- Email: [email protected]
Cultural competency in healthcare: Learning across boundaries
Patient Education and Counseling 73 (2008) 396–397
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Letter to the Editor Cultural competency in healthcare: Learning across boundaries
A R T I C L E I N F O
A B S T R A C T
Keywords: Patient-centered care Doctor–patient relationship Action research Cross-cultural studies Cultural awareness Faculty development
During 2006–2007, I was fortunate to study and work as a Fulbright Scholar at the Institute for Professionalism and Ethical Practice, Children’s Hospital, Boston. As part of my Fulbright experience in the United States, I collaboratively developed a cross-cultural educational experience between the faculty of the Institute of Professionalism and Ethical Practice and of the Chair of Medical Psychology, San Paolo Hospital, Milan to explore how patient-centered care is interpreted and enacted across cultures. Both groups wrote a patient-centered dialogue based on the same clinical scenario. Dialogues were exchanged and each group commented on the other’s dialogue during a videoconference. Both groups identified responding to the patient’s illness experience and emotions as central to patient-centeredness, while patient autonomy was understood differently. Constructing an ideal patient-centered dialogue and the discussion with a group of another culture enabled participants to become more aware of their implicit assumptions about patient-centeredness. This experience helped both groups to better understand our ‘blind spots’ and enhance our cultural humility. It was thanks to the ‘other’ that we ultimately learned more about ourselves. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Cultural competency has been recognized as core component of medical curricula in our increasingly diverse and multicultural society [1]. To date, educational experiences offered in American medical schools and reported in international journals have focused on teaching cultural competency through formal didactics and self-reflection [2]. Yet, the complexity of culture, as a system of meanings shared by a group of people [3], and related cultural sensitivity are difficult to impart cognitively merely on Power Point slides. During 2006–2007, I was fortunate to study and work as a Fulbright Scholar at the Institute for Professionalism and Ethical Practice, Children’s Hospital Boston. The Fulbright Program aims to promote mutual understanding between people of different countries by sponsoring exchange students. I had never been in United States before and the differences between the American and the Italian ‘‘medical culture’’ immediately struck me. As part of my Fulbright experience in the United States, I collaboratively developed a cross-cultural educational experience between the faculty of the Institute of Professionalism and Ethical Practice, Children’s Hospital Boston and Harvard Medical School, and of the Chair of Medical Psychology, San Paolo Hospital, Milan and University of Milan [4]. Faculties of both groups were experienced in teaching and researching communication and relationships in healthcare. During the project, the two groups independently wrote what they considered a patient-centered dialogue between a doctor and a patient in response to the same clinical scenario. The dialogues were translated and exchanged. The two groups then had the opportunity to read and comment independently on the dialogues written by the other faculty by means of a questionnaire. Reciprocal comments generated from 0738-3991/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.07.048
the questionnaire were subsequently e-mailed to each group and then shared through international videoconference. This joint discussion brought to light assumptions and values inherent to the model of patient-centered care in the two groups. The process of constructing an ideal patient-centered dialogue and the discussion with a group of another culture enabled participants to become more aware of their implicit assumptions about patient-centered care, thus gaining insight into their ‘‘blind spots’’ [5]. Both groups identified responding to the patient’s illness experience and emotions as central to patient-centered care, while patient autonomy was identified only by the American group as a feature of patient-centered care. Interestingly, the patient’s physical and psychological boundaries were interpreted differently in the American and Italian dialogues. The Italian physician was more respectful in exploring the patient’s illness experience and less respectful in examining the patient’s body than the American physician, and vice versa. One of the main lessons learned by participants was the importance of finding a balance between medical guidance and respect for patient’s autonomy that might best suit each individual patient in order to provide a truly patient-centered care. Experiential learning about cultural differences in patientcentered care was the focus of the project. The experiential approach described here based on action research methodology offers an engaging, cost-effective means for groups to learn together through actual cultural exchange. Promoting cultural understanding in health care has the potential not only to enhance our sensibility and competence when caring for patients of different cultures, but also to improve our models of care delivery with more genuine awareness. Indeed, this experience affected
Letter to the Editor / Patient Education and Counseling 73 (2008) 396–397
the participants and me personally and professionally and helped both groups to better understand our blind spots and enhance our cultural competence. It was thanks to the ‘‘other’’ that we ultimately learned more about ourselves. Acknowledgments I wish to thank all the American and Italian colleagues who enthusiastically participated in this study. I am very grateful to Raffaella Balestrieri, RN, David Browning, MSW, Elena Faioni, MD, Elaine Meyer, PhD, Emanuela Mauri, MD, Egidio Moja, MD, Elizabeth Rider, MD, Robert Truog, MD, and Elena Vegni, MS, for their time, effort and valuable contributions to the project, and to the Fulbright commission for providing me the opportunity to spend two enriching years in Boston. References [1] Donini-Lenhoff F, Hedrick H. Increasing awareness and implementation of cultural competence principles in health professions education. J Allied Health 2000;29:241–5. [2] Murray-Garcı´a JL, Harrell S, Garcı´a JA, Gizzi E, Simms-Mackey P. Self-reflection in multicultural training: be careful what you ask for. Acad Med 2005;80:694–701.
