Desiree Lie

Does Cultural Competency Training of Health Professionals Improve Patient Outcomes? A Systematic Review and Proposed Algorithm for Future Research

BackgroundCultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities.ObjectiveThe objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research.DesignThe authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included.MeasurementsFour authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted.ResultsSeven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect.ConclusionThere is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Comparative survey of Complementary and Alternative Medicine (CAM) attitudes, use, and information-seeking behaviour among medical students, residents & faculty

BackgroundThere is significant and growing national interest for introducing Complementary and Alternative Medicine (CAM) instruction into allopathic medical education. We measured CAM attitudes, use, and information-seeking behaviors as a baseline to evaluate future planned CAM instruction.MethodsCross-sectional and longitudinal survey data on CAM attitudes, modality use, and common information resources was collected for (a) medical students (n = 355), (b) interns entering residencies in medical and surgical disciplines (n = 258), and (c) faculty from diverse health professions attending workshops on evidence-based CAM (n = 54). One student cohort was tracked longitudinally in their first, second and third years of training.ResultsCompared to medical students and interns, faculty who teach or intend to integrate CAM into their instruction had significantly (p < .0005) more positive attitudes and used CAM modalities significantly (p < .0005) more often. Medical students followed longitudinally showed no change in their already positive attitudes. The 3 survey groups did not differ on the total number of CAM information resources they used. Each group surveyed used about two out of the five common information sources listed, with the Internet and journals most frequently cited.ConclusionStudents, interns and a selected faculty group demonstrate positive attitudes toward CAM and frequently use various CAM modalities. CAM instruction should therefore be focused on acquiring knowledge of available CAM modalities and skills to appraise evidence to appropriately advise patients on best approaches to CAM use. Trainees may benefit from exposure to a wider array of CAM information resources.

Using standardized patients to assess medical students' professionalism.

