Making Progress: The University of Hawai‘i at Manoa's (UHM) Department of Surgery's Cross-Cultural Health Care Efforts from 2008-2018

Abstract

In 2008 the University of Hawai‘i at Manoa's (UHM) Department of Surgery introduced the concept of cross-cultural health care (aka cultural competency) to its faculty and trainees. Much work remains before the cultural efforts wellknown outside the department are embraced within, but it has been prioritized for curriculum development and research. An example of the department's efforts include the Cross-Cultural Health Care Research Collaborative, which was created as a forum for faculty who have an interest in cultural issues related to healthcare and healthcare delivery. Participants from 14 UHM departments and other organizations developed projects and mentored students, resulting in over ten peer-reviewed publications. A related effort is the JABSOM Cultural Competency Resource Guide, which is in its 7th edition and reflects JABSOM activities and those of its collaborators. Another highlight is the Biennial Cross-Cultural Health Care Conference: Collaborative and Multidisciplinary Interventions, with six conferences held since 2010, hosting attendees from 28 US Mainland states and 11 countries. Additionally, the department has been recognized as one of the first to develop a cultural standardized patient exam for surgical residents. These nationally-recognized efforts resulted in invitations to serve on the very first cultural competency panel at the American College of Surgeons Clinical Congress and as a consultant on the development of Brigham and Women's Hospital's Center for Surgery and Public Health's Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a standardized curriculum for surgical residents. The department plans to continue its work on these projects and document outcomes.

Introduction

The role of culture and cultural competency in patient care continues to be a major focus in the healthcare field's attempts to address health disparities based on characteristics such as race, ethnicity, gender, religion, and socio-economic status. Although there is no standardized definition of culture or culcultural competence, one of the more commonly cited definition is as follows:

Cultural and linguistic competence is a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations. “Culture” refers to integrated patterns of human behavior that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups. “Competence” implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities.¹

In undergraduate and graduate medical education, both the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) require the integration of cultural training into medical student and resident curriculum, respectively.^2,3 Legal requirements also reinforce the importance of cultural training, for example, Section 1557 of the Affordable Care Act requires covered entities to develop a language access plan and ensure that limited English proficient patients have meaningful access to healthcare.⁴ Additionally because of the complexity of biological, sociological and psychological factors involved, providing optimal care to diverse patients often requires collaboration between multiple health professionals from different fields.⁵

Although the empirical evidence base for the efficacy of cultural (competency) training is still relatively weak,⁶ the literature on healthcare disparities tied to cultural factors, such as race, continues to grow. This discussion began with the seminal work, Unequal Treatment, in 2003, which found that after all other factors were removed, race/ethnicity remained as the most important reason for disparate treatment of patients.⁷ In another seminal work by Weissman et al. on resident preparedness to provide cross-cultural care, the authors reviewed differences among various medical specialties and found that surgery was one that paid minimal attention to culture in both its training and in practice.⁸ Awareness of this concern led the University of Hawai‘i at Manoa's (UHM) Department of Surgery (referred to in this article as the department) to introduce the concept of cross-cultural health care (aka cultural competency) to its faculty and trainees in 2008. Prior to 2008 and the initiatives described within this paper, there were no efforts to incorporate culture into the department's curriculum. The department could be considered “behind the times” as compared to some of the other departments at the John A. Burns School of Medicine (JABSOM), especially the Department of Native Hawaiian Health who has been the lead in this area. Although its primary focus is on Native Hawaiians, the department and its Cultural Competency Committee (C3) have developed various mandatory curricula for all medical students at JABSOM.⁸

Much work remains before the cultural efforts well-known outside the department are embraced within, but “culture” - in its broadest sense - has been prioritized for curriculum development and research. Therefore, although critical pieces, such as more robust outcome measures, are needed, the department went from having no cultural competency initiatives to several that have been sustained over the past decade. This article provides a description of the department's main cultural projects: 1) the Cross-Cultural Health Care Research Collaborative, 2) the JABSOM Cultural Competency Resource Guide, 3) the Biennial Cross-Cultural Health Care Conference: Collaborative and Multidisciplinary Interventions, and 4) cultural training efforts for general surgery residents.

