Seminar Enhancing cultural competence in the education of healthcare professionals: Where do we stand? Copenhagen, 9 June 2016

Cultural Competence in Medicine: experiences from Holland

Dr. Petra Verdonk p.verdonk@vumc.nl

Prof.dr. Marie-Louise Essink-Bot

In memoriam

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This presentation

• Cultural competence????!!

• The three fixes:

1. Fixing the numbers

2. Fixing the institution

3. Fixing the knowledge

three tightly connected systems…

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Cultural competence

• Health care: recognizes and incorporates culture at all

levels to accommodate to ‘unique’ needs

• Diminish health disparities, increase access and quality

• Professionals: knowledge, attitude, skills to provide optimal

care to patients with diverse backgrounds

• “how people communicate across cultural divides” (Napier et

al., 2014, p. 1611)

Betancourt et al., 2003, Seeleman, 2014; Raamplan, 20094

Diversity as celebration of difference?!

• Interculturalization, cultural diversity, ethnicity, religion

• Business case?! Or social justice

– Equality and equity, fairness

• Diversity work and diversity workers requires commitment

Diversity should NOT “conceal the operation of

systematic inequalities under the banner of

difference” (Ahmed, 2007)

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1. Fixing the numbers

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Students and diversity in higher/med educ

• Strong stereotypes (both sides teachers and students…) o Minority student associated with problems

• Unequal capital (disadvantageous starting position)• E.g. language or study skills

• Complex collaboration between minority/majority students• Social cohesion and exchange limited

• Experiences of discrimination and exclusion

De Jong, 2014; Taylor, 2003; Tjitra et al., 2011; Rifi, 2014; MFVU-DOCS

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• ‘Invisible’ or rather unknown

• 14 interviews, 11 veiled

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Veiled ambitions: Female Muslim medical students(Leyerzapf, Rifi, Abma & Verdonk, in preparation)

Results

Leading a different student life

Constituting a different medical student

Becoming a different doctor

Results

• Constituting a different medical student

• Physical examination

• Intercultural communication

• Rotations

Physical examination and rotations

• “I remember one day, it was during the Summer and we had physical examination

practical. This time it was about examining the leg. Because of the weather, about

half of the class was wearing shorts. Well, exactly that day, the teacher asked me

to come forward in front of the class to let someone practice this particular aspect

of physical examination. Well, I thought: why, out of all the students do you choose

me, it was very annoying.” (6th yr student, 24 yrs)

• “Well during one of my rotations, I had to work with a specialist, so at the start of

my shift I came into the room and introduced myself by saying: “Hello, my name

is…” to which he reacted with “Oh well great, she can speak Dutch without an

accent!”... I thought ooh... (…. ). Well for one instance I really thought: I cannot

take this anymore.” (6th yr student, 24 yrs)

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Recommendations

E.g.:

• Provide a safe climate - harassment and discrimination are not acceptable

• Support teachers how to discuss diversity issues

• Create awareness and understanding among teaching staff and

student councils

2. Fixing the institution(Verdonk et al., in press)

• Policies

• Political support

– (Vice-)deans, education directors, course organizers

• Expertise

• Commitment = resources: time, money, skills

• Broad alliances – recognition and acknowledgement of issues in

common: social justice

• Involve the students…

• Teaching skills

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Cultural competence and teachers(De Graaf et al., submitted; De Jong, 2014)

• Teachers define CC o Multidimensional vs more

essentialist, student diversity,

internationalisation

• Doubts and little self-esteem

• Barrierso Student resistance, (dis)respect

o Little reflexivity/reflection on own

values

o Lack of training/experience

o Lacking support from organization

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3. Fixing the knowledge

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Cultural Competence in medical education

• Cross-cultural approach in medical education,

o not just attitude (awareness or sensitivity approach)

• empathy respect, humility, curiosity, self-awareness…

• important, but abstract

o not just knowledge (categorical approach) • knowlege on health differences, attitudes, beliefs etc.

