The Role of Culture in the Training of Health Care Professionals: A Multidisciplinary Panel Danny M. Takanishi, Jr., MD, FACS Professor and Chair Department of Surgery University of Hawaii October 7, 2011

DISCLOSURE No Disclosures No Disclosures The content of this presentation reflects my perspectives, and not the Organizations I have the honor to serve The content of this presentation reflects my perspectives, and not the Organizations I have the honor to serve ACGME Transitional Year Residency Review Committee, Chair ACGME Council of Review Committees ACGME Common Program Requirements Committee, Chair National Board of Medical Examiners/USMLE Step II Surgery Test Material Development Committee, Chair Hawaii Medical Board, Chair

Learning Objectives At the end of this session the Learner will be able to: At the end of this session the Learner will be able to: Discuss the salient role of cultural competency in medical education; Discuss the salient role of cultural competency in medical education; Describe how accreditation requirements ensure curricular integration of cultural competency initiatives; Describe how accreditation requirements ensure curricular integration of cultural competency initiatives; Demonstrate an understanding of how the Milestones Project serves to further enhance competency-based medical education. Demonstrate an understanding of how the Milestones Project serves to further enhance competency-based medical education.

What is Cultural Competency? Set of Congruent Behaviors, Knowledge, Attitudes, and Policies Set of Congruent Behaviors, Knowledge, Attitudes, and Policies Involve a System or Organization Involve a System or Organization Enables effective work in cross-cultural situations Enables effective work in cross-cultural situations

What is Cultural Competency? “Culture” = integrated patterns of human behavior “Culture” = integrated patterns of human behavior –Language, Thoughts, Actions, Customs, Beliefs –Institutions of Racial, Ethnic, Social, Religious Groups “Competence” = having the capacity to function effectively “Competence” = having the capacity to function effectively –Cultural beliefs, Practices, Needs presented by Patients

What is Cultural Competency? Patient/Family-centered Care Patient/Family-centered Care Social and Cultural Influences Social and Cultural Influences Quality of Medical Services and Therapy Quality of Medical Services and Therapy

LCME 2011 (IS-16) The LCME and the CACMS believe that aspiring future physicians will be best prepared for medical practice in a diverse society if they learn in an environment characterized by, and supportive of, diversity and inclusion. Such an environment will facilitate physician training in: Basic principles of culturally competent health care. Basic principles of culturally competent health care. Recognition of health care disparities and the development of solutions to such burdens. Recognition of health care disparities and the development of solutions to such burdens. The importance of meeting the health care needs of medically underserved populations. The importance of meeting the health care needs of medically underserved populations. The development of core professional attributes (e.g., altruism, social accountability) needed to provide effective care in a multidimensionally diverse society. The development of core professional attributes (e.g., altruism, social accountability) needed to provide effective care in a multidimensionally diverse society.

LCME 2011 (ED-21) The faculty and medical students of a medical education program must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Instruction in the medical education program should stress the need for medical students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on patients’ health. To demonstrate compliance with this standard, the medical education program should be able to document objectives relating to the development of skills in cultural competence, indicate the location in the curriculum where medical students are exposed to such material, and demonstrate the extent to which the objectives are being achieved.

LCME 2011 (ED-22) Medical students in a medical education program must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery. The objectives for instruction in the medical education program should include medical student understanding of demographic influences on health care quality and effectiveness (e.g., racial and ethnic disparities in the diagnosis and treatment of diseases). The objectives should also address the need for self-awareness among medical students regarding any personal biases in their approach to health care delivery.

THE ACGME Founded in 1981 Founded in 1981 Mission: To improve health care by assessing and advancing the quality of resident physicians’ education through exemplary accreditation Mission: To improve health care by assessing and advancing the quality of resident physicians’ education through exemplary accreditation 28 Review Committees 28 Review Committees 8,734 accredited Residencies 8,734 accredited Residencies 130 Specialties and Subspecialties 130 Specialties and Subspecialties Approximately 111,000 active Residents Approximately 111,000 active Residents

THE ACGME AMA AAMC CMSS AHA ABMS ACGME BOARD OF DIRECTORS ACGME 26 RESIDENCY REVIEW COMMITTEES TRANSITIONAL YEAR REVIEW COMMITTEE INSTITUTIONAL REVIEW COMMITTEE COUNCIL OF REVIEW COMMITTEE CHAIRS COUNCIL OF REVIEW COMMITTEE RESIDENTS

