A Comparison of Surgery and Family Medicine Residents' Perceptions of Cross-Cultural Care Training of Cross-Cultural Care Training

Abstract

The need for physicians formally trained to deliver care to diverse patient populations has been widely advocated. Utilizing a validated tool, Weissman and Betancourt's Cross-Cultural Care Survey, the aim of this current study was to compare surgery and family medicine residents' perceptions of their preparedness and skillfulness to provide high quality cross-cultural care. Past research has documented differences between the two groups' reported impressions of importance and level of instruction received in cross-cultural care. Twenty surgery and 15 family medicine residents participated in the study. Significant differences were found between surgery and family medicine residents on most ratings of the amount of training they received in cross-cultural skills. Specifically, family medicine residents reported having received more training on: 1) determining how patients want to be addressed, 2) taking a social history, 3) assessing their understanding of the cause of illness, 4) negotiating their treatment plan, 5) assessing whether they are mistrustful of the health care system and/or doctor, 6) identifying cultural customs, 7) identifying how patients make decisions within the family, and 8) delivering services through a medical interpreter. One unexpected finding was that surgery residents, who reported not receiving much formal cultural training, reported higher mean scores on perceived skillfulness (i.e. ability) than family medicine residents. The disconnect may be linked to the family medicine residents' training in cultural humility — more knowledge and understanding of cross-cultural care can paradoxically lead to perceptions of being less prepared or skillful in this area.

Introduction

Ethnic disparities in health outcomes have been documented in epidemiological studies of a variety of ethnic groups and health conditions in the United States.^1–4 The population of foreign-born individuals in the United States has increased tremendously in the past few decades, and the minority population is projected to increase throughout the next decades surpassing that of non-Hispanic Whites.^5,6 This growing diversity justifies an increase in cross-cultural training to aid in lessening disparities in health treatment and outcomes.

The need for physicians formally trained to deliver care to diverse patient populations has been widely advocated.^7–10 For example, the Accreditation Council for Graduate Medical Education (ACGME) has formalized requirements related to cultural competency, by including it under “Professionalism” and “Interpersonal and Communication Skills.¹¹ The publication of seminal works, such as the Institute of Medicine's Unequal Treatment, laid the groundwork for cross cultural healthcare training and focused on not just individual physician characteristics, but also larger social and institutional factors.¹² Based on their work on residents' perceived preparedness to provide cross-cultural care, Betancourt et al. note four implications for medical education policy that echo the Institute of Medicine's recommendations:¹³

1. Integrating cross-cultural curricula in graduate medical education;

2. Building the cross-cultural curricula on what was learned in medical school so there is continuity;

3. Training of attending physicians and fellows in the curricula so they can serve as role models to the residents; and

4. Conducting mandatory and formalized evaluations of general and cross-cultural communication skills.

Betancourt et al. note the importance of cross-cultural training spanning all disciplines, making particular note of emergency medicine and surgery because of the critical issues of diagnostic accuracy and informed consent.¹³ Other researchers such as Paasche-Orlow would argue that training and providing culturally competent care practices is essentially a matter of ethics.¹⁴ However, research has revealed variations across specialties regarding the degree to which culture is viewed as an important factor in patient care.^15,16

Park et al. conducted a qualitative study involving seven focus groups and ten individual interviews on residents' perceptions of their experiences learning cross-cultural care, which included 68 internal medicine, surgery, pediatrics, obstetrics/gynecology, emergency medicine, psychiatry, and family medicine residents at various institutions in the United States.¹⁶ All residents viewed culture as an important factor in patient care; however, the degree of importance varied among the specialties. Family medicine and psychiatry residents held the strongest views on the importance of cross-cultural training, and also noted having received formal instruction to develop these skills. In contrast, surgery and emergency medicine residents were significantly more likely to report little or no training in areas such as how to address a patient from a different culture. Any skills related to cross-cultural care were largely acquired on an informal and “ad hoc basis.” Although surgery and emergency medicine residents felt that culturally-sensitive care was important, they viewed it as “unrealistic” due to time constraints.

A related quantitative study surveying 2,047 residents from the same specialties in their last year of training, asked residents to assess their perception of their “preparedness” (i.e., readiness) and their “skillfulness” (i.e., ability) to provide cross-cultural care to a diverse patient population.¹⁵ Weissman et al. found that most respondents viewed a patient's culture as an important factor when providing care (moderately important = 26%; very important = 70%). Of note, surgery and emergency medicine residents were less likely to deem cultural issues as “very important” (43% and 47%, respectively), compared with the other specialties, of which 67% to 94% felt it was “very important.” Family medicine residents received more instruction in cross-cultural skills than did residents in any of the other six specialties, and had perceived themselves as more skillful.

