Article
Culturally responsive integrated health care: Key issues for medical education
The International Journal of Psychiatry in Medicine 2015, Vol. 50(1) 92–103 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415592368 ijp.sagepub.com
Rose Anne C Illes1, Aaron J Grace2, Jose´ R Nin˜o3, and Jeffrey M Ring4
Abstract Primary care providers are increasingly responsible for providing mental health care in the United States. For those patients who do receive specialty mental health services, the primary care provider functions as the main entry point into the mental health system. Given the persistent racial and ethnic health disparities in the United States, it is not surprising that mental health disparities also present a difficult challenge for both the U.S. health system and for frontline practitioners. Physicians-in-training require tools for rapid psychiatric assessment that will quickly identify pertinent symptom clusters and distinguish between major psychological disorders. It is incumbent on residency faculty to teach resident physicians how to provide culturally responsive mental health assessment and intervention/referral knowledge and skills toward the elimination of these disparities and toward patient-centered care. This article begins with an overview of health disparities and barriers to health and mental health care access, followed by a discussion of culturally responsive care including an example of a culturally responsive educational program in the United States that is directly targeting the problem of access in that geographic region. It concludes with a review of educational strategies for enhancing culturally responsive behavioral and mental health care by physicians in training. Keywords Health care disparities, graduate medical education, culturally competent care 1
Florida State University Family Medicine Residency at Lee Memorial Health System, Fort Myers, FL, USA Medical College of Wisconsin, Milwaukee, WI, USA 3 Saints Mary and Elizabeth Medical Center, Chicago, IL, USA 4 Health Management Associates, Naples, FL, USA 2
Corresponding author: Rose Anne C Illes, Florida State University Family Medicine Residency at Lee Memorial Health System, 2780 Cleveland Ave. Suite 709, Fort Myers, FL 33901, USA. Email: [email protected]
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Introduction Primary care physicians (PCPs) in the United States are increasingly responsible for delivering mental health interventions. Over half of the patients treated for a mental disorder in the United States receive that care in a primary care setting.1 General practitioners prescribe more than half of all psychotropic medications prescribed in the United States; more than double the number of psychiatrist prescriptions (59% and 23%, respectively).2 Furthermore, although patients with mental health diagnoses receive treatment from providers of multiple disciplines (psychiatrists, psychologists, etc.), the PCP is most commonly the sole provider of mental health treatment.3 It has been estimated that over 80% of patients with medically unexplained symptoms receive psychosocial treatment by a PCP, while roughly only 10% will follow up on a referral to a mental health provider that is not colocated or integrated into the primary care setting.4 Treatment of patients with mental disorders in primary care is particularly difficult given the combination of time constraints and the fact that patients with comorbid mental and physical illnesses report more somatic symptoms than those with chronic medical illness alone.5 The provider’s initial consideration to first address physical complaints often pushes mental health concerns down the priority list to be addressed at a later visit (which may never happen). Moreover, optimal treatment of mental health concerns can be impacted by various patient factors including access to resources, environmental stressors, and racial/ethnic/cultural worldview.6 Given these barriers, primary care practitioners-in-training must learn about the complex relationships between physical, somatic, and psychological problems, and how to address these with a culturally responsive approach.7 This article begins with an overview of health disparities and barriers to health care access, followed by a discussion of culturally responsive care and an illustrative example of a culturally responsive health care educational program directly targeting the problem of care access. It concludes with a discussion of educational imperatives and strategies for enhancing integrated culturally responsive behavioral and mental health care in primary care.
Health disparities In 2002, the Institute of Medicine published a groundbreaking report, Unequal Treatment, underscoring the devastating problem of health disparities in the United States.8 The authors conclude, ‘‘racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when accessrelated factors such as patient’s insurance status and income are controlled’’ (p. 1). The report cites disparity research from multiple areas of health care such as cardiovascular care, pain management, and diabetes care. More recently, the Agency for Health Research and Quality published the 2009 National Healthcare Disparities Report which underscores ongoing serious health deficits
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in minority communities in the areas of prenatal care, colorectal cancer screening, new AIDS cases, diabetes, and so forth.9 The successful elimination of disparities depends on a clear understanding of their etiological factors. The authors of Unequal Treatment write, ‘‘the sources of these disparities are rooted in historic and contemporary inequities and involve many participants at several levels including health systems, their administrative and bureaucratic processes, utilization managers, health care professionals, and patients’’ (p. 1). Through medical leadership, advocacy, and community interventions, practitioners can impact health inequity by addressing those causes embedded in health systems and social determinants of health. To do so, physicians must receive specialized training in medical school and residency. Fundamentally, practitioners must be actively engaged in practice styles that enhance the provision of respectful, culturally and linguistically responsive patient care. In fact, the Federal CLAS Standards (Culturally and Linguistically Appropriate Services)10 implore practitioners to do the important quality improvement work of assessing local outcomes by gender and ethnicity and to assess the quality of care delivered that is linguistically and culturally respectful, accessible, and appropriate. Health-care practitioners must learn the skills of communication in the context of the patient’s level of health literacy and be prepared to assess presenting problems from the patient’s worldview. It is incumbent upon medical educators to know and understand the nature and etiology of health disparities, to intentionally teach about them with regularity and consistency, and to ensure that medical students and resident physicians learn practice strategies for the elimination of such disparities.