• important, but also a risk on stereotyping/essentialism

o but also development of tools and skills• how patients understand their own health complaints

• social context

• physician-patient interaction, shared-decision making

Betancourt, 2003

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Email Feyza: “What I did not like was thepatient case…

• Practical Physician and Reproductive Technology, Course ‘Beginning

of life’, Bachelor year 2

• Case: “ I will not think about my religion at that moment!”

• “I think it is peculiar that such a case was chosen. It assumes that

termination of pregnancy is not allowed and therefore also a taboo in

Islam. It is just the right thing to actually question that.”

• “ How great that I can talk about this with my teachers!”

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Medical education VUmc• 350 students

• 3 years B, 3 years M (rotations)

• In bachelor 2 semesters per yr

• Five modules per semester, mainly tracts (Skin and immune system, Movement)

• Lectures, small tutor groups (12 students), practicals

• One tutor per tutor group per semester

• Different (expert) teachers for practicals

• Per course at least 100 teachers, e.g.

– Medical psychology communication skills

– Family medicine physical examination and clinical reasoning

– Basic scientists and lab practicals

– Medical humanities diversity, ethics, academic development

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Learning pathway interculturalisation anddiversity

• Ethics and interculturalisation (VUmc tradition)

• Learning objectives:

1. Knowledge of the relationship between aspects of diversity with

health differences and disparities: sex/gender, cultural diversity,

SES/class

2. Awareness and knowledge of diversity in communication and

physician-patient interaction

3. Reflexivity … own background and structural position (privilege

and disadvantage)

• Related to Dutch Blueprint 2009 (final objectives), competences, and

other learning pathways19

Intersectional perspective(Verdonk et al., 2015; Verdonk et al, in press)

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Sekse/gender

…….

Klasse

Cultuur/etniciteit

Sex/gender

Ethnicity/culture

SES/Class

Acker, 2006; Hankivsky, 2012; Hankivsky & Cormier, 2009

Screening the VUmc curriculum (Muntinga et al., 2015)

• Focus:

– categories ‘culture’, sex/gender and SES/class in relation to health

and health care

– And the interactions between those categories

• Good practices and points for improvement per learning objective

– Knowledge:

+ Infectious diseases, genetic disorders, tb,

thalassemia/sikkelcelanemia

Health care for undocumented patients

- Language barriers, interpreters, lifestyle

• Hardly any attention for intersections between categories

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Implementation

• Context

– Dpt. Medical Humanities

– Curricular reform starting 2015-2016

– VU University project Diversity Responsive Education

– Alliance Gender and Health 2012-2015

– C2ME-project Erasmus LLP 2013-2015 Cultural Competence in

Medical Education

• Strategies

– Implementationplan curriculum

– Lina Issa Art Partner and student involvement

– Extracurricular activities

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Results?!

• Knowledge- Implementationplan via B-council and coordinators (2015-2016)

- Textbook Wolffers et al. (2013)

- Mastersymposia

- Diversity and clinical reasoning/communication skills practicals

- Elective Diversity bachelor minortrack (3 courses)

- Global Health, Gender & diversity in medicine, Physician in

Conflict Areas

- Ethics practicals

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Results (2)

• Skills – Overcoming language barriers

• Reflexivity– Seven modules with Lina Issa, Art Partner

– What is the norm here?

– Who is the Other?

– When did you feel vulnerable?

– When did you need an interpreter?

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Results (3)

• MFVU-D.O.C.S. and Art Partner

• AMEE– Special Interest group Gender and Diversity

– Diversity track AMEE conference August 2016, Barcelona

– AMEE Symposium

– AMEE Webinar, 24 February 2016, September 2016

• Teacher training Working with Diversity (C2ME, OPDO-project)

• Symposia: – Different in the White Coat (2014)

– Dress Red Day (gender and health) (2015)

– ReVUgees: Dare to Care (2015)

– Gender and Pain (2016)25

Example Physical examination of the lungs

• Practical Physical examination of the lungs Bachelor year 1

– Assignment Where do you stand?