For this study, two specialties — surgery and family medicine — were selected because of the variation in training with regard to cultural competency. For surgery residents, cultural competency is an emerging area of interest, which contrasts with family medicine residents who have cultural training as a formal part of their curriculum. Family medicine also makes a distinction in terminology with a preference for utilizing the term “cultural humility.” The argument is that no one can become “competent” with regard to understanding all cultures, so the approach to take is one of making the patient the expert while placing the physician in the position of learning.¹⁷

Building on past work documenting these differences,^13,15,16 the aim of this current study was to compare surgery and family medicine residents' perceptions of their preparedness and skillfulness to provide high quality cross-cultural care. Other than the studies cited, limited research exists in this area. In light of clear health disparities and residency training requirements, this study is part of a research program that attempts to build on these initial research efforts to examine the needs for resident education in cross-cultural care. The findings will translate into improved training programs that develop surgery residents' preparedness and skillfulness in cross-cultural care. This is of particular interest to residency programs located in culturally diverse locations, such as Hawai‘i.

Methods

With permission from the lead investigators, a copy of the Residency in Cross-Cultural Care survey was obtained for use in this study. This survey was developed by Betancourt and Weissman in an attempt to measure residents' perceptions of their preparedness to provide cross-cultural care and their perceived skillfulness with regard to providing such care.¹⁵ The survey defined culturally diverse patients as those patients who are a member of a culture different from the respondent's own culture. Consisting of five sections, respondents were asked about perceptions regarding their: 1) cross-cultural training beyond medical school, 2) cross-cultural experiences, 3) availability of resources when dealing with a diverse population, 4) skills in their specialty, and 5) demographic information. Park and colleagues' recent psychometric assessment of their measure of residents' perceived readiness and abilities to provide cross-cultural care yielded three components: general cross-cultural preparedness, general cross-cultural skillfulness, and cross-cultural language preparedness and skillfulness.¹⁸ These three components resulted from a weighted principal components analysis and showed adequate internal reliability (with Cronbach's alpha); thus, they were used for this study. Evidence for construct validity was also shown through the total scale's inverse correlation with residents' feelings of helplessness in providing cross-cultural care.

The protocol for this study was submitted to the Committee on Human Studies of the university and was granted an “exclusion” from the Institutional Review Board process. The protocol was also submitted to the Research and Institutional Review Committee of the major teaching hospital and received approval via an expedited process. The findings, conclusions, (etc.), of this study do not necessarily represent the views of the Queen's Medical Center, Honolulu, Hawai‘i.

For the surgery residents, the survey was distributed in April 2008 by the principal investigator's research assistant. All residents who were physically present after Grand Rounds were invited to participate. Participation was strictly voluntary with 20 of 23 surgery residents in attendance and completing the survey. The survey took approximately 20 minutes to complete. The principal investigator administered the survey in May 2008 to family medicine residents present at Grand Rounds. The Director of Research in the Department of Family Medicine and Community Health assisted with distributing surveys to those residents who were not present that day. Participation was also strictly voluntary and 15 of 18 family medicine residents completed the survey.

Simple descriptive analyses were conducted to compare surgery and family medicine residents on their background characteristics, perceptions of preparedness, and perceptions of skillfulness. Cross-cultural skill training variables were analyzed using Multiple Analysis of Variance (MANOVA) to assess the significance of difference between the two independent groups of surgery and family medicine residents on the multiple ratings of various skills training components. T-tests were also conducted to examine differences between these two groups on the General Cross-Cultural Preparedness Scale, the General Cross-Cultural Skillfulness Scale, and the Cross-Cultural Language Preparedness and Skillfulness Scale. An alpha level of 0.05 was used as criteria for statistical significance. All analyses were performed with the SPSS version 11 statistical package.

Results

Table 1 compares basic background information for surgery and family medicine residents who participated in this study. A larger proportion of surgery residents were male (85%) while a larger proportion of family medicine residents were female (67%). The distributions of race/ethnic background reported by residents and whether they were born in the United States were comparable between surgery and family medicine. While all (100%) family medicine residents attended medical school in the United States, 84% of surgery residents attended medical school in the United States.

Table 1.