Access barriers U.S. President Barack Obama signed the Affordable Care Act, commonly referred to as ‘‘Obamacare,’’ on 23 March 2010. Its purpose was comprehensive health care reform within the United States. It aims to expand insurance coverage, reduce the costs of health care, and lower the underinsured and uninsured rate by increasing access to health insurance. Access to care is a key factor in improved health status, particularly among underserved communities. Barriers to accessing mental health care in particular range from structural to attitudinal barriers compounded by other social and environmental barriers such as unemployment, transportation, cost, and practitioner/health system factors.11,12 Barriers lay in patient choices, physician practice, and in the system of care available.13,14 A more comprehensive illustration of potential patient and provider barriers to care is highlighted in Tables 1 to 3. Medical education has a particularly important role in helping learners develop critical thinking about health access. Learners must grapple with
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Table 1. Patient level barriers.11 Patients’ barriers to initiation/continuation of treatment Structural barriers Service hours Language barriers Financial (costs, insurance coverage) Availability of providers Distance to providers
Attitudinal/evaluative barriers Perception of need is low Perception of ineffectiveness Perception that treatment has ended Negative experience with providers Stigma (social rejection, devaluation, indirect stigma, self-stigma)
Transportation
Table 2. Other patient constraints.12,15 Belonging to a minority group, i.e. Black, Hispanic/Latino/a, Asian, or Lesbian, Gay, Bisexual, Transgender, Queer, or Intersex (LGBTQI) Struggling with a language barrier (i.e., Non-English speaking, deaf/hard of hearing) Being undocumented Having minimal education/work skills/job experience Having been in prison Experiencing intolerable/dangerous symptoms Being unemployed Experiencing isolation
Table 3. Provider level barriers.13,14 Provider barriers to inclusion of mental health and consideration of culture in treatment Psychological Knowledge overload Competing demands Cultural blindness Lack of self-confidence/ self-efficacy in treating mental health and with cultural issues Negative experiences with patients Burnout Stigma
Disease process Limited understanding of etiology/pathophysiology Ambiguity and broad range of symptoms/ conditions Constrained by training in medical model Lack of training in cultural competence
Systemic Time constraints Little incentive to address and treat Limited access to mental health providers/services Limited follow-up on measuring MH outcomes once treated
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self-reflection on attitudinal barriers, stereotypes, and behaviors that can unintentionally contribute to misunderstanding and rejection for people suffering from mental illness. Rejection or invisibility in health care will reinforce the distress of affected persons who have come to expect rejection and discrimination when accessing employment, housing, and other basic services.16 ‘‘The reduction of discrimination and stigma, inclusion, encouragement, and empowerment are as important to recovery from mental illnesses as are the specific treatments that are emerging from bioscience research.’’16 At the same time, physicians must be attentive and able to screen for and address psychological issues ranging from depression and anxiety to violence and trauma.
Culturally responsive care Culturally responsive care is the capacity to provide patient-centered care to patients despite differences in race/ethnicity, language, worldview, health beliefs, sexual orientation, religion, and a host of other individual, family, and social variables. Health-care practitioners must be educated and prepared to address cultural aspects of care delivery in a diverse society.17 As such, culture can be broadly defined as ‘‘integrated patterns of human behavior which include the language, thoughts, actions, customs, beliefs and institutions of racial, ethnic, social or religious groups.’’18 The impact of culture on the recognition of symptoms and behaviors related to illness is vital in health care.19 Empirical evidence has demonstrated that physical illness is impacted by emotional, social, and cultural factors.20 Medical education has been making important strides forward in providing a more focused curriculum to include cultural awareness, knowledge, and skills. ‘‘Culturally sensitive health care should be integrated into all educational activities including clinical activities, hospital rounds, precepting, videotaping, journal club, etc.’’19 The health-care professional must be educated to address cultural considerations effectively17 through training experiences focusing on attitudes (such as bias, stereotypes, empathy), knowledge (such as the ability to develop and assess hypotheses about cultural variables in health), skills of clinical practice (such as communication, effective work with interpreters), and skills of administrative practice (such as quality outcome studies stratified by ethnic group, gender, language, etc.).21 The Federal CLAS Standards further emphasize the essential requirements for optimal patient-centered culturally responsive health care delivery.10 With such movements to address culturally appropriate care, along with the current state of health disparities, it is incumbent upon medical education to integrate the clinical application of culturally responsive care into clinical training experiences. There are many strategies with which this can be done, from creating community outreach programs to activities within the curriculum itself.
