Providing Better Care Through Cultural Understanding

BY MATTHEW DOUGHERTY

Know thyself.

FOR PHYSICIANS, THIS ANCIENT GREEK MAXIM INCLUDES knowing the patient, an increasing challenge as American society becomes more multicultural. This necessity is particularly important for many P&S students because living in Washington Heights is their first contact with Dominican and other cultures.
One of the many ways for medical students to become more "culturally competent" is by immersing themselves in Dominican life. Each summer, several P&S, Mailman School of Public Health, and graduate students from other Columbia schools travel to the Dominican Republic to work with nongovernmental organizations through the Academic Exchange Program in the Dominican Republic. The program was developed by Dr. Marilyn Aguirre-Molina, a faculty member in the Department of Population and Family Health at the Mailman School of Public Health. For the 2004-2005 academic year, the program was managed by Tanya Cobbs Leslie, assistant dean for career services at the Mailman School.
In the Dominican Republic, Claudia Tolentino'07 assisted Centro de Orientacion e Investigacion Integral, an organization that provides services to socially marginalized groups, such as health education to battered women and sex workers. The center teaches female sex workers about sexually transmitted diseases, condom use, and safe sex.
Cultural competence is not an abstract concept for Ms. Tolentino, who was born in the Dominican Republic and speaks Spanish. But after spending most of her life in the United States, she feels the experience of working one summer in the Dominican Republic taught her much more about Dominican culture. At the center she assisted with a survey to determine which educational materials were the best for teaching women about a global HIV vaccine study and whether sex workers would be good candidates to participate in the vaccine trials.
"After spending 10 weeks there last summer, I can do a better patient interview," says Ms. Tolentino says. "I can ask better questions because I understand more about Dominican home remedies, diet, and family ties."
Sara Auld'06, who participated in the same program in the summer of 2003, agrees. "You can say, 'I spent two months in Santo Domingo' and you have an immediate connection and rapport with Dominican patients," she says. "I speak their dialect of Spanish, too. I do feel I understand better where they are coming from, especially with women's health and attitudes toward women."
Part of the medical center's capital campaign, led by P. Roy Vagelos'54, is raising funds to help more students go abroad to supplement their health science training and raise their cultural awareness.
In addition to exchange programs, CUMC is working to increase cultural competence education opportunities for students and faculty in Washington Heights. The impetus for this initiative was the 2002 Institute of Medicine report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," which stated that even in populations with equal access to care, "racial and ethnic disparities in health care exist, and because they are associated with worse outcomes in many cases, they are unacceptable."
The report recommended cross-cultural education and programs for current and future health care professionals that raise awareness of disparities. CUMC's Center for Community Health Partnerships formed the Curriculum Development Committee for Cultural Competency, led by Dodi Meyer, M.D., assistant clinical professor of pediatrics, to implement the recommendations across the CUMC schools for students and faculty.
The Center for Community Health Partnerships, led by Vice Dean Allan Formicola, D.D.S., serves all CUMC schools by establishing and supporting academic community collaborations, such as the Northern Manhattan Community Voices Collaborative and the Thelma C. Davidson Adair Medical/Dental Center in central Harlem, designed to help improve equitable health care in that community.
One recent example of the cultural competence curriculum effort was a daylong, cross-cultural communications workshop last September. A group of 30 primary care physicians, dentists, nurses, social workers, and other health care professionals from CUMC, Columbia's School of Social Work, and New York-Presbyterian Hospital attended. The seminar was designed to train Columbia faculty in the skills necessary to deliver culturally competent health care using case-based examples and to create plans for moving cultural competency programs at CUMC forward.
The workshop introduced content areas of a culturally sensitive medical encounter and provided examples of optimal ways to instruct someone in providing culturally sensitive care.
P&S is working to expand existing cultural training elements in its courses as well as add new aspects. The medical school curriculum has a solid foundation, especially in its Clinical Practice course, which features a walking tour of Washington Heights. The first-year Clinical Practice course covers both basic skills necessary to become a physician and content areas that emphasize doctor-patient communication, professional ethics, and social and cultural aspects of health. The course also has units on medical interviewing, epidemiology, health systems, the life cycle, health-related behavior, substance abuse, and nutrition.
The walking tour was made a requirement in 2003 for all incoming P&S students as a way to introduce them to the neighborhood and its people. The tour helps students see how the physical and cultural environment of patients is relevant to their health and well being and to see how this impacts patient care, says Ora F. Pearlstein, M.D., assistant clinical professor of medicine and course director of the Clinical Practice course. The walking tour was developed by Dr. Meyer; Bruce Armstrong, D.S.W., associate clinical professor of public health; and Milagros Batista, M.S.W., one of the community partners.
"With the walking tour, we are trying to improve doctors' understanding of issues related to culture and issues that affect health and treatment," says Dr. Pearlstein. "Students are learning about the community from an asset perspective, such as where the community-based organizations and schools are."
Dr. Meyer, Dr. Pearlstein, and Ayxa Calero-Breckheimer, Ph.D., project leader in the Office of Scholarly Resources, measured the effect of the tour by asking students for a list of adjectives that describe the Washington Heights community before and again after the tour. Student perceptions of the community changed dramatically from homogeneous stereotypes of an inner-city population to a wide range of positive attributes.
Also, as part of Clinical Practice I and the cultural competence curriculum, incoming P&S students must read "The Spirit Catches You and You Fall Down," by Ann Fadiman. The book is about a young girl with epilepsy whose family had moved to the United States from Laos. The girl, caught between the cultures of East and West, is declared brain dead because of misunderstandings and too much medication. The book, which examines the issues of culture and health beliefs, is also used to teach pediatric residents in the Community Pediatrics program led by Dr. Meyer. This program, developed through a grant from the Anne E. Dyson Community Pediatrics Training Initiative, has served as a model for cultural competence training initiatives throughout the medical center.
Clinical Practice features a lecture on cultural competence in the first year and class sessions on racial disparities in health care and medical interviewing using bilingual community members as interpreters in the second year. Cultural competence instruction will eventually span all four years of the Clinical Practice course as the cultural competence curriculum expands, says Dr. Pearlstein.
"With minority populations becoming the fastest growing segment of the American population, there has been a growing recognition of the need and value of culturally competent health care providers," says Robert M. Lewy, M.D., M.P.H., senior associate dean and medical director for the Center for Community Health Partnerships at CUMC. "By 2010, Hispanics, African-Americans, Native Americans, and Asian Pacific Americans will make up 32 percent of the population and, by 2050, will make up 48 percent of the population. Health professionals need to be culturally competent to both address the health needs of diverse populations and to improve the quality of care for minority populations. P&S, as well as the other CUMC schools, are moving in the right direction."

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