Ferguson, Warren J. MD; Keller, David M. MD; Haley, Heather-Lyn PhD; Quirk, Mark EdD
In this article, we describe the first two years of the development of an ongoing cultural competence curriculum that has been integrated into the training of community preceptors from 13 medical schools in New England and New York. The training, entitled Teaching the Culture of the Community, consists of four 2.5 hours modules that include interactive lectures and small group role-play exercises on cultural needs assessment, patient-centered interviewing, feedback on cultural issues and use of the community to enhance cultural understanding.
Over the course of the last decade, disparities in health outcomes for ethnic minority and racial groups in the United States have persisted, despite improvements in the health of the nation as a whole.1,2 Many medical educators have called for medical schools and residency programs to institute training in cultural competency3,4 and to encourage a more diverse medical workforce.5,6 Recently, the Liaison Committee on Medical Education set standards for cultural diversity training as part of the medical school curriculum. These findings imply that physicians require better training to deal with the growing diversity in the U.S. population and foster positive change in patient outcomes.
Two studies published in 1999 and 2000, respectively, reveal that American medical schools have been ill-prepared to meet this requirement. A review article by Louden and colleagues7 concluded that existing curricula on multiculturalism in North American medical schools are nearly always minor components of larger courses and that valid evaluation is needed as to their effectiveness. Flores and colleagues8 surveyed all 132 U.S. and Canadian medical schools and found that only 8% of schools had a separate course on cultural competence. Of the remaining schools, 87% covered their entire cultural competence curriculum in one to three lectures during the preclinical years. Although the growing awareness of the importance of cultural competency training may have stimulated improvements, to our knowledge, no additional studies have documented this.
In the early 1990s, the University of Massachusetts Medical School worked with several constituencies to develop the Primary Care Futures project, a national program that trained community health center–based clinicians as teachers.9 At that time, a module on cross-cultural teaching was developed to meet the needs of students working in community health centers, where culturally diverse populations are common. Since that time, the three primary care disciplines at University of Massachusetts Medical School formed the Community Faculty Development Center (CFDC), developing further into a regional faculty-development center and training community-based preceptors from 15 medical schools in the Northeast. The cornerstone of the CFDC is the Teachers of Tomorrow program (TOT), a series of four, two-day workshops that take place over 18 months. Seventy-five participants come from a variety of teaching and practice sites, about half of which serve culturally diverse populations. During the mid-1990s, a curriculum on teaching about culture was implemented and viewed by the leadership and faculty as a priority. However, it was not highly rated by participants, leading to a completely new design of the curriculum in 1999.
The new curriculum on culture and advocacy is an integral component of the TOT and comprises approximately twenty percent of total contact hours with participants. In this paper, we describe the curriculum, which is called Teaching the Culture of the Community, detail changes in the curriculum in response to participant feedback, and review evaluation and self-reported change data from the first two years of the program. Based on a review of the literature, we believe this to be the first description of a faculty-development curriculum on culture and advocacy.
Getting Participant Buy-In
Although many workshop participants practice in settings with great diversity, others do not and may not view this topic as a high priority. With this in mind, we define “culture” broadly for the participants and introduce the curriculum with a question: “What is it that community preceptors bring to medicine that is often lacking from practice within the tertiary care center?” Our participants resonate with the concept that community-based primary care doctors are experts in understanding illness from the patient’s perspective and skilled at explaining their approach to diagnosis and treatment effectively to patients. They understand the communities in which they practice, and often use special knowledge of the health care needs of specific subpopulations in their communities to inform their medical practices. They know available resources in the communities in which they practice, and how important it is for practitioners to network with those resources. The role a physician plays within a community is dependent on his or her ability to move between the “medical subculture” and the cultures of the patients. It is also dependent on the physician’s perception of himself or herself as a patient advocate. The “special skills and knowledge” of physicians in the primary care specialties help set them apart from those in other disciplines; this philosophy is highly valued by our course participants.
Structure of Course Modules
The TOT workshop methods are founded on adult learning theory and emphasize interaction, application, and collaborative learning.10 The sequence used within modules proceeds from a conceptual framework to methods that facilitate teaching-skills development. Each module is 2.5 hours long. Typically, a module begins with one or two short interactive lectures, followed by a large-group exercise for the entire group, and culminating in small-group exercises. The large-group exercise involves either a role-play or a video vignette of a teaching encounter that reinforces the content of the lectures and prepares attendees for small-group training.