Characteristics of Residents

	Surgery (n = 20)	Family Medicine (n = 15)
Variable	Frequency (Percent)
Sex
Male	17 (85)	5 (33)
Female	3 (15)	10 (67)
Race/Ethnicity
White, non-Hispanic	8 (42)	5 (36)
Black (not of Hispanic origin)	0 (0)	1 (7)
Asian/Pacific Islander	6 (32)	5 (36)
Other	5 (26)	3 (21)
Born in the United States
Yes	15 (75)	11 (73)
No	5 (25)	4 (27)
Location attended medical school
In United States	16 (84)	15 (100)
Outside United States	3 (16)	0 (0)

Surgery and family medicine residents were compared on their mean ratings of the amount of training they received in various cross-cultural skills. The Hotelling's Trace multivariate test of overall differences among groups was statistically significant: F(10,24) = 2.32, p = 0.04. Univariate between-subjects tests revealed statistically significant differences between surgery and family medicine residents on most ratings of the amount of training they received in cross-cultural skills. Specifically, family medicine residents reported having received more training on: 1) determining how patients want to be addressed (F = 12.75, p = 0.001), 2) taking a social history (F = 7.58, p = 0.001), 3) assessing their understanding of the cause of illness (F = 14.54, p = 0.001), 4) negotiating their treatment plan (F = 7.41, p = 0.010), 5) assessing whether they are mistrustful of the health care system and/or doctor (F = 7.39, p = 0.010), 6) identifying cultural customs (F = 8.54, p = 0.006), 7) identifying how patients make decisions within the family (F = 7.87, p = 0.008), and 8) delivering services through a medical interpreter (F = 12.89, p = 0.001). Means, standard deviations, and effect sizes are reported in Table 2.

Table 2.

Reported Training Received For Cross-Cultural Skills

	Surgery		Family Medicine
Cross-Cultural Skill	Meana	Std. Dev.	Meana	Std. Dev.	Effect Sizeb
Determining how a new patient wants to be addressed**	2.10	0.72	3.07	0.88	0.28
Taking a social history**	2.35	0.93	3.20	0.86	0.19
Assessing a patient's understanding of the causes of illness***	2.20	0.83	3.27	0.80	0.31
Negotiating a treatment plan*	2.40	0.75	3.13	0.83	0.18
Identifying mistrust of the system or physician*	2.15	0.81	2.93	0.88	0.18
Identifying ability to read & write English	2.30	0.80	2.87	0.92	0.10
Identifying religious beliefs that might affect care	2.35	0.81	2.93	0.88	0.11
Identifying cultural customs that might affect care**	2.40	0.82	3.20	0.78	0.21
Identifying how patient makes decisions with family**	2.30	0.87	3.07	0.70	0.19
Delivering services through a medical interpreter**	2.45	1.00	3.47	0.52	0.28

^aScale: 1=None, 2=Very Little, 3=Some, 4=A Lot.

^bPartial eta squared.

^*p < .05,

^**p < .01,

^***p < .001

Residents were also compared on their perceptions of their level of general preparedness, general skillfulness, and language preparedness and skillfulness, in delivering cross-cultural care. No significant differences were found between surgery and family medicine residents on the General Cross-Cultural Preparedness Scale (t = −0.02, p = 0.99), General Cross-Cultural Skillfulness Scale (t = −1.34, p = 0.19), or the Cross-Cultural Language Preparedness and Skillful p = 0.99), General Cross-Cultural Skillfulness Scale (t = −1.34, p = 0.19), or the Cross-Cultural Language Preparedness and Skillfulness Scale (t = 0.52, p = 0.61). While significance testing was not conducted on individual scale items, the comparison of item mean scores is noteworthy. Family medicine residents reported higher mean scores on four of the six General Cross-Cultural Preparedness items (Table 3). Surgery residents only reported higher mean scores on their perception of preparedness on dealing with distrust of the U.S. health care system and in the use of alternative/complimentary medicine. Alternatively, surgery residents reported higher perceived skill levels on all ten General Cross-Cultural Skillfulness items (Table 4).

Table 4.

General Cross-Cultural Skillfulness

	Surgery		Family Medicine
Itema	Mean	Std. Dev.	Mean	Std. Dev.
Determining how a new patient wants to be addressed	3.75	0.91	3.27	0.88
Taking a social history	3.95	0.83	3.47	0.92
Assessing a patient's understanding of the causes of illness	3.60	0.88	3.13	0.64
Identifying mistrust of the system or physician	3.25	0.91	2.93	0.70
Negotiating a treatment plan	3.45	0.95	3.27	0.96
Identifying ability to read & write English	3.55	0.89	3.07	0.70
Identifying religious beliefs that might affect care	3.15	1.04	3.00	1.00
Identifying cultural customs that might affect care	3.15	0.99	3.07	0.96
Identifying how patient makes decisions with family	3.35	0.93	3.00	0.76
Delivering services through a medical interpreter	3.60	0.88	3.40	1.06

^aScale: 1=Not At All Skillful, 5=Very Skillful.