397
[3] Geertz. The interpretation of cultures. New York: Basic Books Inc.; 1973. [4] Lamiani G, Meyer EC, Rider EA, Browning DM, Vegni E, Mauri E, Moja EA, Truog RD. Assumptions and blind spots in patient-centeredness: action research between American and Italian healthcare professionals. Med Educ 2008;42: 712–20. [5] Luft J, Ingham H. The Johari window, a graphic model of interpersonal awareness. In: Proceedings of the western training laboratory in group development. Los Angeles: UCLA; 1995.
Giulia Lamiani* Chair of Medical Psychology, San Paolo Hospital, University of Milan, Italy Institute for Professionalism and Ethical Practice, Children’s Hospital, Harvard Medical School, Boston, USA *Correspondence address: San Paolo Hospital, Via Di Rudini’ 8, 20142 Milan, Italy. Tel.: +39 02 5032 3129; fax: +39 02 5032 3015 *E-mail address: [email protected] 13 June 2008
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Letter to the Editor Cultural competency in healthcare: Learning across boundaries
A R T I C L E I N F O
A B S T R A C T
Keywords: Patient-centered care Doctor–patient relationship Action research Cross-cultural studies Cultural awareness Faculty development
During 2006–2007, I was fortunate to study and work as a Fulbright Scholar at the Institute for Professionalism and Ethical Practice, Children’s Hospital, Boston. As part of my Fulbright experience in the United States, I collaboratively developed a cross-cultural educational experience between the faculty of the Institute of Professionalism and Ethical Practice and of the Chair of Medical Psychology, San Paolo Hospital, Milan to explore how patient-centered care is interpreted and enacted across cultures. Both groups wrote a patient-centered dialogue based on the same clinical scenario. Dialogues were exchanged and each group commented on the other’s dialogue during a videoconference. Both groups identified responding to the patient’s illness experience and emotions as central to patient-centeredness, while patient autonomy was understood differently. Constructing an ideal patient-centered dialogue and the discussion with a group of another culture enabled participants to become more aware of their implicit assumptions about patient-centeredness. This experience helped both groups to better understand our ‘blind spots’ and enhance our cultural humility. It was thanks to the ‘other’ that we ultimately learned more about ourselves. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Cultural competency has been recognized as core component of medical curricula in our increasingly diverse and multicultural society [1]. To date, educational experiences offered in American medical schools and reported in international journals have focused on teaching cultural competency through formal didactics and self-reflection [2]. Yet, the complexity of culture, as a system of meanings shared by a group of people [3], and related cultural sensitivity are difficult to impart cognitively merely on Power Point slides. During 2006–2007, I was fortunate to study and work as a Fulbright Scholar at the Institute for Professionalism and Ethical Practice, Children’s Hospital Boston. The Fulbright Program aims to promote mutual understanding between people of different countries by sponsoring exchange students. I had never been in United States before and the differences between the American and the Italian ‘‘medical culture’’ immediately struck me. As part of my Fulbright experience in the United States, I collaboratively developed a cross-cultural educational experience between the faculty of the Institute of Professionalism and Ethical Practice, Children’s Hospital Boston and Harvard Medical School, and of the Chair of Medical Psychology, San Paolo Hospital, Milan and University of Milan [4]. Faculties of both groups were experienced in teaching and researching communication and relationships in healthcare. During the project, the two groups independently wrote what they considered a patient-centered dialogue between a doctor and a patient in response to the same clinical scenario. The dialogues were translated and exchanged. The two groups then had the opportunity to read and comment independently on the dialogues written by the other faculty by means of a questionnaire. Reciprocal comments generated from 0738-3991/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.07.048
