Acad Psychiatry DOI 10.1007/s40596-015-0279-z
COLUMN: EDUCATIONAL CASE REPORT
Novel Brief Cultural Psychiatry Training for Residents Esperanza Díaz & Tichianaa Armah & Caroline T. Linse & Anna Fiskin & Ayana Jordan & Janet Hafler
Received: 1 December 2013 / Accepted: 13 January 2015 # Academic Psychiatry 2015
Cultural sensitivity is crucial for optimal mental health outcomes. In particular, differing expectations can interfere with the delivery of quality care when clinicians and patients do not share the same background and belief systems. Cultural influences are linked to health disparities and the providers’ attitudes in the clinical encounter. Thus, education in cultural sensitivity should include experiences to help learners become aware of unconscious stereotypes, as well as understanding the impact of social and cultural influences on health outcomes [1–3]. There are multiple teaching approaches and cross-cultural curricular designs that address attitudes, knowledge, and skills [4]. The most comprehensive approach, grounded in the social sciences, uses the trainee’s awareness of their own cultural background to teach them how to respond effectively to their patient’s issues that involve culture and ethnicity [5]. We developed a curriculum using experiential learning as the main teaching approach [6]. Residents were the teachers, also addressing the need for trainees to acquire teaching skills [7]. In this paper, we describe the design and implementation of an innovative cultural psychiatry curriculum.
Methods The curriculum was designed over 4 years using action research with systematic inquiries to improve the way in which residents were developing attitudes, knowledge, and skills E. Díaz (*) : T. Armah : A. Fiskin : A. Jordan : J. Hafler Yale University, New Haven, CT, USA e-mail: [email protected] C. T. Linse Queen’s University Belfast, Belfast, UK
around the concepts of culture [8]. Faculty and residents collaborated to obtain the final model, which was implemented during the second year of the psychiatry residency (PGY2) and built on the bio-psychosocial curriculum that is provided for the residents in the first year of residency (PGY1). Four 90-min training sessions were implemented during the PGY2 curriculum and included a list of reading materials and links to websites. The goal of session 1 was to provide the residents with a video case to experience biases and explore implicit assumptions as normal reactions that might influence clinical interactions [9, 10]. The group discussion focused on personal reactions, activation of stereotypes, and implicit assumptions. Session 2 aimed to explore the literature and available evidence on how bias and prejudices impact health disparities. The class divided by groups completed and presented a literature review, and the leaders/teachers facilitated a discussion based on the presentations. The topics were based on the following three themes: 1) attitudes, with a focus on prejudices and stereotypes influencing health care; 2) knowledge, with a focus on health care disparities and consequences; and 3) skills, with a focus on how to conduct a cultural assessment using the Cultural Formulation Interview (CFI) from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM5) [11]. The goal of session 3 was to provide the opportunity to practice strategies that aim to elicit cultural information. In addition, the residents created videos of their own short clinical vignettes portraying cultural assessments that were used for self-assessment in session 4. Session 4’s goal was to develop self-awareness and feedback skills by viewing the recorded role-plays completed in session 3. The residents observed the recorded role-plays to
Acad Psychiatry
explore how the “provider” used the CFI questions and how the “patients” responded. The sample consisted of 16 PGY2 residents, including eight females and eight males: three Hispanic-Whites, three Asians, three African-Americans, and seven Caucasians. One faculty leader (ED) invited the PGY2 residents to select two of their peers to co-lead the curriculum with one faculty and the two resident facilitators from the prior year. The study was reviewed by the Institution Human Investigation Committee and deemed exempted. Questionnaires consisting of eight Likert scale questions and six open-ended questions were administered before and after the implementation of the curriculum. The questions aimed to collect data about the residents’ knowledge of cultural competence, their knowledge of disparities in health care, the likelihood of discussing cultural influences with patients, their level of comfort discussing cultural influences with patients, the likelihood of discussing cultural influences with students, and their comfort discussing cultural influences with students. We also asked if they had prior cultural competence training before residency. For the quantitative component, we used the Wilcoxon signed ranks test to compare the two matched samples before and after implementation. The answers to the open-ended questions were transcribed and coded according to Miles and Huberman [12].