The small groups in our conferences are important and popular elements of the curriculum. We believe that the personal nature of cultural self-assessment and the level of insight required are best nurtured in small-group sessions with the same participants over the course of the four workshops. Case vignettes designed for role-play largely constitute the structured tasks in these sessions. Although some individuals resist role-play, these exercises have been highly valued by participants. Attempts are made to facilitate comfort with role-play by using familiar case scenarios in each conference with modifications to meet the learning objectives.
Content of the Curriculum
List 1 summarizes the curricular elements for the culture and advocacy modules in each of the three workshops piloted in year one (1999). In year two, a fourth workshop was added to the series. The culture and advocacy curriculum mirrors the core curriculum structure of our faculty-development modules, the GNOME (mnemonic for the educational planning process: Goals, Needs, Objectives, Methods and Evaluation).11
Our framework for cultural needs assessment is based on a modification of the ethnosensitivity scale written by Borkan and Neher,12 which describes cultural competence as a dynamic continuum consisting of seven stages. We simplified this model because participants in our course had a difficult time applying seven different stages to clinical teaching. We emphasized that our goal as teachers is to move learners along this cultural sensitivity scale and to try to prevent them from slipping back to more defensive postures when they err in the cultural component of their communications with patients.
* At the lower end of the cultural sensitivity scale, they may approach issues of culture from a learner-centered, or egocentric, position. Learners may react to difference in a clinical encounter from perspectives that reflect their own thinking and world views. Moreover, their reactions to less than desirable outcomes may be to blame the patient rather than consider their part in the outcome. Learners in this stage may fear or deny difference, may react to difference with superiority, or may overgeneralize and stereotype characteristics of patients based on cultural dimensions such as race, ethnicity, gender, socioeconomic status, or sexual orientation.
* In the middle stages of the cultural sensitivity scale, learners may enter encounters with a minimalist attitude, assuming that a universal approach to issues of respect, doctor–patient communication, and medical knowledge and beliefs is generic to all cultures. In this stage, the learner believes that, “If I treat everyone like I’d want my mother to be treated, everything will be just fine.” Learners who minimize the importance of culture may unintentionally offend, miscommunicate with, or misunderstand patients.
* At the upper end of the cultural sensitivity scale, students approach culture from a patient-centered perspective, fully aware of the power differential in the relationship and the dynamics of difference. They resist making assumptions, demonstrate empathy, and consistently integrate reflection on difference into their own behaviors.
Workshop One focuses on eliciting the needs of learners who are more ethnocentric in their attitudes. These learners require teaching methods that help facilitate a heightened level of self-awareness and sensitivity. Participants practice teaching styles taught in the workshop during small group role-plays that describe learners with attitudinal needs. Reflection and modeling are emphasized as particularly important teaching modalities given the critical role of self-awareness for understanding and dealing effectively with cultural differences.
Workshop Two focuses on the middle stages of the scale, when learners are more sensitive but become discouraged by their lack of skill, particularly in the context of their lack of confidence in learning the basics of doctoring. Teaching methods emphasize the skills-based teaching method of patient-centered interviewing as described by Carillo et al.,13 who eloquently argue for generic skills of patient-centered interviewing when engaging in any encounter to avoid assumptions and stereotyping. Negotiation skills are also taught in this session using a modification of the LEARN mnemonic (Listen, Elicit, Assess, Recommend, Negotiate) developed by Berlin and Fowkes.14 Teaching styles are again applied in small groups, and participants are taught the importance of reflection and modeling as useful teaching methods in moving participants up the cultural sensitivity scale described earlier.
