Welcome to Cultural Competency: Surgery's Efforts to Acknowledge Diversity in Residency Training

ORIGINAL REPORTS

Welcome to Cultural Competency: Surgery’s Efforts to Acknowledge Diversity in Residency Training Catherine L. Ly, BA, and Maria B. J. Chun, PhD Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii BACKGROUND: Although cultural competency is not a new concept in healthcare, it has only recently been formally embraced as important in the field of surgery. All physicians, including and especially surgeons, must acknowledge the potential influence of culture in order to provide effective and equitable care for patients of all backgrounds. The Accreditation Council for Graduate Medical Education (ACGME) recognizes cultural competency as a component of ‘‘patient care,’’ ‘‘professionalism,’’ and ‘‘interpersonal and communication skills.’’ METHODS: A systematic literature search was conducted using the MEDLINE, EBSCOhost, Web of Science, and Google Scholar databases. All publications focusing on surgical residents and the assessment of patient care, professionalism, interpersonal and communication skills, or specifically cultural competency and/or were considered. This initial search resulted in 12 articles. To further refine the review, publications discussing curricula in residencies other than surgery, the assessment of technical, or clinical skills and/or without any explicit focus on cultural competency were excluded. RESULTS: Based on the specified inclusion and exclusion

criteria, 5 articles were selected. These studies utilized various methods to improve surgical residents’ cultural competency, including lectures, Objective Structural Clinical Examinations (OSCE), and written exercises and evaluations. CONCLUSIONS: A number of surgical residency programs have made promising strides in training culturally competent surgeons. Ultimately, in order to maximize our collective efforts to improve the quality of health care, the development of cultural competency curricula must be made a priority and such training should be a requirement

*Correspondence: Inquiries to Maria B. J. Chun, PhD, Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, 1356 Lusitana Street, 6th floor, Honolulu, HI 96813-2421; fax: 808-586-3022; e-mail: [email protected]

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for all trainees in surgical residency programs. ( J Surg C 2013 Association of Program Directors in 70:284-290. J Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: cultural competency, surgical resident education, general surgery COMPETENCIES: Patient Care, Professionalism, Inter-

personal and Communication Skills

BACKGROUND As the United States population continues to diversify, so does the prospect of an increasingly wide disparities gap in health and health care. In order to close this gap, physicians must have the knowledge, attitudes, and skills required to provide equitable care for patients of all backgrounds.1 Such capability is collectively referred to as cultural competency, which is often defined as ‘‘a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations.’’2 The Accreditation Council for Graduate Medical Education (ACGME) recognizes cultural competency as a component of ‘‘patient care,’’ ‘‘professionalism,’’ and ‘‘interpersonal and communication skills,’’ 3 of the 6 core competencies mandated by the ACGME Outcome Project.3 The American College of Surgeons’ Code of Professional Conduct recognizes that ‘‘a good surgeon is more than a technician’’ and that each surgeon must possess an ‘‘altruistic commitment to each patient’s unique biologic, psychologic, social, cultural, and spiritual needs.’’4 Consideration of such needs leads to more effective communication and an overall improvement in the doctor-patient relationship, presumably resulting in more positive health outcomes. As recognized by Weissman et al., poorly handled cross-cultural

Journal of Surgical Education  & 2013 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2012.10.005

