Integrating Cultural Competency and Humility Training into Clinical Clerkships: Surgery as a Model

REVIEW

Integrating Cultural Competency and Humility Training into Clinical Clerkships: Surgery as a Model Paris D. Butler, MD,*†‡ Mini Swift, MD,†§储 Shruti Kothari, MPH,† Iman Nazeeri-Simmons, MPH,†¶ Charles M. Friel, MD,* Michael T. Longaker, MD,‡ and L. D. Britt, MD# *Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; †School of Public Health, University of California—Berkeley, Berkeley, California; ‡Department of Surgery, Stanford University, Stanford, California, §Department of Medicine, University of California San Francisco—East Bay, Oakland, California; 储Department of Medicine, Alameda County Medical Center, Oakland, California; ¶San Francisco General Hospital and Trauma Center, San Francisco, California; and #Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia BACKGROUND: Cultural competency is gaining recogni-

tion as an essential strategy by which to address health care disparities. A closer examination of medical school curriculums was undertaken to determine how the need for cultural competency and humility (CCH) training in medical education is being addressed. METHODS: A MEDLINE review of published literature re-

garding CCH training in medical education was performed. Additionally, key informant interviews with influential faculty members from prominent medical institutions were completed. RESULTS: Many academic medical institutions recognize the need for CCH and have successfully integrated it into the first 2 years of their curriculums. However, there seems to be a uniform deficit in CCH training in the third and fourth years of their education. CONCLUSIONS: Recognizing the need for CCH training during the third and fourth years of medical education, we explored the issues inherent to the integration of CCH training in clinical education. Using surgery as a model, we established a set of recommendations to assist clerkship directors and curriculum committees in their efforts to ensure CCH training in the last 2 years of medical education. (J Surg 68:222-230. © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Correspondence: Inquiries to Paris D. Butler, MD, Department of Surgery, University of Virginia School of Medicine, P.O. Box 800300, Charlottesville, VA 22908-0300; fax: (434) 243-5791; e-mail: [email protected]

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INTRODUCTION Improving cultural competency training in medical education will be a fundamental component for addressing existing health care disparities in the United States. The interest in health care provider cultural competence was ignited by a study by CooperPatrick et al.1,2 in 1999 that described that when treated by a Caucasian physician, underrepresented minority (URM) patients viewed their patient– doctor experience as less participatory than Caucasian patients. This might not have served as a tremendous surprise to patients or health care providers around the country, but it was one of the first occasions that there was sound data to support the notion. Health care disparities along cultural and ethnic lines were at the forefront of the Institute of Medicine’s (IOM) agenda at the turn of the 21st century. Undoubtedly influenced by reports, such as that of Cooper-Patrick et al.,2 the IOM suggested that improvement in the health care provider’s level of cultural awareness and competence was as an essential means by which to alleviate health care disparities.3 The U.S. Department of Health and Human Services (DHHS) formulated the first comprehensive review of United States health care disparities related to ethnic, cultural, and socioeconomic status in 2003. As a result, medical education accrediting bodies began to mandate that institutions responsible for providing education in basic science and clinical medicine must also incorporate training for the care of patients from various cultural, ethnic, and socioeconomic backgrounds.1,4 Medical schools have since responded by continuing to refine their educational curricula in the area of cultural competency. Champaneria and Studentjama5 reported that United States medical schools affording cultural competency courses or seminars rose from 13% in 1991 to more than 87% in 2000, a

Journal of Surgical Education • © 2011 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.

1931-7204/$30.00 doi:10.1016/j.jsurg.2011.01.002

reassuring sign that the medical education system was on the right track. Although the initial focus of cultural competency courses in medical schools were important first steps, several challenges regarding how to make this training most effective, yet practical, have arisen. In the setting of medical education, how should cultural competency be defined? At what point in medical education is this training most paramount? Should the skills be taught in a classroom setting, on the wards, or both? Should the skills be taught as adjunct courses or integrated into the current curriculum? How do we measure the effectiveness of the training? We explore all of these questions and pay specific attention to the issues surrounding why a lack of cultural competency training seems to exist once medical students traditionally reach the wards during their third and fourth years. Additionally, a set of recommendations, which includes a sample 8-week surgical clerkship curriculum, has been formulated to assist clerkship directors and curriculum committees in their efforts to ensure that cultural competency is fully integrated into their clinical educational programs.

