Dealing with Diversity:an alternative to

Cultural Competence

Jim Ross, Kristin Kenrick, Chrys Jaye, Peter Radue

Cultural competence

• Required by the HPCA Act (2003) and the Medical Council

• Implies that there is some standard of knowledge, skills and attitudes in this area which can be taught and assessed

• Practitioner-centred (unlike Cultural Safety)

• Confusing when combined with Biculturalism (like Cultural Safety)?

• Does its teaching change knowledge, skills and attitudes?

• Does it lead to changes in health outcomes for marginalised groups?

• Individual-focused Patient-centred Medicine not enough

4th Year ‘Diversity in Practice’ Objectives

• Reflect on vexed concept of cultural competence

• Explore ‘culture’ and its relationship to medical practice

• Defamiliarise the familiar

• Make links between diversity and Patient-centred Medicine

• Start to develop frameworks and strategies to help deal with the diverse needs of patients and patient groups

0. Suggest students review 2nd Year module (+/- pre-readings)3 HOUR WORKSHOP1. Overview2. Revise concepts from HIC – culture, cultural competence/safety,

etc3. Divide into 4 ‘culturally mixed’ groups (+/- a tutor)4. Ice-breaker – what is the origin of your name?5. A group/subculture you identify with: insights about subcultures6. Your experiences of Medicine as (sub)culture,

discuss (“subculture of 1 – overlapping cultures/subcultures”)7. Patient-centred Medicine (whole group)8. Can we improve PCM model to better include culture/diversity?

What specific points can we take from medical practice models?9. Take home message(s) from each group

HOMEWORK12. Articles to take away13. Observe events which relate to these issues at your General

Practice1 HOUR FOLLOWUP SESSION14. Discuss observations in original small group15. Take home messages from each group and from tutors16. Evaluation

Take Home MessagesTutorial 11. Be aware of cultural stereotypes to guide discussions with individual

patients2. ASK if there are cultural issues3. Take opportunities to inform ourselves about cultures and

subcultures4. Whole person understanding (including cultural aspects) is essential

(see 1,2,3 above)5. Rapport is necessary to allow patients to raise things

Tutorial 21. Find out where patient is at, what is important for them, what

information they want2. Communication is the key thing (speak slowly, avoid jargon and

slang, think of synonyms, & consider interpreters)3. Understand individuals in context; beware cultural stereotypes4. Show respect, be adaptable, develop knowledge about cultures (for

relationship-building, to avoid obvious pitfalls, to prepare for possible situations, e.g. whanau involvement)

Evaluation question 1: What useful thing(s) will you take away from the two sessions and the practical exercise on

diversity in medical practice? (1st Quarter 2011)

• “Culture is more than ethnicity”

• “ Understand the patient – culture is one aspect but may not even be a large part of it – But useful viewing the patient in his/her own context”, “Having an awareness of people’s cultures will help you gain rapport and build a relationship. may help you to avoid insulting people” (6 such comments)

• Interpreting phone services are available when the patient does not speak English” (2)

• “Some practical ideas regarding communication” (2)

• “The take home messages are good, succinct: highlighting what’s important is useful”

2. How relevant do you think the material in these sessions and the practical exercise will be to your future medical

practice? Please circle one response.

2. How relevant do you think the material in these sessions and the practical exercise will be to your future medical

practice? Please circle one response.

3. Please comment on anything that made you feel uncomfortable or offended.

• “Nothing”(2), “No”, “Nope”(2), “Nil (2)”, “n/a”, -- (5)

• “I felt uncomfortable talking about different cultures when trying to explain stereotypes whilst trying not to sound as though those stereotypes were my personal view”

• “Awkward silences when people wait for other people to answer”

4. What could have been improved in these sessions and how?

• More information about specific cultures. Common pitfalls to explore with the patient

• Case studies or scenarios to work through (6) – e.g. “in case our own clinical experiences are a bit thin”

• Some role plays

• Slightly more whole group work (2)

• Less theoretical discussion and more of what we did in the second tutorial

5. General comments

Several positive comments (e.g. “Choice”, ‘Is good”, Enjoyable and very relevant”).

Best overall summary of themes was:

“I found the sessions enjoyable and very relevant and it was good to hear others’ stories, and hear how other Doctors deal with tricky situations. But in general I think that ‘cultural competency’ is something that is gained over time from experience”

In particular, “Listening to people’s experiences was the most interesting”

Summary

• Small group learning session regarding Diversity/Culture, using personal experience and discussion as much as possible

• Guest tutors, to add diversity

• Followed by component of real-world clinical practice observation, with reflection in same small groups

• Modification of course content iteratively using formal and informal evaluation

• Generally positive evaluations from students

• Speculations on reasons for less positive reaction from second and third groups - Timing of session? Group differences? Discussion issues?

• Questions and comments – e.g. is this research? Where to now?