issues may result in a variety of negative consequences, such as longer office visits, patient noncompliance, delays in obtaining consent, unnecessary tests, and lower quality of care.5 Traditionally, surgical residents have been expected to improve on patient care, professionalism, and interpersonal and communication skills through independent observation of superiors and personal experiences with patients. However, with the development of the ACGME core competencies and the brightening spotlight on the importance of cultural competency in our increasingly global society, residency programs have recognized the need to develop formal training and evaluation. In order to successfully do so, programs are required to acknowledge and address the numerous barriers cited by faculty and residents alike.6-8 Time constraints, insufficient institutional priority, lack of understanding regarding what such training should entail, inadequate teaching tools, and lack of readily available resources and mentors were among other stated obstacles. But before these issues can be tackled, the programs must overcome what may arguably be the most important obstacle: buy-in. As Betancourt notes, buy-in is critical; residents must understand the impact of cultural competency and its link to quality health care for any efforts to be effective.9 This may be particularly problematic for surgical residency programs. Compared to residents in other fields, surgical residents are less likely to consider their patients’ cultures to be ‘‘very important,’’ and are more likely to feel strongly that effective cross-cultural care is not practical, considering their time constraints in the context of both individual patient visits and overall clinical and academic responsibilities.5,8,10 Currently, there are no specific guidelines regarding the methods by which residency programs should address cultural competency. As a result, a variety of methods have been utilized and studied in an effort to determine those that are most appropriate and effective. Overall, these approaches to cultural competency training and evaluation can be generalized into those based on knowledge, attitudes, and skills.11 Van Eaton and Pellegrini describe how these 3 aspects can be incorporated into residency education through several overlapping means: formal education with a well-structured curriculum, an informal (‘‘hidden’’) curriculum based on role modeling, and active practice and engagement.12 A successful program would ideally take all such means into account. The objective of this review is to identify the surgical residency programs that have specifically addressed cultural competency in their curricula. Through analysis of their various approaches, we seek to synthesize recommendations to inform and guide the development of effective cultural competency training.

METHODS A systematic literature search was conducted using the MEDLINE, EBSCOhost, Web of Science, and Google Scholar databases. All publications focusing on surgical residents and the assessment of patient care, professionalism, interpersonal and communication skills, and/or specifically cultural competency were considered. This initial search resulted in 12 articles. To further refine the review, publications discussing curricula in residencies other than surgery the assessment of technical or clinical skills without any explicit focus on cultural competency were excluded.

RESULTS Many of the initially considered articles discussed the ACGME competencies of ‘‘patient care,’’ ‘‘professionalism,’’ and/or ‘‘interpersonal and communication skills,’’ but did not focus specifically on cultural competency. Therefore, based on the specified inclusion and exclusion criteria, a total of 5 articles were selected (Table 1). Two of the programs addressed cultural competency on its own, while the remaining 3 considered cultural competency in the context of some or all of the ACGME competencies. The 5 articles selected were reviewed and the following data were documented: author, year of publication, training method, evaluation method, and results. Lessons learned from each were compiled to generate more general recommendations. Overview of Selected Programs The Department of Surgery at the University of Hawaii at Manoa (UHM) John A. Burns School of Medicine primarily utilized standardized patient (SP) examinations in its cultural competency-focused curriculum. Working with the UHM Department of Family Medicine and Community Health, which has significant experience with cultural objective structured learning examinations, the department sought to develop a scenario that would allow for the assessment of each resident’s ability to care for a patient with a different and possibly unfamiliar background.13 Prior to the examination, residents’ baseline preparedness to provide cross-cultural care was determined using a revised version of Weissman and Betancourt’s Cross-Cultural Care Survey, also known as the ‘‘resident preparedness’’ survey.5 Subsequently, trained faculty members used a written checklist to assess the residents as they encountered an informed consent scenario involving an elderly Samoan male who requires a leg amputation due to uncontrolled diabetes mellitus. The patient was accompanied not only by his spouse, but also a medical interpreter, allowing for the evaluation of each resident’s ability to

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TABLE 1. Overview of Selected Programs Author(s)

Date

Training Method(s)

Evaluation Method(s)

Results

Cross-Cultural Care Survey, Cultural SP examination with evaluation tool assessing relevant ACGME competencies and cultural awareness OSCE evaluating use of an interpreter

No statistically significant improvement, likely due to negative attitudes toward cultural training

Chun MB, Young KGM, Honda AF, et al.

2012

Journal club or didactic session focused on patient care

Hochberg MS, Kalat A, Zabar S, et al.