– Reflexivity, understanding (own) values and norms towards the

body, touch, inspection (gaze…)

– Have knowledge of diversity between and within groups as

regards the body, touch and inspection

– 20 questions: Which one of three body parts is most intimate?

A. the face

B. the feet

C. the torso

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Examples Care ethics and diversity

• Practical Care ethics and diversity, Bachelor year 2

– Idris Bahce, lung physician

– https://vimeo.com/144348024 (2.45’-5.10’)

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OSCE Diversity, Ethics and Law, Patient Safety

15 min Objective Structured Clinical Examination Bacheloryear 1

CaseYou are an intern in family medicine. Mrs Arslanian, 53 years old, visits your practice

for a consultation, accompanied by a man in his fifties. She had made an appointment

for her swollen, painful leg and shortness of breath.

You welcome them and reach out to shake their hands.

Male student: Mrs Arslanian refuses to shake your hand.

Female student: The man refuses to shake your hand.

Question What is your first impression? What would you ask? Why?

Scoring Reflexivity, Collecting information and clarification, Argumentation

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Example Symposium IPV, M3

• Symposium Intimate Partner Violence, Master year 3

• ‘50 shades of grey’ and normalization of intimate partner violence(dr. Petra Verdonk, psychologist)

– https://www.youtube.com/watch?v=hTlYtqrrvxQ

• Intimate partner violence in the picture (prof.dr. Udo Reijnders, forensic

specialist, Public Health Services Amsterdam)

• Intimate partner violence in practice (dr. Sylvie LoFoWong, family

physician, senior-researcher Radboudumc)

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The next day: “Dear Dr. Verdonk…

- I think that it is very important that physicians are

sensitized for societal issues like this. (…) I always felt

it was a pity that many students are purely oriented

towards biomedical content. This will be probably be

reflected in the evaluation. I hope that this

evaluation will not be a reason for too many changes

in the curriculum. Some issues have to be addressed

just because that is the right thing; even when some

students do not like it.

(…)

Thank you again for the shocking and inspiring

morning!”

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Examples

• Yes, there a lot of things we did not (yet) do:

– disability

– sexual diversity LGBT health issues…

– class!

• And yes, we also have examples of modules that did not work…

• Visit our session at AMEE in Barcelona, August 2016!

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What have we reached? • Feyza’s email, curriculum monitoring project by students

• Rachid and Mecit at C2ME’s final conference

• Nicky Honnef presents at AMEE Barcelona

• Extra meetings at dpt. Family Medicine e.g. about physical examination and

cultural diversity

• Teachers asking for support as they develop their teaching

• Know-VU – diversity at VU University

– Philosophy petition for more female philosophers in education

• Wouter Bos (Chair of Hospital Board) speech and national television …

• Hans Brug (dean) and sex and gender in research

• Discussing teacher training at Health Sciences

• Teacher training as an elective for required teacher training trajectory

• Spin off pilot teacher training

• Diversity among physicians and role models

• Interns e.g. Juliet Beuken studying LGBT health issues in medical education

• Learned about things that might work. And things that might not work.

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Reflections

• Involvement of regular actors: students, teachers, coordinators etc.

• ‘Political’ support and experts (commitment and allocation of

resources)

• Monitoring, expertise

• Local focus/education concepts

• Role of students in development and evaluation of education

• Academic papers

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Reflections

• Curriculum transformation as a quest

• Diversity as neverending (just like anatomy, pathology,

etc…)

• Variation as the norm

– Exchanging aspects of diversity?

• Painful knowledge – dealing and working with emotions!

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Thank you…

• Lina Issa, Art Partner, made the beautiful pictures and the video

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