Workshop Three focuses on moving learners further along the continuum toward ethnosensitive and empathic attitudes. We focus on immersion exercises and use of the “community as teacher” as additional teaching methods. Preceptors discuss ways in which they can use local experts from their office staff, patient base, and community agencies to teach the learner about the culture of the community in which they are practicing. This approach mirrors the “patient-centered interview” mentioned previously, allows preceptors to admit that they might not be the best ones to teach about culture, and pragmatically considers that they may not have sufficient time in their busy lives as practitioners to be the exclusive guide for learners. We also adapt several exercises from master teachers in a variety of disciplines for use by our preceptors. The Windshield Survey was adapted from a course at the Madison School of Social Work, Virginia Commonwealth University, as a concrete way of gathering information about a community. The Community Scavenger Hunt, developed at Dartmouth Medical School, is presented as a method to engage students to speak with people in the community, and to see patients outside of the examining room, in their “natural environment.” In these activities, the preceptor serves as a reflective guide, helping the student make the connection between community, culture, and medicine.
In the second year of the project, we piloted Workshop Four, which focuses on evaluation of learners with respect to their cultural needs. We apply the principles of feedback taught in the series and reinforce the importance of observation of students. Participants practice using the “plus/delta” tool to record positive behaviors and behaviors that need to change during observations of learners with patients. They then practice feeding back what they observe. In essence, the entire workshop series builds on itself, with principles from previous conferences in the series reinforced in subsequent ones.
Experiences of the First Two Cohorts
Participants in the TOT series generally include family physicians, pediatricians, and internists from 15 medical schools in the Northeast. They are chosen from a field of applicants recommended by the primary care leadership from the 15 participating institutions. In the rest of this paper, we focus on the experience of two cohorts, the groups that participated in the first two series of workshops, in 1999–00 and 2000–01. Demographic data, including age, sex, discipline, practice experience, teaching experience, and practice type, were obtained for both groups (and all later ones) at the time of application.
In the first two cohorts,
* There were 137 participants from 15 medical schools;
* There were more women than men (83 versus 54);
* Family medicine preceptors accounted for 42% of participants, a higher percentage than in the other specialties;
* 52% of participants had been in practice for less than 10 years, and 47% of the participants have less than three years of teaching experience; and
* 53% of participants were involved in the care of underserved populations, defined by working in a federally funded community health center, a practice in a medically underserved area, or a designated health professions shortage area.
Evolution of the curriculum
The CFDC board of directors oversees curriculum development for the TOT series. Two authors (WJF and DMK) were charged with design of the new culture curriculum. This was the first major workshop component devoted to teaching one specific clinical content area; thus, integration of the curriculum into the existing structure of TOT became a priority. With this in mind, drafts of the curriculum on culture and advocacy were reviewed and rehearsed with the CFDC faculty, leading to several revisions. Then and now, the entire faculty participates in teaching the curriculum in small-group teaching sessions. Following each presentation to participants, the full faculty (currently 15 members plus six fellows) meets to review participant evaluations and to provide feedback to the session leaders. In the first two years of the curriculum, these sessions led to content refinement of the curriculum in subsequent years.
At the end of each workshop, participants rated overall value, the clarity of the objectives and the effectiveness of the faculty presenters for each course module using a five-item Likert scale. Additionally, participants were encouraged to provide open-ended comments on each of the modules. These measures of satisfaction were collected for both the 1999–00 and the 2000–01 cohorts.
Intent to change behavior
After the pilot year, 1999–00, an additional data-collection strategy was implemented, the intention-to-change analysis. Beginning with the 2000–01 cohort, each participant’s intention to change his or her teaching behavior was assessed using a series of questions asked after Workshops One, Two, and Three. Each participant was asked to “list the teaching behaviors that you intend to change as a result of participating in the TOT in [month] before coming to the [next] conference.” Additionally, before the beginning of Workshops Two and Three, each participant was asked to “list the teaching behaviors that [you] have changed as a result of participating in the TOT in [month].” No data on self-reports of change were collected after Workshop Three. Analyses were subsequently conducted to determine the frequency with which participants listed intended or actual behavior change pertinent to the culture and advocacy curriculum. Item counts of comments referring to culture were carried out by three of the authors (WJF, DMK, HLH) using data that were “blinded” for time of completion, removing possible bias of raters’ expectations for preworkshop and postworkshop responses. Interrater reliability was computed. Two of the raters met to discuss and decide the disposition of those comments with nonmatching codes.
What We Learned
Results of the program evaluation are summarized in Table 1. The program received positive ratings on all measures, with averages above 4.0 on a Likert scale of 1 to 5, with 5 being excellent. There was statistically significant improvement in the ratings on the overall value of the program and the clarity of objectives in 2000–01 in comparison with 1999–00.