METHODS To facilitate our inquiry into the current state of cultural competency training in medical education, the paucity of cultural competency training during clinical clerkships, and how best to improve cultural competency training in the future, a literature review and several expert interviews were performed. A MEDLINE review of published literature from 2000 to 2009 regarding cultural competence training in medical education was performed. Interviews were completed with several influential faculty members from prominent institutions that have revealed persistent dedication to advancing cultural competency in medical education. We recognize and acknowledge fully that several other institutions with corresponding faculty have been quintessential in advancing cultural competency training, but the institutions and individuals for this discussion were selected largely because of their newly implemented curriculums. The interviewees included Dr. Ronald Garcia, Assistant Dean for Minority Affairs at Stanford University School of Medicine (Palo Alto, California); Dr. Renee Navarro, Associate Dean of Academic Affairs, Professor of Anesthesia and Director of Academic Diversity at the University Of California, San Francisco (UCSF) (San Francisco, California); Dr. Rene Salazar, Assistant Clinical Professor of Medicine and director of Diversity, UCSF Office of Graduate Medical Education (San Francisco, California); Dr. Robert Higgins, Professor and Director of the Division of Cardiac Surgery at Ohio State University Medical Center (Columbus, Ohio); and Dr. Alden H. Harken, Professor and Chairman of the Department of Surgery at UCSF–East Bay (Oakland, California). In the discussion section, the current surgical clerkship curriculum from UCSF-East Bay was used as a template to recommend a cultural competency and humility (CCH) integrated clinical curriculum. Ad-

ditional information was gathered from UCSFs social and Behavioral Science’s Tool Box.6

DEFINING CULTURAL COMPETENCY How best to define cultural competency is a fundamental question that has numerous interpretations but lacks one unified answer.5,7-10 Competency implies that a health care provider can attain a certain level of knowledge of varying cultures that will enable them to be prepared to interact with patients from various cultural backgrounds. Alternatively, we propose that the intention of cultural competency training is to provide future physicians with an approach for being receptive, empathetic, and compassionate to the various ideas, customs, and lifestyles of the patients for whom they will be responsible for treating. Tervalon and Murray-Garcia7 pointedly suggest that the concept of cultural competency should be repackaged as cultural humility, where the emphasis is on lifelong learning rather than on the acquisition of knowledge as a skill that can be attained in a few short sittings. This reshapes the mindset of those teaching these skills as well as those learning those principles. Thus, in support of this definition, we suggest that CCH training be the preferred terminology and will use it during this discussion. There will likely be everlasting debate over how best to define cultural competency, but this approach seems both practical and equitable.

LITERATURE REVIEW RESULTS Current Medical Education CCH Training Because of the rigorous and frequently rigid structure of medical education curriculums, determining how to include CCH training was clearly not an easy task. To fill this void, many institutions have created adjunct courses once or twice a month that cover CCH concepts. Although this does satisfy the previous deficiency in CCH training, recently it has become apparent that the implementation of these courses as “tag-along” programs has been largely ineffective. As an adjunct, the CCH skills are not employed in the context of the future physicians’ day-to-day patient care activities. Kai et al.11 described clearly the inadequacies of cultural competency accessory programs and recommend that multidimensional integration into a curriculum is imperative to ensure success. Several institutions in the country are recognizing this and are making concessions to integrate the CCH skills into their standard curriculums to make the teaching more practical, realistic, and worthwhile. This also avoids the logistical demands of finding additional lecture time. With CCH fully integrated, the concern of adding more “nonmedical knowledge” to an already encumbered curriculum becomes a nonissue. Our literature review revealed that most CCH initiatives instituted by medical schools have focused on the first 2 years of training.8,10,12,13 Traditional medical education involves the teaching of fundamental basic science knowledge during the