Results A total of 16 residents (excluding the resident facilitators) completed the pre-curricular assessment. Eight residents completed the post-curricular assessment. The post-questionnaires were administered outside of protected time, late in the day and interfered with on-call schedules and child care, which may account for the low-response rate to the second assessment. Teaching cultural sensitivity using this deliberative curriculum inquiry approach [13] provided the opportunity for the residents to teach, give feedback, self-assess, and explore issues of culture. The results provided evidence that watching themselves on the videos that they recorded facilitated selfreflection, in addition to developing skills by practicing the CFI. Action research guided the modifications made to the curriculum. Our results are based on the curriculum model that was implemented in the fourth year of the design. The main themes that emerged from the open questions were related to comments about the learning experience and suggestions for changes. All the residents made comments about the advantage of having their own biases questioned as part of their learning. They also pointed out the value of experiential exercises and practicing the CFI questions. The following quotes from different residents illustrate typical responses:
Great overviews on an incredibly complex topic, excellent at having our own biases questioned and have time to reflect on how to become more culturally competent/ humble. Getting in touch with my own snap judgments. Opportunity to discuss biases. I plan to use the CFI questions. The videos and the role-playing extremely helpful—really fun! Residents specifically identified the need for more protected time, more time to practice, and more role-plays of bias in clinical interactions. The mean comparisons of ratings from residents who completed pre- and post-training questionnaires (rating 1–7, 1=no change/very uncomfortable, 7=significant change/very comfortable) were as follows: comfort discussing culture with students (3.87–5.37), likely to discuss culture with students (4.37–5.75), comfort discussing culture with patients (3.755.75), likely to discuss patient/provider cultural differences (3–5.75), likely to discuss culture with patient (4.25–5.75), health disparities knowledge (4–5.37), and cultural competence knowledge (3.37–5.12). All comparisons showed significant difference (Wilcoxon signed ranks). Prior training in cultural competence before joining the program did not affect baseline measures, but individuals with prior training were more likely to complete the post-test (Fisher’s exact test p=0.031).
Discussion Our study explored the effects of a novel curriculum to increase awareness about health disparities and how unconscious biases and stereotypes may affect delivery of care to patients. Providing information related to these topics resulted in the resident participants expressing that they were motivated to continue to learn skills to implement culturally sensitive interviews with patients. Previous studies have described the value of combining attitudes, knowledge, and skills [4] to address cultural sensitivity education [14]. However, the current literature does not incorporate the “resident-as-teacher” construct, which may improve approaches implemented to date. To our knowledge, no previous study has used the new CFI questions to build skills in cultural competence. In addition, our methods enabled exploration of the change in attitudes among residents after participation in this curriculum. We have now incorporated these elements, developed over a 4-year period, into an integrated curriculum. Residents as teachers favor a model that allows residents to develop teaching skills, specifically those of content and reflection. It also tailors the curriculum to the needs of the group.
