Health care disparities continue to affect the quality of care received by racial and ethnic minority groups within the U.S. health care system.1 The Institute of Medicine noted indirect evidence that bias, stereotyping, and clinical uncertainty during clinical encounters contribute to health care disparities.2 Further, additional research has found that physicians’ unconscious biases (UBs)—or the cognitive processes by which human beings unconsciously use information to interpret situations—contributes to all types of disparities in care.3 The Institute of Medicine and others recommend addressing disparities through multicultural or cultural competency education, respectively, in the health professions.2,4 Both of these traditionally include specifically reviewing the different beliefs and health behaviors of a variety of cultures.2,5
In the literature there has been abundant discussion about how this traditional approach, often called the categorical approach, can lead to inadvertent adverse consequences. Firstly, information about cultures cannot be reduced to a defined point in time and location; culture is not static but rather, a complex, dynamic phenomenon which evolves over time. Secondly, the categorical approach includes further reductionist thinking that reinforces or even creates internal bias and stereotypical thinking.2,4–6 Thirdly, the Cultural Competency 2.0 position makes similar conclusions by pointing out that by discussing different cultures or groups, they immediately become the other and the persons in the room having the discussion become the us.7 Finally, the use of the word different makes the assumption that someone or something is normative, and that is usually those who are doing the observing. Within patient care, this may result in the quick characterization of patients, lumping them into categories or types.7
Nontraditional approaches to cultural competency curricula have been offered. However, it is our belief that none of them address the aforementioned drawbacks while promoting humanistic care in an efficient manner.3,4 In this report, we describe our novel Original Identity program, which we developed to begin addressing health care disparities while avoiding the pitfalls of traditional approaches. The framework of this program teaches learners how to engage with patients of other cultures regardless of familiarity with that particular cultural group.
We conceptualized and developed this project as part of the culture and health curriculum that is integrated within the Louis Stokes Cleveland VA Medical Center’s Center of Excellence in Primary Care Education Transforming Outpatient Care (CoEPCE-TOPC) program starting in September 2014. The CoEPCE-TOPC is an interprofessional program committed to training future health care professionals to work in a patient-centered medical home model. Trainees participating in the program include internal medicine, nurse practitioner, and health psychology residents as well as nurse practitioner students. Through a collaboration with the Cleveland Museum of Natural History (CMNH), our team developed Original Identity, a novel program to help learners recognize and address UB using a biocultural anthropologic framework (BAF).
The discipline of anthropology uses self-assessment of personal and cultural biases as a starting point in understanding and dealing with different cultures. More specifically, the BAF looks at humans as cultural and biological animals that are continually adapting to their environment through both cultural change and genetic evolution. Although these adaptations have historically been reduced to racial categories, both biological and cultural variability must be taken into account to assess human population variation.
In addition, educational strategies for increasing awareness of UB, although not widely used in medical education, have been investigated in other fields including psychology and education theory.3,4 We integrated those strategies into the BAF as a means of delivering program content. Through understanding biocultural variation in human populations and discovering their own UBs, we aimed to give learners a new framework for understanding health disparities beyond traditional categorical approaches.
Each faculty member of our team, which includes a museum educator, a PhD curator of human health and evolutionary medicine (N.M.B.), and two internal medicine physicians (M.M., M.K.S.), delivers designated sections of the program, which comprises a two-hour initial learning session at the CMNH and a one-hour wrap-up session at the Louis Stokes Cleveland VA Medical Center (see Table 1). Specific objectives of the program include being able to list the components of health care disparities including sources of bias, stereotyping, and clinical uncertainty, and to define approaches to factors that contribute to health care disparities such as language barriers, racial and ethnic differences, clinical uncertainty, and trust within the health care system.
Delivered to advanced learners in the CoEPCE-TOPC program, the three-part structure of the initial learning session includes a guided reflection and educational experience in the CMNH Human Origins Gallery, a didactic and discussion section titled “Shared Genetic Heritage and Culture Construction of Race,” and two applied patient case studies. Using this structure, we reverse the typical approach of multicultural or cultural competency teaching by starting with a discussion of our shared biological heritage using the Human Origins Gallery, which introduces a model of “Lucy” (Australopithecus afarensis), one of our early human ancestors. Learners begin a process of self-discovery by viewing and reflecting on how they are similar to Lucy. While remaining in the exhibit, this reflective experience is followed by covering the migration of Homo sapiens out of Africa and an outline of the genetic constriction event that occurred early in the evolution of H. sapiens, which resulted in humans having a genetic similarity of 99%.8,9
While some learners are familiar with these and other evolutionary principles, they often are not sure how to apply this knowledge to their medical practice and their understanding of health. The “Shared Genetic Heritage and Culture Construction of Race” didactic and discussion section explores our shared genetics and allows learners to reflect on race as a biocultural construct. Learners are provided with specific medical examples of how the forces of evolution affect disease prevalence in human populations and about how humans continue to evolve. One example of this is the high prevalence of sickle cell anemia in areas of endemic malaria due to a genetic adaptation to an environmental disease risk that is heightened by cultural practices such as house and agricultural field construction. Thus, this genetic predisposition is not linked specifically with a skin color if endemic malaria is not a factor, which illustrates to learners that reducing health disparities to a biological basis is problematic and that they need to be mindful of biocultural factors when reading medical literature and engaging with patients.
