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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