Intention to change
Results of the intention to change analysis from the second cohort are summarized in Table 2. Before the first conference, 5.4% (or three of the 52 participants) made comments on intentions to change teaching practices or behaviors that were related to the themes that would be addressed by the culture and advocacy curriculum. An example is: “I would also like to improve my style of teaching about issues that relate specifically to a community health center and the diverse population we serve there.” Another preceptor intended to gain an understanding of “how to best teach medical students and residents about the complicated social situations of the patients and families we care for.”
After participating in Workshop One, 16.6% of respondents (or seven of 42 participants) reported having made behavior changes that were related to the culture curriculum. “I became more aware of cultural impact on interactions,” stated one preceptor, while another claimed to “have incorporated an assessment of the family’s culture and beliefs in discussions of patient care with residents, interns, and acting interns.”
After Workshop Two, a full 48.1% of participants made some reference to culture when stating their intentions to change behaviors. The LEARN model introduced during Workshop Two was a focal point for many of these comments. One participant planned to “introduce more formal methods of collecting social and cultural history on patients,” and a second committed to “using the schema for taking a social history.” Several comments stated an intent to practice and build comfort with the newly introduced strategy to “apply the LEARN tool in learner–patient interaction.”
When asked before Workshop Three whether they had actually made changes to their teaching behaviors, 21.4% of respondents made comments related to culture components. “I use the POSE system before a student or resident steps into the exam room,” commented one participant. “The cultural aspects are being discussed more often with the learner. I have used the LEARN rule plenty of times.” Another participant noted, “I am better at making my learners pay attention to cultural aspects of care, and at assessing where a learner is coming from in terms of their culture and life experience.”
Finally, after Workshop Three, 30.2% of respondents left the series with intentions to work on culture-related teaching behaviors. These comments were most likely to include recognition of local experts and other resources valuable to learners. For example, one preceptor stated an intention to “do more to use the availability of the cultures at GBV [a community health center] to improve cultural-based teaching of students.” Another stated, “I will attempt to arrange learning opportunities in the community for my learners.”
Evolution of the curriculum
Over the course of the last three years, the curriculum has been changed in response to feedback from other faculty leaders and small-group facilitators. The changes have fallen into three categories.
* Minimization of jargon. To teach community physicians the essence of cultural competence, we have tried to simplify some of the constructs used in discussing the subject. For example, the cultural sensitivity scale described by Borkan and Neher consisted of seven steps with two subthemes for each stage. We reduced the potential learner needs down to three core conceptual stages, making it easier to explain the concept of increasing ethnosensitivity without forcing the preceptors to learn a new vocabulary.
* Clarity of objectives. Initially, the lectures focused on teaching attitudes, skills, and knowledge about culture, with little reference to the GNOME model. Over the years, the objectives have been brought in line with the rest of the curriculum, so that we focus on needs assessment, methods, and feedback on culture and advocacy, as do the rest of the talks.
* Refinement of cases for discussion. Initially, the cases for small-group role-play did not specifically match the concepts taught in the large-group lectures, leading to confusion among the preceptors regarding the purpose of the exercise. For example, when we were discussing needs assessment in lecture, the preceptors would discuss teaching methods without completing their assessment of the learner’s need. In rewriting those cases, we focused on needs in the case scenario and discussion questions, and refined the facilitator guides to encourage the participants to stay focused on task. This process has allowed the course faculty to become more facile in discussing culture in the context of the remainder of the TOT curriculum.
To our knowledge, the culture and advocacy curriculum for community-based faculty described here is the first such faculty development curriculum to be described in the medical education literature. Now in its third year, this curriculum has become a mainstay of the CFDC’s TOT course.
Although participants attend this course primarily to improve their teaching, our evaluation data thus far show that the culture and advocacy modules of the program have been well received. In addition, ratings of the overall value of the course and our ability to achieve our learning objectives were both rated statistically higher during the program’s second year of implementation. By defining culture broadly and articulating that it is part of every physician–patient–trainee encounter, we countered the assumption that cultural competence is only an issue for physicians providing care to diverse ethnic and racial populations. We also articulated a goal that held generalists accountable for the provision of culturally competent care as a prerequisite to excellence in our disciplines. We believe that full integration of the modules into the program has helped to validate the curriculum and that input from the faculty has been central to getting acceptance among participants as well. In year one, several participants questioned the wisdom of such a large commitment of course time to the culture curriculum in their qualitative comments as part of the course evaluation. These comments have largely disappeared as the entire faculty has become more comfortable with teaching the curriculum.
