Changing Surgical Culture through Surgical Education: Introduction to The PACTS Trial

Abstract

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients’ needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)’s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and non-traditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multi-center, multi-phased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn non-technical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multi-faceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

The PACTS Curriculum

Racial and ethnic disparities in surgical care impact millions of patients in the U.S. each year, with research discovering new mechanisms accounting for these differences. Provider-level factors, such as poor patient-clinician communication, are known contributors to lower quality of care, poor outcomes, and decreased overall satisfaction for minority patients.¹ Residents in all specialties have reported being unprepared to treat culturally diverse patients,² and only three U.S. surgical residency programs offered formal cultural competency training prior to 2017.³ Recognizing the impact of such factors on the quality of care for minority patients, a 2015 summit hosted by the NIH and American College of Surgeons focused on surgical disparities and identified improving patient-clinician communication through the development of an effective cross-cultural training program as a top priority in their agenda.⁴ In response, the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) trial investigators proposed a paradigm shift from cultural competency to cultural dexterity, defined as “the dynamic application of cultural knowledge, emotional intelligence, and interpersonal skills that is adapted to provide patient-centered care to all patients.” This shift to cultural dexterity, which emphasizes a set of dynamic skills rather than a static collection of facts about a culture, hopes to provide surgeons with the ability to navigate a cross-cultural encounter regardless of their depth of understanding of that specific culture. Cultural dexterity is based on three core values: curiosity, empathy, and respect. Ideally, this transition will reduce the potential for reinforcing stereotypes and biases, ultimately improving surgeon-patient communication.

The PACTS curriculum focuses on four topics integral to the surgical context: (1) patient-surgeon relationship and trust building across cultures; (2) caring for patients with limited English proficiency (LEP); (3) management of pain across cultures; and (4) the informed consent process for patients with diverse backgrounds (Figure 1). These topics were chosen after multi-institutional qualitative interviews with patients, residents, and faculty identified key components of cross-cultural care that warrant improvement.^5,6 PACTS incorporates multiple educational concepts grounded in adult learning theory including: a flipped classroom model with case explorations and lectures, spaced education, simulated standardized patient examinations and reviews, and performance tracking. Through case explorations, residents in turn play the roles of patients, clinicians, and observers working through challenging communication scenarios to improve their ability to explore different perspectives. Surgical faculty and resident focus groups helped further refine the curriculum before implementation.⁵ Residents are first taught foundational concepts through online interactive case-based modules that define key terms (Figure 1). In faculty-proctored groups, residents work through clinical scenarios to practice specific skills, such as effective use of an interpreter. Residents then undergo spaced learning, consisting of case-based questions, over the ensuing four weeks. A cluster-randomized trial of the PACTS curriculum with cross-over design was implemented across eight surgical residency programs in the U.S. in 2019. The eight surgical residencies were chosen based on ongoing research partnerships among surgical education while also ensuring a diverse patient population.

Figure 1.

Curricular modules and main educational components of the multi-institutional, randomized Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) Trial.

All residents (PGY1-PGY5) must have consented to the research components of this trial, such as the surveys, assessments, and OSCEs. Resident time commitments of the curriculum included four thirty-minute e-learning modules, four one-hour case explorations, and spaced learning as desired, all over the course of one year. The case explorations were part of the dedicated educational time for each program and therefore all residents attended and participated in this aspect of the trial. The PACTS trial also provided a facilitator guide which all faculty at each site had access to for utilization during didactic sessions or case explorations. Time commitment included reviewing the materials and attending the resident case explorations. Patient time commitment included filling out the survey, which took approximately 10 minutes and could be filled out at their leisure throughout the day if needed. Data was collected by research assistants at each site and managed either locally or centrally at the main site (BWH) depending on local IRB requirements.

The implementation of the PACTS trial has been modified due to several significant events during the trial period including the COVID-19 pandemic. Thus, virtual educational strategies were developed and implemented at each site independently to allow trial continuation. These modified educational strategies included virtual breakout-rooms with small group discussions and virtual standardized patient clinical exams with subsequent evaluation and feedback. In addition, the COVID-19 pandemic further highlighted the disproportionate impact of the pandemic on people of color and other under-resourced groups, illustrating the critical need for education about and action on institutional and interpersonal racism in surgical care.⁷ Published data of 494 patients from the academic medical centers participating in the PACTS trial demonstrated that about half did not perceive their surgical care as culturally dexterous, with Black patients significantly more likely to report less dexterous care than White patients.¹¹