2010

Krajewski A, Rader C, Voytovich A, et al.

2008

Interactive session entitled ‘‘Working across language and cultural barriers: ensuring a truly informed consent’’ 2 interactive lectures with breakout sessions

Joyner BD, Vemulakonda VM

2007

‘‘Voices of Professionalism’’ lecture and workshop, teaching conferences

Yudkowsky R, Alseidi A, Cintron J

2004

Case-specific handout

involve family members and communicate effectively with patients with limited English-speaking skills. Immediately afterward, the SPs completed an evaluation form while the residents received feedback from their faculty preceptors and one of the study investigators and completed a selfassessment/self-reflection form. In the following month, residents also participated in a journal club or a didactic session focused on a cultural aspect of patient care. On completion of all the training interventions, both the Cross-Cultural Core Survey and the SP examination were re-administered. In this case, posttraining analyses did not reveal statistically significant improvement. A needs assessment demonstrated a somewhat negative attitude toward cultural training, thus supporting the difficulty that may be encountered when working with residents who have not been exposed to the importance of cultural competency in practice.6 The Surgical Professionalism in Clinical Education (SPICE) program at New York University addressed cultural competency as part of its study of the teaching and assessment of professionalism and interpersonal and communication skills.14,15 The study began with an evaluation of residents’ baseline competencies through a 6-station Objective Structured Clinical Examination (OSCE) utilizing SPs. In the third station, residents were evaluated on their use of an interpreter to describe a proposed breast surgery to a Thai-speaking woman. The subsequent teaching component of the SPICE curriculum consisted of a series of 6 (later increased to 7) 1-hour interactive seminars, one of which focused on working 286

Written assessments (Healthcare Cultural Competency Test, Cultural Skills Acquisition, Clinical Skills Scenarios Evaluation) ACGME Global Resident Competency Rating Form

‘‘Treatment Refusal’’ OSCE

Statistically significant improvement in ‘‘being sensitive to patient’’ and ‘‘working with an interpreter’’ Statistically significant improvement in all three evaluations Statistically significant improvement in all fields, including sensitivity to patient culture, age, gender, and disabilities Residents found feedback from OSCE to be valuable

across language and cultural barriers to ensure truly informed consent. This particular seminar included both role-play between residents and SPs and a mini-lecture on cultural competency. Residents were expected to practice and improve on a number of professionalism skills: patient education, shared decision-making, overcoming language barriers, cultural competency (e.g., effective use of an interpreter), and elements of informed consent. Twelve months after their baseline evaluations, the residents were re-assessed using the same OSCE scenarios and SPs. Results revealed statistically significant improvement in all aspects of professionalism and communication, including scores in ‘‘being sensitive to patient’’ and ‘‘working with an interpreter.’’ During the 3-year study period, the program also administered annual self-assessments of the residents’ perceived abilities to perform 22 defined tasks representing core ACGME domains.15 This included acting without discrimination or bias when working with patients and colleagues; asking patients and families about their beliefs, practices, and values when relevant to the medical issue; showing tolerance for a range of behaviors and beliefs; and treating the patient as an individual by taking life circumstances, beliefs, personal idiosyncrasies, and support systems into account. The results revealed a statistically significant positive trend in aggregate perceived professionalism among the residents, with the greatest improvement in altruism and patient sensitivity. The Department of Surgery at the University of Illinois also utilized the OSCE to evaluate its residents’ patient communication and interpersonal skills.16 In this study,