Cross-Cultural Health Care Research Collaborative (CCHCRC)

The CCHCRC is a research group that was created in September 2008 as a forum for faculty with an interest in cultural issues related to healthcare/healthcare delivery. Suggested by Dr. Richard Kasuya, then Director of the JABSOM Office of Medical Education (OME) and the OME Fellowship, several members of the fellowship cohort formed a group to further their interest in culturally-related training efforts and research including faculty from the Departments of Internal Medicine (Brad Chun MD) and Psychiatry (John Huh MD). Because of their active research interests in cross-cultural healthcare, Martina Kamaka MD (C3 program lead from the Department of Native Hawaiian Health), Gregory Maskarinec PhD (Department of Family Medicine and Community Health), Marianne Tanabe MD (Department of Geriatric Medicine), and Angel Sy (Office of Public Health Studies) were also invited along with Ginny Tanji MSLS, MEd, then Director of the Health Sciences Library, for her expertise in identifying cultural resources. Led by the UHM Department of Surgery, the initial goals of the Cross-Cultural Health Care Research Collaborative (CCHCRC) were to identify departmental contacts and individuals who were 1) interested in developing cultural competency/humility initiatives, and 2) willing to share their cultural competency/humility initiatives with other departments and individuals. Over the past ten years, there have been multiple participants from UHM and other organizations — a total of 14 faculty from the aforementioned UH JABSOM Departments; UHM Office of Public Health Studies; UHM Dept of Psychology; UHM Shidler College of Business; University of Southern California (USC) School of Social Work and three community partners from Kokua Kalihi Valley, Queen's Native Hawaiian Health Program, and Queen Emma Clinic. The group did not “recruit” members perse, but faculty, residents/fellows, students extended invitations to collaborative partners who shared similar research interests. Replacements were sometimes suggested when faculty left due to shifting interest and responsibilities or when residents/fellows and students left due to graduating/completing their studies.

Group members bonded during quarterly meetings, which provided updates on culturally-related activities, discussions on possible research project partnering, research advice from other members on topics such as instrument development, data collection, analysis and interpretation, professional development opportunities, and lessons learned over common obstacles faced when working on culturally-related projects. Quarterly meetings also allowed groups to plan the Cross-Cultural Health Care Conference, as discussed later in this article. For example, some have recruited speakers or have even presented at the conference themselves; others serve as volunteers and assist with tasks such as abstract review, speaker introductions, and room monitoring.

A number of CCHCRC faculty served as mentors for student projects producing over ten peer-reviewed publications. Mentees included six premedical students, seven medical students, one nursing student, two psychology graduate students, two public health graduate students, and one geriatric medicine fellow. Table 1 lists the publications in chronological order and Table 2 lists other publications and scholarly activities resulting from group collaborations.

Table 1.

CCHCRC Faculty-Mentored Peer-Reviewed Publications [ie, Faculty Mentored Student(s)]

