Integrated Immersive Approaches to Cultural Competence
Clarence H. Braddock III, MD, MPH;
Senior Associate Dean for Medical Education
Director, Coordinating Center @ Stanford
Stanford University School of Medicine Principal Investigator
(650) 498-5923
Ronald D. Garcia, PhD;
Program Director, Center of Excellence
Assistant Dean, Minority Affairs
Physician Assistant Program/Family Medicine
Stanford University School of Medicine
Sylvia Bereknyei, MS;
Research Assistant, General Internal Medicine
Project Manager, Coordinating Center @ Stanford
Stanford University School of Medicine
Our overall goal remains to develop an integrated curriculum in cultural competence for learners across the educational continuum from medical students to house staff to faculty and community physicians. The curriculum is building on immersive learning methods with content reflecting provider-based factors that influence the multi-cultural clinical encounter. We have a unique opportunity to develop this type of curriculum at Stanford. We are in the midst of revolutionary curriculum change, including a major emphasis on the patient-physician relationship and use of immersive and interactive teaching approaches.
Our specific aims are to:
Develop, pilot test, evaluate, and disseminate a prototypic facilitator-training module in cultural competence for medical teachers using immersive learning approaches, to: describe cultural competence learning goals and objectives, conceptual approaches and teaching methods, teaching skill practice with feedback and reflective inquiry.
Develop, pilot test, evaluate, and disseminate a prototypic module in cultural competence for medical students in cardiovascular disease prevention with a Latino and an African-American patient with Type II diabetes mellitus, obesity, and hypertension, using an immersive learning approaches, such as: watching the film, "World's Apart", small group facilitated discussion, and standardized patient skill practice.
Develop, pilot test, evaluate, and disseminate a prototypic module in cultural competence for medical residents in cardiovascular disease prevention with a Latino and an African-American patient with Type II diabetes mellitus, obesity, and hypertension using immersive learning approaches such as: reflective inquiry into barriers to promoting medication adherence, cognizant of cultural biases, multi-station exercise for skill practice in advising patients on medication, complementary or alternative therapies, and Kleinman's explanatory model, and role-play and skill-building workshops for patient-centered communication.
Develop, pilot test, evaluate, and disseminate a prototypic module in cultural competence for practicing community physicians in cardiovascular disease prevention with a Latino and an African-American patient with Type II diabetes mellitus, obesity, and hypertension, using immersive learning approaches such as: baseline interactive vignettes with similar clinical histories but different cultural, language, and racial/ethnic background, debrief and reflective inquiry to identify factors influencing clinician decision making, and skill building sessions with feedback.
Faculty Development Program in Cultural Competence: We have developed a facilitator-training module in cultural competence for medical teachers, incorporated into the faculty development program of Dr. Kelley Skeff and the Stanford Faculty Development Center. The program, entitled "Professionalism in Contemporary Practice," prepares faculty to teach residents and other faculty concepts and skills including reflective practice, patient-centered communication, and evidence-based practice. We developed and piloted a module on cultural competence, including definitions of race, ethnicity and culture, review of data on health care disparities, and communication skills related to cultural competence. We used role-playing to enhance participants' skills using Kleinman's explanatory model in medical interviewing. In our initial presentation of this module, we were able to measure significant changes in participants' attitude towards cultural issues in practice, using the Health Beliefs Attitude Survey. Each faculty participant from the September 2005 program is now teaching this material at their respective faculty settings. A group of medical educators in Singapore were trained in this module summer 2006 and another set of faculty will attend the course in September 2006 and continue to disseminate. We evaluated faculty learners using the "Health Belief and Attitudes Survey" and found statistically significantly increases in attitudinal dimension in cultural competence
Medical Student Cultural Competence Curriculum: We have instituted new components to the pre-clinical curriculum, all as part of a course entitled, "Practice of Medicine." This is a six-quarter sequence in which students learn the medical interview and physical examination, as well as bioethics, nutrition, evidence-based medicine, and health policy. The cultural competence curriculum includes:
Communication skills session on the Kleinman explanatory model: students review an on-line tutorial, including videotape demonstration, on incorporating these questions into the medical interview. Then students practice interviewing standardized patients (SP), attempting to gain insight into the SP's health beliefs. Students are evaluated on perspectives of cross-cultural communication by "Health Beliefs and Attitudes Survey" (HBAS), resulting in statistically significant impact in cultural competence domains.
Working with medical interpreters: students are introduced to guidelines for working effectively with interpreters to overcome linguistic barriers, again as part of the communication skills sessions. They review and critique a role-play demonstration to consolidate their learning. We incorporated an online learning module (in collaboration with NYU and members of the NHLBI Collaborative) with an end-of-year Standardized Patient-Interpreter assessment.