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participating residents were rated by SPs based on their ability to maintain a patient-centered approach across 6 communication tasks. One of these tasks, entitled ‘‘Treatment Refusal,’’ involved a patient with an acute gastrointestinal bleed who refuses transfusion due to his beliefs as a Jehovah’s Witness. Following the completion of each of these tasks, residents were given case-specific learning material and were asked to give feedback about their experiences and participate in focus group sessions. Analysis of the results found that 92% of the residents found the verbal feedback from the SPs to be particularly valuable and that the scenarios were realistic in their content, but that there was not enough time during each station. A study at the University of Connecticut specifically sought to develop means through which surgical residents could improve their performance on written assessments of cultural competency.7 In the first step, each resident’s baseline preparedness was evaluated through 3 tools: (1) the Healthcare Cultural Competency Test, which is comprised of 30 questions to assess general healthcare competency; (2) the Cultural Skills Acquisition, which asks residents to reflect whether they had acquired the necessary skills to provide culturally competent care and to define barriers to such care; and (3) the Clinical Scenarios Evaluation (CSE), which assessed the application of cultural competency skills to specific clinical scenarios. The second step was the educational intervention, a 2-part lecture focusing on the principles of cultural competency and continued self-learning. Smaller breakout sessions for various specialties were also held to address specialtyspecific issues in cultural competency. In the final step, residents were re-evaluated using the same tools used in the first step. Comparison of the pre- and post-tests revealed statistically significant improvement for all residents in all 3 assessments. When feedback was elicited from the residents, they consistently reported a belief that the educational interventions had improved their cultural competency. The University of Washington’s Department of Urology approached the topic of cultural competency in the context of professionalism from a slightly different angle. It sought to assess whether defining professionalism in addition to training faculty and residents in the evaluation process would improve behavior.17 The residents were first assessed using the ACGME Global Resident Competency Rating Form, a previously validated tool that was distributed to the clinical faculty after each rotation. Three specific professionalism questions from the form were used as representations of standard professional behaviors: (1) demonstrates respect, compassion, integrity, and reliability; (2) shows commitment to ethical principles; and (3) is sensitive to patient culture, age, gender, and disabilities. After 21 months, both faculty and residents were presented with a lecture and workshop entitled ‘‘Voices of Professionalism,’’

which included a video featuring discussion of ideas about professionalism and professional behavior. Various teaching conferences also attempted to introduce the hidden curriculum of humanism in residency. In addition, at the department’s annual retreat, faculty received focused instruction on the new standards of professionalism and resident evaluation strategies. Following these interventions, all trained faculty again completed a Global Resident Competency Rating Form for every resident after each rotation. Statistically significant improvement was noted for all 3 representative questions, with the greatest change in mean in the question of sensitivity to patient culture, age, sex, and disability. The study concluded that it is important to initially focus on defining values and educating the faculty role models before setting out to teach the residents. Training Methods As previously mentioned, formal education with a wellstructured curriculum is one way to incorporate cultural competency training in residency programs. Formal education tends to take the form of either a single didactic session or a lecture series. In the SPICE program, faculty facilitators presented a series of 1-hour interactive seminars spread out throughout the academic year, but just one focused specifically on cultural competency.14,15 At the University of Hawaii, residents attended either a journal club or a didactic session focusing on the cultural aspect of patient care.13 In contrast, the University of Connecticut developed a cultural competency-focused curriculum involving 2 two-hour sessions. The first was an interactive introduction by the Director of the Office of Cultural Diversity and the second was a talk by a nationally recognized leader in cultural diversity education.7 A common theme in all of the aforementioned didactic sessions was interactivity. They all strove to present the information through a variety of means and/or encouraged role-playing or active participation in discussions regarding relevant issues. This was a critical component in the effectiveness of these lectures, as active practice and engagement have previously been validated as essential parts of clinical skills training.12 Other programs did not develop a formal curriculum for training and instead considered improvement in the evaluation of residents’ competencies and subsequent feedback as a means of education. Evaluation Methods Evaluation of residents’ competencies is necessary to assess the effectiveness of new methods and to determine the need for additional efforts. In general, assessments of competency can be divided into 2 major categories: assessment of maximal performance and assessment of typical