Acad Psychiatry
Further, residents are introduced to teaching and a possible career path as a clinician educator. Modifications to the curriculum by participant feedback promoted further understanding of cultural sensitivity, content, and teaching strategies. By constructing a curriculum based on experiential learning and real vignettes, the residents had an opportunity to increase awareness of their own cultural backgrounds and biases as well as introspection on their clinical practice [5]. Using groups to discuss these biases built collaboration and fostered acceptance of each other’s differences. Stereotypes and prejudices can be minimized and the ability to tolerate uncertainty optimized with this approach [15]. Our quantitative results showed significant change on all the measures. These results are influenced by a small sample, and the development of the curriculum over 4 years precludes the use of data from the development years: Those data were used to create the curriculum presented in this study. Our results indicate that while prior training did affect participation in the post-curricular assessment, it did not affect baseline measures. This may reflect that residents who answered the post-questionnaires had an interest in the subject. Collaboration with educators, librarians, website developers, and video technicians provided an integrated approach to facilitate what some might regard as a difficult subject to teach. The department and the medical school support were crucial in creating space and time for the project and fostering the development of tools to teach. While our study has strengths, some limitations should be noted. First, the sample was small, which may have affected our ability to detect meaningful changes in attitudes and knowledge. Second, sessions conducted outside of protected time might have influenced participation in the assessments. Despite these limitations, we implemented a feasible curriculum that is now part of the core resident curriculum. In addition, framing the case vignettes as brief verbal accounts, as opposed to written cases, allowed us to implement role-plays that were relevant to the participants. These were easy to create, enjoyable, and memorable for the residents. The combination of several teaching methods related to experiential learning, reflection, self-assessment, “residents teaching residents,” and action research enabled successful development of a cultural psychiatry curriculum. The curricular approach, which included video recording of case vignettes roleplayed by the residents, and the use of the CFI questions was effective in increasing awareness of health disparities and cultural biases in clinical care as well as addressing attitudes that
influence the clinical encounter. Consequently, the residents were motivated to learn how to be culturally sensitive in a model that is feasible to implement.
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Berger JT. The influence of physicians' demographic characteristics and their patients' demographic characteristics on physician practice: implications for education and research. Acad Med. 2008;83:100–5. 2. Stone J, Moskowitz G. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ. 2011;45:768–76. 3. Kohn-Wood LP, Hooper LM. Cultural competency, culturally tailored care, and the primary care setting: possible solutions to reduce racial/ethnic disparities in mental health care. J Ment Health Couns. 2014;36:173–88. 4. Betancourt JR. Cultural competence and medical education: many names, many perspectives. One Goal Academic Med. 2006;81: 499–501. 5. Kirmayer LJ, Rousseau C, Corin E, D. G. Training researchers in cultural psychiatry: The McGill-CIHR Strategic Training Program. Acad Psychiatry. 2008;32. 6. Kolb DA, Boyatzis RE, Mainemelis C. Experiential learning theory: previous research and new directions. In Sternberg, Robert J [Ed]; Zhang, Li-fang [Ed] [2001] Perspectives on thinking, learning, and cognitive styles [pp 227-247] x, 276 pp Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; US2001. pp. 227-247. 7. Grady Weliky TA, Chaudron LH, DiGiovanni SK. Psychiatric residents' self-assessment of teaching knowledge and skills following a brief "psychiatric residents-as-teachers" course: A pilot study. Acad Psychiatry. 2010;34:442–4. 8. Saucier D, Paré L, Côté L, Baillargeon L. How core competencies are taught during clinical supervision: participatory action research in family medicine. Med Educ. 2012;46:1194–205. 9. Schools S. “The Lunch Date" A Video for Developing Cultural SelfAwareness in Film from 1989 Davidson. Edited by Gallavan NP, http://www.youtube.com/watch?v=epuTZigxUY8; 2005. 10. Gallavan NP, Ramirez MG. The lunch date: a video for developing cultural self awareness. Multicult Perspect. 2005;7:33–9. 11. APA. Diagnostic and statistical manual of mental disorders: DSM-5 [5th ed.]. Arlington: American Psychiatric Publishing, Inc; 2013. 12. Miles MB, Huberman AM. Analysing data II: qualitative data analysis in qualitative data analysis: an expanded source book. Thousand Oaks: Sage Publications; 1994. p. 54. 13. Harris I. Perspectives for curriculum renewal in medical education. Acad Med. 1993;68:484–6. 14. Lim RF, Lu FG. Culture and psychiatric education. Acad Psychiatry. 2008;32:269–71. 15. Guzder J, Rousseau C. A diversity of voices: the McGill 'working with culture' seminars. Cult Med Psychiatry. 2013;37:347–64.