Year	Citation
2009	Chun MB, Young KG, Jackson DS. Incorporating cultural competency into the general surgery residency curriculum: a preliminary assessment. Int J Surg. 2009 Aug;7(4):368–72.
2010	Chun MB, Jackson DS, Lin SY, Park ER. A comparison of surgery and family medicine residents' perceptions of cross-cultural care training. Hawaii Med J. 2010 Dec;69(12):289–93.
2012	Chun MB, Young KG, Honda AF, Belcher GF, Maskarinec GG. The development of a cultural standardized patient examination for a general surgery residency program. J Surg Educ. 2012 Sep–Oct;69(5):650–8
2013	Ly CL, Chun MB. Welcome to cultural competency: surgery's efforts to acknowledge diversity in residency training. J Surg Educ. 2013 Mar-Apr;70(2):284–90.
2013	Deptula P, Chun MB. A literature review of professionalism in surgical education: suggested components for development of a curriculum. J Surg Educ. 2013 May–Jun;70(3):408–22.
2013	Ambrose AJ, Lin SY, Chun MB. Cultural competency training requirements in graduate medical education. J Grad Med Educ. 2013 Jun;5(2):227–31
2013	Morihara SK, Jackson DS, Chun MB. Making the professionalism curriculum for undergraduate medical education more relevant. Med Teach. 2013 Nov;35(11):908–14.
2014	Chun MB, Deptula P, Morihara S, Jackson DS. The refinement of a cultural standardized patient examination for a general surgery residency program. J Surg Educ. 2014 May-Jun;71(3):398–404.
2017	Shah SS, Sapigao FB, Chun MBJ. An overview of cultural competency curricula in ACGME-accredited general surgery residency programs. J Surg Educ. 2017; 74: 16–22.
2017	Yeung F, Yuan C, Jackson DS, Chun MBJ. Gone, but not forgotten? Survey of resident attitudes toward a cultural standardized patient examination for a general surgery residency program. Health Equity. 2017 Sep 1;1(1):150–155.

Table 2.

CCHCRC Faculty Publications/Scholarly Activities from Collaboration Among Group Members

Year	Citation
2009	Chun MB, Huh J, Hew C, Chun B. An evaluation tool to measure cultural competency in graduate medical education. Hawaii Med J. 2009 Jun;68(5):116–7.
2010	Chun MB, Yamada AM, Huh J, Hew C, Tasaka S. Using the cross-cultural care survey to assess cultural competency in graduate medical education. J Grad Med Educ. 2010 Mar;2(1):96–101.
2012	Chun MBJ, Chun BA, Sy A. Collaborating on Teams with Diverse Professions: Experiences with “Cultural” Matters in Administrative, Clinical, and Research Settings in Psychology, Medicine, and Public Health.” Hawai‘i Psychological Association Annual Convention. October 20, 2012, Ko‘olau Ballrooms, Kaneohe, Hawai‘i.
2012	Cross-Cultural Training at JABSOM; A Panel Discussion. Co-presenter with Bradley Chun, Martina Kamaka, & Glenn Rediger. UHM Department of Medicine, Grand Rounds, February 28, 2012, Queen's Conference Center, Honolulu, Hawai‘i.
2013	Alden DL, Friend J, Chun MB. Shared decision making and patient decision aids: knowledge, attitudes, and practices among Hawai’i physicians. Hawaii J Med Public Health. 2013 Nov;72(11):396–400.
2013	Chun MBJ, Lubimir K. Third Cross-Cultural Health Care Conference: Collaborative and Multidisciplinary Interventions; February 8-9, 2013. Hawaii J Med Public Health. 2013; 72(8 Suppl 3): 3–27.

JABSOM Cultural Competency Resource Guide

A product of the Cross-Cultural Health Care Collaborative is a resource guide that aids the UHM Department of Surgery's in identifying potential collaborators. Suggested by Dr. Kasuya, the guide was initiated in Spring 2008 summarizing UHM JABSOM's cultural competency initiatives/programs and encouraging partnerships both within and outside the medical school. A survey was done to “catalog” the existing cultural initiatives within the Office of the Dean and throughout each of the medical school's departments. At that time, JABSOM was preparing for accreditation and the specific LCME criteria regarding culture in the curriculum was being considered. With faculty already interested in incorporating culture into its residency curriculum, the UHM Department of Surgery took the lead on collecting and compiling the data for what would become known as the JABSOM Cultural Competency Resource Guide. Given that a listing of all the cultural initiatives at JABSOM did not exist, the guide provided helpful information to faculty, students, and staff, and was also beneficial for accreditation.

