Culture Clash: The Medical Encounter as a Source of Health Disparities

In 2002, the Institute of Medicine (IOM) issued its landmark report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report identified three potential sources of healthcare disparities for minority and other underserved communities - patient-level factors, healthcare system-level factors, and care process-level factors. Care process-level factors included issues such as bias, stereotyping, prejudice and clinical uncertainty on the part of healthcare providers. Recommendations to address these factors included a call for additional research, interventions to enhance patient-provider communication, and integration of cross-cultural education into the training of all current and future health professionals. In this presentation, I will briefly review models of health disparities and the role of provider beliefs in these disparities. I will describe various forms of bias (e.g., stereotypes, prejudice,implicit, explicit) and patient-level outcomes of experiencing bias. I will discuss the current research into provider bias and its limitations. Finally, I will discuss the relationship of cultural competence to bias. Specifically, I will propose a model for Culturally Competent Communication and how the use of the model for assessing and training provider behavior could serve as a framework for addressing provider bias as a cause of health disparities

Tools to Assess Behavioral and Social Science Competencies in Medical Education: A Systematic Review

Behavioral and social science (BSS) competencies are needed to provide quality health care, but psychometrically validated measures to assess these competencies are difficult to find. Moreover, they have not been mapped to existing frameworks, like those from the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). This systematic review aimed to identify and evaluate the quality of assessment tools used to measure BSS competencies

Changes in Pharmacy Students After Experiencing Interprofessional Education Activities

Background: Interprofessional education (IPE) has become increasingly important among healthcare professionals. The purpose of this study was to assess the impact of IPE experiences on pharmacy students’ perceived level of comfort with and level of reliability regarding other healthcare professionals. Methods and Findings: A survey of third- and fourth-year pharmacy students (N = 190) was analyzed using descriptive statistics and bivariate analyses to address the study objectives. Students experienced a significant increase in their level of comfort with questioning other professions after IPE (pre IPE: 5.45 ± 2.24 and post IPE: 7.22 ± 1.62, p<0.01) and being questioned by other professions (pre IPE: 5.39 ± 2.24 and post IPE: 7.04 ± 1.68, p<0.01). Students also experienced a significant increase in the perceived reliability and accuracy of information from nurses after IPE (pre IPE: 5.91 ± 1.82 and post IPE: 6.41 ± 1.62, p = 0.01). Conclusions: Pharmacy students who experienced any IPE perceived themselves as more comfortable with questioning and being questioned by other healthcare professionals than students without IPE. Additional research is needed to more clearly define the benefits of IPE and how it should be designed

Critical elements of culturally competent communication in the medical encounter: A review and model

Increasing the cultural competence of physicians is one means of responding to demographic changes in the USA, as well as reducing health disparities. However, in spite of the development and implementation of cultural competence training programs, little is known about the ways cultural competence manifests itself in medical encounters. This paper will present a model of culturally competent communication that offers a framework of studying cultural competence 'in action.' First, we describe four critical elements of culturally competent communication in the medical encounter - communication repertoire, situational awareness, adaptability, and knowledge about core cultural issues. We present a model of culturally competent physician communication that integrates existing frameworks for cultural competence in patient care with models of effective patient-centered communication. The culturally competent communication model includes five communication skills that are depicted as elements of a set in which acquisition of more skills corresponds to increasing complexity and culturally competent communication. The culturally competent communication model utilizes each of the four critical elements to fully develop each skill and apply increasingly sophisticated, contextually appropriate communication behaviors to engage with culturally different patients in complex interactions. It is designed to foster maximum physician sensitivity to cultural variation in patients as the foundation of physician-communication competence in interacting with patients.Cultural competence Patient-physician communication Physician education USA

Near-peers improve patient safety training in the preclinical curriculum

Background: Accrediting bodies require medical schools to teach patient safety and residents to develop teaching skills in patient safety. We created a patient safety course in the preclinical curriculum and used continuous quality improvement to make changes over time. Objective: To assess the impact of resident teaching on student perceptions of a Patient Safety course. Design: Using the Institute for Healthcare Improvement patient safety curriculum as a frame, the course included the seven IHI modules, large group lectures and small group facilitated discussions. Applying a social action methodology, we evaluated the course for four years (Y1–Y4). Results: In Y1, Y2, Y3 and Y4, we distributed a course evaluation to each student (n = 184, 189, 191, and 184, respectively) and the response rate was 96, 97, 95 and 100%, respectively. Overall course quality, clarity of course goals and value of small group discussions increased in Y2 after the introduction of residents as small group facilitators. The value of residents and the overall value of the course increased in Y3 after we provided residents with small group facilitation training. Conclusions: Preclinical students value the interaction with residents and may perceive the overall value of a course to be improved based on near-peer involvement. Residents gain valuable experience in small group facilitation and leadership

