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Integration of Cross-Cultural Care into the Teaching of Pathophysiology Using Harvard Business School Teaching Strategies Helen M. Shields, M.D., F.A.C.P., A.G.A.F. Professor of Medicine Associate Master, Oliver Wendell Holmes Society Harvard Medical School Brigham and Women’s Hospital Inspiration Professor David Garvin, C. Roland Christensen Professor of Business Administration, of Harvard Business School, gave the keynote address at the June 2002 Experienced Tutor Retreat. Improving the Teaching of Pathophysiology: Key Teaching Strategies Adapted From Harvard Business School Training tutors to be discussion leaders who: 1. Ask questions 2. Summarize the major points 3. Provide a visual schematic take-away • Shields HM, et al. Acad Med 2007; 82: 486-492. The Art of Asking Questions • Learn to question, listen, respond • Exposure to multiple types of questions – Open-ended (What is going on?) – Informational (How does the lower esophageal sphincter work?) – Diagnostic (How would you go about sorting out the possibilities?) James Honan & Louis Barnes, Some Different Kinds of Questioning. Discussion Leadership Course: Harvard Graduate School of Education, 2003. The Art of Asking Questions • Exposure to multiple types of questions (continued) – Challenge (Why do you say that?) – Extension (What else?) – Priority (Which factors do you consider most important?) – Prediction (What would you predict might be found on the X-ray?) James Honan & Louis Barnes, Some Different Kinds of Questioning. Discussion Leadership Course: Harvard Graduate School of Education, 2003. Summarizing with Diagrams • Summary – Short (3-5 minutes). Prepared ahead but tailored to the discussion. – Emphasize and reiterate important concepts – Misconceptions are corrected: distinguish “right from wrong” • Visual diagram of concepts – An organizational framework – Clarifies central concepts – Copyright clearance obtained for all figures Integration of Cross-Cultural Care into a Pre-Clinical Pathophysiology Course Target the tutorial: • Awareness • Respect • Knowledge • Integration • Shields HM, et al. Clin Gastroenterol Hepatol 2009; 7: 279-284. “Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled.” Hobgood C, et al. Academic Emergency Medicine 2006; 13:1288-1295. Colorectal cancer age-adjusted mortality rates per 100,000 in South Carolina by race and gender, 1998-2003 40 White Black All Races 35 Mortality Rate 30 25 20 15 10 5 0 Men Women Men & Women Daguise VG, Burch JB, Horner M-J, et al. J S C Med Assoc. 2006;102:214. Primary Hepatocellular Carcinoma Surgical Intervention by Stage 50 Localized HCC 70 Black White 40 Regional spread Black White 60 30 p<0.001 20 Percent Percent 50 40 p<0.012 30 20 10 10 0 0 Not recommended Performed Surgery Not recommended Performed Surgery Sloane D, Chen H, Howell C. Journal of the National Medical Association 2006; 98(12):1934-1939 Relevant Triggers and Probing Questions Stimulate Cross-Cultural Care Discussion What Are Tutorial Case Triggers? • Cultural, ethnic, racial, socioeconomic factors • Integrated into problem-based cases • Relevant to understanding pathophysiology or science • Trigger discussion • Create objectives to cover discussion of triggers Culturally Competent Care Triggers in Tutorial Cases • Case I – Obesity – Inability to pay for essential medications • Case 2 – Use of alternative therapy with side effects • Case 3 – Effect of alcohol on mortality from cirrhosis – Resources for alcohol cessation – Salty snacks increase ascites 2007 Student Assessment of Cultural Triggers • 2006 Faculty Development Program did not significantly change tutors’ actively teaching cross-cultural care • Invited student subcommittee of the CrossCultural Care Committee to revise cases • Received enthusiastic and thoughtful responses that led to important case revisions • Each student’s name is listed at end of each copyrighted case • Shields HM, et al. Kaoshiung J Med Sci 2009; 25: 493-502. Tool for Tutors to Create Questions Tutor Questions Louis Garrison Case: • Is his race a relevant factor? • How would you open up a conversation with this patient about his obesity? • How would you ask the patient if he can afford to pay for his essential medications? Tutor questions Laura Chen Case: • Would you ask questions about alternative medication only if the patient is Asian? • What is the relevance and impact of the herbal preparation on the pathophysiology of the patient’s illness? • How would you work with patients who wish to have alternative medicine along with Western medicine? Tutor Questions Wally Zimansky Case: • What are the obstacles to change for Mr. Zimansky? • What are the issues that may arise with his wife as chronic care-taker? • What are the potential economic and social problems and issues with major life saving surgery such as a liver transplant in an elderly patient? Triggers’ Relevance to Pathophysiology Association between body-mass index and the risk of frequent symptoms of gastroesophageal reflux disease Jacobson BD, et al. NEJM 2006;354:2340-8. Enzinger PC, Mayer RJ. N Engl J Med 2003;349:224152. Melanosis Coli from Senna use Ahmed S and Gunaratnam NT, NEJM 2003; 349(14):349 Melanosis Coli Pathophysiology Sleisenger & Fordtran, Gastrointestinal and Liver Diseases, 2002; 7th ed. Baseline Characteristics of Respondents Who Used Herbs in the Past 12 Months During the past 12 months, did you use an herb for your own health or treatment? Characteristics Population % Yes P value<.05 18.6 n=5,787 Race/Ethnicity Hispanic Non-Hispanic white Non-Hispanic black Non-Hispanic other <.0001 10.1 75.5 8.7 5.7 <.0001 Gender Male Female 42.3 57.7 Gardiner P, et al. Alternative Therapies. 2007; 13:22-29. Negative effects of alcohol on the liver Ethanol Gut permeability LPS Menon KVN, Gores GJ, Shah VH. Mayo Clin Proc. 2001;76:1021-1029. Five-year survival for alcoholic liver disease (the effect of abstinence) Schiff ER, Sorrell MF, Maddrey WC. Schiff’s Diseases of the Liver. 9th ed. Vol. 2 Philadelphia: Lippincott Williams & Wilkins, p.1034. Short Video of Tutor Leading a Cross-Cultural Discussion Longitudinal Reinforcement • Weekly tutor meetings • Expert guidance • Sharing tutor-to-tutor anecdotes • Peer support Integrating Cross-Cultural Care into Pathopysiology Tutorials with the Tutor as Discussion Leader 1. Design relevant triggers and matching objectives 2. Modify triggers based on student input 3. Get tutor buy-in 4. Ask tutors to create questions 5. Provide practical examples (video tape) 6. Address tutor concerns 6. Encourage weekly tutor-to-tutor dialogue Acknowledgements Daniel Leffler, MD, MS Jane Hayward, MS Augustus White III, MD, PhD Sheila Salamone, BA Janet Hafler, EdD Andrea Lenco, BA Stephen Pelletier, PhD Paola Blanco, MD Richard O’Farrell, MBBS Antoinette Peters, PhD Roxana Llerena-Quinn, PhD Vinod Nambudiri, MD, MBA