Measuring Medical Students' Preparedness and Skills to Provide Cross-Cultural Care.

Purpose: Cross-cultural education is an integral and required part of undergraduate medical curricula. However, the teaching of cross-cultural care varies widely and methods of evaluation are lacking. We sought to better understand medical students' perspectives on their own cultural competency across the 4-year curriculum using a validated survey instrument. Methods:We conducted an annual Internet-based survey at Harvard Medical School with students in all 4 years of training, for four consecutive years. We used a tool previously validated with residents and slightly modified it for medical students, assessing their (1) preparedness, (2) skillfulness, and (3) perspectives on the educational curriculum and learning climate. Results: Of 2592 possible survey responses, we received 1561 (60% response rate). Fourth-year students had significantly higher scores than first-year students (p<0.001) for all but one preparedness item (caring for transgender patients) and all but one skillfulness item (identifying ability to read/write English). Less than 50% of students felt adequately prepared/skilled by their fourth year on 8 of 11 preparedness items and 5 of 10 skillfulness items. Lack of practical experience caring for diverse patients was the most frequently cited challenge. Conclusions: While students reported that preparedness and skillfulness to care for culturally diverse patients seem to increase with training, fourth-year students still felt inadequately prepared and skilled in many important aspects of cross-cultural care. Medical schools can use this tool with students to self-assess cultural competency and to help guide enhancements to their curricula focusing on cross-cultural care.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006.

OBJECTIVES: This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain. METHODS: A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics. RESULTS: Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered. CONCLUSIONS: Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Leveraging quality improvement to achieve equity in health care.

INEQUALITY IN QUALITY: Disparities in health care and quality for racial, ethnic, linguistic, and other disadvantaged groups are widespread and persistent. Health care organizations are engaged in efforts to improve quality in general but often make little attempt to address disparities. STANDARD VERSUS CULTURALLY COMPETENT QUALITY IMPROVEMENT (QI): Most QI interventions are broadly targeted to the general population-a "one-size-fits-all" approach. These standard QI efforts may preferentially improve quality for more advantaged patients and maintain or even worsen existing disparities. Culturally competent QI interventions place specific emphasis on addressing the unique needs of minority groups and the root causes of disparities. HOW QI CAN REDUCE DISPARITIES: QI interventions can reduce disparities in at least three ways: (1) In some cases, standard QI interventions can improve quality more for those with the lowest quality, but this is unreliable; (2) group-targeted QI interventions can reduce disparities by preferentially targeting disparity groups; and (3) culturally competent QI interventions, by tailoring care to cultural and linguistic barriers that cause disparities, can improve care for everyone but especially for disparity groups. GUIDELINES FOR CULTURALLY COMPETENT QI: A culturally competent approach to QI should (1) identify disparities and use disparities data to guide and monitor interventions, (2) address barriers unique to specific disparity groups, and (3) address barriers common to many disparity group. CONCLUSIONS: To achieve equity in health care, hospitals and other health care organizations should move toward culturally competent QI and disparities-targeted QI interventions to achieve equity in health care, a key pillar of quality.

Cross-cultural medical education in the United States: key principles and experiences.

The field of cross-cultural care focuses on the ability to communicate effectively and provide quality health care to patients from diverse sociocultural backgrounds. In recent years, medical schools in the United States have increasingly recognized the growing importance of incorporating cross-cultural curricula into medical education. Cross-cultural medical education in the United States has emerged for four reasons: (1) the need for providers to have the skills to care for a diverse patient population; (2) the link between effective communication and health outcomes; (3) the presence of racial/ethnic disparities that are, in part, due to poor communication across cultures; and (4) medical school accreditation requirements. There are three major approaches to cross-cultural education: (1) the cultural sensitivity/awareness approach that focuses on attitudes; (2) the multicultural/categorical approach that focuses on knowledge; and (3) the cross-cultural approach that focuses on skills. The patient-based approach to cross-cultural care combines these three concepts into a framework that can be used to care for any patient, anytime, anywhere. Ultimately, if cross-cultural medical education is to evolve, students must believe it is important and understand that the categorical approach can lead to stereotyping; it should be taught using patient cases and highlighting clinical applications; it should be embedded in a longitudinal, developmentally appropriate fashion; and it should be integrated into the larger curriculum whenever possible. At the Harvard Medical School, we have tried to apply all of these lessons to our work, and we have started to develop a strategic integration process where we try to raise awareness, impart knowledge, and teach cross-cultural skills over the 4 years of schooling.