Gaining perspective on the patient's perspective: students read Anne Fadiman's book, "The Spirit Catches You and You Fall Down," which chronicles the experiences of a Hmong family with a daughter with a seizure disorder and their interactions with the health care system. To consolidate the themes from the reading, students write essays on one of several themes in the book, and participate in seminar-style discussion of the reading. We also have an invited presentation with the two physicians depicted in the narrative.
"World's Apart" This is a series of film vignettes directed by award-winning physician/filmmaker and Director of the Biomedical Ethics in Film Project, Maren Grainger-Monsen, MD. The films examine the personal experiences of patients and families faced with critical medical decisions and the challenges they face in the health care system. Shot in patients' homes, neighborhoods, and places of worship, hospital wards and community clinics, Worlds Apart provides a balanced yet penetrating look at both the patient's culture and the culture of medicine. Accompanying the four videos is a study guide designed by cross-cultural medicine educators Drs. Alexander Green and Joseph Betancourt. "Worlds Apart" is shown to students, followed by facilitated small group discussion, with the goal of enhancing insight into cross-cultural communication and cultural sensitivity.
"Hold Your Breath" This is an award-winning film based on one of the characters in "Worlds Apart", directed by Maren Grainger-Monsen. We implemented a new session into "Applied Biomedical Science" seminars, a series of inter-sessions between clerkships. The session includes viewing of the film, followed by a facilitated discussion session.
Pediatrics clerkship implemented a newly developed Standardized Patient cultural competence curriculum involving four Standardized Patient encounters. The students are able to witness and experience various situations incorporating Kleinman explanatory model/Stewart trigger questions with additional learning objectives such as: folk illness remedies, impact of illness on family, domestic violence, and principles of effectively using an interpreter. Each student in a set of four students has a Standardized Patient encounter, while the remaining students watch the scenario through closed-circuit television, followed by an extensive debriefing session. .
Assessment Implementation of baseline evaluations using "Cross-Cultural Adaptability Index" (CCAI), a valid and reliable measure, which will be used across the curriculum for individual development and curricular evaluation
Residency Cultural Competence Curriculum: We have developed a cultural competence clinical teaching module that was implemented to all general internal medicine residents at Stanford. The module incorporates the use of reflective practice to facilitate discussion of personal cultural attitudes and emphasizes the use of the Kleinman explanatory model questions to enhance communication skills.
The primary significance of our local project to date is the development and piloting of cultural competence modules on three fronts: medical students, residents, and medical faculty. These modules enable us to expand our curricular repertoire and gain experience designing and evaluating cultural competence curriculum.
In addition, we have an extensive collection of resources (definitions, literature) with a dissemination plan through our website portal, funded by the NHLBI. This utility enhances our goal of a shared objective of multi-institutional collaboration for cultural competence education.
Plans for the upcoming year include continued implementation and evaluation of medical student cultural competence curriculum plans over the two-year course. We are also continuing to develop a full faculty development cultural competence education course. We are currently pilot testing the clerkship cross-cultural education standardized patient program, with full implementation plans for fall of 2006. A residency training program is currently in progress as well.
In order to support the dissemination mandate of the original RFA, we have developed and implemented a web-based curriculum portal for cultural competence education. This web-based resource will provide a platform to highlight and disseminate the curriculum products from investigator-educators funded through the NHLBI RFA in cultural competence education.
We also coordinate monthly conference calls with the other investigators in the collaborative. These conference calls have fostered sharing of ideas in areas of curriculum, evaluation, and implementation strategies, as well as enabling us to develop several small working groups among the members. The coordinating center has enabled these small groups to overcome significant challenges across institutions, and can be used as a model for future collaboratives. The small working groups have preliminary results that are currently being analyzed. We expect that each of these groups will lead to significant curricular interventions, as well as adding the medical education literature in this area.
Additionally, we have formed collaborations with national organizations (AAMC through TACCT and MedEd Portal, the California Endowment, NYU, and Office of Minority Health).
We also coordinated the first annual conferences of all the program investigators in Washington, DC in September 2005. At this meeting, we had the opportunity for more face-to-face discussion of shared interests and activities. Existing working groups presented their progress reports, and new awardees were invited to join these efforts. In addition, we collaboratively developed several new working groups, as well as developing a mission statement and work plan for the coming year. We also conducted planning for manuscript preparation as well as upcoming conference presentations
Clarence H. Braddock III, MD, MPH; 
Ronald D. Garcia, PhD; 
Sylvia Bereknyei, MS; 