The guide is viewed as a work in progress. Initially, yearly requests for new information and revisions were requested via email or through in-person meetings using the same survey distributed to those departments who participated in the first edition. When little change was noted within a one-year period and some departments expressed difficulty finding someone to regularly coordinate their responses, the frequency of updates was reduced. As JABSOM's collaboration grew, invitations were extended to include information from Hawai‘inuiakea School of Hawaiian Knowledge, the College of Health Sciences and Social Welfare (ie, School of Nursing and Dental Hygiene, School of Social Work, and the Office of Public Health Studies). The guide is now in its seventh edition. Recently, most of the updates include adding new research publications and other scholarly activities, and updating faculty and staff information.

Premedical or medical students were mentored to produce the updated guides while networking with faculty and learning about JABSOM's departments and programs. The recent inclusion of UHM schools, colleges, departments outside of JABSOM has increased the resource guide's impact. Since its inception, the guide has been featured on the JABSOM Health Sciences Library under its Cultural Resource for Health Professionals page (https://libguides.jabsom.hawaii.edu/culture) and is available to anyone who has access to the internet via https://www.researchgate.net/publication/319968956_UHM_JABSOM_Cultural_Competency_Resource_Guide_August_2017_Seventh_ Edition. The current version of the guide has been read over 63 times.

Cross-Cultural Health Care Conference (CCHCC): Collaborative and Multidisciplinary Interventions

The CCHCC was developed primarily in response to the department‘s desire to provide more in-depth professional development in the area of cultural competency for its faculty, residents, and fellows. Prior to this, the surgical department had no formal training program in cultural competency/cross-cultural health care. In addition to inviting known experts from the field of cultural competency and healthcare disparities, a conscious attempt was made to invite surgeons who had an interest and expertise in the cultural aspects of healthcare. Because formal recognition of the importance of culture to the surgical field was emerging around the same time as the initiation of the conference, 10 some of the surgical experts framed their presentations within the context of professionalism and/or interpersonal and communication skills (ie, the ability to care for diverse patients is related to these two ACGME competencies). Over time, presentations directly addressed cultural competency, to the point where a new term has been coined — “cultural dexterity”¹¹ and formal curricula for general surgery residents is being developed with the goal of nationwide implementation.

The inaugural CCHCC conference was held in October 2010 utilizing seed money provided by former Chair of Surgery, Dr. Danny Takanishi, Jr. Since that time, the conference has been self-sustaining through registration and exhibitor fees, grants, and donations. Additionally, dedicated time and resources continue to be provided by current Chair of Surgery, Dr. Kenric Murayama. Conference attendance has grown from 95 at the first conference to an average of 150 to 160, with peak attendance of 244 in 2015. The conference provides an overview of critical issues facing healthcare professionals who care for diverse patient populations and serves as a forum to discuss the “evidence base” regarding cross-cultural healthcare training and treatment interventions; it fosters interprofessional collaboration (eg, medicine, psychology, public health, social work, nursing, pharmacy, and Hawaiian studies); and has welcomed attendees from 28 US Mainland states (AL, AZ, CA, FL, GA, ID, IL, IN, IA, LA, MA, MD, MI, MN, MO, MT, NC, NJ, NM, NV, NY, OK, OR, PA, TN, TX, WA, WI) and 11 countries (Australia, Canada, Germany, Italy, Japan, Nepal, New Zealand, Norway, Saudi Arabia, Sweden, and the UK).

Due to national/international recognition, the department was able to bring scholars with knowledge and expertise in cultural competence to present at the Hawai‘i conference. With the exception of the many invited UHM faculty and members of local community organizations who have shared their time and expertise, Table 3 provides a listing of national and international guest presenters and their area(s) of expertise as related to cultural competency/cross-cultural health care. More detailed information on each of the six conferences can be found at: http://cchc-conference.jabsom.hawaii.edu/.

Table 3.