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Overcoming access barriers: Case example Addressing access barriers is challenging, and effective models of care can take many creative forms. Figure 1 demonstrates an example of a model that is currently working to address barriers within an underserved community in the Midwest section of the United States. In this model, a community clinic is paired with a local high school to provide culturally and linguistically appropriate services to a Spanish-Speaking community of mostly immigrant students who are often marginalized from the predominantly wealthier community where they attend school. The program enhances visibility and promotes selfesteem for these students, provides them with tangible life and study skills, and opens a pathway to culturally responsive counseling resources at the mental health clinic. An integrated team of a social worker, a bilingual psychology graduate student, teachers, and a physician build a bridge for vulnerable students from the school community to the resources of the mental health clinic. This model can certainly be expanded as communities and health systems look to enhance services for vulnerable populations and to better integrate clinical services for both health and behavioral challenges in the lives of patients. For vulnerable communities such as in our example, these stressors include economics, legal problems, housing, transportation, racism and oppression, violence, and heightened risk for a number of health and substance use problems.
Figure 1. Successful program model. HS: public high school; MHA: local mental health agency; SW: social worker.
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To better understand the cultural viewpoints of their patients, learners should be encouraged to conduct a brief cultural ‘‘micro-assessment’’ within each encounter. This often takes the form of asking one or two questions regarding the patients’ cultural background, the role of culture in their life or illness, their experience of health care, or any other respectful extension of the clinician’s curiosity about the patient’s unique viewpoint. This method of multiple 60 - to 90-s conversations added together across multiple visits is more conducive to the time pressures of primary care than a single in-depth cultural assessment conversation.
Curriculum development At some point, educators and curriculum teams will have to grapple with the question of how best to teach culturally responsive health care. Will there be a longitudinal didactic curriculum? Will the skills be taught at bedside, in clinic precepting, and/or on rounds? How will learners be involved in tracking and evaluating their own learning? The U.S. Accreditation Council for Graduate Medical Education (ACGME) for residency training in family medicine requires that learners are constantly growing in their awareness of social determinants of health as well as embracing a whole-person approach to patient care.22 In 2013, the ACGME put forth Milestones for residency training in the United States. The Family Medicine Milestones including patient care, communication, professionalism, practice base learning and improvement, and medical knowledge are all areas with important cultural relevance. The patient care Milestone, for example, stated that resident physicians are expected to ‘‘identify the roles of behavior, social determinants of health, and genetics as factors in health promotion and disease prevention.’’22(p. 3) Ring et al.7 have elaborated and provided curricular guidelines on enhancing training of culturally responsive care in terms of awareness/attitudes, knowledge, and skills. Medical learners will benefit from specific tools and strategies for providing culturally responsive care. These strategies include relationship building, communication, culturally respectful assessment, attention to health literacy levels, and negotiating treatment plans. More frequently, primary care practitioners are building their skills in motivational interviewing23 and directly taking on behavior change within the context of the medical appointment, and/or collaborating in interdisciplinary teams as part of integrated health care.8,24 Arthur Kleinman et al.25 and Grieger26 provide key medical anthropology contributions to the development of medical education and practice in this arena. Kleinman et al.25 created a set of questions to elicit the patient’s perspective. Currently, this framework is used in medical education to aid the provider in obtaining knowledge of the beliefs the patient holds about an illness, the personal and social meaning attached to the illness/disorder, expectations about what will happen, and expectations about the provider’s role and own goals.
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This framework, published in the late 1970s, has only grown in its value and importance over the years. Another example of a framework, derived from the Multicultural Psychology literature, is the Cultural Assessment Framework by Ingrid Grieger.26 Her Cultural Assessment Interview Protocol includes questions to aid the provider in assessing the patient’s perspective on various sociocultural domains, along with expectations for treatment and outcomes. Frameworks or guidelines such as the ones described above are excellent guides for culturally responsive clinical assessment. Simultaneously, resident physicians and medical students must personally struggle with the challenges of conducting a culturally responsive assessment that considers both physical and mental health aspects of the patient in front of them. Educators have long struggled with how to encourage clinician-learners to gather information about patients’ cultural viewpoints while being cognizant of the other demands of primary care. One method is to encourage them to elaborate their own interviewing and communication style. Educators should resist the urge to provide complete assessment tools and instead provide a skeleton framework of strategies and guidelines. A learner’s self-development of a natural, personal culturally responsive interviewing strategy will more likely be remembered and implemented and be responsive to the patient’s health literacy levels.