the questionnaire were subsequently e-mailed to each group and then shared through international videoconference. This joint discussion brought to light assumptions and values inherent to the model of patient-centered care in the two groups. The process of constructing an ideal patient-centered dialogue and the discussion with a group of another culture enabled participants to become more aware of their implicit assumptions about patient-centered care, thus gaining insight into their ‘‘blind spots’’ [5]. Both groups identified responding to the patient’s illness experience and emotions as central to patient-centered care, while patient autonomy was identified only by the American group as a feature of patient-centered care. Interestingly, the patient’s physical and psychological boundaries were interpreted differently in the American and Italian dialogues. The Italian physician was more respectful in exploring the patient’s illness experience and less respectful in examining the patient’s body than the American physician, and vice versa. One of the main lessons learned by participants was the importance of finding a balance between medical guidance and respect for patient’s autonomy that might best suit each individual patient in order to provide a truly patient-centered care. Experiential learning about cultural differences in patientcentered care was the focus of the project. The experiential approach described here based on action research methodology offers an engaging, cost-effective means for groups to learn together through actual cultural exchange. Promoting cultural understanding in health care has the potential not only to enhance our sensibility and competence when caring for patients of different cultures, but also to improve our models of care delivery with more genuine awareness. Indeed, this experience affected
Letter to the Editor / Patient Education and Counseling 73 (2008) 396–397
the participants and me personally and professionally and helped both groups to better understand our blind spots and enhance our cultural competence. It was thanks to the ‘‘other’’ that we ultimately learned more about ourselves. Acknowledgments I wish to thank all the American and Italian colleagues who enthusiastically participated in this study. I am very grateful to Raffaella Balestrieri, RN, David Browning, MSW, Elena Faioni, MD, Elaine Meyer, PhD, Emanuela Mauri, MD, Egidio Moja, MD, Elizabeth Rider, MD, Robert Truog, MD, and Elena Vegni, MS, for their time, effort and valuable contributions to the project, and to the Fulbright commission for providing me the opportunity to spend two enriching years in Boston. References [1] Donini-Lenhoff F, Hedrick H. Increasing awareness and implementation of cultural competence principles in health professions education. J Allied Health 2000;29:241–5. [2] Murray-Garcı´a JL, Harrell S, Garcı´a JA, Gizzi E, Simms-Mackey P. Self-reflection in multicultural training: be careful what you ask for. Acad Med 2005;80:694–701.
397
[3] Geertz. The interpretation of cultures. New York: Basic Books Inc.; 1973. [4] Lamiani G, Meyer EC, Rider EA, Browning DM, Vegni E, Mauri E, Moja EA, Truog RD. Assumptions and blind spots in patient-centeredness: action research between American and Italian healthcare professionals. Med Educ 2008;42: 712–20. [5] Luft J, Ingham H. The Johari window, a graphic model of interpersonal awareness. In: Proceedings of the western training laboratory in group development. Los Angeles: UCLA; 1995.
Giulia Lamiani* Chair of Medical Psychology, San Paolo Hospital, University of Milan, Italy Institute for Professionalism and Ethical Practice, Children’s Hospital, Harvard Medical School, Boston, USA *Correspondence address: San Paolo Hospital, Via Di Rudini’ 8, 20142 Milan, Italy. Tel.: +39 02 5032 3129; fax: +39 02 5032 3015 *E-mail address: [email protected] 13 June 2008