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Author, title, and year of publication Journal Study type Purpose Data collection method Major findings Battat, R., et al. (2010). Global health competencies and approaches in medical education: A literature review. BMC Medical Education Literature review Identify competencies and educational approaches for teaching global health in medical schools. Pre-defined search strategy; Ovid MEDLINE and Web of Science (1996-2009) N = 32 • Most common educational approaches for teaching global health were didactics and experiential learning. • Steps are underway to build consensus among global health experts regarding basic global health training for medical students Cherniak, W. A., et al (2013). Educational objectives for international medical electives: A literature review. Journal of the Association of American Medical Colleges Literature review Compile and categorize a comprehensive set of educational objectives for international medical electives (IMEs) SciVerse Scopus online (SVSo); english only; 2012 N = 11 • Most of the objectives are concerned competency (both clinical and experiential) and cultural awareness • When trainees engage in IMEs, they improve their clinical skills, which may result in trainees gaining confidence and becoming better able to work with foreign medical professionals. This may potentially contribute to the two educational objectives of “understanding different health care systems” and “understanding cultural differences in treating patients Fung, K., et al (2008). An integrative approach to cultural competence in the psychiatric curriculum. Journal of the American Association of Directors of Psychiatric Residency Training Systematic review Document the approach to cultural competence training being developed in the Department of Psychiatry at the University of Toronto PubMed, Psyc-INFO, PsycArticles, CINAHL, Social Science Abstracts, and Sociological Abstracts; by searching government and professional association publications N=41 • Cultural psychiatry curriculum at the University of Toronto includes both generic and specific cultural competence components and utilizes a unique integrative framework. • The curriculum has been shaped by evaluation methods, and advances in education, (development of competency-based objectives, the implementation of an integrated teaching program, and the use of formative assessment tools, such as a modified exam score sheet for mock oral exam practices) • The implemented core curriculum changes were met with positive responses from residents based on voluntary feedback forms. Gustafson, D. L.,et al (2010). How are we 'doing' cultural diversity? A look across english canadian undergraduate medical school programmes. Medical Teacher Review Maps the approaches to cultural diversity education in English Canadian medical schools Database search; PubMed (1993-2008) N = 37 • Two medical schools have adopted the cultural competency model; five have adopted a critical cultural approach to diversity; and the remaining seven have incorporated some aspects of both approaches. • More research is needed to map the theoretical approaches to cultural diversity at Canadian medical schools and to evaluate the long-term effectiveness of these approaches on improving physician–patient relationships, reducing health disparities, improving health outcomes and producing positive learning outcomes in physicians. Horvat, L., et al (2014). Cultural competence education for health professionals. Cochrane database of systematic reviews Systematic Review Assess the effects of cultural competence education interventions for health professionals on patient-related outcomes, health professional outcomes, and healthcare organization outcomes. Database search; MEDLINE; Cochrane Central Register of Controlled Trials; EMBASE; CINAHL; PsycINFO (1946-2012) Proquest Dissertations and Theses database (1861-2012). N = 14 • The studies differed in how the education was provided and which outcome measures were used. • There was no evidence of an effect on a range of treatment outcomes or evaluations of care. None of the five included studies examined the effect of cultural competence education on healthcare organizations, or assessed adverse outcomes. • Future research on cultural competence education for health professionals should seek greater consensus on the core components of cultural competence education, how participants are described and the outcomes assessed. Kirmayer, L. J., et al (2008). Training clinicians in cultural psychiatry: A Canadian perspective. Academic Psychiatry Evaluation Summarize the pedagogical approaches and curriculum used in the training of clinicians in cultural psychiatry at the Division of Social and Transcultural Psychiatry, McGill University. Reviewed available published and unpublished reports on the history and development of training in cultural psychiatry, and student evaluations of teaching