Introduction :
Relevant to any discussion regarding principles of Integrated Medicine is the topic of culture. In recent years the medical education community has witnessed a significant push to address integrated medicine or, more specifically, Complementary and Alternative Medicine (CAM). 1,2 Topics such as religion, spirituality, herbal medicine, diverse “traditional” treatments, and culturally different views on health have all come under consideration in various explorations of CAM in medical research and education. 3,4 Nevertheless, we are reminded by Huffard 5 that what has recently fallen under the domain of CAM has long resided under the umbrella of cultural diversity.
It might be argued that teaching cultural competency to medical residents has never been more important. This may be particularly true for large urban medical centers, which often represent a microcosm of globalization and cultural inter-mingling. In such settings, doctors of diverse cultural backgrounds are obliged to collaborate with patients and families from equally diverse roots. Furthermore, residents may have received their medical education abroad, where focus on CAM or cultural diversity may not have been of significant importance. Inasmuch, residency training programs have an ethical responsibility to instill competencies necessary to utilize medical expertise in encounters with culturally different patients. Abilities to evaluate the cultural context of patients' concerns and communicate effectively with culturally diverse patients are vital for every physician.
Maimonides Medical Center in Brooklyn , New York , presents a noteworthy example of a heterogeneous cultural atmosphere that can exist within a large urban medical center. Maimonides is located in the heart of Borough Park , Brooklyn . While the medical center's immediate community represents one of the largest Orthodox Jewish centers in the U.S. , Brooklyn 's diverse immigrant population is unmistakably represented in its patient population. Cultural groups from Russia , Eastern Europe , China , the Asian Sub-Continent, the Middle East , Central and South America , and the Caribbean are regularly present at Maimonides. It is this cultural diversity that often attracts residents to the medical center.
The Culture OSCE :
Knowledge about cultural differences and sensitivity as well as the ability to communicate across cultural boundaries are part of cultural competence and indicators of good medical care. Residency training programs often utilize lectures, readings or small group discussions to instill such competencies. While these approaches are certainly important, educational models must reach beyond strictly informative methods. Training for culturally appropriate care must encompass practical skill development in tandem with acquired didactic information. In the fall of 1999, a seminal Culture OSCE, or Objective Structured Clinical Exercise/Exam, was developed to meet this need at Maimonides. 6
The development of the Culture OSCE was spearheaded by Lisa Altshuler, Ph.D., Co-Director of Developmental and Behavioral Pediatrics and approved by the Departmental Medical Education Committee. Under Dr. Altshuler's leadership, the Behavioral and Development Curriculum Committee, an ongoing multidisciplinary committee representing the fields of psychology, medicine, nursing, genetic counseling, social work, medical education, child life, art therapy, massage therapy as well as local community groups, was founded to design and implement the training. The committee's challenge was to design a training program that went beyond mere introduction to culturally specific information and offered experiences that highlighted the complexity of cross-cultural interaction. Opportunities to build skills that facilitate exploration of unique cultural perspectives, cross-cultural communication, and doctor/patient collaboration would be key. Organized practice, specific feedback, and explorations of personal reactions would be critical aspects of the training.
Since its inception in 1999, the Culture OSCE, administered to all second year pediatric residents, has evolved to consist of a didactic workshop followed by six consecutive interactive stations and a group feedback period. The six stations represent the practical aspect of the OSCE. Five of the six stations require interactions with standardized patients: professional actors who play the role of various patients/families in defined scenarios based on actual events that have occurred at Maimonides. The sixth station is a pencil and paper task. In these stations each resident has ten minutes to perform a given task and five minutes to process the experience with a faculty observer and the standardized patient. Faculty observers are formally trained to assess residents' general communication skills, cultural beliefs and management of differences. It is important to note that this training does not advocate the supremacy of allopathic medicine over non-dominant practices or beliefs. Rather, residents are encouraged to explore culturally respectful and mutually beneficial solutions that may include allopathic approaches, “traditional” approaches or both.
Several stations have been designed since the inception of the Culture OSCE. Some of the stations, which include areas typically considered in discussions of CAM , are briefly described as follows:
1) Informed Consent - Requesting consent for a child's emergency surgery and blood transfusions from a parent who is a Jehovah's Witness.