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performance. The former evaluates skills in a structured setting in which residents are well-prepared, whereas the latter employs retrospective judgment of daily behaviors over the course of their rotations.18 It is important to note that there are few guidelines surrounding the specific evaluation of cultural competency, which is to be expected considering the lack of a standardized definition. Accordingly, the specific focus on cultural competency in the greater context of patient care, professionalism, and interpersonal and communication skills varied depending on the programs. The OSCE has emerged as a primary tool to both evaluate and improve residents’ clinical skills in all settings. It is the prime example of an assessment of maximal performance. Four of the selected programs utilized SPs to assess how residents approached patients who were from different and possibly unfamiliar backgrounds. The selected scenarios were similar in that they required residents to address cultural issues that may have a direct effect on the outcome of the patient encounter. Traditionally, assessments of typical performance are achieved through faculty ratings of residents at the end of their rotations. For instance, the University of Washington’s Department of Urology utilized the Global Resident Competency Rating Form, which was given to clinical faculty after each rotation to evaluate the residents’ demonstration of respect, compassion, integrity, and reliability; commitment to ethical principles; and sensitivity to patient culture, age, gender, and disabilities.17 Other programs, however, utilized self-assessment to evaluate typical performance. In the annual evaluation of the SPICE program, residents were asked to comment on their perceived abilities to perform 22 defined tasks.13 Other forms of self-assessment include the previously described Healthcare Cultural Competency Test and the Cultural Skills Acquisition, both of which were utilized at the University of Connecticut,7 as well as the Cross-Cultural Care Survey, which was used at the University of Hawaii.13

DISCUSSION Direct comparison of the programs is difficult due to the wide variability in their curricula, but valuable lessons can be drawn from each of their experiences. Before knowledge and skills can be improved, attitudes must be addressed. As noted at the University of Hawaii, a lack of the belief in the importance or relevance of cultural competency or both can hamper efforts.13 Buy-in is critical to the success of any program initiative and may be enhanced by making cultural competency training a requirement in residency programs. This is partly why participation in the cultural competency curriculum is considered mandatory for all PGY1 surgical residents at the University of Hawaii. Likewise, at New York 288

University, demonstration of adequate professionalism and communication skills is a requirement for graduation from residency and a post-curricular OSCE failure triggers closer resident observation and remediation.14 By prioritizing the issue, it imparts the importance of having the knowledge, attitudes, and skills to provide effective crosscultural care to all of the surgical residents. However, simply creating a requirement is not sufficient and can itself be counterproductive. It is also important to integrate cultural competency into other clinical teaching in conjunction with positive role modeling from both senior residents and faculty who can demonstrate its important role in providing quality patient care.9 Several other factors may also be considered to further promote buy-in. Programs should not only seek to create a curriculum that is a mixture of faculty-identified concepts and resident input, but also request ongoing feedback for continued improvement.18 Formal education by means of lectures is an efficient way to provide residents with the knowledge required for effective patient care. In the development of curricula, scheduling and timing must be taken into consideration. Timing in terms of resident years is critical; the importance of cultural competency should be emphasized as early as possible in residency training. In a study of PGY1 surgical residents’ clinical and interpersonal skills at the beginning and end of the academic year at the State University of New York, analysis showed an increase in self-confidence without a corresponding increase in ability.19 This overconfidence and false sense of ability could naturally hinder a resident’s ability to learn and self-adjust. In terms of scheduling the formal curricula, efforts must also be taken to ensure sufficient time to effectively teach the knowledge and skills, but not so much time as to burden residents and faculty who already have busy clinical demands. For example, in the SPICE group, only 15 of the 27 eligible surgical residents completed all phases of the study due to variations in their schedules.14 Such circumstances are, of course, not unique to that institution and are to be expected, considering all residents’ extensive responsibilities. Whether a program decides to hold multiple lectures throughout the academic year or just a single session will depend on the individual program’s needs and expectations. Finding the appropriate balance of time and efficacy is a challenge all programs must overcome. Programs may also consider presenting supplemental information through other means that may be more convenient, such as online modules. The American Academy of Orthopaedic Surgeons, for example, has developed a self-directed Culturally Competent Care Guidebook with an online learning module and test.20 Online modules, however, cannot be the only component in the training, as active face-to-face participation and engagement in roleplaying and discussions are essential. Faculty and resident feedback can be particularly helpful in this aspect of

