Cultural Competency Training: Current Efforts at the University of Hawaii John A. Burns School of Medicine

1. Martina L. Kamaka, MD Department of Native Hawaiian Health LIME II, September 23-25, 2007 Cultural Competency Training: Current Efforts at the University of Hawaii John A. Burns School of Medicine

2. The Department of Native Hawaiian Health • Created in October 2003 • Vision: Ku Pono: Hawaii Maoli achieving optimal health and wellness • Mission: To be center of excellence in education, research and quality health care practices committed to the optimal health and wellness of Hawaii Maoli, their families and communities that embraces traditional Hawaiian values and practices.

3. The Department of Native Hawaiian Health (DNHH) • Incorporated two existing programs • Imi Hoola (post baccalaureate program) • NHCOE (Native Hawaiian Center of Excellence) • Key differences: • Community advisory board • Help keep focus on vision and mission • Multidisciplinary faculty • Only medical school department in US committed solely to indigenous health

4. DNHH Educational Efforts • Post baccalaureate program: Imi Hoola • Recruitment and Retention • Medical Student Curriculum • Cultural “Competency” focus • Lectures • Workshops • Problem Based Learning • Cultural immersion • Electives

5. The Imi Hoola Program • Imi Hoola (those who seek to heal) began in 1973 • Funded by US federal government • Competitive, preparatory program for medical school • Focus on a successful application • Targeted underrepresented minorities • In 1996 becomes a post baccalaureate program • Federal funding changes • Provisional medical school acceptance to 10 students • In 1990’s, expanded to include financially, educationally and socially disadvantaged students

6. Profile of Imi Hoola Medical School Graduates (n=188) • Ethnicity • Native Hawaiian 40% • Filipino 24.5% • Samoan 7% • Micronesian 12% • Gender • Male 59% • Female 41% • Specialty (2002 data) • Primary Care 76% • Specialty Care 24% • Practice Location • Hawaii 45% (50% in rural communities) • Greater Pacific 5% (Micronesia, Samoa) • Continental US 24% • Still in Residency 21% (32% in Hawaii)

7. Imi Hoola Retention Services for Medical Students • Tutoring program: • Started in 2003 • 60% of former Imi Hoola students failed the USMLE 1 on first attempt • Prior to 2003, average of 30% failure rate on first attempt • Meet every 2 weeks during 1st and 2nd year of medical school • Meet for two hours • Review course material, review questions • Results • First and Second year Unit Pass rates • Improved • USMLE part 1 pass rates • Past 3 years, 100% passed on first attempt • Future directions • Expand tutoring into 3rd and 4th years • USMLE 2 exam prep • Student mentorships

8. DNNH Recruitment Efforts • DNHH part of a recruitment team • Members include JABSOM, Imi Hoola, DNHH, AHEC • Visits with secondary school and college students • Increase cost effectiveness, reach • Assists with science enrichment programs with UH Manoa(i.e.: Na Pua Noeau) • Summer research internships • Challenges: • Funding support • Coordinating efforts • Need for a central place for students: • Mentoring, applications, advising, financial aid

9. DNHH Medical School Curricular Efforts

10. Cultural Competency in the Curricula • Focus Groups • Question: How can the medical school improve student cultural competency training? • Stakeholders: Native Hawaiian patients, physicians and students • Lecture: Introduction to Native Hawaiian Health-new initiative • One hour lecture for first year • Topic: “Ola” • Native Hawaiian health from a cultural and historical viewpoint, Hawaiian values

11. Four Hour Workshop (first year students) • Overview NH health & health disparities • Cultural trauma • Self discovery: small group discussions • The patient-physician interaction • Traditional healing • Problem Based Learning Family Stream (units 2 through 4)-new initiative • Unit 2: elderly NH male, retired with diabetes. • Importance of family (effect on illness, treatment) • Culturally appropriate treatment • Role of traditional healing • Proposed future PBL case: son of the first patient • Mental health and substance abuse • Issues such as access to land, water rights • Cultural trauma

12. Cultural Immersion Weekend

13. Immersion Experience • Pilot study • Students selected randomly • Group size ranges from 7-15 • Curricular components: • Intense weekend experience • Self discovery exercises, small group discussions • Native Hawaiian cultural activities • Participating in protocol • Visiting a community health center • Learning about how a healthy ahupuaarelates to health (mountain to sea land division), working in the taro patch (loi) • Sessions with traditional healers • Canoe paddling, navigation and stargazing • Cultural access to Makua Valley

14. Community Health: Research and Clinical Practice (BIOM 512,513,514 Elective) • Year long elective • 4 hours weekly • Basic research methodology • Encouraged to pursue research focusing on Native Hawaiian health • Bench vs. community based • Research mentor • Lectures: • Native Hawaiian health/health disparities • Traditional healing • Cultural competence in research and clinical practice • Community based participatory research

15. DNHH 1st Year Elective • Title: Native Hawaiian Health and Healing • Duration: 10 weeks, 2 hours per week (offered twice a year) • Faculty: Traditional healers, faculty with cultural expertise • Topics: • Intro to NH health & Culture • General concepts i.e. Ola, Lokahi (balance) • Traditional diet • Land issues/ahupuaa • field trip to fishpond • Traditional healing • LaauLapaau, Laau Kahea, • Hooponopono, Lomilomi,

16. DNHH 4th Year Elective • Title: Health Care in Native Hawaiian Communities (NHH 545 elective) • Began in 2003 (previously an internal medicine elective) • 4 week duration • 4-8 students/year (5 international students so far) • Tailored to student needs • i.e.: a student interested in OB is assigned to work with an OB and a midwife • Discussion/Lecture sessions • Clinical care at community health centers with large Native Hawaiian populations • Work with traditional healers/cultural specialists • Lomilomi, Laau Kahea, Laau Lapaau

17. Challenges/Future Plans • Curriculum • Inclusion of coursework into the third and fourth year • Financial sustainability • Institutionalization of some, not all programs • Dependence on Grants • Faculty • Assessment • Revision of assessment tools • Development of a “cultural” standardized patient • Summative assessment needed near graduation

18. Mahalo!!! For information contact: http://jabsom.hawaii.edu/JABSOM http://www.dnhh.hawaii.edu martinak@hawaii.edu