at McGill. • The McGill program includes core teaching, clinical rotations, an intensive summer program, and annual Advanced Study Institutes. • The interdisciplinary training setting emphasizes general knowledge rather than specific ethnocultural groups, including: understanding the cultural assumptions implicit in psychiatric theory and practice; exploring the clinician’s personal and professional identity and social position; evidence-based conceptual frameworks for understanding the interaction of culture and psychopathology; and developing skills for working with interpreters and culture-brokers, who mediate and interpret the cultural meaning and assumptions of patient and clinician. • An approach to cultural psychiatry grounded in basic social science perspectives and in trainees’ appreciation of their own background can prepare clinicians to respond effectively to the changing configurations of culture, ethnicity, and identity in contemporary health care settings. Like, R. C. (2011). Educating clinicians about cultural competence and disparities in health and health care. Journal of Continuing Education in the Health Professions Review Overview of health care policy, legislative, accreditation, and professional initiatives relating to cultural competency and health disparities. n/a • Training clinicians to provide culturally competent care is a key strategy for helping to reduce healthcare disparities minority, ethnic, and socioeconomically disadvantaged communities.. • Health care policy, legislative, accreditation, and professional initiatives have highlighted the importance of culturally competent service delivery and the elimination of racial and ethnic disparities. • There is some research evidence for the positive impact of cross-cultural education, and a growing number of curricular re- sources and e-learning programs are now available. Papic, O., et al (2012). Survey of family physicians' perspectives on management of immigrant patients: Attitudes, barriers, strategies, and training needs. Patient Education & Counseling Evaluation Evaluate family physicians’ perspectives on the care of immigrant population. Questionnaires distributed to family physicians in Montreal; N = 598 • Family physicians find communication difficulties to be the key barrier and would like to see the access to interpreters improved. • Only a minority of physicians have received specific cross-cultural competence training but those who have seem to provide better quality of care. • Knowledge of physician perspectives is an essential element on which to base interventions to improve the quality of care to this population. • Practice implications: Physicians should be reminded of the importance of using professional interpretation services in multi- lingual encounters. Cross-cultural training should be further advanced in Canadian medical curricula. Pottie, K., et al (2007). Health advocacy for refugees: Medical student primer for competence in cultural matters and global health. Canadian Family Physician Journal article; Program Evaluation Evaluate a program used to train medical students to work with newly arriving refugees, to foster competence in handling cultural issues Follow-up interviews with students, family physicians, and refugees. • The program is composed of an Internet-based training module and a self- assessment quiz focused on global and refugee health, a workshop to increase competence in cultural matters, an experience working with at least 1 refugee family at a shelter for newly arriving refugees, and family physician mentorship. • The program has been received enthusiastically by students, refugees, and family physicians. Working with refugees provides a powerful introduction to issues related to global health and competence in cultural matters. The program also provides an opportunity for medical students to work alongside family physicians and nurtures their interest in working with disadvantaged populations. • Working at a community refugee shelter provided a powerful learning experience for students and enhanced their perspective on the importance of primary care and cultural competence skills Reitmanova, S. (2011). Cross-cultural undergraduate medical education in north america: Theoretical concepts and educational approaches. Teaching and Learning in Medicine: An International Journal Literature Review Review available conceptual models of cross-cultural medical education. Database search; scientific literature about cultural diversity education in PubMed (1995-2010); N=53 • Approaches to cross-cultural health education can be organized under the rubric of two specific conceptual models: cultural competence and critical culturalism. • The variation in the conception of culture adopted in these two models results in differences in all curricular components: learning outcomes, content, educational strategies, teaching methods, student assessment, and program evaluation. • Medical schools