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first 2 years. As a result, a significant portion of time is spent in the lecture hall where the entire class typically is gathered in 1 place. Logistically, this is an ample opportunity for CCH training to be provided to all the matriculants in a relatively uniform manner. From introductory CCH seminars to fully integrated, case-based CCH lectures, many medical institutions have spent an exhaustive amount of time and attention in these first- and second-year courses. In contrast, our MEDLINE review indicated that a paucity of literature describes exposure to CCH concepts during the third and fourth years of medical education, where students leave the classroom and enter the medical/ surgical wards. The 2 articles that were identified displayed that their programs (which they admittedly felt required subsequent study) were commodious in improving the knowledge, attitudes, and perceptions of their students regarding the care of diverse patient populations.14,15 The dearth of literature, in combination with the recent study from Bussey-Jones et al.9 revealing that the mean knowledge of cultural competence among surveyed third-year medical students was nominal, points to a potential opportunity to enhance CCH education.

cational requirements of the interns and residents, with student teaching intertwined. Unfortunately, CCH training has not uniformly percolated to the level of residency programs and therefore, medical students may not consistently have opportunities to integrate concepts that were imparted in the classroom with experiences at the bedside. By no means are we implying that clinical clerkships do not value CCH as much as preclinical departments. However, because of the lack of uniformity of the teaching setting, clerkships face a more difficult task of how best to implement CCH, and Offices of Curricular Affairs have a difficult time ensuring that it takes place successfully. A third hurdle is the fact that there is a lack of ownership of CCH training by individual departments. Many medical schools have faculty dedicated to ensuring that CCH is included in the first 2 years of medical training. This is frequently not the case for individual clinical departments, and as a result, there is a lack of dedication and accountability to CCH integration at the clinical clerkship or resident education level.

Hurdles to Integration of CCH Training in Clinical Clerkships

Ronald Garcia

Despite the multiple benefits of advances in medical-schoolbased CCH initiatives, much work remains to be done. Students seem to receive a robust exposure to CCH in the classroom during the first and second years but still lack an integrated forum for practice in critical areas where lifelong professional habits are developed. Typically, the third and fourth years of medical school are spent in clinical clerkships in major clinical disciplines, such as surgery, internal medicine, and pediatrics. The length of these clinical rotations varies between 4 and 12 weeks. Unlike the first 2 years of education, this phase of learning takes place in the context of clinical situations, specifically at the bedside, in the operating room, or in clinic. On the inpatient services, medical students are assigned to a team that consists usually of an attending physician, resident physicians, and interns who are responsible for patient care and educating the student. Because of this structure, several hurdles exist to fully integrated CCH training. The first obstacle to integrating CCH training is the volume of medical knowledge that must be reviewed and integrated into clinical practice. Numerous topics must be discussed and a finite amount of time. The second impediment is the lack of influence that the Office of Curricular Affairs has over each clinical department. Unlike the first 2 years of medical school where all the students are typically confined to 1 large classroom with a standard set of lectures heavily influenced by the Office of Curricular Affairs, the students’ clerkship curriculums during their third and fourth years are controlled largely by the individual medical/ surgical departments because of the uniqueness of each medical discipline. Typically, clinical departments are structured around the medical/surgical needs of the patients and the edu224

INTERVIEW RESULTS

Dr. Ronald Garcia, Assistant Dean for Minority Affairs at Stanford University School of Medicine, revealed that in 2004 – 2005, Stanford restructured their entire medical school curriculum to institute a systems-based learning program (R. Garcia, personal communication, February 2009). The new first- and second-year curriculum is organized by systems in the human body. Information regarding biochemistry, anatomy, histology, and other basic and clinical sciences are discussed as they relate to each organ system, replacing the traditional approach in which courses were taught sequentially and separately. Additionally, throughout the first 2 years of medical education, Stanford students take a “Practice of Medicine” course where they are provided education on professionalism, ethics, and patient–physician interactions, which would include cultural competency training.16 Dr. Garcia feels that the change in curriculum has been well received and, particularly the commitment to a 2 year long “Practice of Medicine” course, has effectively improved the cultural climate at Stanford University’s School of Medicine. On the contrary, he is concerned that there is a lack of comprehensive and coordinated exposure to CCH training during the clinical clerkships in the third and fourth years of medical education. Dr. Garcia reiterated that during the third and fourth years of medical school, the responsibility of CCH training rests heavily with individual departments (Surgery, Internal Medicine, OB/ GYN, etc). The third and fourth years of training is the time when medical students learn to put theory into practice. Habits formed during these years are the foundation for a lifetime of clinical work. The absence of CCH training during this time could result potentially in the provision of culturally insensitive care by these future physicians after graduation. Required clerkships in pediatrics and family medicine include cultural com-