Improving quality of care through improved audit and feedback

Abstract Background The Department of Veterans Affairs (VA) has led the industry in measuring facility performance as a critical element in improving quality of care, investing substantial resources to develop and maintain valid and cost-effective measures. The External Peer Review Program (EPRP) of the VA is the official data source for monitoring facility performance, used to prioritize the quality areas needing most attention. Facility performance measurement has significantly improved preventive and chronic care, as well as overall quality; however, much variability still exists in levels of performance across measures and facilities. Audit and feedback (A&F), an important component of effective performance measurement, can help reduce this variability and improve overall performance. Previous research suggests that VA Medical Centers (VAMCs) with high EPRP performance scores tend to use EPRP data as a feedback source. However, the manner in which EPRP data are used as a feedback source by individual providers as well as service line, facility, and network leadership is not well understood. An in-depth understanding of mental models, strategies, and specific feedback process characteristics adopted by high-performing facilities is thus urgently needed. This research compares how leaders of high, low, and moderately performing VAMCs use clinical performance data from the EPRP as a feedback tool to maintain and improve quality of care. Methods We will conduct a qualitative, grounded theory analysis of up to 64 interviews using a novel method of sampling primary care, facility, and Veterans Integrated Service Network (VISN) leadership at high-, moderate-, and low-performing facilities. We will analyze interviews for evidence of cross-facility differences in perceptions of performance data usefulness and strategies for disseminating performance data evaluating performance, with particular attention to timeliness, individualization, and punitiveness of feedback delivery. Discussion Most research examining feedback to improve provider and facility performance lacks a detailed understanding of the elements of effective feedback. This research will highlight the elements most commonly used at high-performing facilities and identify additional features of their successful feedback strategies not previously identified. Armed with this information, practices can implement more effective A&F interventions to improve quality of care.</p

Measuring the quality of Patients’ goals and action plans: development and validation of a novel tool

Abstract Background The purpose of this study is to develop and test reliability, validity, and utility of the Goal-Setting Evaluation Tool for Diabetes (GET-D). The effectiveness of diabetes self-management is predicated on goal-setting and action planning strategies. Evaluation of self-management interventions is hampered by the absence of tools to assess quality of goals and action plans. To address this gap, we developed the GET-D, a criteria-based, observer rating scale that measures the quality of patients’ diabetes goals and action plans. Methods We conducted 3-stage development of GET-D, including identification of criteria for observer ratings of goals and action plans, rater training and pilot testing; and then performed psychometric testing of the GET-D. Results Trained raters could effectively rate the quality of patient-generated goals and action plans using the GET-D. Ratings performed by trained evaluators demonstrated good raw agreement (94.4%) and inter-rater reliability (Kappa = 0.66). Scores on the GET-D correlated well with measures theoretically associated with goal-setting, including patient activation (r=.252, P Conclusions The GET-D can reliably and validly rate the quality of goals and action plans. It holds promise as a measure of intervention fidelity for clinical interventions that promote diabetes self-management behaviors to improve clinical outcomes. Trial registration Clinicaltrials.gov Identifier: NCT00481286</p

Using Jazz as a Metaphor to Teach Improvisational Communication Skills

Metaphor helps humans understand complex concepts by “mapping” them onto accessible concepts. The purpose of this study was to investigate the effects of using jazz as a metaphor to teach senior medical students improvisational communication skills, and to understand student learning experiences. The authors designed a month-long course that used jazz to teach improvisational communication. A sample of fourth-year medical students (N = 30) completed the course between 2011 and 2014. Evaluation consisted of quantitative and qualitative data collected pre- and post-course, with comparison to a concurrent control group on some measures. Measures included: (a) Student self-reports of knowledge and ability performing communicative tasks; (b) blinded standardized patient assessment of students’ adaptability and quality of listening; and (c) qualitative course evaluation data and open-ended interviews with course students. Compared to control students, course students demonstrated statistically significant and educationally meaningful gains in adaptability and listening behaviors. Students’ course experiences suggested that the jazz components led to high engagement and creativity, and provided a model to guide application of improvisational concepts to their own communication behaviors. Metaphor proved to be a powerful tool in this study, partly through enabling increased reflection and decreased resistance to behaviors that, on the surface, tended to run counter to generally accepted norms. The use of jazz as a metaphor to teach improvisational communication warrants further refinement and investigation

Measurement in Veterans Affairs Health Services Research: Veterans as a Special Population

OBJECTIVE: To introduce this supplemental issue on measurement within health services research by using the population of U.S. veterans as an illustrative example of population and system influences on measurement quality. PRINCIPAL FINDINGS: Measurement quality may be affected by differences in demographic characteristics, illness burden, psychological health, cultural identity, or health care setting. The U.S. veteran population and the VA health system represent a microcosm in which a broad range of measurement issues can be assessed. CONCLUSIONS: Measurement is the foundation on which health decisions are made. Poor measurement quality can affect both the quality of health care decisions and decisions about health care policy. The accompanying articles in this issue highlight a subset of measurement issues that have applicability to the broad community of health services research. It is our hope that they stimulate a broad discussion of the measurement challenges posed by conducting “state-of-the-art” health services research