Ascertaining Resident Physicians’ Attitudes, Perceptions and Practices Related to Cultural Competency Training

1. Ascertaining Resident Physicians’ Attitudes, Perceptions and Practices Related to Cultural Competency Training Ilana S. Mittman, PhD, MS; David A. Mann, MD, PhD Carlessia A. Hussein, DrPH, RN and Mary C. Russell, PhD Maryland Department of Health and Mental Hygiene Office of Minority Health and Health Disparities Sixth National Conference on Quality Health Care for Culturally Diverse Populations Minneapolis, Minnesota September 23, 2008 1409 – Resident Physicians’ Attitudes on Cultural Competency

2. Benefits of Cultural Competence Greater quality of provider-patient communication More successful patient education (higher information recall) Increased patient health-seeking behavior Increased patient satisfaction Increased use of preventive services, and reduced use of acute care services. Fewer diagnostic errors Greater adherence to treatment regimen Increased trust in the provider Cooper et al., 2003; The Diversity Research Forum, Summer 2007 1409 - Resident Physicians’ Attitudes on Cultural Competency

3. Should Cultural Competency Training (CCT) Be Mandated? • Mandating health professionals’ education in cultural competency (and in general) has been controversial • Historically, traditional measures of continuing education mandate only attendance not learning and have no measurable performance end point • Although states have taken steps to mandate CCT, providers’ attitudes about the utility of CCT and issues of enforcement have not been studied yet • Comparisons between states that have implemented mandatory training to others than have not yet taken place • The effectiveness of encouragements only - not studied 1409 - Resident Physicians’ Attitudes on Cultural Competency

4. Cultural Competency Legislation in the U.S. • New Jersey SB 144 – physicians required to receive CCT as pre-requisite for licensure/re-licensure • California AB 144 – All continuing medical education courses must contain CC curricula (unless exempt) • Washington SB 6194 – Each program poised to train healthcare providers in an accredited discipline must include a course in “multicultural health” • Maryland SB 905, 942 and 883 – Recommending development of cultural competency training; mandating reporting of cultural diversity efforts and cultural competency courses • New Mexico SB 600 – Enactment of health education cultural competency task force 1409 - Resident Physicians’ Attitudes on Cultural Competency

5. Legislation Mandating or Strongly Requiring Cultural Competency Training – U.S. Source: US Dept of Health and Human Services, 2008 WA NY NJ IL CO CA OH MD AZ GA NM FL Purple – Legislation referred to committee Navy Blue – Legislation passed, requiring or strongly recommending CCT Royal Blue – Legislation died in committee or vetoed 1409 - Resident Physicians’ Attitudes on Cultural Competency

6. Cultural Competency Directives U.S. • The Joint Commission on Hospital Accreditation (JCOHA) • The Liaison Committee on Medical Education (LCME) • The Accreditation Council for Graduate Medical Education (ACMGE) • Center for Medicare and Medicaid Services (CMS) 1409 - Resident Physicians’ Attitudes on Cultural Competency

7. The Maryland Case • Maryland ranks second nationally with respect to active physicians, with 355.0 per 100,000 • Maryland ranks 6th in training of resident physicians • Maryland is home to prestigious teaching hospitals taking in trainees from around the nation and the world • Maryland is highly diverse with its population being 41% racial/ethnic minority, and 12.2% being foreign born in 2006 1409 - Resident Physicians’ Attitudes on Cultural Competency

8. Encouraging Cultural Competency Training: Maryland House Bill 883 (2003) • 20-801: “encourage courses or seminars that identify and eliminate Health care services disparities of minority populations” • 20-803: “health care professionals licensing may offer/require staff to take courses on disparities” 1409 - Resident Physicians’ Attitudes on Cultural Competency

9. First Attempt to Mandate CCTMaryland HB 1295 (2006) Proposed requiring schools of medicine to include instruction on cultural competency as a pre-requisite for graduation Proposed requiring completion of cultural competency education as a pre-requisite for licensure and re-licensure Faced fierce opposition and was amended to require the Department of Health and Mental Hygiene (DHMH) to organize a workgroup of representatives from the Health Occupations Boards and the Office of Minority Health and Health Disparities (MHHD) to discuss specific recommendations Amended bill failed and a voluntary partnership between DHMH and the Boards was established 1409 - Resident Physicians’ Attitudes on Cultural Competency

10. Second Attempt to Mandate CCTMaryland HB 100 (2007) Stipulated the convening of a workgroup to require each health occupational board to develop recommendations for requiring individuals licensed by the boards to receive instruction in cultural competency Facing fierce opposition the bill was withdrawn in March of 2007 1409 - Resident Physicians’ Attitudes on Cultural Competency

11. Mandated Reporting of CCT ActivitiesMaryland HB 905 & HB 942 (2008) Public and private higher education institutions required to report their “cultural diversity” initiates to the legislature, state bodies overseeing higher education and the Office of Minority Health and Health Disparities 1409 - Resident Physicians’ Attitudes on Cultural Competency