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petence training and evaluation in their core clerkships. Thus, all Stanford medical students are exposed to CCH training from the perspective of these disciplines. Dr. Garcia feels that Stanford’s Center of Excellence’s collaborative efforts with clerkship directors and the Associate Dean for Medical Education provide an opportunity to expand CCH in other clerkships. However, the lack of faculty prepared to teach cultural competency remains a significant barrier in the subsequent expansion of CCH training. Renee Navarro and Rene Salazar Dr. Renee Navarro, Associate Dean of Academic Affairs, Director of Academic Diversity, and Professor of Anesthesiology at UCSF, disclosed that like Stanford, UCSF, has also redesigned their curriculum recently to incorporate a more systemsbased approach during the first 2 years of medical school (J. R. Navarro, personal communication, February 2009). Similarly, UCSF requires their students to take a professionalism course during their first 2 years of medical school; this course is called “Foundations of Patient Care.”17 In a separate interview, Dr. Rene Salazar, Director of Diversity for the Office of Graduate Medical Education and Assistant Clinical Professor of Medicine at UCSF, added that in addition to the “Foundation of Patient Care” course, UCSF incorporates upward of 7 CCH modules or seminars into the core UCSF organ system first- and second-year academic curriculum (the Essential Core) (R. Salazar, personal communication, March 2009). Incorporation of these CCH seminars is intended to reinforce the significance of the provision of culturally sensitive care to their future patients. Both Dr. Navarro and Dr. Salazar attribute the improvement in opportunities for CCH training at UCSF to the support from the school’s leadership and outside grant funding. Under the direction of the Chancellor of UCSF, several new positions targeting diversity have been created and funded over the last 5 years. Interestingly, despite the success of CCH integration into their curriculum during the first 2 years of their medical students training, Dr. Navarro and Dr. Salazar echoed Dr. Garcia’s concern about the lack of continuity in CCH training during the third and fourth year. Similar to the situation at Stanford, the UCSF Office of Curricular Affairs lacks sufficient influence over the clinical curriculums of the third and fourth years, as they are left to the discretion of the individual medical/surgical departments. Dr. Navarro explained candidly that it has been an uphill battle trying to get the departments fully on board with CCH training of students, residents and faculty, but she remains optimistic.

gain insight into how departmental leadership felt about barriers to and mechanism for improving cultural CCH training in clinical clerkships (R. S. Higgins, personal communication, May 2009). Dr. Higgins expressed many of the same perspectives as the other interviewees; however, he emphasized that diversity of clinical faculty is a cornerstone for addressing health care disparities and CCH training at the clerkship level. Dr. Higgins is published in the area of clinical workforce diversity and has commented on the paucity of URM in academic surgery.18 He advocates for and has identified many advantages of initiatives that seek to increase the diversity of medical school faculty. He has assisted in the development of cultural competency programs in his own institution directed primarily toward first-year medical students as a foundation for ongoing programs through the training cycle. In Dr. Higgins’ estimation, “an effective program to train medical personnel in cross-cultural competence and humility should include the following: self-awareness of one’s own culture and assumptions of Western medical culture, development of basic knowledge of and familiarity with other cultures and the role of the traditional healer in ethnic communities, appreciation for the importance of verbal and nonverbal communication, and the use of trained medical advocates or interpreters in complex medical environments when appropriate.” Alden H. Harken Dr. Harken, former regent of the American College of Surgeons and current Chairman of the Department of Surgery at the University of California, San Francisco-East Bay, has been an advocate for the implementation of CCH training into his surgical department for several years. He shares the sentiment that cultural competence and humility are essential dimensions of medical professionalism. Specifically, Dr. Harken, spoke to the necessity of all medical students, interns, and residents being exposed to a diverse patient population (A. Harken, personal communication, April 2009). He remarked directly that, “augmenting diversity within the teaching environment should, and does, optimize opportunities for professional growth.” He was remiss that more academic institutions do not provide students and residents with an opportunity to work with, learn from, and serve more diverse patient populations. Dr. Harken has been dedicated to promoting the cultural growth of his faculty, residents, students, and entire medical center since assuming the position as Chairman of the Department of Surgery at UCSF-East Bay in 2003. Dr. Harken challenged that it is of the utmost responsibility of the leadership of academic medical school departments, regardless of discipline, to ensure proper diversity among their faculty and resident physicians, in addition to the educational environment from which students and residents should learn.