STANDARDIZED PATIENTS—WILL THE QUESTIONS NEVER END? Moderator: Craig Scott, PhD Using Standardized Patients to Assess Medical Students’ Professionalism ´ LIE, JOHANNA SHAPIRO, JOHN BOKER, and STEPHEN RADECKI MICHAEL D. PRISLIN, DESIREE The subject of professionalism is currently engendering great inter- est within the medical education community. Concern exists that conditions within the health care delivery environment threaten established standards of professional behavior, and, perhaps more insidiously, that the medical education experience itself may be negatively influencing the development of physicians’ profession- alism. 1–3 As a consequence, much energy has recently been directed toward defining competencies that reflect professionalism and in creating corresponding curricula that will foster learning in this domain. 4–6 However, having instruments that can accurately measure the attainment of professionalism remains an elusive goal. 7–9 This study examines the utility of standardized patient-based assessments of professional characteristics. Comparisons are made with other mea- sures of professionalism, such as faculty evaluation, performance on a written self-reflective exercise, and student-reported participation in community service activities. Method This study was conducted at the University of California, Irvine (UCI), College of Medicine. Participants were students completing the year two patient–doctor course during the 1999–00 academic year. This course represents the second segment of a vertically in- tegrated four-year course sequence in professional skill develop- ment. The year two segment focuses on patient–physician com- munications, physical diagnosis, and the development of basic clinical reasoning skills. Eight core clinical modules are linked to topics concurrently being taught in the year-two pathology, path- ophysiology, and pharmacology courses. Each module begins with a standardized patient interaction, followed by generation of learn- ing issues within small tutorial groups. Mid-module activities in- clude topical didactic presentations and physical diagnosis instruc- tion. Each module concludes with a wrap-up session in which the diverse learning activities are tied together through small-group dis- cussion of the original learning issues. These discussions typically feature a heavy emphasis on patient–physician communication and professional behavior. Assessments of students occurring during the course consist of a written final examination, structured written evaluations completed by the faculty group leaders, and an appraisal of clinical skills. The clinical skills appraisal for 1999–00 consisted of a three-station standardized-patient–based examination. The cases were a patient presenting with fatigue, a patient presenting with upper gastroin- testinal and chest discomfort, and a patient presenting with tran- sient neurologic deficits. The first two cases each entailed 25 minutes and the third case entailed 35 minutes of patient contact. Each station required students to perform a history and physical examination. In addition, students performed a rapid computer- based literature search following the initial encounter with the neu- rology case, written and oral clinical presentations following the fatigue case, and a written reflective essay, pertaining to students’ reactions to a poem describing a 39-year-old man experiencing an acute myocardial infarction and sudden death, following the upper gastrointestinal and chest pain case. Each standardized patient en- counter included assessments of history and physical exam perfor- mance based on a checklist and assessments of communication S90 skills and professionalism using a rating scale. The rating scale for communication skills used in this study was a modification of the Communications Skills Form developed at East Tennessee State University by Forrest Lang, MD, to assess patient-centered com- munications as evaluated by standardized patients. It is based upon an instrument developed by the American Board of Internal Med- icine to assess patients’ satisfaction. The rating scale includes six items relating to communication that are reported here as the cu- mulative communication score; a single item relating to overall professional competence; and a single item relating to overall stan- dardized patients’ satisfaction. The professionalism scale used for this study was constructed based upon the work of Arnold and colleagues, 9 and consisted of three items: one that allowed stan- dardized patients to rate students’ knowledge and competence, one that rated students’ integrity, and one that rated students’ altruism. Taken together, these three items are reported as the cumulative professionalism score. The specific rating scale items for commu- nication and professionalism are presented in List 1. Both the communication and the professionalism rating instru- ments used five-point Likert scales with the following specific an- chors: 5—outstanding; 4—very good; 3—good; 2—needs improve- ment; 1—marginal. Therefore, the maximum achievable scores were: cumulative communications—30 points, cumulative profes- sionalism—15 points, professional competence—5 points, and overall satisfaction—5 points. Standardized patients received de- tailed verbal and written instructions on how to complete the com- munication scale, including descriptive anchors for performance at varying levels of competence, and were observed rating perfor- mances using practice tapes before participating in the examina- tion. In terms of the specific professionalism items, the standardized patients were instructed to respond based upon their own personal perceptions of the students. Fourteen standardized patients were used during the course of the examination: seven for the fatigue case, three for the chest-discomfort case, and four for the neurology case. Faculty evaluations of students’ performances during the patient– doctor II course were based on an 11-item rating scale in which one item assessed whether the student ‘‘demonstrates professional behavior.’’ This evaluation also used a five-point Likert scale in which five represented outstanding, four represented above ex- pected, three represented at expected, two represented below ex- pected, and one represented problematic performance. Hence the maximum possible score for faculty professionalism ratings was five points. Evaluating faculty received verbal instructions regarding evaluating students’ performances during faculty development ses- sions. Evaluation of the professionalism item focused on students’ citizenship and academic honesty, team participation, and inter- actions with standardized patients during the interview sessions. The essay was scored by one of the study’s authors for emotional content and problem-solving capacity using a modification of a method described by Pennebaker and colleagues. 10 Subscale scores relating to empathy and positive coping attitudes were used as mea- sures reflecting students’ expressions of professional attributes. The scores students received represented a sum of these two subscales. Students’ descriptions of their participation in community ser- vice activities were elicited by means of a written survey distributed at the conclusion of the skills-appraisal exercise. Participation was scored as ‘‘did’’ or ‘‘did not’’ participate. A CADEMIC M EDICINE , V OL . 76, N O . 10 / O CTOBER S UPPLEMENT 2001

Interpreting Values Conflicts Experienced by Obstetrics-Gynecology Clerkship Students Using Reflective Writing