Curriculum strategies Teaching culturally responsive care in residency training is challenging for several reasons. Learners can present as culturally naı¨ ve, lacking in self-awareness or self-reflective capacity, as dismissive, or perceive themselves to already hold sufficient knowledge and skill capacity. A systemic challenge often seen within U.S. society is ethnocentric monoculturalism, which is the individual, institutional, or societal expression of the superiority of one group’s cultural heritage over another’s.6 A clinician-learner displaying ethnocentric monoculturalism can prevent incorporation of the patient’s perspective into the treatment plan. As such, core components of training curricula must address how practitioner ethnic identity and awareness directly impact patient care. Moreover, the instructor–learner relationship begins to take on important parallels to the clinical relationship in terms of respect, communication, empathy, and encouragement. Clearly, every patient encounter and every teaching encounter is an interpersonal exchange that requires training, experience, supervision, and an opportunity for learner reflection and feedback.7 It is imperative for an educator to embrace a learner-centered approach and to meet the resident physician or medical student wherever they are along the developmental continuum, and to do so with warmth, encouragement, and explicit behavioral feedback. To push learners further than their capacity is to potentially cause distress and demoralization. To insufficiently challenge learners to
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grow is to do a disservice to their learning and to their future patient care. Educators must model empathic responding, attend to nonverbal behavior, and when conflicts arise, make efforts to gain understanding of what the conflict means on the road to negotiating solutions. When discussing barriers to culturally responsive physical and mental health care, it is imperative to start by asking oneself about one’s own experiences, such as assessing level of knowledge and awareness of the barriers that patients encounter when seeking mental health care. Moreover, an enlightened instructor must be self-aware of his or her own responses to the learner and cultural differences within the exchange and be able to navigate differences with confidence, openness, and maturity. It is useful to understand how emotions affect behavior or cognition in various situations, and resident physicians and medical students can learn specific skills and techniques to address various experiences with patients. Experiential teaching strategies lend themselves especially well to learning culturally responsive care. These activities can often provide a learner time to conceptualize patient concerns without the time constraints of the patient encounter. Such activities can include: autobiography/narrative selfreflection, the inclusion of the Implicit Association Test (IAT) (see below), video clips from popular culture to stimulate discussion, standardized patients, and role playing for skills learning. Autobiographies and narratives are useful in self-reflection not only for increasing personal awareness but also for a deepening understanding of the relationship between the provider and the patient, and the patient’s background. Learners require classroom opportunities to conceptualize patient concerns without the time pressure of live encounters. The IAT was developed by Project Implicit at Harvard University and is an online assessment of various areas of racism/bias.27 Learner IAT experience and debriefing can be very helpful components in working with cultural awareness/ attitudes. There are several different tests on implicit attitudes that are rated and can highlight one’s own views regarding bias. Similarly, video and role-plays creatively encourage learning about culturally responsive clinical and interpersonal skills for patient care.
Summary The United States is changing rapidly both in terms of diversity and health care delivery. The health-care system is shifting rapidly to address the new demands of a diverse patient population. To plan for these enhancements of health care delivery, the ACGME and the American Board of Family Medicine released a new standard for evaluating resident physicians and residency programs. Known as the Family Medicine Milestone Project, this set of 22 behaviorally anchored rating scales lists different levels of skills and behaviors that are desirable for resident physicians to display at various stages of their training. One such
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Milestone, PROF-3, measures to what extent the resident physician: ‘‘Demonstrates Humanism and Cultural Proficiency.’’22 As articulated by the ACGME, resident physicians must have the skills to communicate clearly and negotiate mutually agreeable treatment plans with their patients in a context of trust, respect, and capacity to navigate differences and conflicts.7 The role for medical educators is clear and essential. It becomes incumbent upon educators to understand the changing needs of society, be aware of their own biases, and acquire the skills necessary to deliver culturally responsive care. Doing so will begin to eliminate health disparities and cultivate true patient-centered care. Authors’ note This article is presented at the Forum for Behavioral Sciences in Family Medicine in Chicago, IL on 18–21 September 2014.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Russell L. Mental health care services in primary care: tackling the issues in the context of health care reform. Washington, DC: Center for American Progress, 2010. 2. Mark T, Levit K and Buck J. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv 2009; 60: 1167. 3. Wang PS, Demler O, Olfson M, et al. Changing profiles of service sectors used for mental health care in the United States. Am J Psychiatry 2006; 163: 1187–1198. 4. American Psychological Association. Briefing series on the role of psychology in health care: primary care, http://apa.org/health/briefs/index.aspx (accessed 5 December 2014). 5. Katon W, Lin EHB and Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 2007; 29: 147–155. 6. Sue DW and Sue D. Counseling the culturally diverse: theory and practice, 6th ed. Hoboken, NJ: John Wiley & Sons, 2013. 7. Ring JM, Nyquist JG, Mitchell S, et al. Curriculum for culturally responsive health care: the step by step guide for cultural competence training. Oxford, UK: Radcliffe Publishing, 2008. 8. Institute of Medicine of the National Academies. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press, http://www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-andEthnic-Disparities-in-Health-Care.aspx (2002, accessed 13 June 2015).