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development, especially because programs do not want to inadvertently promote the idea that there is no time for cultural competency in surgery. The importance of sustained coaching with repeated practice cannot be understated; it is the only way by which skills can be improved. As noted in a different University of Connecticut study, case-specific skills may be taught and reinforced in a short period of time, but improvement in more general communication skills requires additional efforts.21 Practice in cultural competency must be encouraged not only during formal curricula, but also during everyday clinical practice as well. Evidence from various programs has shown the OSCE to be a very effective tool in the evaluation of all ACGME competencies. When using this tool specifically for cultural competency evaluation, however, it is particularly important that selected scenarios demonstrate how patients’ backgrounds can affect care without reinforcing any negative stereotypes of the depicted cultures. Programs should also recognize that the OSCE may be limited by its ‘‘artificial’’ feeling, an issue that is much more difficult to address, as no change in protocol can change the fact that residents know they are being observed in an isolated environment.22 In addition, programs must treat the OSCE not only as an evaluation tool, but also as a means of education, in order to maximize its potential. They should ensure that residents receive adequate feedback regarding their clinical skills from both faculty observers and SPs, as it may be through this exercise that residents learn their most worthwhile lessons. Due to its extensive logistics, cost, and inherent artificiality, the OSCE or any other type of clinical simulation cannot be the only method through which cultural competency is evaluated. Assessments of typical performance through regular faculty evaluations such as with the Global Competency Rating Form can be used to provide a more complete perspective of residents’ skills in a nonfabricated environment. Such evaluation, however, may be limited by its requirement to assess a resident retrospectively and the possibility that evaluators may be biased in their judgments as a result of the types of situations in which they happened to interact with the resident. Selfassessments may be considered occasionally, as such data can also provide valuable information, especially when considered in conjunction with the results from the OSCE. Peer assessments are another option, as Maker and Donnelly provided evidence for the value of such feedback when they asked junior residents to identify qualities that differentiated senior residents as role models.23 Regardless of the type, the results of any and all of assessments must be revealed to the residents in some way to allow for the opportunity to learn and grow from their previous experiences. This review has several limitations. First, we only included information from programs that published their

results. There may be other surgical residency programs that have incorporated cultural competency into their curricula, but may not have published their results or have not brought them out in a format accessible through an electronic database search. Second, we did not include literature based outside the United States or any nonEnglish-language studies. With our increasingly global society, it is not only the United States that has made efforts to emphasize the importance of cultural competency and it is possible that analysis of international programs may provide additional lessons. Finally, although most of the selected programs demonstrate the positive impact of cultural competency training efforts, long-term effectiveness of these interventions is currently unknown; generally speaking, this is an area in which more work needs to be done.

CONCLUSION The need for culturally competent surgeons will only become more important in the years to come. Several residency programs throughout the nation have already made promising strides and have shown that the development of cultural competency training is not an insurmountable task. Consideration of variables such as buy-in, opportunities for adequate practice and evaluation, effective feedback, and role modeling are essential to the success of these programs. The future holds great potential for improvement in cultural competency training in surgical residency programs. It is critical to learn from the strengths and weaknesses of these and future programs. It will also be necessary to determine the long-term effectiveness of these interventions to identify unforeseen issues and to promote further improvement. In addition, further prospective research needs to be conducted regarding other methods of cultural competency training, such as the incorporation of global health (e.g., rotations in other countries) into surgical residency programs.24-26 Programs should also look to their peers in other medical specialties, such as family medicine, that have already formally incorporated cultural competency training into their residency programs.27,28 Ultimately, in order to maximize our collective efforts to improve the quality of health care, the development of cultural competency curricula must be made a priority and such training should be a requirement for all trainees in surgical residency programs.

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