COLUMN: EDUCATIONAL CASE REPORT
Novel Brief Cultural Psychiatry Training for Residents Esperanza Díaz & Tichianaa Armah & Caroline T. Linse & Anna Fiskin & Ayana Jordan & Janet Hafler
Received: 1 December 2013 / Accepted: 13 January 2015 # Academic Psychiatry 2015
Cultural sensitivity is crucial for optimal mental health outcomes. In particular, differing expectations can interfere with the delivery of quality care when clinicians and patients do not share the same background and belief systems. Cultural influences are linked to health disparities and the providers’ attitudes in the clinical encounter. Thus, education in cultural sensitivity should include experiences to help learners become aware of unconscious stereotypes, as well as understanding the impact of social and cultural influences on health outcomes [1–3]. There are multiple teaching approaches and cross-cultural curricular designs that address attitudes, knowledge, and skills [4]. The most comprehensive approach, grounded in the social sciences, uses the trainee’s awareness of their own cultural background to teach them how to respond effectively to their patient’s issues that involve culture and ethnicity [5]. We developed a curriculum using experiential learning as the main teaching approach [6]. Residents were the teachers, also addressing the need for trainees to acquire teaching skills [7]. In this paper, we describe the design and implementation of an innovative cultural psychiatry curriculum.
Methods The curriculum was designed over 4 years using action research with systematic inquiries to improve the way in which residents were developing attitudes, knowledge, and skills E. Díaz (*) : T. Armah : A. Fiskin : A. Jordan : J. Hafler Yale University, New Haven, CT, USA e-mail: [email protected] C. T. Linse Queen’s University Belfast, Belfast, UK
around the concepts of culture [8]. Faculty and residents collaborated to obtain the final model, which was implemented during the second year of the psychiatry residency (PGY2) and built on the bio-psychosocial curriculum that is provided for the residents in the first year of residency (PGY1). Four 90-min training sessions were implemented during the PGY2 curriculum and included a list of reading materials and links to websites. The goal of session 1 was to provide the residents with a video case to experience biases and explore implicit assumptions as normal reactions that might influence clinical interactions [9, 10]. The group discussion focused on personal reactions, activation of stereotypes, and implicit assumptions. Session 2 aimed to explore the literature and available evidence on how bias and prejudices impact health disparities. The class divided by groups completed and presented a literature review, and the leaders/teachers facilitated a discussion based on the presentations. The topics were based on the following three themes: 1) attitudes, with a focus on prejudices and stereotypes influencing health care; 2) knowledge, with a focus on health care disparities and consequences; and 3) skills, with a focus on how to conduct a cultural assessment using the Cultural Formulation Interview (CFI) from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM5) [11]. The goal of session 3 was to provide the opportunity to practice strategies that aim to elicit cultural information. In addition, the residents created videos of their own short clinical vignettes portraying cultural assessments that were used for self-assessment in session 4. Session 4’s goal was to develop self-awareness and feedback skills by viewing the recorded role-plays completed in session 3. The residents observed the recorded role-plays to
Acad Psychiatry
explore how the “provider” used the CFI questions and how the “patients” responded. The sample consisted of 16 PGY2 residents, including eight females and eight males: three Hispanic-Whites, three Asians, three African-Americans, and seven Caucasians. One faculty leader (ED) invited the PGY2 residents to select two of their peers to co-lead the curriculum with one faculty and the two resident facilitators from the prior year. The study was reviewed by the Institution Human Investigation Committee and deemed exempted. Questionnaires consisting of eight Likert scale questions and six open-ended questions were administered before and after the implementation of the curriculum. The questions aimed to collect data about the residents’ knowledge of cultural competence, their knowledge of disparities in health care, the likelihood of discussing cultural influences with patients, their level of comfort discussing cultural influences with patients, the likelihood of discussing cultural influences with students, and their comfort discussing cultural influences with students. We also asked if they had prior cultural competence training before residency. For the quantitative component, we used the Wilcoxon signed ranks test to compare the two matched samples before and after implementation. The answers to the open-ended questions were transcribed and coded according to Miles and Huberman [12].
