Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial.

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

An Analysis of East Asian American Inpatient Psychiatric Data from the Hawai'i Health Information Corporation Database.

Past research has examined the complex reasons for the apparent reluctance of East Asian Americans (ie, Chinese, Japanese, Koreans) to seek mental health services when needed. The current study analyzed East Asian American (EAA) mental health, utilizing inpatient hospitalization data from the Hawai'i Health Information Corporation (HHIC) database. Frequency of inpatient hospitalizations for specific mental health diagnoses (depression, bipolar disorder, schizophrenia, and suicide attempts/ideation) in EAA patients was examined. White, Native Hawaiian, and Filipino patients were included for comparative purposes. Retrospective data on adult (18 years and over) inpatient visits in Hawai'i from 2007 to 2017 were analyzed. Variables available for analysis were detailed race/ethnicity, age, sex, island, and insurance type as well as readmission rates, severity of illness (SOI), and initial length of stay (LOS). Overall, there were no significant differences between race/ethnicity groups in regards to readmission, SOI, or LOS for a majority of the diagnoses. However, for depression, even when adjusting for other demographics, Japanese and Chinese patients had significantly higher initial LOS and SOI than White patients, though the strength of this association was weak (R Squared model fits being less than .1 for both outcomes). The reason for these findings requires further examination, including whether EAAs may be reticent to seek help and/or whether healthcare providers are not recognizing the need for assistance.

Mentoring as a Means to Achieving Workforce Diversification in Orthopaedic Surgery.

Orthopaedic surgery is no stranger to health care disparities and the American Academy of Orthopaedic Surgeons (AAOS) has expressed a commitment to a culturally competent and diverse workforce. Addressing workforce diversification is critical to recruiting a more diverse orthopaedic workforce and engaging the community to improve patient care and ensure equitable care for all. Unfortunately, these concerns were acknowledged by the AAOS almost 2 decades ago, without much significant progress. This article discusses mentoring as a means to address workforce diversification in orthopaedics and provides recommendations on how orthopaedics can enhance its efforts.

Implementation of a Business of Healthcare Curriculum for General Surgery Residents.

OBJECTIVE: To better prepare general surgery residents for handling the business aspects of healthcare, this project evaluation reports on the implementation of a business of healthcare curriculum (BHC) in a general surgery residency program. We evaluated (pre and post curriculum) self-perceived knowledge and attitudes toward common business topics. DESIGN: General surgery residents were administered a 13-item survey (7 Likert-type and 3 open-ended items assessing self-perceived knowledge and attitudes toward BHC, and 3 demographic questions) prior to the start of the curriculum. The curriculum was comprised of four core sessions, which included didactic lectures and group projects, including the creation of a business plan. At the conclusion of the curriculum, a post-test with the same items was administered. A total of 21 residents completed both the pre and post-tests. SETTING: The BHC was a mandatory part of the general surgery residency program and was conducted in Honolulu, Hawaii (University of Hawaii at Manoa). PARTICIPANTS: All general surgery residents, PGY-1 to PGY-5, were required to participate in the curriculum. RESULTS: Statistically significant increases in resident knowledge were found overall and specifically for healthcare reform legislation, differences between practice settings, financial matters, contracting and coding and billing for services. Additionally, responses to open-ended questions showed that residents had a positive attitude toward the curriculum and found it useful. CONCLUSIONS: General surgery residency programs can successfully create an impactful business of healthcare curriculum with minimal cost if volunteers and existing resources are utilized.

Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review.

BACKGROUND: Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs. OBJECTIVE: The authors sought to determine what cultural competency curricula exist specifically in GME. METHODS: In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends. RESULTS: Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation. CONCLUSIONS: Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows.

Scoping Review of Economical, Efficient, and Effective Cultural Competency Measures.

Identifying practical and effective tools to evaluate the efficacy of cultural competency (cc) training in medicine continues to be a challenge. Multiple measures of various lengths and stages of psychometric testing exist, but none have emerged as a "gold standard." This review attempts to identify cc measures with potential to economically, efficiently, and effectively provide insight regarding the value of cc training efforts to make it easier for wider audience utilization. A scoping review of 11 online reference databases/search engines initially yielded 9,626 items mentioning cc measures. After the initial review, focus was placed on measures that assessed cultural competence of medical students, residents, and/or attending physicians. Six measures were identified and reviewed: (1) Cross-Cultural Care Survey, (2) Cultural Competence Health Practitioner Assessment, (3) Cultural Humility Scale, (4) Health Beliefs Attitudes Survey, (5) Tool for Assessing Cultural Competency Training, and (6) the Tucker-Culturally Sensitive Health-Care Provider Inventory. Relevant literature documenting use and current psychometric assessments for each measure were noted. Each measure was found to be of value for its particular purpose but needs more strenuous reliability and validity testing. A commitment to include psychometric assessments should be an expected part of studies utilizing these measures.

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum.

OBJECTIVE: Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum. DESIGN, SETTING, AND PARTICIPANTS: Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method. RESULTS: Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors. CONCLUSIONS: Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills.