To help learners translate the BAF into practice, we end the initial learning session with two patient case studies. The purpose of these cases is to explicitly tie together the entire experience for the learners. One case focuses on race and cultural bias, and the second shifts the focus to gender bias, thereby illustrating how the BAF is transferable to all patient groups. Learners use their new understanding of humans’ shared genetic heritage and cultural constructs to examine the sources of their own UBs and reconceptualize these beliefs. The physician faculty member encourages learners to candidly discuss their own UBs and consider strategies for managing them during a clinical encounter.
During the wrap-up session, held one week later, learners discuss their reactions, observations, and additional applications of the BAF. Additional applications are identified by the learners from experiences in patient care settings, and the group often discusses examples from current media. Using these points of discussion, the physician faculty member also presents an additional application of the BAF by illustrating how socioeconomic status variation historically has been a confounder to health care disparities and that it is important to examine the source of knowledge they are using during patient encounters.
At the end of the wrap-up session, learners could provide feedback on the Original Identity program’s initial learning session by completing minute paper evaluations,10 which included three numeric-scale questions (see Table 2 for an explanation of the scales). The first of these questions asked learners to rate the usefulness of the session overall, the second asked learners to rate how much their confidence was increased regarding use of the tools or skills addressed, and the third asked how likely they would be to recommend the program to colleagues. In addition, an open-ended question asked learners to reflect on what kinds of tools or skills they gained from the session. We also audio recorded and transcribed all of the wrap-up sessions to monitor learner progress and improve the learning experience.
We delivered the complete Original Identity program four times between March and November 2015, with 30 CoEPCE-TOPC learners participating. Those participants included 14 (47%) internal medicine residents, 5 (17%) nurse practitioner residents, 5 (17%) nurse practitioner students, and 2 (7%) health psychology residents; 4 (13%) participants did not indicate a specific profession. As illustrated in Table 2, learners’ mean ratings (n = 29; response rate: 97%) for the three questions on the initial learning session were consistently high (4.2–4.6), indicating that they found the session useful, their confidence with regard to using the tools or skills covered increased, and they would recommend the session to colleagues. The lowest-scoring area was increased confidence in using the tools or skills covered, illustrating an area for improvement.
In support of the program’s objectives, the majority of the responses to the open-ended question asking what tools or skills the session addressed listed bias, assumptions, and stereotyping, or to think differently about their approach during patient encounters. For the same participant group described above, learner understanding of the program objectives was further illustrated during the four audio-recorded wrap-up sessions. For example, when asked their thoughts and reactions to the initial learning session, typical responses included the following:
I think it’s helpful in maybe uncovering some of our own internal biases that you don’t necessarily take the time to reflect [on] and acknowledge.
I think it was just a great exercise to do, just to realize that a lot of us do make assumptions and then just step back and realize that we do it. And we have to, you know, try to better ourselves on evaluating patients and not making that assumption.
Also, some learners noted observations they had during clinical interactions that related to the program. For example, one learner shared:
And so I was in my Hep-C Clinic this week and there was a man who had come to start treatment. And he was a white guy who was in a higher socioeconomic background and he was a really heavy drinker. But the assumption had been made by somebody months ago that he didn’t warrant really extensive evaluation in that area and that there was just a question made and then it never was followed through [on]. Whereas I think if it was a minority person in a lower or nonminority in a lower socioeconomic standpoint that they would have pressed it more. And so it impeded the treatment of this man [who was in Hep-C Clinic] because when they found this out they had to address this issue.
There were two main lessons learned during the process of developing and administering this program. First, given the interprofessional nature of the faculty team and the innovative content of the session, it was important that each faculty member gain a high understanding of the content. To address this, the members of our faculty team observed each other’s sections and provided ongoing feedback to improve content delivery and connections between the sections. These refinements, along with learner feedback, led us to clarify the learning experience and objectives.
Second, it was essential to use patient case studies to highlight culture, race, and gender biases in a clinical context. The cases exemplified the effect of UB on individual patient care and challenged learners to uncover their own UBs. Similarly, the wrap-up session focused on further contextualizing what they had learned so they could apply it to daily clinical care and critically question clinical guidelines that make specific recommendations based on race or gender alone. All of these components assist learners in balancing between the deductive population health approach and the inductive patient-centered approach to clinical encounters as they grapple with questions such as “Why do certain drugs work better in one racial group versus another? Might it have more to do with biocultural elements, such as diet, than genetic causes as traditionally thought?”
The Original Identity program has become an integral part of the Louis Stokes Cleveland VA Medical Center’s CoEPCE-TOPC culture and health curriculum. In our experience, it has been an efficient program that resonates with a wide variety of health care professionals. However, this program is just the first step in developing a larger integrated curriculum that includes resources for learners to increase confidence in tools or skills to mitigate the influences of UB in clinical practice. To further inform this goal, we are completing additional qualitative analysis on the wrap-up session transcriptions, through which we hope to clarify factors that make the program successful, details of learners’ experience of the program, and any interprofessional differences in interpreting content.
In developing this program, our collaboration with the CMNH was essential. Most medical education institutions are located in areas with a natural history museum or a university with anthropology faculty who can facilitate the implementation of a similar program. If a close-proximity collaboration is not possible, however, there are many online natural history resources that institutions could use to set up a similar program. Given the persistent reality of health care disparities, we believe our approach is an innovative addition to health care education that warrants further exploration and research.
Acknowledgments: The authors wish to thank Nancy Howell the educator for the gallery tours at the Cleveland Museum of Natural History for participating as faculty and Lisa Bell from the Center of Excellence in Primary Care Education Transforming Outpatient Care for administrative and evaluation support.
1. Agency for Healthcare Research and Quality. 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. AHRQ pub. no. 16-0015. http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr15/2015nhqdr.pdf
. Published April 2016. Accessed January 4, 2017.
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