THE FOCUS OF GRADUATE MEDICAL EDUCATION HAS CHANGED The Past Process oriented with focus on “what is covered” The Past Process oriented with focus on “what is covered” The Past Then focus was on “what residents are able to do as a result of their training” The Past Then focus was on “what residents are able to do as a result of their training” The Present Focus is on patient outcome The Present Focus is on patient outcome

The Six Competencies –Medical Knowledge –Patient Care –Practice Based Learning and Improvement –Systems Based Practice –Interpersonal and Communications Skills –Professionalism

Medical Knowledge Medical Knowledge Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social- behavioral) sciences and how to apply this knowledge to patient care. Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social- behavioral) sciences and how to apply this knowledge to patient care. –Acquisition –Analysis –Application

Patient Care Patient Care Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. –Gathering information –Synthesis –Partnering with patients/families

Practice Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. –Life-long learning –Evidence based medicine –Quality improvement –Teaching skills

Systems-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal health care –Health care delivery system –Cost effective practice –Patient safety and advocacy/Systems causes of error

Professionalism Residents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Residents must demonstrate professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population –Professional behavior –Ethical principles –Cultural competence

Teaching Professionalism Content Cultural Competence Cultural Competence Setting Clinical teaching Clinical teaching Case based teaching Case based teaching Interactive Workshops Interactive Workshops Lecture/Conference/Seminar Lecture/Conference/Seminar Institutional Initiatives Institutional Initiatives Role modeling Role modeling Mentoring Mentoring

Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. o Communicating with patients and families o Communicating with team members o Scholarly Communication

QUALITY CARE AND PROFESSIONALISM TASK FORCE Proposed New Standards directed at: Proposed New Standards directed at: –Resident Duty Hours –Fatigue Mitigation –Resident Supervision –Transitions of Care –Clinical Responsibilities –Patient Safety –Quality Improvement Systems –Interdisciplinary Teams

JCAHO LOOKS TO ACGME FOR MEDICAL STAFF STANDARDS EFFECTIVE = OUTCOMES EFFECTIVE = OUTCOMES (e.g., mortality rates) APPROPRIATE = PROCESSES APPROPRIATE = PROCESSES (i.e., core measures) COMPASSIONATE = COMMUNICATION WITH PATIENTS AND FAMILIES COMPASSIONATE = COMMUNICATION WITH PATIENTS AND FAMILIES (e.g., informed consent)

Milestones Project Milestone Milestone “Behavior, attitude, or outcome related to general competency domains that describe a significant accomplishment expected of a Resident by a particular point in time.” Susan Swing, PhD Vice-President, Outcome Assessment ACGME

Milestones

Core Principles The ACGME Competencies provide the framework The ACGME Competencies provide the framework Context is Patient Care Context is Patient Care Medical Education is a continuum Medical Education is a continuum –UME GMECPD/MOC Behavioral descriptors provide developmental model Behavioral descriptors provide developmental model Concept of “Stop Points” Concept of “Stop Points”

PROFICIENT EXPERT NOVICEADVANCED BEGINNERCOMPETENT

NRMP Match ENTRY TESTING INITIAL TRAININGSKILLS TESTING MILESTONES SUMMATIVE EXAMINATION CONDITIONAL INDEPENDENCE FINAL EXAMINATION INDEPENDENCE MOC

Assessment and Reporting Resident Evaluation and Promotion Committee Semi-Annual Feedback Meeting Report to ACGME 1 – Global Scores 2 – Scored Assessments

Benefits Refines/Reframes the Competencies Refines/Reframes the Competencies Provides for development of national benchmarks for outcomes assessment Provides for development of national benchmarks for outcomes assessment Provides for improved reporting (“national accountability”) Provides for improved reporting (“national accountability”) Improves Transparency (Resident expectations) Improves Transparency (Resident expectations) Improves Resident Feedback Improves Resident Feedback –Earlier identification of deficits

Benefits Provides gap analysis to Programs Provides gap analysis to Programs Informs Curriculum development process Informs Curriculum development process Promotes patient safety Promotes patient safety Improves confidence with decision making Improves confidence with decision making