PURPOSE: Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills. METHODS: Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16. RESULTS: A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05). CONCLUSIONS: At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

GRSF1 is an age-related regulator of senescence.

Senescent cells that accumulate in multiple tissues with age are thought to increase pathological phenotypes. The removal of senescent cells can improve lifespan and/or healthspan in mouse models. Global hypomethylation and local hypermethylation in DNA are hallmarks of aging but it is unclear if such age-dependent methylation changes affect specific genes that regulate cellular senescence. Because mitochondria play important roles in aging and senescence, we tested if age-associated methylation changes in nuclear-encoded mitochondrial proteins were involved in regulating cellular senescence. Here, we examined the role of hypermethylation of the G-rich sequence factor 1 (GRSF1) promoter region, a mitochondrial RNA binding protein, in replication- and doxorubicin-induced cellular senescence. GRSF1 expression was lower in senescent fibroblasts, and GRSF1 knockdown induced senescence in human primary fibroblasts. These results suggest that the age-dependent hypermethylation of GRSF1 reduces its expression, which can potentially contribute to cellular senescence during aging.

Making Progress: The University of Hawai'i at Manoa's (UHM) Department of Surgery's Cross-Cultural Health Care Efforts from 2008-2018.

In 2008 the University of Hawai'i at Manoa's (UHM) Department of Surgery introduced the concept of cross-cultural health care (aka cultural competency) to its faculty and trainees. Much work remains before the cultural efforts wellknown outside the department are embraced within, but it has been prioritized for curriculum development and research. An example of the department's efforts include the Cross-Cultural Health Care Research Collaborative, which was created as a forum for faculty who have an interest in cultural issues related to healthcare and healthcare delivery. Participants from 14 UHM departments and other organizations developed projects and mentored students, resulting in over ten peer-reviewed publications. A related effort is the JABSOM Cultural Competency Resource Guide, which is in its 7th edition and reflects JABSOM activities and those of its collaborators. Another highlight is the Biennial Cross-Cultural Health Care Conference: Collaborative and Multidisciplinary Interventions, with six conferences held since 2010, hosting attendees from 28 US Mainland states and 11 countries. Additionally, the department has been recognized as one of the first to develop a cultural standardized patient exam for surgical residents. These nationally-recognized efforts resulted in invitations to serve on the very first cultural competency panel at the American College of Surgeons Clinical Congress and as a consultant on the development of Brigham and Women's Hospital's Center for Surgery and Public Health's Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a standardized curriculum for surgical residents. The department plans to continue its work on these projects and document outcomes.

Bispecific Antibody Binding To RANKL and Osteonectin with Enhanced Localization to the Bone.

Therapeutics reducing bone turnover, such as denosumab (Dmab), an anti-RANKL antibody, can provide treatments for patients with bone destruction. However, some patients with osteoporosis or localized primary bone tumors and many patients with various types of bone-metastatic cancer display unsatisfactory responses to Dmab. For achieving greater efficiency of RANKL neutralization in the bone microenvironment by enhancing the distribution of Dmab to the bone, we reengineered Dmab by fusing with single-chain variable fragments of an antibody specific for osteonectin (On), which is abundantly expressed in osseous tissues. The bispecific antibody, Dmab-FvOn, showed a similar activity as Dmab in inhibiting RANKL as examined in an osteoclast differentiation assay. When administered to mice, Dmab-FvOn was found to localize in increased proportions at the endosteum of the bone where osteonectin is abundant. Our study suggests that by linking anti-RANKL with an osteonectin-targeting moiety, a greater proportion of the therapeutic effector can be distributed in the bone. Future studies are needed to investigate whether the bispecific antibody can achieve higher therapeutic efficacy and lower toxicity.

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.

Gone, But Not Forgotten? Survey of Resident Attitudes Toward a Cultural Standardized Patient Examination for a General Surgery Residency Program.

Purpose: Various tools have been utilized for cultural competency training in residency programs, including cultural standardized patient examinations. However, it is unknown whether residents feel the training they received has a long-term impact on how they care for patients. The purpose of this study was to assess whether surgical residents who participated in a cultural standardized patient examination view the experience as beneficial. Methods: Surgical residents who completed a standardized patient examination from Fall 2009 to Spring 2015 were asked to complete a 13-question survey assessing the following: (1) did participants feel prepared when dealing with patients from different cultural backgrounds, (2) did they feel the standardized patient experience was beneficial or improved their ability to care for patients, and (3) did they perceive that cultural competence was important when dealing with patients. Results: Sixty current/former residents were asked to participate and 24 (40%) completed the survey. All agreed cross-cultural skills were important and almost all reported daily interaction with patients from different cultural backgrounds. Sixteen participants (67%) reported the cultural standardized patient examination aided their ability to care for culturally dissimilar patients, and 13 (54%) said the training helped improve their communication skills with patients. Thirteen (54%) reported they would participate in another cultural standardized patient examination. Conclusion: Development of effective cultural competency training remains challenging. This study provides some preliminary results that demonstrate the potential lasting impact of cultural competency training. Participants found the skills gained from cultural standardized patient examinations helpful.