List of National and International Guest Presenters at the Cross-Cultural Health Care Conference and Area of Expertise (2010 – 2019)*

Year(s) Presented	Name	Area(s) of Expertise
2019	David A. Acosta MD	Diversity and inclusion in medical education
2019	Fabricio Balcazar PhD	Development of systematic approaches for effective involvement of people with disabilities in consumer advocacy organizations; culturally competent service provision for minorities with disabilities
2013	Jeff Belkora PhD	Development, implementation, and evaluation of patient education, decision support, and participation programs
2019	Russell S. Berman MD, FACS	Professionalism in surgical residency training; Surgical Professionalism and Interpersonal Communication Education (SPICE) curriculum
2010, 2011, 2013, 2015, 2017, 2019	Joseph Betancourt MD, MPH	Cross-cultural care and communication; racial/ethnic disparities in health and health care; hypertension, diabetes, and cerebrovascular disease in minority communities; cross-cultural care and education; workforce diversity; impact of language barriers on health care
2013	Christina Cordero PhD	Standards development projects for the hospital and laboratory accreditation programs, including patient-centered communication standards, cultural competence, and patient- and family-centered care
2011, 2015	Janice Dreachslin PhD	Diversity leadership in health services management; organizational cultural competence
2017	Glyn Elwyn MD, MSc, FRCGP, PhD	Patient engagement; shared decision making; decision aids; informed medical decisions
2015	Kevin Eva PhD	Educational practices within the health professions
2010	Bruce Gewertz MD, FACS	Professionalism in surgical residency training
2015	Tawara Goode MA	Development of curricula, assessment instruments, professional development series, and other resources that support cultural and linguistic competence
2015, 2017	Alexander Green MD, MPH	Culturally competent approaches to quality improvement; unconscious bias in health care delivery, language barriers and patient safety; cultural competence education for health professionals
2017	Amelia Grover MD, FACS	Surgical workforce diversity; healthcare disparities
2017	Adil Haider MD, MPH	Trauma disparities research; healthcare inequities including, describing and mitigating unequal outcomes based on gender, race, sexual orientation, ethnicity, age and socioeconomic status; optimal treatment of trauma/critically ill patients in resource-poor settings; Co-PI of Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) cultural dexterity curriculum for surgical residents
2013	Mark Hochberg MD, FACS	Professionalism in surgical residency training; Surgical Professionalism and Interpersonal Communication Education (SPICE) curriculum
2015	Maria Jibaja-Weiss EdD	Health promotion and cancer prevention and control research utilizing novel strategies to engage minority, multilingual audiences with limited health literacy
2010, 2011	Michael Kruley JD	Legal aspects of culturally competent care as it relates to equal access to and opportunity to participate in and receive services from all US Department of Health and Human Services (DHHS) programs
2015, 2017, 2019	Michael Leoz JD	Legal aspects of culturally competent care as it relates to equal access to and opportunity to participate in and receive services from all US Department of Health and Human Services (DHHS) programs
2010, 2011	Desiree Lie MD	Cultural competency curricula/training; efficacy of cultural competency training, including tools such as the Tool for Assessing Cultural Competence Training (TACCT)
2013	Robert Like MD, MS	Development of medical education programs and provision of training and technical assistance relating to the delivery of patient-centered, culturally responsive care to diverse populations
2010	Martin Martinez, MPP	Cultural competency and healthcare reform; culturally competent care and prevention strategies for African American and Latino men, and for Gay and Bisexual men of color and Transgender individuals.
2017	Julia Puebla Fortier	Linguistic and cultural competence in health care; federal health policy analysis; principal author of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care for the US DHHS
2015	Chirk Jenn Ng, MBBS, MMEd, PhD	Shared decision making; Patient decision aids
2013	Elyse Park PhD	Cultural competency curricula/training; cultural competency measures, such as the Cross-Cultural Care Survey (CCCS); health-related behaviors, especially tobacco treatment among vulnerable medical populations; role of culture on cancer preventive behaviors and health care utilization
2019	Christopher S. Saigal MD, MPH	Nexus of quality of care and trends in medical technology; shared decision-making using computer applications
2019	Douglas S. Smink MD, MPH	Communication, leadership, and decision-making for surgeons and surgical teams; co-PI of Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) cultural dexterity curriculum for surgical residents
2010	Ellen Wu MPH	Cultural competency and healthcare reform; healthcare disparities