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9. Agency for Research and Health Care Quality. National healthcare disparities report. Rockville, MD: U.S. Department of Health and Human Services, http://www.canatx. org/CAN-Research/Reports/2008/nhdr08.pdf (2009, accessed 13 June 2015). 10. Office of Minority Health. National standards for culturally and linguistically appropriate services in health and health care, http://minorityhealth.hhs.gov/omh/browse. aspx?lvl¼2&lvlid¼53 (accessed 10 December 2014). 11. Mojtabai R, Olfson M, Sampson NA, et al. Barriers to mental health treatment: results from the national comorbidity survey replication. Psychol Med 2011; 41: 1751–1761. 12. Pescosolido BA, Martin JK, Long JS, et al. ‘‘A disease like any other’’? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. Am J Psychiatry 2010; 167: 1321–1330. 13. Cunningham PJ. Beyond parity: primary care physicians’ perspectives on access to mental health care. J Health Aff 2009; 28: 490–501. 14. Thielke S, Vannoy S and Unutzer J. Integrating mental health and primary care. Prim Care: Clin Off Pract 2007; 34: 571–592. 15. Corrigan P. How stigma interferes with mental health care. Am Psychol 2004; 59: 614–625. 16. Wahl OF. Stigma as a barrier to recovery from mental illness. Trends Cogn Sci 2012; 16: 9–10. 17. Association of American Medical Colleges. Cultural competence education, https:// www.aamc.org/download/54338/data/culturalcomped.pdf (2005, accessed 30 July 2014). 18. Ring JM. Psychology and medical education: collaborations for culturally responsive care. J Clin Psychol Med Settings 2009; 16: 120–126. 19. Like RC, Steiner RP and Rubel AJ. STFM core curriculum guidelines. Fam Med 1996; 28: 291–297. 20. Petersen S, Shrader G, Hutchings P, et al. Integrating health care: the clear advantage for underserved diverse populations. Psychol Serv 2011; 8: 69–81. 21. Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997; 19: 98–111. 22. Accreditation Council for Graduate Medical Education and American Board of Family Medicine. Family medicine mile stone project, http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf (2013, accessed 3 December 2014). 23. Poirier MK, Clark MM, Cerhan JH, et al. Teaching motivational interviewing to first-year medical students to improve counseling skills in health behavior change. Mayo Clin Proc 2004; 79: 327–331. 24. Sanchez K, Chapa T, Ybarra R, et al. Eliminating disparities through the integration of behavioral health and primary care services for racial and ethnic minorities, including populations with limited English proficiency: a review of the literature. U.S. Department of Health and Human Services, Office of Minority Health and the Hogg Foundation for Mental Health, 2012. 25. Kleinman A, Eisenberg L and Good B. Culture, illness, and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med 1978; 88: 251–258.
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26. Grieger I. A cultural assessment framework and interview protocol. In: Suzuki LA, Ponterotto JG (eds) Handbook of multicultural assessment: clinical, psychological and educational applications, 3rd ed. San Francisco, CA: Jossey-Bass, 2008, pp.132–161. 27. Harvard University. Implicit association test [Internet], https://implicit.harvard.edu/ implicit/ (2011, accessed 10 December 2014)
Culturally responsive integrated health care: Key issues for medical education
The International Journal of Psychiatry in Medicine 2015, Vol. 50(1) 92–103 ß The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0091217415592368 ijp.sagepub.com
Rose Anne C Illes1, Aaron J Grace2, Jose´ R Nin˜o3, and Jeffrey M Ring4
Abstract Primary care providers are increasingly responsible for providing mental health care in the United States. For those patients who do receive specialty mental health services, the primary care provider functions as the main entry point into the mental health system. Given the persistent racial and ethnic health disparities in the United States, it is not surprising that mental health disparities also present a difficult challenge for both the U.S. health system and for frontline practitioners. Physicians-in-training require tools for rapid psychiatric assessment that will quickly identify pertinent symptom clusters and distinguish between major psychological disorders. It is incumbent on residency faculty to teach resident physicians how to provide culturally responsive mental health assessment and intervention/referral knowledge and skills toward the elimination of these disparities and toward patient-centered care. This article begins with an overview of health disparities and barriers to health and mental health care access, followed by a discussion of culturally responsive care including an example of a culturally responsive educational program in the United States that is directly targeting the problem of access in that geographic region. It concludes with a review of educational strategies for enhancing culturally responsive behavioral and mental health care by physicians in training. Keywords Health care disparities, graduate medical education, culturally competent care 1
Florida State University Family Medicine Residency at Lee Memorial Health System, Fort Myers, FL, USA Medical College of Wisconsin, Milwaukee, WI, USA 3 Saints Mary and Elizabeth Medical Center, Chicago, IL, USA 4 Health Management Associates, Naples, FL, USA 2
Corresponding author: Rose Anne C Illes, Florida State University Family Medicine Residency at Lee Memorial Health System, 2780 Cleveland Ave. Suite 709, Fort Myers, FL 33901, USA. Email: [email protected]
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Introduction Primary care physicians (PCPs) in the United States are increasingly responsible for delivering mental health interventions. Over half of the patients treated for a mental disorder in the United States receive that care in a primary care setting.1 General practitioners prescribe more than half of all psychotropic medications prescribed in the United States; more than double the number of psychiatrist prescriptions (59% and 23%, respectively).2 Furthermore, although patients with mental health diagnoses receive treatment from providers of multiple disciplines (psychiatrists, psychologists, etc.), the PCP is most commonly the sole provider of mental health treatment.3 It has been estimated that over 80% of patients with medically unexplained symptoms receive psychosocial treatment by a PCP, while roughly only 10% will follow up on a referral to a mental health provider that is not colocated or integrated into the primary care setting.4 Treatment of patients with mental disorders in primary care is particularly difficult given the combination of time constraints and the fact that patients with comorbid mental and physical illnesses report more somatic symptoms than those with chronic medical illness alone.5 The provider’s initial consideration to first address physical complaints often pushes mental health concerns down the priority list to be addressed at a later visit (which may never happen). Moreover, optimal treatment of mental health concerns can be impacted by various patient factors including access to resources, environmental stressors, and racial/ethnic/cultural worldview.6 Given these barriers, primary care practitioners-in-training must learn about the complex relationships between physical, somatic, and psychological problems, and how to address these with a culturally responsive approach.7 This article begins with an overview of health disparities and barriers to health care access, followed by a discussion of culturally responsive care and an illustrative example of a culturally responsive health care educational program directly targeting the problem of care access. It concludes with a discussion of educational imperatives and strategies for enhancing integrated culturally responsive behavioral and mental health care in primary care.
