A Strategy for Improving Health Disparities Education in Medicine
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- Ross, P.T., Wiley Cené, C., Bussey-Jones, J. et al. J GEN INTERN MED (2010) 25: 160. doi:10.1007/s11606-010-1283-3
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A health disparities curriculum that uses evidence-based knowledge rooted in pedagogic theory is needed to educate health care providers to meet the needs of an increasingly diverse U.S. population.
The Health Disparities Education: Beyond Cultural Competency Precourse, along with its accompanying Train the Trainer Guide: Health Disparities Education (2008), developed by the Society of General Internal Medicine (SGIM) Disparities Task Force (DTF), is a comprehensive tool to facilitate developing, implementing and evaluating health disparities education. The curriculum includes five modules highlighting several fundamental concepts in health disparities, suggestions for teaching about health disparities in a wide range of settings and strategies for curriculum evaluation. The modules are Disparities Foundations, Teaching Disparities in the Clinical Setting, Disparities Beyond the Clinical Setting, Teaching about Disparities Through Community Involvement, and Curriculum Evaluation.
All five modules were delivered as a precourse at the 31st Annual SGIM Annual Meeting in Pittsburgh, PA and received the “Best Precourse Award”. This award is given to the most highly rated precourse based on participant evaluations. The modules have also been adapted into a web-based guide that has been downloaded at least 59 times.
Ultimately, the modules are designed to develop a professional commitment to eliminating racial and ethnic disparities in health care quality, promote an understanding of the role of health care providers in reducing health care disparities through comprehensive education and training, and provide a framework with which providers can address the causes of disparities in various educational settings.
Key Wordshealth disparitiesmedical educationfaculty development
In order to improve the health of the diverse U.S. population, it is essential to develop and implement educational programs that teach physicians about the pervasiveness of racial and ethnic health disparities and help them develop strategies to deliver quality care to diverse and underserved populations.1,2 The Institute of Medicine’s Unequal Treatment: Confronting racial and ethnic disparities in health care (2002) defined healthcare disparities as “racial or ethnic differences in the quality of healthcare that are not due to access related factors or clinical needs, preferences, and appropriateness of intervention”.1 Nonetheless, pedagogy for health disparities education is still in its infancy and has received limited acceptance and implementation into undergraduate and graduate medical education curricula.3–6 Moreover, there is considerable variability in the design and implementation of health disparities curricula, and few curricula comprehensively address the various ways to eliminate health disparities. Many focus on cultural competence, in an attempt to increase understanding of cultural beliefs and to outline best practices for communication with minority populations. Some curricula highlight systemic barriers such as limited access, insurance and language; yet few use evidence-based principles to guide learners in developing meaningful clinical responses to overcome such disparities.1,7,8 The Institute of Medicine’s report highlighted the role of health care providers in addressing disparities in health care; thus the development of curricula specifically designed to educate providers seemed a logical step toward meeting this need.
The aim of this article is to briefly outline the materials developed by the Society in General Internal Medicine’s Disparities Taskforce, which represents a comprehensive curriculum for teaching and evaluating health disparities education. These materials can be easily incorporated into faculty development efforts to address issues of health disparities, or improve upon existing educational modules. We also describe the process of delivering the curricular content during a precourse at the Society of General Internal Medicine National Meeting in 2008.
DEVELOPMENT OF THE TRAIN-THE-TRAINER CURRICULUM
Members of the Society of General Internal Medicine (SGIM) recognized the need for an effective module for educating physicians on the underpinnings of health care disparities and ultimately formed the Disparities Task Force (DTF). This group includes volunteers from the Society of General Internal Medicine membership, many of whom have experience teaching ethics, health disparities, and cross-cultural care at their institutions. The contributing faculty were primarily junior and mid-level health professions educators, clinician-educators and clinician-investigators. Over the course of three years, task force members worked in small-groups, participated in conference calls, e-mail exchanges, and in-person meetings to develop the curriculum. A workshop based on the materials and how they might be used in training colleagues to teach with them was proposed and accepted for presentation at the 2008 SGIM national meeting.
The task force selected a train-the-trainer model since the goal was to provide materials and teaching strategies to SGIM members that they could use in their home institutions to increase the number of faculty members prepared to teach about health disparities at the bedside, in small group seminars, and through community-based projects.9,10 Further, as our aim was to develop a model that would be used to train individuals who would later train others, the active learning experience incorporated into this model is critical for developing teaching and improving facilitation skills.11,12
The curriculum as represented in the Train-the-Trainer Guide: Health Disparities Education Guide (2008) is a comprehensive curriculum, consisting of five modules, designed to facilitate developing, implementing and evaluating health disparities education. All participating Task Force members presented topics for inclusion in the curriculum; however considerations were only given to those topics that gave evidence of academic rigor, as evidenced by implementation and evaluation at another institution. These items were then discussed during a retreat and subsequent conference calls to determine the final content included in the curriculum.
Target Audience and Facilitator Skills
We anticipated that this curriculum would be applicable to a variety of health care providers, including physicians, nurses, dentists, and allied health professionals, who are responsible for teaching students in the various health professions. While the materials provide information, which is useful for a variety of learners who have a desire or responsibility to educate others, individuals with limited teaching experience or health disparities knowledge may need additional training to feel comfortable teaching a topic as multi-factorial and complex as health disparities. Although these modules can be used by individuals with varied experienced, optimally those teaching these modules should have prior training or experience employing active learning modalities (e.g., small group discussions, role-plays, and experiential activities). Additionally, we recommend that teachers have experience facilitating discussions on multicultural issues in health care as discussions about cultural difference, race, bias, and disparities can be emotionally charged and often raise complex ethical questions. It is also important to consider the learning environment in which these modules are presented (e.g. specialty, institution, practice, etc.), and allow for appropriate implementation.