Robert Higgins Dr. Higgins has served as president of the United Network for Organ Sharing (UNOS), is a recent past-president of the Society of Black Academic Surgeons (SBAS), and is currently the Director of the Ohio State University Medical Center Comprehensive Transplant Center and Professor and Director of the Division of Cardiac Surgery. Dr. Higgins was interviewed to

DISCUSSION Recommendations for Integrating CCH Training into Surgical Clerkships Provided next is a set of recommendations aimed to assist department chairmen and clerkship directors in the successful

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integration of CCH training into clinical clerkships. Our recommendations are based on approaches that have proven to be effective in the literature and from the suggestions rendered by our expert interviewees. We gathered successful components of existing CCH training programs and in conglomerate created a comprehensive set of recommendations, a sample curriculum, and an evaluation tool. We recognize fully that most clerkship directors lack the authority to unilaterally hire new faculty or establish a new position, such as a Director of Diversity. However, in concert with a department chair, a residency program director, and a medical school dean all dedicated to CCH medical education training, these recommendations are indeed attainable. In addition to benefiting patients and future physicians, exhibiting a universal commitment to CCH training is paramount now, perhaps to avoid having them levied by outside organizations when we will likely have limited influence in the matter (which has already been insinuated by 1 state legislature).19,20 Leadership Dedication Several options are available to ensure that leadership is in place for integrating CCH training into medical/surgical clerkships. The Chancellor of the USCF established a formal position titled “Director of Academic Diversity.” This person works with the Dean of USCF’s medical school and with the help of the Graduate Medical Education Director of Diversity and other directors works with the Associate Dean of Curricular Affairs and the medical school curriculum committee to ensure that CCH training is adequately integrated. Many institutions do not currently have such positions, but most do have Offices of Multicultural Affairs. Thus, for medical schools that do not have the financial resources to create a separate administrative position, they could enhance the authority and responsibility of their Director/Dean of Multicultural Affairs to serve in this capacity. Most paradigm shifts start with effective and dedicated leadership. Strong leadership that accepts nothing less than full cooperation from individual departments will be imperative.

DEPARTMENTAL POINT PERSON AND FULL INTEGRATION Each clinical department should train and dedicate 1 of their clinical faculty members to be the point person regarding how CCH education is provided to their medical students and residents. That person should work as the liaison between the departmental clerkship director and the Director/Dean of Academic Diversity or Multicultural Affairs. Faculty members who do not have a strong interest in basic science research and are more fervent about their teaching commitment would be ideal candidates for such a position. This appointed faculty member is afforded the responsibility of integrating CCH training into the existing academic program of their specific discipline (stu226