Multimodality Learning and Feedback

Just as the trend in undergraduate medical education is transitioning to a multimodal, flipped classroom approach,⁸ the PACTS curriculum utilizes similar modern educational techniques. These include asynchronous, interactive e-learning modules to prepare residents for live sessions either in person or virtual. Live sessions include brief introductory didactic lectures followed by in-depth case explorations using role-play with peer-to-peer discussions and feedback. PACTS also utilizes objective structured clinical examinations (OSCEs) with standardized patients, information sheets within resident workspace/common areas, and spaced education using streams of multiple-choice questions that are completed on residents’ handheld devices over multiple weeks. The repetitive nature of the curriculum in multiple formats provides residents the opportunity to learn from the mode they find most effective, but also iteratively, so that important concepts are reemphasized often.⁹ Although many published educational curricula include some of these modalities, very few include them in combination, which allows the PACTS trial to directly compare different methods. While some modalities are more resource-demanding than others, the PACTS curriculum offers a toolkit that will allow residency programs to choose resources based on individual program abilities and needs.

In addition to multimodality learning, peer-to-peer discussions through case explorations provided the space for residents to learn from each other and discuss challenging clinical situations that often occur in a setting not observed by other residents or faculty. This setting may be a more comfortable environment in which residents can examine their own biases and teach from their personal experiences, rather than settings led by faculty.¹⁰ Case explorations create opportunities for practical learning in multiple ACGME competencies including Practice-Based Learning and Improvement, Professionalism, Interpersonal and Communication Skills, as well as Patient Care.

Engaging Key Stakeholders from Multiple Institutions

The PACTS trial was fully conceptualized and developed with early feedback from, and active engagement by, key stakeholders from multiple institutions as well as through a stakeholder advisory board, which includes residency program directors, medical education experts, patient/community representatives, and representatives from national accrediting bodies. Commitment from a diverse set of surgical programs, all of which recognized the urgent need to implement this novel curriculum, provided broad support for subsequent NIH funding. Program directors and educational experts at each of the eight sites were actively involved with the development and rollout of the curriculum, ensuring lectures and case explorations occurred during dedicated educational time. Halfway through, PACTS leadership recognized that participation could be further increased through designating a resident “champion:” a resident who would help answer any questions and promote participation in the trial. The combination of program director and peer involvement led to active promotion of the materials. In addition, and importantly, the PACTS trial had significant and intentional racial, ethnic, and gender diversity among its stakeholders, institutions, and patient advocates. These diverse resources provided significant input about the material and educational format, allowing for improved generalizability for different types of residency programs and educational structures.

Educational Outcomes

In addition to its educational innovations, the PACTS trial connects a specific curriculum with patient outcomes. Although some medical school curricula have demonstrated educational interventions improve patient outcomes,¹¹ most surgical curricula, rely primarily on pre- and post-curriculum testing. The PACTS trial includes objective clinical outcome metrics such as morbidity, mortality, and readmission rates as well as a 28-question patient survey to thousands of surgical patients about their care relevant to the PACTS curriculum after residents had completed the curriculum. These additional steps represent a gold standard in educational research utilizing all four levels of Kirkpatrick’s learning model.¹² Although the PACTS trial still utilized traditional educational trial outcomes such as resident knowledge, cultural dexterity skills were also assessed in a simulated clinical setting using OSCEs to assess performance in a more real-world scenario. When designing educational interventions, researchers must consider the ultimate educational outcome: not only resident retention of knowledge, but the downstream impact of that retention via patient perceptions and clinical outcomes.

Conclusion

The increased attention within surgical education over the past two years to diversity, equity, and inclusion is long overdue. Healthcare inequities demand immediate systemic improvements, yet incorporation of change into surgical training can be a long-term endeavor, often taking many years to prove effectiveness, distribute to other programs, and implement on a large scale. Surgeons must move swiftly and effectively to improve patient care by adapting to cultural changes in society. For the optimal treatment of all patients, training programs must effectively educate their residents on cultural dexterity and interpersonal skills that improve patient trust, patient communication, and the patient-surgeon relationship for diverse residents and patients. Past surgical education has tended to focus more on clinical topics and technical skills, rather than patient experience, cultural diversity, and contemporary concepts of professionalism. The PACTS trial aims to improve surgical residents’ cross-cultural knowledge, attitudes, and skills surrounding the care of patients from diverse cultural backgrounds, as well as clinical and patient-reported health outcomes for patients treated by surgical residents undergoing this training. The lessons learned through the development and implementation of the PACTS trial may be applicable to the medical education community more broadly. Through seeking multi-institutional collaboration, offering residents several different teaching and feedback platforms, and focusing on both resident and patient outcomes, the PACTS trial may be a model for an improved form of surgical education and for the development of rigorous educational trials in the future.