In year two of the program, additional evaluation demonstrated that program participants intend to change their practices as a result of the culture curriculum. In one study, self-reported behavior change as an evaluation procedure for continuing medical education has been validated by studying actual behavior change by physicians.15 Interestingly, expressed commitments to change applied to both the context of teaching as well as patient care. This reinforced our hypothesis that content-based faculty development may be conceptually new for some participants, and may potentially elevate the quality of teaching both directly and indirectly (through modeling).
The most powerful response to the curriculum regarding intended change followed the second workshop. This workshop focused on teaching communication and relationship-building skills, providing participants with tangible applications for both practice and teaching. It was more concrete than the first workshop, offering more prescription for change. The third workshop focused on community-based advocacy, a topic that may not resonate with every participant. Finally, it should be noted that in both instances when we asked participants to self-report what they actually changed, fewer fell into the domain of the culture and advocacy curriculum, perhaps demonstrating the need for further training or reinforcement of these concepts.
Limitations of Evaluation
The curriculum as presented seems to work well, but the evaluation of any regional faculty-development program is challenging. The community preceptors who choose to take the course come from a variety of practices, backgrounds, specialties, and medical schools. Selecting an appropriate control or comparison group would be very difficult. As we have seen, the curriculum under evaluation is constantly changing, making multiyear comparisons difficult. We have chosen to combine the data from two cohorts of preceptors, even though they were exposed to a curriculum that was under development. There is no accepted standard for the evaluation of the “cultural competence” of a preceptor. Although the same self-report evaluation was used in both cohorts to garner feedback about the course, the “intention-to-change data” was only collected in the second cohort. The “intention-to-change” questionnaire relies on self-report rather than objective measures of behavior change. Finally, none of these measures address the impact of the community preceptor on learners in various stages of training, the ultimate outcome that we are trying to maximize.
Limitation of the Program
Although we speak to a broad definition of culture, race and ethnicity are generally important elements in defining an individual’s culture. Moreover, the increasing population diversity in this country has been a central tenet for development of cultural competence curricula. Our participant base from medical schools in the New York and New England has led to a diverse group of preceptors in the TOT course. Our faculty have not been as successful in modeling diversity in race and ethnicity, reflecting the lack of diversity in medical school faculty throughout our region.
Plans for the Future
We have three goals for further improvement of the curriculum. First, we are changing a discussion of teaching about cultural difference between trainees and patients into a discussion of teaching about cultural difference between teachers and trainees. We’ve been delighted that this has naturally evolved, in part because of our participants and faculty. For example, in a session called “The Problem Learner,” hypotheses about a particular learner’s needs in a case-based large group session now include cultural differences between the trainee and the faculty member who is teaching the trainee. Second, we would like faculty leaders on other topics to incorporate some of the culture and advocacy concepts in their topic areas. For example, a session that focuses on practical tips for efficient office-based teaching could include the practicality of using community-based agencies and cultural immersion exercises as methods to teach about the communities in which they practice. Third, we hope to further refine our measures of the outcomes of our curriculum. Does the curriculum influence the care provided by the participants? Are they modeling culturally competent care? Are they encouraging learners to self-reflect when difference becomes problematic and supporting their learners to move up the cultural-sensitivity continuum?
In an effort to address the last question, we are currently performing content analysis on the third component of our evaluation, before and after critique of teaching video vignettes. These vignettes are specifically designed to include elements of each curriculum topic during each workshop.
A Call for Action
Pursuant to the need for more explicit training of medical students and residents for preparation to serve a more diverse society, it is essential that faculty demonstrate expertise as teachers and role models in teaching students from diverse backgrounds. Moreover, our generations of established clinicians must take ownership of the findings of a growing number of studies on disparities in communication and relationship building experienced by ethnic and racial minorities in this country.16,17 We believe that this is achievable and that cultural competency training can become institutionalized as a critical element of faculty-development training.