dent lectures, tumor board or morbidity and mortality conference cases, journal clubs, grand rounds, guest lecturers, etc.). To provide an example, UCSF–East Bay’s surgical clerkship curriculum is examined.21 The surgical clerkship is 8 weeks in length and consists of 16 one-hour lectures on different surgical topics. In an attempt to integrate CCH training into these lectures, it would be commodious to divide these lectures into groups of three or four by general subject matter. Then, after each group, have a lecture with CCH associated clinical vignettes/cases (Table 1). To avoid the stereotypic, “tag-along” CCH lecture concept, these cases will integrate basic medical principles with culturally sensitive discussion points. A proposed 8-week surgical clerkship calendar with sample CCH vignettes is attached (Fig. 1). Student Evaluation It is well recognized that the evaluation process is necessary to ensure the viability of any initiative. Assessing whether an initiative is effective in achieving its intended goals is critical. Surveys are to be completed by medical students at the onset of their first year of medical school and then again at the start of each successive year. Acknowledging the recommendations from Kumas-Tan et al.22 regarding the formulation of CCH measures, surveys should include mixed methods as they are more time and cost efficient than purely qualitative evaluations and more insightful than purely quantitative ones. Additionally, Kumas-Tan et al.22 emphasize that CCH surveys must not assume that culture is only a matter of ethnicity, that culture is only possessed by the minority groups, that cultural incompetence is always a result of discriminatory attitudes toward minority groups, and that cultural competence is measured by the amount of facts a person knows about other cultures. Mandatory completion of the annual surveys should be required, but the results are to be nonpunitive in nature. The surveys should be intended to be reflective, providing feedback to the faculty regarding the effectiveness of the training and yielding opportunities for students to gauge their innate feelings about cultural sensitivity and humility. Examples of an initial and final survey are shown in Fig. 2. At the conclusion of their clinical clerkships, students receive a grade typically composed of a written examination and a subjective evaluation from the faculty and residents of that department. Thus, as part of their subjective evaluation, consideration of their level of CCH displayed to colleagues, residents, faculty, staff, and patients (not just professionalism) will be included. Feedback to the students regarding their academic, professional, and CCH progress will be provided by faculty members during their end of clerkship exit interviews as is customarily performed. Increase the Number of URM Faculty and Residents Dr. Navarro commented that it would be extremely beneficial if medical students were exposed to lectures given by URM fac-

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TABLE 1. Current and Proposed 8-Week Surgical Clerkship Curriculums6,21 Current Surgical Clerkship Curriculum 1. Preoperative care 2. Postoperative complication 3. Abdominal pain 4. Fluid, electrolyte, and acid base Disorders 5. Shock 6. Neck masses/hypercalcemia 7. Swallowing difficulty and pain 8. Vomiting, diarrhea, and constipation

9. Abdominal masses 10. Nonhealing wounds/ plastic surgery 11. Gastrointestinal hemorrhage 12. Biliary and jaundice 13. Abdominal wall and groin masses 14. Skin and soft tissue lesions 15. Gastroesophageal reflux 16. Anorectal problems

Proposed Surgical Clerkship Curriculum 1. Preoperative care 2. Nonhealing wounds/ plastic surgery 3. Skin and soft tissue ⴱ 4. CCH vignettes/cases 5. Vomiting/constipation/ diarrhea 6. Esophagus/gastrointestinal reflux 7. Abdominal pain and masses 8. Gastrointestinal hemorrhage † 9. CCH vignettes/cases

10. 11. 12. ‡ 13. 14.

Hepatobiliary/jaundice Groin mass/urogenital Anorectal CCH vignettes/cases Shock/trauma/acid base 15. Postoperative complications§ 16. CCH vignettes/cases

