Developing CrossDeveloping Cross--cultural cultural Communication Teaching for Communication Teaching for

Medical StudentsMedical Students

CEEBL 2006/07CEEBL 2006/07

Val WassProfessor of Community-Based

Medical Education

Maria AhmedFinal Year Medical Student

Jo HartLecturer in

Communication

Olivia ClancyOlivia Clancy

Tammy Towers Tammy Towers

Stephenie TiewStephenie Tiew

Student team Student team representativesrepresentatives

Content

BackgroundBackground

Aims, Objectives, OutcomesAims, Objectives, Outcomes

MethodsMethods

Preliminary ResultsPreliminary Results

ReflectionsReflections

What Next?What Next?

Background

•• Manchester is a cosmopolitan cityManchester is a cosmopolitan city

•• Cultural awareness and sensitivity crucialCultural awareness and sensitivity crucial

•• Poorly taught at Medical SchoolPoorly taught at Medical School

•• EnquiryEnquiry--Based LearningBased Learning

•• Simulated patient roleSimulated patient role--playplay

Aims

•• Develop an enquiryDevelop an enquiry--based studentbased student--led led learning module on learning module on patientpatient--centredcentredCultural CompetencyCultural Competency

•• Enable students to demonstrate Enable students to demonstrate awareness of and respect for cultural awareness of and respect for cultural diversity when communicating with adult diversity when communicating with adult patients of different cultural backgroundspatients of different cultural backgrounds

•• Develop an individualDevelop an individual’’s character and s character and belief system, as influenced by race, belief system, as influenced by race, ethnicity and religionethnicity and religion

Outcomes

•• Enhance student knowledge and respect for Enhance student knowledge and respect for different cultural practices different cultural practices

•• Improve student confidence in dealing with Improve student confidence in dealing with patients and/or peers of different cultural patients and/or peers of different cultural backgroundsbackgrounds

•• Enable selfEnable self-- and formative assessment of and formative assessment of clinical cultural competencyclinical cultural competency

•• Contribution to medical student training Contribution to medical student training (Tomorrow(Tomorrow’’s Doctors, GMC)s Doctors, GMC)

Methods 1

••Identify realIdentify real--life examples of crosslife examples of cross--cultural dilemmascultural dilemmas

•• Manchester Royal Infirmary & Manchester Royal Infirmary & RusholmeRusholme Health CentreHealth Centre

•• SemiSemi--structured interviewsstructured interviews

•• Purposive samplingPurposive sampling

•• 10 doctors, 8 students, 6 patients10 doctors, 8 students, 6 patients

•• Student questionnaire: little responseStudent questionnaire: little response

Methods 2

Develop roleDevelop role--play scenarios from realplay scenarios from real--life exampleslife examples

• Student Team led by Maria: Student Team led by Maria:

-- 2 M, 6 F, 32 M, 6 F, 3rdrd & 4& 4thth yearyear

-- 2 Caucasian, 3 Asian, 2 Oriental, 1 Mixed race2 Caucasian, 3 Asian, 2 Oriental, 1 Mixed race

••Monthly meetingsMonthly meetings

•• Selected cases, scenario templates Selected cases, scenario templates

•• Feedback via Jo and ValFeedback via Jo and Val

•• Piloted with Byron (Experienced SP)Piloted with Byron (Experienced SP)

Methods 3

Pilot role-play scenarios with students & SPs

•• Recruited student volunteers: great responseRecruited student volunteers: great response

•• Recruited Recruited SPsSPs via Byron (SP coordinator)via Byron (SP coordinator)

•• Groups of 5Groups of 5--6 students6 students

•• 8 scenarios 8 scenarios -- each roleeach role--played twiceplayed twice

•• Jo & Val facilitatorsJo & Val facilitators

•• VideoVideo--tapedtaped

Methods 3

Diversity Workshop 1

1. Caucasian patient with heart failure; complaining re: ‘Indian nurse’ incompetence

2. Asian lady wanting abortion if baby is a girl

3. Student required to examine thyroid goitre of Muslim hijab-wearing lady

4. Orthodox Jewish son refusing post-mortem for father

Methods 3

Diversity Workshop 2

5. American citizen complaining about NHS system

6. Asian lady with poor English complaining of ‘pain all over / bad pain’ -/+ interpreter

7. Jehovah’s Witness patient refusing blood transfusion

8. Afro-Caribbean lady with impaired glucose tolerance needing lifestyle advice

Methods 4

Focus groups and analysis

• Pre & post-session Questionnaires

• Post-session focus group with Sarah Smithson

• Student Team focus group

• Due to be formally analysed

• Videos to be analysed by expert in culture and discourse analysis

Preliminary Results 1

Student volunteer demographics:Student volunteer demographics:

•• 16 female, 5 male (3:1)16 female, 5 male (3:1)

