Forschung Migration und Gesundheit im Rah - Bundesamt für ...

However, after much discussion among the research team
members, we came to the conclusion that physicians (especially
private physicians) would probably be unwilling or unable
to take time out of their busy schedules to conduct consultations
with standardized patients. In order to address our study
objectives we need each physician to conduct several consultations,
which would represent a considerable time commitment
on their part. We felt that the heavy investment in
terms of time and resources (training of standardized patients,
scheduling of consultations, filming and analysis of consultations,
etc.) would not be justified if we did not recruit a minimum
of 100 physicians, which seemed unlikely.
Therefore, even though we felt that standardized patients represented
a more valid method for evaluating physicians’ cultural
competence skills, we decided to explore the possibility
of incorporating our clinical scenarios into a simulated patient
program. These are interactive, computer-based programs that
present a clinical situation to the physician, who must then ask
questions to the “patient”, and make decisions based on the answers
provided. Such programs can record the formulation and
sequencing of questions asked by the physician, thus allowing
us to evaluate whether the physician has addressed the particular
themes we are interested in.
The simulated patient programs are less realistic than standardized
patients, and technical limitations of the programs mean
that the skills assessment will be narrower than what would be
possible with standardized patients. However, the advantage of
this approach is that physicians can access the patient scenarios
at their convenience via Internet – in their homes, offices or at
the hospital. We hope that this flexibility will help increase our
recruitment of physicians.
We are currently working with a Swiss developer, VIPS„ (Virtual
Internet Patient Simulator) to incorporate our scenarios into their
patient data base.
2.2 Administration of the two research tools
During February till April 2006, the cultural competence questionnaire
will be administered to:
a random sample of 600 physicians working at the Geneva
University Hospital
a random sample of 600 private physicians working in Geneva
250 Geneva medical students (all 4th-, 5th- and 6th-year
students)
Once initial analyses have been conducted, we will recruit a
representative sample of approximately 200 physicians who
responded to the questionnaire, and invite them to conduct
simulated patient consultations (medical students will not
be recruited for this phase of the research). For each simulated
patient consultation, a score will be generated based on
whether key topics were addressed, and whether the information
provided or question asked was formulated appropriately
(open- vs. closed-ended questions; non-technical language,
etc.). Associations between questionnaire and simulated patient
scores will be explored.
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3 Results
The project is on-going at this time (February 2006). In this
section we highlight key findings from the literature review
which influenced the development of our questionnaire, and
describe the main features of the questionnaire.
3.1 Findings from the literature review
The most commonly quoted definition of cultural competence
is that proposed by Cross et al. (1989): “a set of congruent behaviors,
attitudes and policies that come together in a system,
agency or among professionals that enables effective work
in cross-cultural situations”. Cultural competence can operate
at the level of the health service (structures and processes),
or at the level of the individual clinician, and is founded on
the recognition of the importance of culture in people’s lives,
respect for cultural difference, and a commitment to minimize
any negative consequences of cultural difference. Our study is
specifically interested in physician-level cultural competence,
which can be understood as the ability to provide patient-centered,
culturally sensitive care to patients from diverse backgrounds.
Many professional organizations in different areas of health
have developed policies and guidelines that define and promote
culturally competent practices by physicians. There are
also a number of examples in the medical literature of pregraduate
and postgraduate training activities aimed at increasing
clinicians’ cultural competence. Based on our review of
these materials, there seems to be general agreement among
experts with regards to the general attitudes, knowledge and
skills that learners should possess in order to be able to deliver
high-quality care to diverse populations. These include:
attitudes: respect and tolerance for social/cultural differences;
awareness and self-reflection regarding one’s own culture
and biases; acceptance by the clinician of his or her responsibility
to understand and respond to cultural aspects of health
and illness; and willingness to make their own clinical settings
more accessible to patients by taking into consideration social
and cultural factors.
general knowledge: basic social science concepts such as
culture and the illness/disease distinction; an understanding of
how culture influences health, illness and health care; awareness
of social and cultural barriers to health care; sources of
cross-cultural misunderstandings; awareness of cross-cultural
communication approaches for bridging patient/provider differences.
skills: effective collaboration with translators; approaches
for eliciting the patient’s understanding of the illness and determining
the patient’s social context; negotiation of treatment
and referral plans with patients and families that incorporate
social and cultural issues; collaboration with other health and
social resources.
However, while there appears to be general agreement about
the core attitudes, knowledge and skills that culturally competent
physicians should possess, it is unclear what training
approaches are most effective for reaching these objectives.
Betancourt (2003) identified three main approaches to teaching
cross-cultural medicine: the awareness/sensitivity approach
which focuses on developing attitudes; the categorical ap-