JAMA report finds training lacking in key areas, suggests improvements needed
Although most resident physicians responding to a national survey acknowledge the importance of providing care that accommodates the needs of today's diverse patient population, many of them do not feel prepared to address cross-cultural issues they commonly face in practice. Most also report receiving little or no training in providing cross-cultural care during their residencies, and fewer still say they were evaluated on cultural aspects of their patient communication skills. The report from the Massachusetts General Hospital (MGH) Institute for Health Policy appears in the Sept. 7 issue of the Journal of the American Medical Association.
"Residents are getting mixed messages during their training," says Joel S. Weissman, PhD, of the MGH Institute for Health Policy, the study's lead author. "On one hand they recognize that these issues are important, but on the other hand they have little clinical time to address cultural issues, they receive limited instruction and little or no evaluation, and there are too few good role models and mentors." Weissman has studied medical care access problems of the uninsured and racial and ethnic minorities for many years.
Increasing attention has been paid recently to how sociocultural differences between patients and providers can complicate health care – leading to poor communication, patient dissatisfaction and reduced quality of care. In the past ten years both the American Medical Association and the Accreditation Council for Graduate Medical Education have issued statements emphasizing the importance of training in cross-cultural care. In 2002 the Institute of Medicine released a report highlighting racial and ethnic disparities disparities in health care and recommending cross-cultural education of health professionals as one method of addressing this crisis. The JAMA paper is the first national study of young physicians' readiness to care for a culturally diverse population.
The research team mailed surveys to about 3,500 residents in the final years of their training programs in seven specialties at 149 academic health centers across the U.S. Of the more than 2,000 respondents, almost all acknowledged the importance of considering a patient's culture when providing care. Many of them agreed that culturally based difficulties could result in such problems as longer office visits and patients' not understanding or complying with instructions.
Although only a few residents indicated that they felt unprepared in response to general questions about caring for patients of different cultures or ethnic and racial minorities, when asked about specific situations – such as caring for patients who mistrust the U.S. health system, have health beliefs that conflict with Western medicine or are recent immigrants – 20 to 25 percent replied that they felt unprepared. A similar percentage felt they could not recognize mistrust in patients or identify cultural or religious customs that might have an impact on care. As a comparison, only 2 to 3 percent of respondents indicated not feeling ready to handle typical clinical problems.
When questioned about their residency experiences, one third to one half the respondents reported receiving little or no training in handling such situations as properly addressing patients from other cultures, understanding different family decision-making structures, or working with interpreters. Even in programs that offer cross-cultural training, significant numbers of residents reported no instruction in key areas. Lack of time was cited most frequently as a barrier to providing cross-cultural care; and other problems mentioned included poor access to interpreters, absence of written materials in needed languages and limited experience. A lack of good role models or mentors for cross-cultural care was reported by 30 percent of respondents, and more than 60 percent reported not being evaluated on cross-cultural skills.
"Given the growing racial and ethnic diversity of our nation, it is troubling that many of our newest doctors feel unprepared to communicate effectively with patients from a broad range of cultural backgrounds," says Joseph Betancourt, MD, MPH, director of the MGH Disparities Solutions Center and co-lead author of the JAMA report. "We suggest that residency programs integrate cross-cultural education as part of both formal and informal training experiences, provide mentorship, and evaluate resident physicians' performance in this critical area." A member of the team that produced the Institute of Medicine report, Betancourt is an assistant professor of Medicine at Harvard Medical School (HMS).
Adds Weissman, an associate professor of Health Care Policy at HMS, "The contrast between residents' preparedness to handle everyday clinical problems and their confidence in dealing with cultural issues suggests that graduate medical education may be too heavily weighted toward technical skills. We know that communication is a critical part of good patient care, and our study indicates that there is lots of room for improvement in our training programs."
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