*CCH 4 —Case #1: Seventy-year-old Native American diabetic man with presentation of lower extremity gangrene leading to amputation. (Learning objectives: etiology of gangrene and treatment regimen, relationship of diet and ethnicity, role of age in the doctor-patient interaction, and barriers to following through with the treatment). Case # 2: Forty-five-year-old African American woman with newly diagnosed stage III, triple-negative breast cancer. (Learning Objectives: breast cancer staging, triple-negative breast cancer and its prognosis, reasons for delay in diagnosis, barriers to breast cancer screening, breast cancer treatment, and issues involving breast reconstruction). †CCH 9 —Case # 1: Forty-eight-year-old Cambodian woman with bowel obstruction secondary to newly diagnosed Stage IV cervical cancer. (Learning Objectives: Causes of bowel obstruction and treatment options; Cervical cancer screening recommendations; Barriers to primary are screening in the immigrant population, Sexual history Taking). Case #2: Fifty-two-year-old Latino American man with bowel perforation found to have stage III colon cancer. (Learning objectives: stages of colon cancer and treatment regimens, colon cancer screening recommendations, barriers to colon cancer screening, language access issues, and economic burden of major surgery). ‡CCH 13—Case #1: Seventy-eight-year-old African American man presents with metastatic prostate cancer. (Learning objectives: hematogenous vs lymphatic spreading tumors, prostate cancer screening and demographic prevalence, provider mistrust, link between diagnosis and identity group, end-of-life care— deciding when not to operate/hospice). Case #2: Twenty-seven-year-old Caucasian man observed in consultation about transgender surgery. (Learning objectives: transgender surgical options, nonjudgmental sexual history-taking techniques, lesbian/gay/bisexual/transsexual lifestyle risks and awareness, self-reflection on unfamiliar situations as a provider, interdisciplinary professional collaboration). §CCH 16 —Case #1: Forty-seven-year-old Spanish-speaking Latino American woman with readmission for wound dehiscence after open cholecystectomy 5 days prior. (Learning Objectives: Diagnosing Cholecystitis; postoperative care for surgical incisions; Dehiscence vs. Evisceration; ASK-TEACH-ASK method for providing postoperative instructions; appropriate use of interpreter services). Case # 2: Nineteen-year-old morbidly obese African American woman observed in consultation for gastric bypass. (Learning objectives: defining obesity; bariatric surgical options and whether age plays a role in treatment, ethnicity, diet, and exercise; sensitive consultation; resource use with social work/dieticians/primary care).

ulty beyond the stereotypical “multicultural lecture.” For this to take place, departments will have to recruit and hire a more culturally diverse faculty to teach medical students (and residents) traditional patient care subject matter. Hiring practices are to be monitored closely by the Director/Dean of Academic Diversity or Multicultural Affairs, who is given significant influence by the Dean of the institution to ensure that URMs are well represented in the applicant pools for faculty vacancies and that search committee members are aware of best practices for recruiting minority faculty. Clinical Immersion Medical students should be required to spend at least 1 day in a specialty concordant underserved clinic or facility for every 4 weeks of a given clerkship (Fig. 1). Obviously, for institutions that serve a culturally diverse patient population already, additional experiences would not be necessary. Nonetheless, there are many places where the primary academic hospital cares for a homogenous population. In these latter cases, the opportunity for students to be exposed to a more diverse health care environment could be profound.

Mandatory Faculty Training Annual mandatory faculty training courses (possibly online) should be completed by all faculty members. As an example, both the Department of Health and Human Services Office of Minority Health and the Virtual Lecture Hall offer online courses that grant CME credit.23,24 Participation data should be collected by the departmental point person and reported to the departmental chairperson and the Director/Dean of Academic Diversity or Multicultural Affairs. The completion of the training will be linked to the Joint Commission on the Accreditation of Health Care Organization’s regulations and quality assurance. Legislation passed in 2005 by the New Jersey state government and enforced by the New Jersey Board of Medical Examiners, now requires the training of physicians in cultural competency; thus, a national movement is likely to be forthcoming.20 Academic medicine should be proactive and implement a CCH training module now rather than waiting for a mandate. Accountability For CCH training to become integrated into clinical clerkship training, someone must take ownership of this initiative and be held accountable. The departmental point person would obvi-

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FIGURE 1. Proposed 8-week surgical clerkship calendar. *Lectures are grouped according to similar subject matter with a corresponding CCH Vignette lecture to follow each group. sAdditionally, students are to participate in the provision of care at an underserved clinic one day for every four weeks of a given clerkship.

ously be evaluated; however, clerkship directors, residency program directors, and departmental chairs should be scrutinized equally regarding CCH teaching opportunities, level of support for the point person, faculty hiring practices, and student/resident survey results. Ultimately, the Director/Dean of Academic Diversity or Multicultural Affairs in connection with the dean of the medical institution would have the authority to control promotions and bonus allocations according to their performance in this arena.