^*Expertise described is as it relates to cultural competency/cross-cultural health care

Another positive impact of the conference is the free conference registration that has been provided for over 100 UHM undergraduate students from a variety of backgrounds and disciplines. This is separate from an additional 100 free registrations for UHM medical students and residents. The scholarship allows trainees to experience a “national/international” scientific conference in a friendly environment without the travel costs. The department also provides faculty and staff with opportunities to serve as invited speakers and have also welcomed them to submit abstracts for breakout and poster sessions. Additionally, special student breakout sessions have also been featured. A highlight is the panel of Deans, which have been comprised of the Deans from Medicine, Social Work, Public Health, Nursing, and Hawai‘inuiakea, and most recently Pharmacy, who have discussed diversity enhancing collaborations between the various schools, colleges, and programs. Web site access at http://cchc-conference.jabsom.hawaii.edu/ is also available after the conference to anyone wanting to become familiar with experts in the field of culture and diversity.

Cultural Training Efforts for General Surgery Residents

The UHM Department of Surgery is recognized nationally as one of the first general surgery residency programs to develop a cultural competency curriculum. This is significant because, as noted, surgery is one of the last medical specialties to formally incorporate cultural competency into its residency training. Initiated in 2008, the project is now in its eleventh year. Since 2009, all PGY-1/first year surgical residents participate in a cultural standardized patient exam that was developed in collaboration with the UHM Dept of Family Medicine and Community Health (Maskarinec & Buenconsejo-Lum) who had been utilizing cultural standardized patients for over a decade in its residency curriculum. A standardized patient (SP) scenario was designed involving a surgeon attempting to obtain informed consent from an elderly Samoan man who needs to have his leg amputated or face certain death. Two additional standardized patients also participate in the scenario – the patient's wife and a medical interpreter. Certified Samoan medical interpreters from a local community health clinic provided input on the authenticity of the case during its formulation.

Two measures are used to assess resident performance: 1) The Cross-Cultural Care Survey or CCCS developed by Weissman and Betancourt. Keeping the survey's scales intact, this abbreviated version of the survey focuses on preparedness and skillfulness;¹² and 2) a revised version of a written checklist (ie, rating sheet) developed by the UHM's Department of Family Medicine and Community Health.¹³ The edits to the original version of the survey did not impact the reliability and validity of the survey. The rating sheet is comprised of a table that lists three of the six ACGME competencies that are most-related to the provision of culturally competent care (ie, Professionalism, Interpersonal and Communication Skills, and Patient Care) as well as Cultural Awareness. Categories of Below Expectations (1–2), Meets Expectations (3–4), and Exceed Expectations (5) are accompanied by detailed descriptions on what skills the resident needs to demonstrate to achieve a certain rating. The rating sheet is used by both the faculty preceptor and the standardized patients as well as the resident; the resident version, however, has additional questions regarding the exam.¹³

Immediately after completing the exam, the resident receives feedback from the faculty observer and the standardized patient as part of the debriefing process. In addition, the surgery resident completes a self-assessment form. The self-assessment/selfreflection allows the resident to compare their self-perceptions with the ratings of both the faculty and the standardized patient. The sessions are video recorded to allow residents to view their performance and other faculty who were not present can utilize the same standardized checklist to rate the resident. Prior to the post-test (typically one month after the pretest), the surgery residents participate in a Grand Rounds lecture, didactic session, or journal club. In years when there is a conference, senior-level residents (PGY-3,4,5) were required to attend the Cross-Cultural Health Care Conference.

A post-test is conducted three months later, and residents are readministered the Cross-Cultural Care Survey and cultural SP exam to determine the impact the lecture/didactic session/journal club, initial SP exam, and/or the debriefing had on resident perception of preparedness to provide cross-cultural care. So far, results of the two studies conducted have not demonstrated any statistically significant impact,^13,14 but have aided in informing the department and others who would like to implement similar programs of potential issues for consideration, The sample sizes for both studies are small, but provide some results to be considered.