Health disparities In 2002, the Institute of Medicine published a groundbreaking report, Unequal Treatment, underscoring the devastating problem of health disparities in the United States.8 The authors conclude, ‘‘racial and ethnic minorities tend to receive a lower quality of health care than nonminorities, even when accessrelated factors such as patient’s insurance status and income are controlled’’ (p. 1). The report cites disparity research from multiple areas of health care such as cardiovascular care, pain management, and diabetes care. More recently, the Agency for Health Research and Quality published the 2009 National Healthcare Disparities Report which underscores ongoing serious health deficits
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in minority communities in the areas of prenatal care, colorectal cancer screening, new AIDS cases, diabetes, and so forth.9 The successful elimination of disparities depends on a clear understanding of their etiological factors. The authors of Unequal Treatment write, ‘‘the sources of these disparities are rooted in historic and contemporary inequities and involve many participants at several levels including health systems, their administrative and bureaucratic processes, utilization managers, health care professionals, and patients’’ (p. 1). Through medical leadership, advocacy, and community interventions, practitioners can impact health inequity by addressing those causes embedded in health systems and social determinants of health. To do so, physicians must receive specialized training in medical school and residency. Fundamentally, practitioners must be actively engaged in practice styles that enhance the provision of respectful, culturally and linguistically responsive patient care. In fact, the Federal CLAS Standards (Culturally and Linguistically Appropriate Services)10 implore practitioners to do the important quality improvement work of assessing local outcomes by gender and ethnicity and to assess the quality of care delivered that is linguistically and culturally respectful, accessible, and appropriate. Health-care practitioners must learn the skills of communication in the context of the patient’s level of health literacy and be prepared to assess presenting problems from the patient’s worldview. It is incumbent upon medical educators to know and understand the nature and etiology of health disparities, to intentionally teach about them with regularity and consistency, and to ensure that medical students and resident physicians learn practice strategies for the elimination of such disparities.
Access barriers U.S. President Barack Obama signed the Affordable Care Act, commonly referred to as ‘‘Obamacare,’’ on 23 March 2010. Its purpose was comprehensive health care reform within the United States. It aims to expand insurance coverage, reduce the costs of health care, and lower the underinsured and uninsured rate by increasing access to health insurance. Access to care is a key factor in improved health status, particularly among underserved communities. Barriers to accessing mental health care in particular range from structural to attitudinal barriers compounded by other social and environmental barriers such as unemployment, transportation, cost, and practitioner/health system factors.11,12 Barriers lay in patient choices, physician practice, and in the system of care available.13,14 A more comprehensive illustration of potential patient and provider barriers to care is highlighted in Tables 1 to 3. Medical education has a particularly important role in helping learners develop critical thinking about health access. Learners must grapple with
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Table 1. Patient level barriers.11 Patients’ barriers to initiation/continuation of treatment Structural barriers Service hours Language barriers Financial (costs, insurance coverage) Availability of providers Distance to providers
Attitudinal/evaluative barriers Perception of need is low Perception of ineffectiveness Perception that treatment has ended Negative experience with providers Stigma (social rejection, devaluation, indirect stigma, self-stigma)
Transportation
Table 2. Other patient constraints.12,15 Belonging to a minority group, i.e. Black, Hispanic/Latino/a, Asian, or Lesbian, Gay, Bisexual, Transgender, Queer, or Intersex (LGBTQI) Struggling with a language barrier (i.e., Non-English speaking, deaf/hard of hearing) Being undocumented Having minimal education/work skills/job experience Having been in prison Experiencing intolerable/dangerous symptoms Being unemployed Experiencing isolation
Table 3. Provider level barriers.13,14 Provider barriers to inclusion of mental health and consideration of culture in treatment Psychological Knowledge overload Competing demands Cultural blindness Lack of self-confidence/ self-efficacy in treating mental health and with cultural issues Negative experiences with patients Burnout Stigma
Disease process Limited understanding of etiology/pathophysiology Ambiguity and broad range of symptoms/ conditions Constrained by training in medical model Lack of training in cultural competence
Systemic Time constraints Little incentive to address and treat Limited access to mental health providers/services Limited follow-up on measuring MH outcomes once treated
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self-reflection on attitudinal barriers, stereotypes, and behaviors that can unintentionally contribute to misunderstanding and rejection for people suffering from mental illness. Rejection or invisibility in health care will reinforce the distress of affected persons who have come to expect rejection and discrimination when accessing employment, housing, and other basic services.16 ‘‘The reduction of discrimination and stigma, inclusion, encouragement, and empowerment are as important to recovery from mental illnesses as are the specific treatments that are emerging from bioscience research.’’16 At the same time, physicians must be attentive and able to screen for and address psychological issues ranging from depression and anxiety to violence and trauma.