2) Life Threatening Illness - Discussing the possibility of openly disclosing/addressing a teenager's cancer with his Nigerian parents who are opposed to such practices.
3) Chinese Herbs - Explore a family's use of herbs with a child's suffering from a persistent cough.
4) Religion/Spirituality - Negotiate a Catholic family's request for prayer with the resident during a pre-operative review of procedures.
5) Downs Syndrome - Exploring expectations of a couple about their Orthodox Jewish community's reactions to the birth of a child with Downs Syndrome.
6) Pelvic Exam - Explaining the need for a pelvic exam to rule out pelvic inflammatory disease to a girl from a traditional Muslim background who fears her sexual activity will be severely punished.
7) Alternative Medicine (paper and pencil task) - Match questions about “traditional” treatments and photo identification of resulting skin marks that may be mistaken as child abuse (e.g. cupping, coining, and moxibustion).
Discussion :
Residents and faculty have found the Culture OSCE to be a useful learning experience. It has generated much discussion within Maimonides' Department of Pediatrics regarding how to address such challenging situations. Additionally, the Culture OSCE has been presented and well received at several medical education conferences. 7,8,9 However, positive feedback aside, can it be determined if the training has lasting effects? In the three years since it's founding, the Culture OSCE has undergone several evolutions. New members of the Behavioral and Development Curriculum Committee have been recruited, the range of possible case scenarios has been expanded, and the faculty observer assessment criteria refined. Most importantly, a two-year prospective study that will help determine the efficacy of the Culture OSCE is near completion. Preliminary data has supported the usefulness of the Culture OSCE. 10 Final results of the study are expected near the end of 2002.
Inquiries :
For more information about the Culture OSCE, please contact Lisa Altshuler, Ph.D., Co-Director of Behavioral and Developmental Pediatrics, Chair/Principal Investigator of the Behavioral and Development Curriculum Committee. Maimonides Medical Center Department of Pediatrics, 4802 10th Avenue, Brooklyn, New York 11219. Address e-mails to altgold@yahoo.com
About The Authors :
Stephen Koepfer, MA, ATR, LMT is a Child Life Specialist/Art Therapist and member of the Behavioral and Development Curriculum Committee. He is a Fellow of the American Association of Integrated Medicine and sits on the advisory board for Alternative Therapies in Health and Medicine. Mr. Koepfer can be contacted via e-mail at s.r.k@att.net
Shannon K. Barrett, MS, CGC is a Genetic Counselor, Clinical Instructor of Pediatrics, and member of the Behavioral and Development Curriculum Committee. She is a Diplomat of the American Board of Genetic Counselors. Ms. Barrett can be contacted at sbarrett@maimonidesmed.org
References:
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6 Altshuler L, Kachur E. A culture OSCE: Teaching residents to bridge different worlds. Academic Medicine. 2001; 76(5): 514.
7 Altshuler L, Kachur E, Aeder L, Barrett S, Fitzgerald W, Hilfer A, Koepfer S, Kruger H. Culture Objective Structured Clinical Exams to Assess Cultural Competence of Pediatrics Residents. Accreditation Council for Graduate Medical Education. Chicago, Il. 2002.
8 Altshuler L, Kachur E, Aeder L, Barrett S, Fitzgerald W, Hilfer A, Kruger H. Enhancing Resident's Cultural Competence through Culture Objective Structured Clinical Exams/Exercises (OSCEs). Innovations in Medical Education. Washington, D.C. 2001.
9 Altshuler L, Kachur E, Aeder L, Adamenko R, Barrett S, Hilfer A, Kruger H, Kinsella M. Cross Culture OSCE: Teaching Residents to Bridge Different Worlds. 9th Annual Ottawa Conference on Medical Education. Johannesburg, South Africa. 2000.
10 Altshuler LA, Kachur E, Sussman NM, Aeder L, Barrett S, Fitzgerald W, Hilfer A, Koepfer S, Kruger H. Use of the Intercultural Development Inventory (IDI) in Assessing Changes in Intercultural Sensitivity Among Pediatric Residents. 10th Annual Ottawa Conference on Medical Education. Ottawa, Canada. 2002.