could benefit from more theoretical guidance on the learning outcomes, content, and educational strategies provided to them by governing and licensing bodies. • More student assessments and program evaluations are needed in order to appraise the effectiveness of cross-cultural undergraduate medical education. Zhang, C., et al (2014). Bridging the gap: Enhancing cultural competence of medical students through online videos. Journal of Immigrant and Minority Health Journal Article; survey report Assess the effectiveness of the videos in enhancing medical students’ cultural competency and confidence in working with Chinese immigrants Survey; N = 105 • 67.3 % reported that they had learned specific and useful strategies to better serve immigrant patients. • 79.6 % of respondents stated that online videos can be an effective method in cultural competency training. • 81.6 % of respondents felt that medical schools should provide more training to improve their cultural competency. • Suggestions from students include: incorporating immigrant patients and cultural issues into Problem Based Learning (PBL) cases, and increasing the cultural diversity of volunteer patients during the simulated patient-encounter sessions. • Video-recorded interviews could serve as an effective, low-cost, and easily accessible teaching tool to fill a void in the medical school curriculum. Contributes to educational objectives of “understanding different health care systems” and “understanding cultural differences in treating patients (Cherniak, 2013). Trainees may gain confidence and become better able to work with foreign medical professionals and patients (Cherniak, 2013). Curricula based on the cultural competence model offers optional courses that include one or more learning objectives about diversity. (Gustafson, 2010) Most common recommended educational approaches for teaching global health topics were didactics and experiential learning (Battat, 2010). Curricula from a critical cultural approach, focuses on how the concept of culture is influenced by political, historical and socio- economic factors (Gustafson, 2010) University of Toronto program emphasizes a generic approach to cultural competence and utilize an integration framework (Fung, 2008) McGill program follows an interdisciplinary approach, emphasizing general knowledge rather than specific ethnocultural groups (Kirmayer, 2008) Educational approaches Collaborator Role: collaborating with the ethnic communities and available resources Professional role: respect for diversity Health advocate role: addressing the impact of racism, access barriers, and social factors leading to disparities. Scholar role: culturally informed research skills Learning objectives derived from 6 core competencies of a physician - defined by the Canadian Medical Education Directions for Specialists (Fung, 2008) Main goal: enable students to assess the level of risk associated with incorporating culturally specific preferences and practices into treatment plans and developing alternative strategies when necessary to reduce risk of harm (Gustafson, 2010) Educational Objectives Methods of Teaching Evaluation Benefits Thematic Analysis Results Communicator role: the use of interpreters Video-recorded interviews could serve as an effective, low-cost, and easily accessible teaching tool to fill a void in the medical school curriculum (Zhang, 2014) Case study method is used to analyse the complexity of cultural influences on patient presentation and clinicians’ own practices to address their implicit biases and tacit assumptions (Kirmayer, 2008) Include cultural diversity in electives and workshops Assist students with identifying clients’ culturally specific beliefs and practices that may put them at risk for ill health; (Gustafson, 2010) Provide students with opportunities to examine their ethnocentrism, neutralize their discriminatory attitudes and enhance their communication skills in identifying cultural similarities and differences. (Gustafson, 2010) Survey results showed great support for the videos; 67.3 % reported that they had learned specific and useful strategies to better serve immigrant patients; 79.6 % of respondents stated that online videos can be an effective method in cultural competency training (Zhang, 2014). UBC Study: medical students watched instructional videos and completed an online survey to assess the effectiveness of the videos in enhancing medical students’ cultural competency and confidence in working with Chinese immigrants (Zhang,2014). A program composed of an Internet-based training module and a self- assessment has been received enthusiastically by students, refugees, and family physicians (Pottie, 2007) In another study, however, a majority of physicians (69%) received no cross- cultural training at all during their medical education and careers, meaning a significant portion of family physicians in Canada may not be providing optimal care to their immigrant