Back in 2003, researchers surveyed thousands of medical residents on cross-cultural care, attempting to tease out a clearer picture of the residents’ ability to practice medicine in ways that could eventually narrow health disparities.
The results, published in 2005 in JAMA, found that while nearly all respondents believed it was important to address cultural issues in care delivery, fewer than half felt well prepared to treat patients from diverse cultures, underserved populations or different socioeconomic classes, and racial and ethnic minority groups. The findings “set the stage” for developing a disparities-focused curriculum for graduate medical education (GME) that was practical, actionable, and discipline specific, said Joseph Betancourt, MD, MPH, one of the study’s authors.
“It’s important that medical students get a good foundation in this topic,” said Betancourt, director of the Disparities Solution Center and multicultural education at Massachusetts General Hospital (MGH) in Boston. “But as a med student, it’s still fairly theoretical. It’s in the GME space that you develop habits and behaviors, and that’s why it’s essential that we really embed this in resident education.”
Since that 2005 study, many more residency programs have adopted curricula and activities that educate about health disparities, but there’s still quite a way to go. According to a February 2017 report from the Accreditation Council for Graduate Medical Education (ACGME), about 60% of residents and fellows reported they understood the health disparities priorities in their clinical learning environment.
At MGH, residency disparities education has greatly expanded since it first began in 2001, Betancourt said. Today, the disparities curriculum, which includes an online module and one-on-one learning with faculty, is required for all in the Department of Medicine. The curriculum incorporates teaching scenarios based on real-life cases, such as a black woman in her 60s who presents with chest pain but refuses testing. Such a scenario, Betancourt said, gives residents a chance to explore why certain patients are distrustful of doctors and how they can begin repairing that relationship. Variations of the cross-cultural curriculum are also available to MGH’s physicians, nurses, and frontline staff.
“We don’t teach dos and don’ts—we think that contributes to stereotyping,” he said. “We try to offer a framework to help [trainees] understand the social and cultural factors that might impact care.”
This education seems to be paying off. According to Betancourt, surveys showed that the percentage of Hispanic patients treated at MGH who believed that white patients received better care declined from 25% in 2004 to 9% in 2012. Among black patients, 21% in 2004 thought white patients received better care, compared with 6% in 2012.
Teaching about equity, social determinants
At Henry Ford Health System in Detroit, Mich., much of the GME disparities curriculum is focused on its family medicine residents. According to Denise White Perkins, MD, PhD, director of the system’s Institute on Multicultural Health, residents receive a fairly intensive education on the social determinants of health that shape disparities and the central role of health equity in quality improvement efforts.
“It’s important that medical students get a good foundation in this topic. But as a med student, it’s still fairly theoretical. It’s in the GME space that you develop habits and behaviors, and that’s why it’s essential that we really embed this in resident education.”
Joseph Betancourt, MD, MPH
Massachusetts General Hospital
“As health equity conversations have evolved, we realize it’s no longer adequate to approach this in a cookbook style,” said Perkins, also a faculty member in the system’s Department of Family Medicine residency program. “Instead, we need to prepare residents to have a sense of cultural humility—to seek to understand patients in their contexts.”
For Henry Ford’s family medicine residents, disparities education begins during orientation and continues throughout the training years. In addition to a number of workshops, residents complete a required one-month rotation at the Institute on Multicultural Health that includes a mix of independent self-study and assigned work. Among the teaching tools Perkins uses with residents is an online game that puts students in the virtual shoes of a patient with limited resources. Residents also take an implicit bias test designed to help reveal attitudes that people may be unwilling or unable to acknowledge on their own.
To highlight bias, Perkins uses a scenario involving a young woman getting her annual gynecological checkup. After learning the patient is sexually active but doesn’t use contraception, most residents immediately assume she needs birth control—in other words, they automatically identify the patient as being heterosexual.
“To do this work, we have to create a safe and trusting environment with the learner,” Perkins said. “But you also have to be willing to find that edge of discomfort, go to it, and move past it.”
Using community data to drive quality improvement
Many, if not most, of the factors that lead to health disparities happen outside hospital walls. At St. Luke’s University Health Network in Pennsylvania, family medicine residents get an intimate view of those factors while helping with the network’s community health needs assessment (CHNA). St. Luke’s has administered CHNAs since the mid-1990s but started a more standardized process on all seven of its campuses in 2010 when the Affordable Care Act began requiring nonprofit hospitals to conduct CHNAs. Since then, residents’ engagement with CHNAs has grown considerably; family medicine residents are now required to go out into the community and survey residents, according to Bonnie Coyle, MD, MS, chair of the network’s Department of Community Health and Preventive Medicine.
“When they see the data broken down, it really gets their attention,” Coyle said. “It shows them just how often people with low incomes are in poorer health, have higher rates of diabetes, have poorly controlled diabetes, get less screenings … it becomes a eureka moment for them.”
For example, residents also help analyze CHNA data to develop and implement quality improvement initiatives. After assessments revealed disproportionately high rates of late-stage cancer diagnoses, residents began working on a colorectal cancer screening project at four clinic sites, said Rajika Reed, PhD, MPH, MEd, network director of epidemiology at St. Luke’s. As part of the effort, residents are developing culturally sensitive educational materials on the value of early screenings.
St. Luke’s is also piloting a new orientation program for first-year family medicine residents called “See the Community You Serve.” During the program, residents review CHNA data, hear from local leaders, and visit community organizations. The goal is to expose the residents to the social determinants that contribute to poor health and give them the opportunity to connect patients with local resources that will help them maintain better health. “Then, from day one as they walk into the hospital, they’re much more connected to the community,” Coyle said. “And that means they’re more prepared to help their patients.”