•• Age range 21Age range 21--26, mean 23 years26, mean 23 years

•• EthnicityEthnicity

7 Caucasian, 6 Asian, 2 Black, 5 Mixed, 1 Other7 Caucasian, 6 Asian, 2 Black, 5 Mixed, 1 Other

•• ReligionReligion

7 None, 7 Islam, 5 Christianity, 1 Sikh, 1 Hindu7 None, 7 Islam, 5 Christianity, 1 Sikh, 1 Hindu

Outcomes

•• Enhance student knowledge and respect for different cultural Enhance student knowledge and respect for different cultural practices practices

•• Improve student confidence in dealing with patients and/or Improve student confidence in dealing with patients and/or peers of different cultural backgroundspeers of different cultural backgrounds

•• Enable selfEnable self-- and formative assessment of clinical cultural and formative assessment of clinical cultural competencycompetency

•• Contribution to medical student training (TomorrowContribution to medical student training (Tomorrow’’s s Doctors, GMC)Doctors, GMC)

Preliminary Results 2

Student Views:Student Views:

•• How much past training have you received in CCC?How much past training have you received in CCC?

95% 95% ‘‘NoneNone’’ or or ‘‘A littleA little’’

•• How important is CCC training?How important is CCC training?

90% 90% ‘‘VeryVery’’ or or ‘‘QuiteQuite’’

•• How useful was this workshop?How useful was this workshop?

90% 90% ‘‘VeryVery’’ or or ‘‘QuiteQuite’’

•• Should this workshop be included in curriculum?Should this workshop be included in curriculum?

20 Yes vs. 1 No (want more clinical skills training20 Yes vs. 1 No (want more clinical skills training……))

Preliminary Results 3

Some quotes about the workshop:

‘…it was a good way to practice real-life situations in an environment where you could afford to make mistakes and learn from it…’

Preliminary Results 3

Some quotes about workshop:

‘…the topics covered were very realistic and covered a wide range of multicultural dilemmas…’

Methods 3

Diversity Workshop 1Diversity Workshop 1

1.1. Caucasian patient with heart failure; complaining re: Caucasian patient with heart failure; complaining re: ‘‘Indian nurseIndian nurse’’ incompetenceincompetence

2.2. Asian lady wanting abortion if baby is a girl Asian lady wanting abortion if baby is a girl

3.3. Student required to examine thyroid goitre of Muslim Student required to examine thyroid goitre of Muslim hijabhijab--wearing lady wearing lady

4.4. Orthodox Jewish son refusing postOrthodox Jewish son refusing post--mortem for father mortem for father

“We thought the racist scenario was really good in getting an English girl or boy to do it first or second and a non-white person to do it before of after whatever.”

“…I was deeply quite offended by it………….

And one of the suggestions was that I explain my background. It’s like “What’s that got to do with anything ? She didn’t have to , why should I?”

“…“Where are you from?” You say “Oh London in Dulwich.”

And they say “No. Where are you from?”

And then you know you have to elaborate…”

“…Yeah, there’s no one is there, for you to go and say

“This person was racist and it upset me. What shouldI do about it?”

There is no one to go and speak to……”

‘I have learnt a lot about my assumptions

over different cultures and how they might

affect the way I behave towards patients…’

Methods 3

Diversity Workshop 2

5. American citizen complaining about NHS system

6. Asian lady with poor English complaining of ‘pain all over / bad pain’ -/+ interpreter

7. Jehovah’s Witness patient refusing blood transfusion

8. Afro-Caribbean lady with impaired glucose tolerance needing lifestyle advice

‘I have learnt a lot about my assumptions

over different cultures and how they might

affect the way I behave towards patients…’

Didn’t speak a word of English and lookedabsolutely petrified

They put him in a dentist's chair and he looked absolutely petrified

What no one realised is ….he was actually an asylum seeker because he’d been tortured at home, it turned out when the interpreter actually turned up.

So we had put this poor guy, he’d been sat there, under this spotlight in a dentist’s chair …..

‘ Yeah. The interpreter one was brilliant. It’s such a situation that you always see, that no doctor ..I’ve not seen one doctor do it well. They always get it wrong ‘

Preliminary Results 3

‘…It was useful seeing how patients’ cultures affect their ideas and agendas in consultations and how difficult it can be sometimes to deal with it…’

Reflections

• Used EBL at various levels

• Spectrum: subtleties to major ethical dilemmas

• Students want more training in cross-cultural issues

• Recruitment of culturally diverse SPs difficult

• Scenarios need to contain knowledge about different cultures

• Scenarios need to have detail

What Next?

• Formally analyse

• Disseminate findings:

Locally: CEEBL, CEWP, MRI Grand Round

Nationally: ASME conference

Internationally: OTTAWA conference, publications

• Incorporate into current curriculum at Manchester

• Other projects