Purpose To examine students’ responses to reflective practice assignments used in medical ethics and professionalism education. The study goals include an examination of what reflective writing reveals about students’ personal and professional values, identification of the narrative typologies students use to tell stories of ethical dilemmas, and a determination of the usefulness of reflective writing in informing ethics/professionalism curricula assessment and development. Method This study employed a mixed-methods design generating both descriptive data and interpretive analysis. Students’ reflective writing assignments, guided by a series of six questions designed to elicit students’ perceptions of moral conflicts they have encountered and their personal and professional ethical values, were collected from three successive cohorts of third-year medical students (n = 299) from July 2002 to January 2006 during an obstetrics-gynecology clerkship at the University of California, Irvine, School of Medicine. Content, thematic, and global narrative analyses of students’ reflective writing were conducted, drawing on content analysis, grounded theory, and narrative methodologies. Results Values conflicts usually were patient centered (181; 60.5%) and student centered (172; 57.5%), without much regard for important contextual issues such as patients’ socioeconomic status, insurance coverage, or culture. Common personal values included religious beliefs (82; 27.4%), respect (72; 24.1%), and the Golden Rule (66; 22.1%); frequent professional values were respect (72; 25.1%), beneficence (71; 23.7%), nonmaleficence (69; 23.1%), and autonomy (65; 21.7%). Whereas 35.5% (106) claimed to have addressed conflicts, 23.4% (70) said they did nothing. Restitution narratives (113; 37.8%) dominated. Conclusions This analytic approach facilitated assessment of student values, conflict sources, and narrative types. Findings reveal aspects of the influence of the hidden curriculum and can inform strategies for effective implementation of bioethics/professionalism curricula.

Being the best we can be: medical students' reflections on physician responsibility in the social media era.

Purpose To examine attitudes, self-reported behaviors, and intended actions related to medical students’ use of online social media after an educational intervention. Method In 2011, 180 first-year medical students at the Keck School of Medicine participated in a required two-hour session on the relevance of online social media use to professionalism. Students submitted postsession written reflections about their online presence and professional roles. The authors qualitatively analyzed and coded these reflections for emerging themes. They also examined postsession evaluations and conducted a four-month follow-up survey to identify changes in students’ online social networking behaviors. Results All 180 students submitted written reflections and postsession evaluations. The authors identified 10 theme categories within three domains (immediate action, intended future action, value change) from the reflections. The most common themes were “role awareness” (144/539), “did nothing” (94/539), and “intention to edit” (84/539). On a scale of 1 to 5, students rated the overall session quality at 3.92 (standard deviation 0.28). Sixty-four percent (115/180) of the students responded to the follow-up survey. Of those, 40% (46/115) reported editing or changing their Web presence after the session, and 24% (28/115) anticipated spending less time on online social networking. Conclusions Attending a required session in a professionalism course led to thoughtful reflection, increased professional role awareness, and intention to edit and monitor future online presence among first-year medical students. After four months, students reported continued monitoring and editing of their online presence. Future studies should examine whether reinforcement throughout training is needed to maintain vigilance.

What Do Health Literacy and Cultural Competence Have in Common? Calling for a Collaborative Health Professional Pedagogy

Limited health literacy is recognized as contributing to racial/ethnic and other health disparities through mechanisms of poor understanding and adherence, as well as to limited access to health care. Recent studies have focused on interventions to address literacy gaps between patients and health care providers, focusing on communication techniques and redefining the responsibility for closing gaps. Cultural differences between patient and provider, if left unaddressed, have been shown to contribute to poor health outcomes through misunderstanding, value conflicts, and disparate concepts of health and illness. The dual challenges of limited health literacy and cultural differences are likely to increase with an expanding, increasingly diverse, and older population. There is evidence that training providers to attend to both issues can reduce medical errors, improve adherence, patient-provider-family communication, and outcomes of care at both individual and population levels. The two fields continue to have separate trajectories, vocabularies, and research agendas, competing for limited curricular resources. This article presents a conceptual framework for health professions education that attends simultaneously to limited health literacy and cultural differences as a coherent way forward in training culturally competent providers with a common skill-set to deliver patient-centered care that focuses on health disparities reduction.

