Improve GME

Residents’ cultural competence starts with strong dose of humility

Disparities in health care are an unfortunate reality. Confronting and, eventually, eradicating them will require a multifaceted approach. One weapon in the effort is an attribute that is essential to patient care: understanding.

Recognizing patients’ cultural, professional and biological differences can lead to more effective diagnosis, treatment and management. This concept, often referred to as cultural competency, can play a significant role in addressing disparities.

The AMA is tackling this subject with a module on cultural competency in its GME Competency Education Program. Launched in June, the program is designed to help engage residents through interactive, online tutorials and track their progress in fulfilling the core-competency requirements of the Accreditation Council for Graduate Medical Education (ACGME).

Tap patients’ expertise

The evolution of big data and electronic health records provide physicians with the opportunity to make information-driven diagnosis. One unintended consequence of those technological advancements is they can lead to a dynamic in which patient interactions are robotic. This can be remedied by looking at things from the patient’s perspective and working with them.

“What I try to impart to residents and students is that patients are experts from their perspective,” said Tonya L. Fancher, MD, MPH, who co-wrote the GME Competency Education Program module on cultural competency. “That’s something we can’t ever forget. Even if you may know more about a medication, the patient has a lot to teach us about what it means for them to take the medication or not take the medication. That’s the key to it. That’s where the humility to me comes in.”

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As the U.S. has become increasingly multicultural, so, too, have its patient and physician populations. The diverse backgrounds a physician may encounter on a daily basis require an understanding of how to communicate with patients. As the module points out, in some instances that may require an interpreter. It also may require speaking with the family as a whole—in certain cultures, decisions may be made by a patriarch, matriarch or elder.

To aid in patient-physician interactions, the GCEP module touts the acronym LEARN, a communication framework designed by Elois Ann Berlin, PhD, and William C. Fowkes Jr., MD. This spells out like so:

L: Listen, encouraging patients to explain their situation. E: Explain clearly.   A: Acknowledge the differences between what patients understand and what you know. R: Recommend a treatment plan that is consistent with your conversation with a patient. N: Negotiate, to get agreement from patients on a course of action.

What assumptions can do

Personal biases are often unconscious. To effectively navigate diverse patient populations, the GCEP module highlights that a physician must understand their own biases as well as those their patients may harbor.

“If our commitment is to provide equal care to everyone, we have to be able to recognize our own biases before we do that,” said Dr. Fancher, associate dean of workforce innovation and community engagement, and interim associate dean for student and resident diversity at the University of California, Davis, School of Medicine. “Sometimes they are just assumptions when you go into a clinical encounter. This is checking your assumptions at the door. If you recognize your assumptions, you can then ask or check in or address them before they cause harm or lead you to unconsciously make a decision that has been clouded by your own bias.”

Another module that is part of the GME Competency Education Program, “Managing Unconscious Bias,” explores this phenomenon in greater detail.

Dr. Fancher believes that cultural humility—the commitment a physician makes in engaging in a process of self-evaluation and self-critique—is a lifelong commitment.

“With medical knowledge, you have to be humble to recognize knowledge changes constantly, so you’re always updating your knowledge,” she said. “This is the same idea. You’re always updating how to best take care of patients. Knowledge is part of that. But, clearly, having a relationship with your patients, communication [skills] and being respectful—those are all things that we have to keep working on and take as our responsibility.”

With contributions by subject-matter experts from around the country, the GME Competency Education Program’s offerings include 33 course modules that residents can access online, on their own schedule. Among these experts are several—including Dr. Fancher—who contributed to the AMA’s Health Systems Science textbook, which draws insights from faculty at medical schools that are part of the Association’s Accelerating Change in Medical Education Consortium.

GME Competency Education Program modules cover five of the six topics—patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice—within the ACGME’s core-competency requirements that residents must fulfill as part of their training. The cultural competency module falls under the umbrella of interpersonal and communication skills.

For more information about the AMA’s GME Competency Education Program, or to request a demo, email [email protected].

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