Understand attitudes such as mistrust, subconscious bias and stereotyping that practitioners and/or patients may bring to the clinical encounter
Attain knowledge of the existence and magnitude of health disparities, including the multi-factorial etiologies of and the multiple solutions required to eliminate them
Acquire the skills to effectively communicate and negotiate across cultures, including trust-building and the use of key tools to improve cross-cultural communication
Disparities Foundations (30 minutes)
Review of Disparities Data
• Infant mortality rates are twice as high among African-American infants as whites
• Hispanics less likely to receive smoking cessation messages
Role of Social determinants
• Socioeconomic status accounts for much of the observed
• Racial disparities in health outcomes
• Literacy, and/or employment, which are powerful determinants of health
Role of Health Care
• Minorities more often lack health insurance or a usual source of care, Uninsured individuals are less likely to have a regular source of care, are more likely to report delaying seeking care, and are more likely to report that they have not received needed care—all resulting in increased avoidable hospitalizations, emergency hospital care, and adverse health outcomes
Role of Provider-Patient Encounter
• Providers’ beliefs about patients’ characteristics may influence decision-making. Patients perceived as likely to adhere with strong social support may be more likely to receive certain treatments. In one study using vignettes, African American patients were more likely to be rated as non-adherent than their otherwise identical counterparts
Resources for Updating Disparities Information
• Agency for Healthcare Research and Quality’s National Healthcare
• Disparities Report
• “Data2010”(sponsored by Healthy People 2010)
• Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services
Teaching Disparities in the Clinical Setting (30 minutes)
• Covers following areas: Limited English Proficiency, Medical Mistake, Limited Literacy, Stereotyping, Informed Consent
Challenges to Teaching in the Clinical Setting
• Institutional Culture
• Team dynamics
• Hidden curriculum
Suggestions for working with Skeptical Learners
• Explore reasons for resistance, model and recognize good behavior, demonstrate knowledge and skills, etc.
Disparities Beyond the Clinical Setting (30 minutes)
Sample Exercises: Increasing Awareness of Self and Others
• Pass around a bag of M&M’s. Tell the trainees to take as many as they want. Once all the trainees have M&M’s, tell them that for each M&M they took they have to say one thing about themselves. For instance, if a trainee took 10 M&M’s, they would have to say 10 things about themselves. If someone took no M&M make them explain why and then share something about themselves
Small Group Teaching Triggers
• To begin to explore the meaning and dimensions of culture, particularly those aspects of culture that are not immediately apparent upon meeting a patient for the first time. To begin to think about the assumptions and stereotypes we make about other people based on how they differ from what may be considered “normal”
Large Group Lectures:
• Patient mistrust – Example review the landmark “Tuskegee Study of Untreated Syphilis in the Negro Male”
• Can you reflect on a clinical scenario where your bias has interfered with your care of a patient or patients?
Samples Cases, Vignettes and Video Resources
• A 38 y/o male presents for a clinic appointment he had scheduled weeks ago when he called saying that he needed a routine physical. When his care-provider, a white female resident, enters the exam room the patient looks at her calmly and states that he would prefer to have a black doctor. He adds that he had seen a black doctor in the waiting room, and that he is willing to wait for that physician to see him. She tells him that she will go discuss his request with a supervising attending physician
Teaching About Disparities through Community Involvement (30 minutes)
Overview of Module and Objectives
• The US Health Care System—overview and description of how it contributes to health care disparities
• Introduction to Community—discussion of and then visit to a local community that experiences high rates of disparity. Residents learn first hand from community members and visit the factors that contribute to health care disparities
• Worlds Apart: Mr. Phillp’s Story—discussion of mistrust of health care and racism and how they contribute to health care disparities, particularly in some African American communities
• Community as a Positive Force---visit to local community organization working at the grass roots level to reduce health care disparities
Curriculum Evaluation (30 minutes)
• Explore program evaluation as a form of disciplined scholarly inquiry, consider the design features of an evaluation study that allow the investigator to:
• Draw sound conclusions about the specific instance and generalize to other instances
• Identify threats to reliability and validity
Disparities Precourse Evaluation Results
Anchors of Rating Scale
Please rate the following aspects of this session:
Overall Evaluation Rating
1=Poor – 5=Outstanding
Quality of Content
Amount of Material Covered
Prior to this workshop, my overall knowledge of the topic covered was:
1=Poor –5 =Expert
The audience size for this session was:
1=Too Small – 3=Too Big
How likely is it that you will make a concrete change in your teaching, research, patient care, or administrative work as a result of this workshop?
1=Definitely will not change – 5=Extremely likely to change
Would you recommend inviting this workshop to your institution for presentation?
1=No – 5=Definitely
There remains an ongoing need for institutions to implement health disparities into their curricula. The SGIM precourse was found to be an effective way to deliver the Disparities Curriculum. The SGIM Health Disparities Curriculum is uniquely designed to aid in that effort and develop well-trained health care providers who are committed and prepared to eliminate disparities in health care quality and promote an understanding of the health care provider’s role in addressing this pressing issue. The curriculum was made available as a downloadable document via the SGIM Education website (http://www.sgim.org/index.cfm?pageId=269) in July 2008. To date, the curriculum has been downloaded over 50 times as of January 2010.
Funding for the initial phases of this work was provided by the Society of General Internal Medicine (SGIM) Council. Dr. C. Cené is supported through the UNC Clinical Translational Science Award-K12 Scholars Program (1KL2RR025746-01). Dr. A. Fernández is supported by the Arnold P. Gold Foundation. Dr. M. Peek is supported through the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program and National Institute of Diabetes and Digestive and Kidney Diseases (K23DK075006-04).