Results A total of 16 residents (excluding the resident facilitators) completed the pre-curricular assessment. Eight residents completed the post-curricular assessment. The post-questionnaires were administered outside of protected time, late in the day and interfered with on-call schedules and child care, which may account for the low-response rate to the second assessment. Teaching cultural sensitivity using this deliberative curriculum inquiry approach [13] provided the opportunity for the residents to teach, give feedback, self-assess, and explore issues of culture. The results provided evidence that watching themselves on the videos that they recorded facilitated selfreflection, in addition to developing skills by practicing the CFI. Action research guided the modifications made to the curriculum. Our results are based on the curriculum model that was implemented in the fourth year of the design. The main themes that emerged from the open questions were related to comments about the learning experience and suggestions for changes. All the residents made comments about the advantage of having their own biases questioned as part of their learning. They also pointed out the value of experiential exercises and practicing the CFI questions. The following quotes from different residents illustrate typical responses:
Great overviews on an incredibly complex topic, excellent at having our own biases questioned and have time to reflect on how to become more culturally competent/ humble. Getting in touch with my own snap judgments. Opportunity to discuss biases. I plan to use the CFI questions. The videos and the role-playing extremely helpful—really fun! Residents specifically identified the need for more protected time, more time to practice, and more role-plays of bias in clinical interactions. The mean comparisons of ratings from residents who completed pre- and post-training questionnaires (rating 1–7, 1=no change/very uncomfortable, 7=significant change/very comfortable) were as follows: comfort discussing culture with students (3.87–5.37), likely to discuss culture with students (4.37–5.75), comfort discussing culture with patients (3.755.75), likely to discuss patient/provider cultural differences (3–5.75), likely to discuss culture with patient (4.25–5.75), health disparities knowledge (4–5.37), and cultural competence knowledge (3.37–5.12). All comparisons showed significant difference (Wilcoxon signed ranks). Prior training in cultural competence before joining the program did not affect baseline measures, but individuals with prior training were more likely to complete the post-test (Fisher’s exact test p=0.031).
Discussion Our study explored the effects of a novel curriculum to increase awareness about health disparities and how unconscious biases and stereotypes may affect delivery of care to patients. Providing information related to these topics resulted in the resident participants expressing that they were motivated to continue to learn skills to implement culturally sensitive interviews with patients. Previous studies have described the value of combining attitudes, knowledge, and skills [4] to address cultural sensitivity education [14]. However, the current literature does not incorporate the “resident-as-teacher” construct, which may improve approaches implemented to date. To our knowledge, no previous study has used the new CFI questions to build skills in cultural competence. In addition, our methods enabled exploration of the change in attitudes among residents after participation in this curriculum. We have now incorporated these elements, developed over a 4-year period, into an integrated curriculum. Residents as teachers favor a model that allows residents to develop teaching skills, specifically those of content and reflection. It also tailors the curriculum to the needs of the group.