An Overview of Cultural Competency Curricula in ACGME-accredited General Surgery Residency Programs.

OBJECTIVE: Cultural competency(CC) in surgical residency curricula is not the novel idea it was fourteen years ago when the ACGME challenged program directors to teach and assess six core competencies. CC is recognized as a component of "patient care", "professionalism", and "interpersonal and communication skills." The results of five programs (2004-2012) with CC curricula were identified in a 2013 paper by Ly and Chun. The primary objective of this paper is to provide the current status of CC curricula in general surgery residency programs. DESIGN: Three sources were used for this study. First, a four question survey on the current status of CC education was sent to program directors of ACGME-accredited surgery residency programs. Second, the lead authors from five programs previously reported in the 2013 paper were interviewed. Third, the survey mentioned above was resent to 52 residency programs who implemented New York University's (NYU) SPICE program, which has a CC component. PARTICIPANTS: Participants for the survey consisted of program directors of ACGME-accredited surgery residency programs. The interviews were conducted with the corresponding authors from the previous study by Ly and Chun. RESULTS: Of the 256 surveyed, nine responded; seven stated that CC is not taught formally at their institution while four stated that they do not feel any part of CC curricula is missing from their program. Due to the low response rate, we identified and conducted interviews with general surgery residency programs with CC curricula. Of the five programs contacted, only three remain active and utilize Objective Structured Clinical Examinations (OSCEs) to teach cultural competency. One of the three, the SPICE program at NYU, has expanded to 52 other residency programs in the US. CONCLUSIONS: Although the importance of CC has been identified in general surgery, formal curricula and documentation of implementation remains elusive.

The Effect of Mobile Tablet Computer (iPad) Implementation on Graduate Medical Education at a Multi-specialty Residency Institution.

Use of mobile tablet computers (MTCs) in residency education has grown. The objective of this study was to investigate the impact of MTCs on multiple specialties' residency training and identify MTC adoption impediments. To our knowledge, this current project is one of the first multispecialty studies of MTC implementation. A prospective cohort study was formulated. In June 2012 iPad2s were issued to all residents after completion of privacy/confidentiality agreements and a mandatory hard-copy pre-survey regarding four domains of usage (general, self-directed learning, clinical duties, and patient education). Residents who received iPads previously were excluded. A voluntary post-survey was conducted online in June 2013. One-hundred eighty-five subjects completed pre-survey and 107 completed post-survey (58% overall response rate). Eighty-six pre- and post-surveys were linked (response rate of 46%). There was a significant increase in residents accessing patient information/records and charting electronically (26.9% to 79.1%; P<.001), but a significant decrease in looking up drug and treatment reference material (97.0% to 82.1%; P=.0039). There was a significant increase in MTC use as a primary means of charting when conducting rounds (4.9% to 39.5%; P<.001) and a significant decrease in using paper charts (30.1% to 15.7%; P=.0073). There was also a significant increase in MTC use as a primary means for explaining a diagnosis (7.7% to 57.7%; P<.001). The use of MTC has an impact on how residents approach medical education, clinical practice, and patient education. The survey tool may be useful in collecting data on MTC use by other graduate medical education programs.

The refinement of a cultural standardized patient examination for a general surgery residency program.

BACKGROUND: Recent articles have documented the importance of cultural competency in surgery. Surgical residency programs have used the Objective Structured Clinical Examinations or cultural standardized patient examinations as a training tool. Past studies evaluating cultural competency have noted the importance of including an observational (control) arm, which would allow for a more objective assessment of a resident's competency in this area. The purpose of our article is to present the results of a follow-up study to a pilot cultural standardized patient examination for surgery residents. METHODS: All first-year surgery residents were required to participate in the videotaped cultural SP examination as part of the general surgery residency curriculum. Two measures were used to assess resident performance. On the day of the examination, the Cross-Cultural Care Survey was administered. The examination was assessed by the residents themselves, faculty observers, and standardized patients, using a written checklist that was developed to evaluate residents on all 6 Accreditation Council for Graduate Medical Education competencies. RESULTS: The current study includes 20 first-year surgery residents from academic years 2011 to 2012 and 2012 to 2013. The examination of pretest differences in groups found that students born outside of the United States had significantly higher scores on attitude (t = -2.68, df = 18, p = 0.02), but no statistically significant differences were found in skillfulness or knowledge or in the overall rating scale. For the overall rating scale, change from pretest to posttest was statistically significant (t = -2.25, df = 18, p = 0.04). Further analysis revealed that students who were born in the United States demonstrated a significant increase in ratings (t = -3.08, df = 10, p = 0.01) whereas students who were not born in the United States showed little change (t = -0.35, df = 7, p = 0.74). These results show that the means in attitude scales changed little for all groups, but both white and US-born students showed greater improvement on skillfulness and knowledge. CONCLUSIONS: Training and measurement of cross-cultural health care skills remains challenging. However, studies like these provide a good starting point from which to build.