Culturally responsive care Culturally responsive care is the capacity to provide patient-centered care to patients despite differences in race/ethnicity, language, worldview, health beliefs, sexual orientation, religion, and a host of other individual, family, and social variables. Health-care practitioners must be educated and prepared to address cultural aspects of care delivery in a diverse society.17 As such, culture can be broadly defined as ‘‘integrated patterns of human behavior which include the language, thoughts, actions, customs, beliefs and institutions of racial, ethnic, social or religious groups.’’18 The impact of culture on the recognition of symptoms and behaviors related to illness is vital in health care.19 Empirical evidence has demonstrated that physical illness is impacted by emotional, social, and cultural factors.20 Medical education has been making important strides forward in providing a more focused curriculum to include cultural awareness, knowledge, and skills. ‘‘Culturally sensitive health care should be integrated into all educational activities including clinical activities, hospital rounds, precepting, videotaping, journal club, etc.’’19 The health-care professional must be educated to address cultural considerations effectively17 through training experiences focusing on attitudes (such as bias, stereotypes, empathy), knowledge (such as the ability to develop and assess hypotheses about cultural variables in health), skills of clinical practice (such as communication, effective work with interpreters), and skills of administrative practice (such as quality outcome studies stratified by ethnic group, gender, language, etc.).21 The Federal CLAS Standards further emphasize the essential requirements for optimal patient-centered culturally responsive health care delivery.10 With such movements to address culturally appropriate care, along with the current state of health disparities, it is incumbent upon medical education to integrate the clinical application of culturally responsive care into clinical training experiences. There are many strategies with which this can be done, from creating community outreach programs to activities within the curriculum itself.
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Overcoming access barriers: Case example Addressing access barriers is challenging, and effective models of care can take many creative forms. Figure 1 demonstrates an example of a model that is currently working to address barriers within an underserved community in the Midwest section of the United States. In this model, a community clinic is paired with a local high school to provide culturally and linguistically appropriate services to a Spanish-Speaking community of mostly immigrant students who are often marginalized from the predominantly wealthier community where they attend school. The program enhances visibility and promotes selfesteem for these students, provides them with tangible life and study skills, and opens a pathway to culturally responsive counseling resources at the mental health clinic. An integrated team of a social worker, a bilingual psychology graduate student, teachers, and a physician build a bridge for vulnerable students from the school community to the resources of the mental health clinic. This model can certainly be expanded as communities and health systems look to enhance services for vulnerable populations and to better integrate clinical services for both health and behavioral challenges in the lives of patients. For vulnerable communities such as in our example, these stressors include economics, legal problems, housing, transportation, racism and oppression, violence, and heightened risk for a number of health and substance use problems.
Figure 1. Successful program model. HS: public high school; MHA: local mental health agency; SW: social worker.
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To better understand the cultural viewpoints of their patients, learners should be encouraged to conduct a brief cultural ‘‘micro-assessment’’ within each encounter. This often takes the form of asking one or two questions regarding the patients’ cultural background, the role of culture in their life or illness, their experience of health care, or any other respectful extension of the clinician’s curiosity about the patient’s unique viewpoint. This method of multiple 60 - to 90-s conversations added together across multiple visits is more conducive to the time pressures of primary care than a single in-depth cultural assessment conversation.