CONCLUSIONS Dr. Barbara Ramsey, Medical Director of Lifelong Care in Alameda County, has observed, “treating everyone the way you would like to be treated works great . . . if everyone is exactly 228

like you” (R. Ramsey, personal communication, 2009). When asked about his study published in the Archives of Internal Medicine, Dr. Thomas Sequist was quoted by the New York Times as saying, “it isn’t that providers are doing different things for different patients. It’s that we’re doing the same thing for every patient and not accounting for their individual needs. Our one-size-fits-all approach may leave minority patients with needs that aren’t being met.”25 These thoughtful, experienced clinicians have evolved practical pearls regarding patient centered care. Their solutions for health care disparities are the result of years of rigorous clinical practice. When a medical student becomes a physician, the enhanced skill levels can be anticipated, but the huge cultural shifts are ignored routinely. The result is a formidable detriment to both patient and doctor. The expectation is for graduating physicians to assume roles that they were

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Proposed First and Fourth Year Medical Student Cultural Co mpetency and Cultural Humility Survey Evaluations 1) In your opinion how strongly is patient quality related with a doctor’s ability to provide ‘Culture Humility’? Qualitative Data 2) In your opinion, in general what are the main problems/obstacles that arise when treating a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are? Qualitative Data 3) What areas do you think you personally need to improve on in regards to treating a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are? Qualitative Data 4) On a scale of 1-10 how comfortable would you feel treating a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are? One being very uncomfortable and ten being very comfortable. Quantitative data 5) Why did you rate yourself the way you did in the previous question? Qualitative Data 6) On a scale of 1-10 how much additional training do you think you need in order to provide efficient and proper care for patients who are of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are
One being you don’t need any additional training. Quantitative data 7) If additional training was provided, what would you like to learn in regards to providing care to those who are “different” than you? Qualitative Data

1) From your first year survey, have your opinions about how strongly patient quality is related with a doctor’s ability to provide ‘Culture Humility’ changed? Why or why not? Qualitative Data 2) In your opinion, in general what are the main problems/obstacles that arise when treating a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are? Qualitative Data 3) How would you deal with the obstacles/problems that you listed above? Qualitative Data 4) On a scale of 1-10 how comfortable would you feel treating a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you are? One being very uncomfortable and ten being very comfortable. Quantitative data 5) On a scale of 1-10, how much do you think you have improved from your first year until now in regards to your ability to treat a patient who is of a different race, ethnicity, gender, social class, sexual orientation, and/or faith than you? One is that you have not changed. Quantitative data 6) Why did you rate yourself the way you did in the previous question? Qualitative Data 7) On a scale of 1-10 how useful were the “Cultural humility trainings” you received in your four years here at medical school? One being that the trainings were useless. Quantitative data 8) On a scale of 1-10 how useful would continued trainings on ‘Cultural humility’ throughout your residency program be? One being useless and ten being very useful. Quantitative data 9) On a scale of 1-10 how interested would you personally be in continued trainings on ‘Cultural humility’ throughout your residency program? One being uninterested and ten being very interested. Quantitative data 10) If additional training was provided, what would you like to learn in regards to providing care to those who are “different” than you? Qualitative Data

FIGURE 2. Proposed first- and fourth-year medical student cultural competency and cultural humility survey evaluations. Medical student surveys containing both quantitative and qualitative questions to be filled out annually as a means of assessing the cultural competency and cultural humility training provided by the medical institution.

never adequately trained or prepared for during medical school. The charters on professional conduct from both the American College of Physicians and the American College of Surgeons describe the contract physicians share with society. Inherent in this contract is the concept of altruism. Trust is the bedrock supporting the patient–physician relationship. Several studies have proven that CCH training enhances the knowledge of health professionals, enriches the attitudes and skills of health care providers, and improves patient satisfaction.26 To achieve success in training future physicians to be receptive to the needs of their patients, CCH training must be integrated into every aspect of medical training. We anticipate that the aforementioned recommendations will be useful in assisting medical school and departmental leadership in their efforts to ensure the provision of culturally appropriate and sensitive care by the future physicians they are responsible for training.

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Journal of Surgical Education • Volume 68/Number 3 • May/June 2011