patients (Papic, 2012). Almost 89% of 771 Canadian medical graduates surveyed in 2007 reported that that they were appropriately trained to care for individuals of diverse backgrounds (Gustafson, 2010) When trainees engage in International Medical Electives, they improve their clinical skills (Cherniak, 2013). Manager role: addressing power inequities within demographics Cultural competence can be defined as “the ability of health care professionals to communicate with and effectively provide high-quality care to patients from diverse sociocultural backgrounds ” (Like, 196). It entails the appreciation of cross-cultural differences in recognizing and communicating illness, in health- and care-seeking behavior patterns, in understanding and adherence to a prescribed therapy, and in expectations of care (Reitmanova, 2011). As Canada is becoming increasingly ethnically and culturally diverse, there is more potential for misunderstanding, miscommunication, and lack of appreciation of cross-cultural variations in the medical encounter what can result in patient poor health outcomes and consequent health and healthcare disparities (Reitmanova, 2011). In 1995, The World Health Organization called for medical schools to respond to the impact of demographic shifts on the health needs of world communities (Gustafson, 2010). Subsequently medical educators have been developing objectives and programs to meet the demands. This study examines the extent to which efforts have been made to provide cultural competence education in medical schools in Canada, a country with rapidly growing multicultural population groups. Pubmed N = 1287 Scopus N = 1492 PsychINFO N = 172 Medline N = 271 CINAHL N = 117 Total Articles from Database search N = 3068 • Duplicates Removed • N = 1033 Limited to Canadian publications from 2005-2016 N = 470 • Duplicates removed • N = 200 Excluded: opinion pieces, commentaries, position papers, letters; Included: empirical studies, interviews, surveys, focus groups, review pieces (literature/systematic/scoping) N = 98 • Duplicates removed • N = 46 Refined quality assessment of selected literature by using six criteria: applicability, accuracy, credibility, currentness, clarity, and variety. N = 11 References Family Doctor in Brooklyn. (2016). Retrieved from http://medical.firstresponseurgentcare.com/wp- content/uploads/2015/09/19532646_xxl.jpg Gustafson, D. L., & Reitmanova, S. (2010). How are we 'doing' cultural diversity? A look across english canadian undergraduate medical school programmes. Medical Teacher, 32(10), 816-823. Like, R. C. (2011). Educating clinicians about cultural competence and disparities in health and health care. Journal of Continuing Education in the Health Professions, 31(3), 196-206 11p. Office of Global Health. (2016). Retrieved from https://www.schulich.uwo.ca/globalhealth/img/homepage/holding- globe.jpg Reitmanova, S. (2011). Cross-cultural undergraduate medical education in north america: Theoretical concepts and educational approaches. Teaching and Learning in Medicine, 23(2), 197-203. University of Ottawa Logo. (2016). Retrieved from http://www.uottawa.ca/brand/sites/www.uottawa.ca.brand/files/uott awa_hor_white.eps Contact info Rayhan Pitigala E-mail: [email protected] Phone: 613-252-2771 By: Rayhan Pitigala – Department of Health Sciences, University of Ottawa And Dr. Rukhsana Ahmed – Department of Communication, Faculty of Arts, University of Ottawa Cultural Competence in Medical Education: A Systematic Review Search Terms: “Cultural competence” and “medical education,” “medical training,” “medical schools”, or “medical curricula,” Conclusion Overall, Canadian medical schools recognize the need for cultural competence training, in light of the increase in diverse populations. There is a lack of consensus among the medical education contingencies about what their objectives are with regards to teaching and implementing cultural competence programs. The approaches to instruction and exposure to cultural competence is not standardized and varies between different institutions. The efficacy of the programs in place need to be evaluated with further research in order to modify and improve the curricula and teaching methods. Acknowledgements I’d like to thank my faculty sponsor, Dr. RukhsanaAhmed, for the support and mentorship throughout the research process, and for giving me a foundation of basic research skills. I’d like to thank Tea Rokolj and Karine Fournier of the Library at the University of Ottawa for assisting me with my database searches. I would also like to thank the University of Ottawa Undergraduate Research Program for the opportunity to get involved in research. Topics are taught by interdisciplinary faculty including social scientists, medical anthropologists, or social workers (Reitmanova, 2011) Offer students encounters with various cultural groups to increase awareness and knowledge of particular beliefs and behaviours (Gustafson, 2010)