Revising the Tool for Assessing Cultural Competence Training (TACCT) for curriculum evaluation: Findings derived from seven US schools and expert consensus

Abstract Background: The 67-item TACCT currently used for needs assessment has potential for evaluating evolving cultural competence (CC) curricula. Purpose: To validate a shortened, more practical TACCT measure. Methods: The 67-item TACCT was administered to students and course directors at US schools. Course directors and students reported which of 67 TACCT items were taught. Intraclass correlation coefficients (ICC) examined faculty-student agreement. Under-addressed content was identified. A new and shortened TACCT configuration was proposed and validated with expert educator input. Results: Across-school faculty and student response rates ranged from 75% to 100%. Aggregate ICC was 0.90 (95% CI: 0.84, 0.94) for the 67-item TACCT, demonstrating faculty-student agreement. Experts agreed on reduction from 67 to 42 items and domain revision from five to six domains to match under-addressed content. Item analysis showed high internal consistency for all 6 new domains and the total revised 42-item TACCT. Conclusions: A shorter, more practical TACCT measure is valid and reliable and focuses on under-addressed CC content. Use for curricular evaluation is suggested.

Herbals Used for Diabetes, Obesity, and Metabolic Syndrome

Diabetes mellitus and particularly noninsulin-dependent diabetes (type 2 diabetes) is an increasingly prevalent condition worldwide with serious consequences of multiorgan involvement and in particular cardiovascular and renal disease. Obesity is a significant risk factor for type 2 diabetes, and its incidence has doubled in the past 2 decades among younger adults, adolescents, and children globally. Inflammation and insulin resistance are the underlying mechanisms for metabolic syndrome (MetS) and its increased risk of cardiovascular, renal, and pulmonary morbidity and mortality. MetS is affecting younger populations with adverse consequences seen in later years. Dietary supplements and herbals are often marketed for these conditions. This article review common herbals and supplements marketed or used by patients with diabetes, obesity, and MetS.

Comparison of emergency medical services systems in the pan-Asian resuscitation outcomes study countries: Report from a literature review and survey

Asia–Pacific countries have unique prehospital emergency care or emergency medical services (EMS) systems, which are different from European or Anglo‐American models. We aimed to compare the EMS systems of eight Asia–Pacific countries/regions as part of the Pan Asian Resuscitation Outcomes Study (PAROS), to provide a basis for future comparative studies across systems of care.

A comparison of two scales for assessing health professional students’ attitude toward interprofessional learning

Rationale The validated 19-item Readiness for Interprofessional Learning Scale (RIPLS) is often used for assessing attitudes toward interprofessional education (IPE). The 12-item Interdisciplinary Education Perception Scale (IEPS), also used for this purpose, has not been validated among the professions of medicine, pharmacy, and physician assistants (PAs). The discriminatory ability of the two scales has not been directly compared. Comparison of the two will aid educators in selecting the optimal scale. Objective To compare psychometric properties of the RIPLS and IEPS and to examine the ability of each scale to discriminate mean scores among student subgroups (gender, profession, seniority, and prior IPE exposure). Method We conducted a cross-sectional (Qualtrics©) survey (RIPLS and IEPS) of junior and senior students in medicine (n=360), pharmacy (n=360), and the PA profession (n=106). Descriptive statistics were used to report aggregate mean scores of subgroups. The internal consistency of each scale was assessed using Cronbachs α. Concurrent validity was measured by Pearsons correlation coefficients. Independent-sample t-tests and analysis of variances (ANOVAs) were performed to assess the discriminatory ability of each scale. Cohens d effect sizes were calculated for all significant pair-wise comparisons. Results Response rate was 82%. Cronbachs α was 0.85 (RIPLS) and 0.91 (IEPS). The RIPLS discriminated scores by gender among junior students only, and scores by IPE exposure among all students. The IEPS distinguished score differences for the three professions among junior students and by prior IPE exposure for all three professions. Neither scale detected differences in mean scores by profession among all students or by level of training among the three professions. Conclusions Neither the RIPLS nor the IEPS has greater discriminatory ability for detecting attitude differences among the student subgroups. Reason for differences may be explained by slightly different scale constructs. The RIPLS is designed to assess students’ own attitude toward interprofessional learning, while the IEPS discerns perceived attitudes about team collaboration for students’ own professions and may be more appropriate for more advanced students.