LIME 2009LIME 2009

Culturally Safe CliniciansCulturally Safe Clinicians

Training and EducationTraining and Education

Undergraduate, graduate Undergraduate, graduate courseworkcoursework

Prevocational and vocational trainingPrevocational and vocational training Vertical integration of curriculum and Vertical integration of curriculum and

clinical experienceclinical experience CMECME Responsibility across sector, health Responsibility across sector, health

workforceworkforce

Systems Issues Systems Issues Creating culturally safe environmentsCreating culturally safe environments Systems reform inclusive of attitudinal Systems reform inclusive of attitudinal

and behavioural changeand behavioural change Zero tolerance for racist, Zero tolerance for racist,

discriminatory behaviours discriminatory behaviours Accountability – incentives, Accountability – incentives,

consequencesconsequences Facilitate advocacy – students, Facilitate advocacy – students,

clinicians, communityclinicians, community

What does a culturally safe What does a culturally safe clinician look like?clinician look like?

Critical self-awarenessCritical self-awareness Understands the impact of ownUnderstands the impact of own

culture & that of the health systemculture & that of the health systemon patient outcomeson patient outcomes

Committed to indigenous healthCommitted to indigenous healthand reducing inequitiesand reducing inequities

t

SES

Access tohealth care

Healthoutcomes

The Impacts of Racism on Health

Ensuring culturally safe Ensuring culturally safe cliniciansclinicians

Undergraduate:Undergraduate:– Encourage critical self-reflection and lifelong Encourage critical self-reflection and lifelong

learninglearning– Engage learners as ‘disciples’Engage learners as ‘disciples’– Evidence-based assessment to identify unsafe Evidence-based assessment to identify unsafe

studentsstudents Postgraduate:Postgraduate:

– Integrate competencies, teaching and Integrate competencies, teaching and assessment into specialty training programmesassessment into specialty training programmes

– CME to monitor cultural safety, not just CME to monitor cultural safety, not just participation in cultural competence activitiesparticipation in cultural competence activities

One example: University of One example: University of Hawaii John A. Burns School of Hawaii John A. Burns School of

MedicineMedicine In 1999, Native In 1999, Native Hawaiian Center of Hawaiian Center of ExcellenceExcellence– Federally funded, HRSAFederally funded, HRSA– Director realized Director realized few few

faculty aware of Native faculty aware of Native Hawaiian Health Hawaiian Health DisparitiesDisparities

– Many faculty were Many faculty were clinical, volunteer facultyclinical, volunteer faculty

Faculty trained in era of Faculty trained in era of “treat all patients the “treat all patients the same”same”– Failure of that mindsetFailure of that mindset– Health disparities not Health disparities not

improvedimproved

Photo courtesy of: NHCOE and Herb Kane (the artist)

Faculty Development in Faculty Development in Cultural CompetencyCultural Competency

Series of conferences to teach faculty about Series of conferences to teach faculty about Native Hawaiian health and health Native Hawaiian health and health disparitiesdisparities

Traditional medicine and concepts of health and well Traditional medicine and concepts of health and well beingbeing

Improving teaching skillsImproving teaching skills Addressing the needs of Native Hawaiian Addressing the needs of Native Hawaiian

DoctorsDoctors Can cultural competency in providers improve the Can cultural competency in providers improve the

poor health statistics for Native Hawaiians?poor health statistics for Native Hawaiians? Can physicians trained in western medicine Can physicians trained in western medicine

and western ways of thinking bridge the gap and western ways of thinking bridge the gap that exists with traditional Native Hawaiian that exists with traditional Native Hawaiian approaches to health and healing?approaches to health and healing?

Cultural Cultural ImmersionImmersion

5 Day experience on the island of Kahoolawe, 5 Day experience on the island of Kahoolawe, damaged by bombs, goats, cattledamaged by bombs, goats, cattle– Healing the land, healing the peopleHealing the land, healing the people

Participants: physicians, faculty, medical students, Participants: physicians, faculty, medical students, nurses, traditional healers, family membersnurses, traditional healers, family members

Intense cultural immersion experienceIntense cultural immersion experience Incorporate traditional Hawaiian values and Incorporate traditional Hawaiian values and

protocolprotocol CME coursesCME courses

Photos courtesy of ‘Ahahui o na Kauka and Martina Kamaka

Post Immersion Physician Focus Post Immersion Physician Focus GroupsGroups

Native Hawaiian PhysiciansNative Hawaiian PhysiciansFaculty/community, male/female, various ages and specialties represented.Faculty/community, male/female, various ages and specialties represented.All underwent “cultural competency” curriculum Kaho‘olawe.All underwent “cultural competency” curriculum Kaho‘olawe.

(Questions:(Questions: centered on whether previous experiences with cultural centered on whether previous experiences with cultural competency training had an effect, and on the use of cultural immersion as competency training had an effect, and on the use of cultural immersion as a teaching strategy)a teaching strategy)

Primary Theme 1:Primary Theme 1: Cultural sensitivity/humility training leading to Cultural sensitivity/humility training leading to personal transformationpersonal transformationIncreased cultural awareness, prideIncreased cultural awareness, prideUnderstood connectedness to land, spiritualityUnderstood connectedness to land, spiritualityAcquired sense of generational responsibilityAcquired sense of generational responsibility

Photo courtesy of ‘Ahahui o na Kauka

Secondary Theme 1: Secondary Theme 1: Improved medical practiceImproved medical practice– Improved patient communicationImproved patient communication– Awareness of conflict of cultures (Western vs. Awareness of conflict of cultures (Western vs.

Traditional)Traditional)– Increased knowledge of/openness to traditional healingIncreased knowledge of/openness to traditional healing

Secondary Theme 2: Secondary Theme 2: Cultural sensitivity/humility Cultural sensitivity/humility related student trainingrelated student training– Allow time for self discovery and reflectionAllow time for self discovery and reflection– Discuss culture of medicine, potential conflictsDiscuss culture of medicine, potential conflicts– Consider diversity of backgrounds, stages of readinessConsider diversity of backgrounds, stages of readiness– Sustainability of lessons; need follow-up activitiesSustainability of lessons; need follow-up activities– Cultural Immersion experiences should include: Cultural Immersion experiences should include:

spiritual/emotional preparation spiritual/emotional preparation training in protocol and history training in protocol and history exposure to traditional healingexposure to traditional healing

Additional stepsAdditional steps Native Hawaiian research fellowship (new Native Hawaiian research fellowship (new

grant)grant) Yearly departmental conferences that include Yearly departmental conferences that include

cultural competency training in some waycultural competency training in some way Cultural competency curricula being introduced Cultural competency curricula being introduced

at residency level in various specialtiesat residency level in various specialties Standardized cultural patients being used in FP Standardized cultural patients being used in FP

residencyresidency– Surgery residency is piloting casesSurgery residency is piloting cases

More regular immersion experiences for More regular immersion experiences for clincians, faculty being proposedclincians, faculty being proposed

Looking to the FutureLooking to the Future

AAMC: USMLE II AAMC: USMLE II

standardized patient clinical skills stations-must standardized patient clinical skills stations-must pass!!!pass!!!

Specialty boardsSpecialty boards

online courses in cultural competencyonline courses in cultural competency

coming soon to a specialty board near you…..coming soon to a specialty board near you…..

standardized patient clinical skills stations!!standardized patient clinical skills stations!!Photo courtesy of ‘Ahahui o na Kauka