12. A Study to Inform Future Cultural Competency Legislation Exploratory Questions: • Given encouragement only (HB 883) what is the existing degree of cultural competency training in Maryland Hospitals? • What are existing attitudes about cultural competency training among Maryland healthcare providers? • What is the providers’ knowledge about national guidelines on cultural competency training? • Are there differences in the responses based on participant demographics? 1409 - Resident Physicians’ Attitudes on Cultural Competency

13. Research Design Develop and disseminate a survey to assess existing practices, perceptions and preferences on CCT • Pilot a survey to resident physicians in three community hospitals in Maryland • Amend survey based on responses and expand to include additional hospital and health workers in Maryland • Collaborate with states who already have mandated CCT • Make comparisons among disciplines and among states This presentation focuses on the pilot study only 1409 - Resident Physicians’ Attitudes on Cultural Competency

14. Target Population • Three community-based hospitals serving medically underserved areas - internal medicine residency program • One large teaching hospital situated within a diverse low-income population – anesthesiology residency program 1409 - Resident Physicians’ Attitudes on Cultural Competency

15. The Survey Administered on-line (SurveyMonkey) Participant demographics Assessment of existing cultural competency training Measure attitudes and perceptions related to cultural competency training (A four-point Likert Scale) Measure knowledge of national and state guidelines pertaining to cultural competency 1409 - Resident Physicians’ Attitudes on Cultural Competency

16. Survey Participants Demographics (n=55) 1409 - Resident Physicians’ Attitudes on Cultural Competency

17. Survey Participants Demographics (n=55) 1409 - Resident Physicians’ Attitudes on Cultural Competency

18. “Cultural competency training is mandatory in my hospital” 1409 - Resident Physicians’ Attitudes on Cultural Competency

19. Perceptions 1409 - Resident Physicians’ Attitudes on Cultural Competency

20. Perceptions by Specialty Type(statistically significant comparisons) 1409 - Resident Physicians’ Attitudes on Cultural Competency

21. Perceptions by Gender(statistically significant comparisons) 1409 - Resident Physicians’ Attitudes on Cultural Competency

22. Example of Distribution of Responses by Specialty to the Statement: “Cultural competency is important in healthcare delivery” 1409 - Resident Physicians’ Attitudes on Cultural Competency

23. Awareness of National Guidelines: Responses to the Statement:“Do the following bodies either require or recommend cultural competency preparedness of medical staff?” 1409 - Resident Physicians’ Attitudes on Cultural Competency

24. Reported Training Styles 1409 - Resident Physicians’ Attitudes on Cultural Competency

25. Results Highlights (1) • The majority of respondents agreed with the importance and utility of CCT • The majority of respondents disagreed that CCT is too difficult to teach in residency • There is confusion about requirements related to CCT even within one’s institution • The vast majority of respondents were unsure about licensing and accreditation boards’ recommendations related to CCT 1409 - Resident Physicians’ Attitudes on Cultural Competency

26. Results Highlights (2) • There were no statistically significant differences in perceptions related to CCT between minorities and non-minorities • There were significant differences by specialty type in the strength of agreement that CCT is important (internal medicine agreeing more strongly) • There were significant differences by gender in the strength of agreement that CCT is important (women agreeing more strongly) • Some findings of this study (regarding interest and level of formal training) are supported by earlier studies (Park et al., 2006) 1409 - Resident Physicians’ Attitudes on Cultural Competency

27. Conclusions and Recommendations • Overall, in our study, physicians in residency regardless of race and ethnicity recognize the importance of CCT and do not view the training as a hard task • Residents with more limited patient contact may be less likely to value CCT • Teaching faculty and residency directors must communicate CCT recommendations and guidelines put forth by the institution and by external accreditation agencies • CCT is essential in residency, often the last point of supervised medical training 1409 - Resident Physicians’ Attitudes on Cultural Competency

28. Study Limitations • Convenience sampling – external validity • Small sample size • Volunteer participation may introduce a selection bias (in favor of CCT) • Comparisons between specialties should be made with physicians within the same hospital 1409 - Resident Physicians’ Attitudes on Cultural Competency

29. Future Studies • Survey to be disseminated to the entire healthcare workforce in Maryland hospitals comparing specialties (60 hospitals in MD) • Perceptions related to mandated training for graduation; licensing and re-licensing to be ascertained • Comparisons to be made with states that have implemented mandatory training 1409 - Resident Physicians’ Attitudes on Cultural Competency

30. Contact Information Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 500 Baltimore, MD 21201 Phone: 410-767-7117 Fax: 410-333-5100 Email: healthdisparities@dhmh.state.md.us Website: www.mdhealthdisparities.org 1409 - Resident Physicians’ Attitudes on Cultural Competency