In the first study, no statistically significant improvement regarding surgery resident knowledge, skill and attitude towards cross-cultural care between the pre- and post-tests was noted.13 However, there were significant differences by ethnicity in all three categories of the Cross-Cultural Care Survey (attitude, knowledge and skills) on the pretest and for knowledge on the posttest. These results suggest that more tailored training as opposed to a “one size fits all” approach is needed. The study also noted that negative resident attitudes toward cultural competency training may be encountered. To mitigate this, collection of more data was suggested regarding the residents’ past cultural competency training, which may impact his/her attitude toward the training. Another suggestion was to provide more opportunities for formal instruction on cultural competency, including a “boot camp” approach to cross-cultural skills training.¹³

In the second study, there was also a paucity of statistically significant findings.¹⁴ However, note was made of the differences between US Born versus non-US Born residents. Non-US Born residents had a significantly higher score on attitude toward cross-cultural care than US Born residents, but not on knowledge and skills. Although one would assume that a more positive attitude would correspond to stronger skills and knowledge, this was not the case. In fact, US Born residents performed significantly better on the post-test as compared with the non-US born who showed little change. A potential concern was raised regarding observers and/or standardized patients potentially holding the non-White residents to different standards. The study noted that as with patients, trainees are also growing more diverse and issues such as language or “cultural” barriers will not only become a concern for patients, but also for residents/providers. Focus needs to be placed on both provider and patient characteristics.

Because the department was one of the first to implement an ongoing, formal cultural competency training, it was able to provide a “lessons learned” perspective and advise others seeking to implement similar programs on what worked and didn’t work. It shared its measurement tools which may be adapted by others for their curricula. Invitations were extended to the department to speak at the first ever panel on cultural competency at the 2014 American College of Surgeons (ACS) Clinical Congress, and to serve as an expert consultant in 2015 on Brigham and Women's Hospital's Center for Surgery and Public Health's cultural dexterity program for surgeons, known as PACTS (Provider Awareness and Cultural dexterity Toolkit for Surgeons). In 2018, the department was also invited to serve on the curriculum committee. PACTS will be the most standardized and comprehensive cultural competency training developed to date for training general surgery residents. Implementation of PACTS at pilot sites begins in July 2019. Because the department's curriculum is largely comprised of one cultural SP exam, it would like to expand to include more exams and methods to evaluate outcomes. Once the curriculum is finalized, the department plans to adapt the PACTS curriculum to the extent possible, time and administrative and fiscal resources permitting.

Conclusion

The UHM Department of Surgery has made strides in the area of cultural training but has a long way to go. One key item that needs to be addressed is the impact and effectiveness of these efforts. Have these projects helped participants, and have they really made a difference? In 2017, one of its publications (Shah, Sapigao, Chun) was featured on the ACS Committee on Diversity Issues Web page as a resource: https://www.facs.org/about-acs/governance/acs-committees/committee-on-diversityissues/diversity-resources and demonstrates an attempt to begin to answer this question.¹⁵ The article discusses shortfalls of the department and other programs, as well as positive factors that contribute to the projects’ long-term sustainability. Now entering its second decade, the department plans to be more proactive when it comes to documenting outcomes. For example, if the department is able to adapt the PACTS curriculum, it will be able to utilize the standardized measures that were developed and be able to gauge whether the cultural training efforts had a positive impact on the most critical of evaluation criteria - patient outcomes. As interest, time, and/or funding permits, the department also plans to continue its other cultural competency initiatives.

Abbreviations

ACGME

Accreditation Council for Graduate Medical Education

CCHCC

Cross-Cultural Healthcare Conference

CCHCRC

Cross-Cultural Health Care Research Collaborative

C3

Cultural Competency Committee

JABSOM

John A. Burns School of Medicine

LCME

Liaison Committee on Medical Education

PACTS

Provider Awareness and Cultural dexterity Toolkit for Surgeons

SP

Standardized Patient

UHM

University of Hawai‘i at Manoa

Conflict of Interest

The author does not identify any conflict of interest to report.