notion of
cultural competency
Cultural competency isn’t an endpoint, but rather
a ongoing process involving multiple factors
…..as is culture.
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Synergistic processes
Cultural awareness
understanding differences and one’s own assumptions,
values, and biases
Cultural security
provision of services offered by the health system will
not compromise the legitimate cultural rights, values
and expectations
Cultural respect
recognition, protection and continued advancement
of the inherent rights, cultures and traditions
Cultural safety
undertaking a process of reflection on one’s own
cultural identity and recognizes the impact of our own
culture on our practice. Unsafe cultural practice is any
action which diminishes, demeans or disempowers the
cultural identity and well-being of an individual. (Papps,
2005, p. 25)
Cultural humility
lifelong commitment to self-evaluation and critique;
addressing the power imbalances between patientphysician (teacher/student) and developing mutually
beneficial…partnerships (Tervalon, Murray-Garcia)
What is the object of knowledge in
Cultural Competency
? learning a series of lists of cultural attributes,
which can create dehumanizing stereotypes
? a skill-set of questions and demeanors we
should assume when encountering a patient
(student) who is not like us
• Development of a critical consciousness of the
knowledge and awareness to carry out the
social roles and responsibilities of a physician
(and teacher)
•
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Kumagai et al, 2009
Cultural Competency Initiative
Jaspreet Mangat, Andrew Wong, Aiza Waheed, Sally Ke
• Introduction to Communications Skills
INDE 410 – first year medicine
• Pilot – year one – readings and
discussion, including a self-assessment
survey and discussion
• Pilot – year two – modify readings, add
video teaching tool – interviews of patients
and physicians; LEARN / RESPECT
model
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LEARN
• Listen with sympathy and understanding to the
patient's perception of the problem*
• Explain your perceptions of the problem
• Acknowledge and discuss the differences and
similarities
• Recommend treatment / plan
• Negotiate agreement / plan
• *Year one focus on FIFE and explanatory model approach
•
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Berlin, E. & Fowkes, W.A.(1983)
RESPECT
• Respect
• Explanatory model
• Social context, including Stressors, Supports,
Strengths, and Spirituality
• Power
• Empathy
• Concerns
• Trust/ Therapeutic alliance/ Team.
•
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Welch, M. (1998). Enhancing awareness and improving cultural competence in health care. A
partnership guide for teaching diversity and cross-cultural concepts in heath professional training.
Translating RESPECT to the
preceptor-student relationship
• Empathic listening skills may wither in
students whose own concerns are
routinely ignored
• Incorporating the student’s own values,
worldview, and experiences
• Addressing power dynamics in teaching
relates to the concept of eliminating health
disparities and a call for social justice and
respect for social roles and responsibilities
•
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Kumagai et al, 2009
Precepting with RESPECT
Adapting patient-care model to preceptor-learner relationship
• Harnessing the
parallels between
educational and
clinical encounters
•
(Carol Mostow et al)
Respect/Rapport
• Doctor - patient
• A demonstrable
attitude
communicating the
value and autonomy
of the patient and the
validity of his/her
concerns
• Preceptor - resident
• Approach learner with
respect
• Builds learner
confidence and
preceptor-resident
relationship
• Reduces
defensiveness
Explanatory Model
• The patient’s
• Elicit the resident’s
understanding of what
thoughts about the
causes their illness,
patient and the
or what will help it
interest in the
patient’s perspective
• Helps preceptor learn
what resident knows
and creates starting
point for discussion
Social Context
• Impact of patient's life
upon illness and of
illness on his/her life.
Include stressors,
supports, strengths,
spiritual resources
that influence patient,
health or care
• Check re. resident’s
well-being and
context; explore
professional and
personal stressors
• Builds relationship
• Models how to act
with patients
Power
• Shared access to
status, control,
resources, options,
and ability to produce
desired outcomes
• Emphasize
partnership,
negotiation or roles
• Find ways to share
power and support
resident self-efficacy;
resist temptation to
takeover in face of
learner’s uncertainty
• Investment in service
and learning
partnership
Empathy
• Verbal and nonverbal
responses that
validate patients’
emotions and cause
them to feel
understood.
• Let resident know
their frustrations and
emotions are heard
• Observe for decline in
resident’s mood and
empathy, as well as
any difference in
patient’s background
• Support resident to
engage more
effectively with patient
Concerns/Fears
• Worries about symptoms,
diagnosis, or treatment,
often unexpressed
• Elicit and address
resident’s concern about
situations they don’t feel
confident handling or fear
will make the visit to long
• Develop strategies to find
solutions
• Replace anxiety with
information to improve
quality and efficiency
Trust, Team-building
• Relationship built on
understanding,
power-sharing and
empathy; patient
confident that doctor
acts on his behalf
• Build on the above
skills to foster trust in
preceptor-student
relationship
• Learners may be
more willing to identify
areas of challenge
References
•
Treating and Precepting with RESPECT: A Relational Model Addressing Race,
Ethnicity, and Culture in Medical Training, Carol Mostow, LICSW,1 Julie Crosson,
MD,2,9 Sandra Gordon, MD,3,9 Sheila Chapman, MD,3,9 Peter Gonzalez, MD,10,11
Eric Hardt, MD,6,9 Leyda Delgado, MD,3,8,9 Thea James, MD,7,9 and Michele
David, MD, MPH, MBA3,4,5,9 ; J General Intern. Med. 2010 May
•
Beyond Cultural Competence: Critical Consciousness, Social Justice, and
Multicultural Education, Arno K. Kumagai, MD, and Monica L. Lypson, MD; Acad
Med, 2009; 84:782-787
•
Anthropology in the Clinic: The Problem of Cultural Competency and How to
Fix It, Arthur Kleinman, Peter Benson, PLoS Medicine, October 2006, Volume 3,
Issue 10, e294
•
Principles and Practices of Cultural Competency: A Review of the Literature
http://www.deewr.gov.au/Indigenous/HigherEducation/Programs/IHEAC/Documents/
PrinciplePracCulturalComp.pdf