Acad Psychiatry
Further, residents are introduced to teaching and a possible career path as a clinician educator. Modifications to the curriculum by participant feedback promoted further understanding of cultural sensitivity, content, and teaching strategies. By constructing a curriculum based on experiential learning and real vignettes, the residents had an opportunity to increase awareness of their own cultural backgrounds and biases as well as introspection on their clinical practice [5]. Using groups to discuss these biases built collaboration and fostered acceptance of each other’s differences. Stereotypes and prejudices can be minimized and the ability to tolerate uncertainty optimized with this approach [15]. Our quantitative results showed significant change on all the measures. These results are influenced by a small sample, and the development of the curriculum over 4 years precludes the use of data from the development years: Those data were used to create the curriculum presented in this study. Our results indicate that while prior training did affect participation in the post-curricular assessment, it did not affect baseline measures. This may reflect that residents who answered the post-questionnaires had an interest in the subject. Collaboration with educators, librarians, website developers, and video technicians provided an integrated approach to facilitate what some might regard as a difficult subject to teach. The department and the medical school support were crucial in creating space and time for the project and fostering the development of tools to teach. While our study has strengths, some limitations should be noted. First, the sample was small, which may have affected our ability to detect meaningful changes in attitudes and knowledge. Second, sessions conducted outside of protected time might have influenced participation in the assessments. Despite these limitations, we implemented a feasible curriculum that is now part of the core resident curriculum. In addition, framing the case vignettes as brief verbal accounts, as opposed to written cases, allowed us to implement role-plays that were relevant to the participants. These were easy to create, enjoyable, and memorable for the residents. The combination of several teaching methods related to experiential learning, reflection, self-assessment, “residents teaching residents,” and action research enabled successful development of a cultural psychiatry curriculum. The curricular approach, which included video recording of case vignettes roleplayed by the residents, and the use of the CFI questions was effective in increasing awareness of health disparities and cultural biases in clinical care as well as addressing attitudes that
influence the clinical encounter. Consequently, the residents were motivated to learn how to be culturally sensitive in a model that is feasible to implement.
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Berger JT. The influence of physicians' demographic characteristics and their patients' demographic characteristics on physician practice: implications for education and research. Acad Med. 2008;83:100–5. 2. Stone J, Moskowitz G. Non-conscious bias in medical decision making: what can be done to reduce it? Med Educ. 2011;45:768–76. 3. Kohn-Wood LP, Hooper LM. Cultural competency, culturally tailored care, and the primary care setting: possible solutions to reduce racial/ethnic disparities in mental health care. J Ment Health Couns. 2014;36:173–88. 4. Betancourt JR. Cultural competence and medical education: many names, many perspectives. One Goal Academic Med. 2006;81: 499–501. 5. Kirmayer LJ, Rousseau C, Corin E, D. G. Training researchers in cultural psychiatry: The McGill-CIHR Strategic Training Program. Acad Psychiatry. 2008;32. 6. Kolb DA, Boyatzis RE, Mainemelis C. Experiential learning theory: previous research and new directions. In Sternberg, Robert J [Ed]; Zhang, Li-fang [Ed] [2001] Perspectives on thinking, learning, and cognitive styles [pp 227-247] x, 276 pp Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; US2001. pp. 227-247. 7. Grady Weliky TA, Chaudron LH, DiGiovanni SK. Psychiatric residents' self-assessment of teaching knowledge and skills following a brief "psychiatric residents-as-teachers" course: A pilot study. Acad Psychiatry. 2010;34:442–4. 8. Saucier D, Paré L, Côté L, Baillargeon L. How core competencies are taught during clinical supervision: participatory action research in family medicine. Med Educ. 2012;46:1194–205. 9. Schools S. “The Lunch Date" A Video for Developing Cultural SelfAwareness in Film from 1989 Davidson. Edited by Gallavan NP, http://www.youtube.com/watch?v=epuTZigxUY8; 2005. 10. Gallavan NP, Ramirez MG. The lunch date: a video for developing cultural self awareness. Multicult Perspect. 2005;7:33–9. 11. APA. Diagnostic and statistical manual of mental disorders: DSM-5 [5th ed.]. Arlington: American Psychiatric Publishing, Inc; 2013. 12. Miles MB, Huberman AM. Analysing data II: qualitative data analysis in qualitative data analysis: an expanded source book. Thousand Oaks: Sage Publications; 1994. p. 54. 13. Harris I. Perspectives for curriculum renewal in medical education. Acad Med. 1993;68:484–6. 14. Lim RF, Lu FG. Culture and psychiatric education. Acad Psychiatry. 2008;32:269–71. 15. Guzder J, Rousseau C. A diversity of voices: the McGill 'working with culture' seminars. Cult Med Psychiatry. 2013;37:347–64.