Discussion

We sought to compare surgery and family medicine residents' perceptions of their preparedness and skillfulness to provide high quality cross-cultural care. In light of clear health disparities and requirements of such medical education accrediting bodies as the ACGME, this study is part of a research program that attempts to build on initial research efforts to examine the need for resident education in cross-cultural care. Validating prior research, the results reflect that family medicine residents receive more formal cross-cultural care skills training than surgery residents. This is not surprising given that cultural competency is an emerging area of interest in surgery, whereas cultural training is integrated within family medicine graduate programs. On a related note, family medicine residents generally reported perceiving themselves as more prepared to deal with cross-cultural care issues than surgery residents.

One unexpected finding was that surgery residents, who reported not receiving much formal cultural training, rated their perceived skillfulness (i.e., ability) as higher than family medicine residents. This conflicts with prior research that found a positive correlation between perceived preparedness and perceived skillfulness.¹⁵ Although more research is needed to explain this discrepancy, the disconnect may be linked to the surgery residents reflecting that although they had not received formal training (preparedness) they feel they still have the skills (ability) to deliver cross-cultural care. The responses may also be a reflection of the ethnic diversity of the residents and their past exposure to cross-cultural situations. With regard to the family medicine residents, the cultural humility perspective that is promoted in their training may provide a rationale for why those who reported more training, also reported lower perceived skillfulness.¹⁹ Park et al. have described it as the “preparedness paradox,” whereby residents expressed that the more exposure to patients from different backgrounds, the less prepared one feels.²⁰

Recommendations for Future Study

This study builds on the work of Weissman et al., particularly their development and refinement of a valid and reliable measure — the Cross-Cultural Care Survey — to assess resident preparedness to provide cross-cultural care. In order to assess and establish the efficacy of training in cross-cultural healthcare, such a tool can both serve as a baseline and a means to gauge improvement. Therefore, further research on this tool and its practical application is important. However, the current study has some limitations that can be addressed in future work. To build on this work and address this study's limitations, subsequent investigations should:

1. Increase the sample size to improve the generalizability of the findings to other residency programs outside of Hawai‘i and beyond. With a larger sample and multisite work, analyses can be conducted by program year to identify any potential differences;

2. Collect additional residents' sociodemographic information for examination of mechanisms explaining perceived preparedness and skillfulness. For example, more information on the residents' cultural training experiences in medical school could be obtained as well as how experiences outside of the formal residency curriculum impact their ability to provide cross-cultural care; and

3. Utilize an “objective” tool to corroborate the self-assessment. Self-assessment tools are often an accepted part of the evaluation of skills-based curricula, but research on resident self-assessment have been inconclusive.^21–24 In addition to self-report and other written assessments, future evaluations of both surgery and family medicine residents' preparedness and skillfulness to provide cross-cultural care should include observations in actual and/or simulated settings. This would allow for a more objective view of a resident's skill level based on specified criteria.

Finally, any training opportunities should be conducted with a standardized protocol to allow for formal evaluation of whether the intervention was truly successful and to potentially allow for comparisons across different programs. By utilizing the Cross-Cultural Care Survey, this study has made a positive contribution to this effort.

Table 3.

General Cross-Cultural Preparedness

	Surgery		Family Medicine
Itema	Mean	Std. Dev.	Mean	Std. Dev.
From cultures different from own	3.75	1.07	3.80	1.01
With health beliefs at odds with Western medicine	3.35	1.09	3.40	0.99
With a distrust of the US health system	3.30	1.08	3.07	1.16
Whose religious beliefs affect treatment	3.30	1.13	3.40	0.99
Who use alternative/complementary medicine	3.55	1.00	3.40	0.83
Racial/ethnic minority	3.85	0.99	4.00	1.07

^aScale: 1=Very Unprepared, 2=Somewhat Unprepared, 3=Somewhat Prepared, 4=Well Prepared, 5=Very Well Prepared.

Table 5.

Cross-Cultural Language Preparedness and Skillfulness

	Surgery		Family Medicine
Item	Mean	Std. Dev.	Mean	Std. Dev.
With limited English proficiencya	3.20	1.01	3.47	1.06
New immigrantsa	3.05	1.15	3.47	0.99
Working effectively through a medical interpreterb	3.60	0.88	3.40	1.06

^aScale: 1=Very Unprepared, 2=Somewhat Unprepared, 3=Somewhat Prepared, 4=Well Prepared, 5=Very Well Prepared.

^bScale: 1=Not At All Skillful, 5=Very Skillful.