Curriculum development At some point, educators and curriculum teams will have to grapple with the question of how best to teach culturally responsive health care. Will there be a longitudinal didactic curriculum? Will the skills be taught at bedside, in clinic precepting, and/or on rounds? How will learners be involved in tracking and evaluating their own learning? The U.S. Accreditation Council for Graduate Medical Education (ACGME) for residency training in family medicine requires that learners are constantly growing in their awareness of social determinants of health as well as embracing a whole-person approach to patient care.22 In 2013, the ACGME put forth Milestones for residency training in the United States. The Family Medicine Milestones including patient care, communication, professionalism, practice base learning and improvement, and medical knowledge are all areas with important cultural relevance. The patient care Milestone, for example, stated that resident physicians are expected to ‘‘identify the roles of behavior, social determinants of health, and genetics as factors in health promotion and disease prevention.’’22(p. 3) Ring et al.7 have elaborated and provided curricular guidelines on enhancing training of culturally responsive care in terms of awareness/attitudes, knowledge, and skills. Medical learners will benefit from specific tools and strategies for providing culturally responsive care. These strategies include relationship building, communication, culturally respectful assessment, attention to health literacy levels, and negotiating treatment plans. More frequently, primary care practitioners are building their skills in motivational interviewing23 and directly taking on behavior change within the context of the medical appointment, and/or collaborating in interdisciplinary teams as part of integrated health care.8,24 Arthur Kleinman et al.25 and Grieger26 provide key medical anthropology contributions to the development of medical education and practice in this arena. Kleinman et al.25 created a set of questions to elicit the patient’s perspective. Currently, this framework is used in medical education to aid the provider in obtaining knowledge of the beliefs the patient holds about an illness, the personal and social meaning attached to the illness/disorder, expectations about what will happen, and expectations about the provider’s role and own goals.
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This framework, published in the late 1970s, has only grown in its value and importance over the years. Another example of a framework, derived from the Multicultural Psychology literature, is the Cultural Assessment Framework by Ingrid Grieger.26 Her Cultural Assessment Interview Protocol includes questions to aid the provider in assessing the patient’s perspective on various sociocultural domains, along with expectations for treatment and outcomes. Frameworks or guidelines such as the ones described above are excellent guides for culturally responsive clinical assessment. Simultaneously, resident physicians and medical students must personally struggle with the challenges of conducting a culturally responsive assessment that considers both physical and mental health aspects of the patient in front of them. Educators have long struggled with how to encourage clinician-learners to gather information about patients’ cultural viewpoints while being cognizant of the other demands of primary care. One method is to encourage them to elaborate their own interviewing and communication style. Educators should resist the urge to provide complete assessment tools and instead provide a skeleton framework of strategies and guidelines. A learner’s self-development of a natural, personal culturally responsive interviewing strategy will more likely be remembered and implemented and be responsive to the patient’s health literacy levels.
Curriculum strategies Teaching culturally responsive care in residency training is challenging for several reasons. Learners can present as culturally naı¨ ve, lacking in self-awareness or self-reflective capacity, as dismissive, or perceive themselves to already hold sufficient knowledge and skill capacity. A systemic challenge often seen within U.S. society is ethnocentric monoculturalism, which is the individual, institutional, or societal expression of the superiority of one group’s cultural heritage over another’s.6 A clinician-learner displaying ethnocentric monoculturalism can prevent incorporation of the patient’s perspective into the treatment plan. As such, core components of training curricula must address how practitioner ethnic identity and awareness directly impact patient care. Moreover, the instructor–learner relationship begins to take on important parallels to the clinical relationship in terms of respect, communication, empathy, and encouragement. Clearly, every patient encounter and every teaching encounter is an interpersonal exchange that requires training, experience, supervision, and an opportunity for learner reflection and feedback.7 It is imperative for an educator to embrace a learner-centered approach and to meet the resident physician or medical student wherever they are along the developmental continuum, and to do so with warmth, encouragement, and explicit behavioral feedback. To push learners further than their capacity is to potentially cause distress and demoralization. To insufficiently challenge learners to
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grow is to do a disservice to their learning and to their future patient care. Educators must model empathic responding, attend to nonverbal behavior, and when conflicts arise, make efforts to gain understanding of what the conflict means on the road to negotiating solutions. When discussing barriers to culturally responsive physical and mental health care, it is imperative to start by asking oneself about one’s own experiences, such as assessing level of knowledge and awareness of the barriers that patients encounter when seeking mental health care. Moreover, an enlightened instructor must be self-aware of his or her own responses to the learner and cultural differences within the exchange and be able to navigate differences with confidence, openness, and maturity. It is useful to understand how emotions affect behavior or cognition in various situations, and resident physicians and medical students can learn specific skills and techniques to address various experiences with patients. Experiential teaching strategies lend themselves especially well to learning culturally responsive care. These activities can often provide a learner time to conceptualize patient concerns without the time constraints of the patient encounter. Such activities can include: autobiography/narrative selfreflection, the inclusion of the Implicit Association Test (IAT) (see below), video clips from popular culture to stimulate discussion, standardized patients, and role playing for skills learning. Autobiographies and narratives are useful in self-reflection not only for increasing personal awareness but also for a deepening understanding of the relationship between the provider and the patient, and the patient’s background. Learners require classroom opportunities to conceptualize patient concerns without the time pressure of live encounters. The IAT was developed by Project Implicit at Harvard University and is an online assessment of various areas of racism/bias.27 Learner IAT experience and debriefing can be very helpful components in working with cultural awareness/ attitudes. There are several different tests on implicit attitudes that are rated and can highlight one’s own views regarding bias. Similarly, video and role-plays creatively encourage learning about culturally responsive clinical and interpersonal skills for patient care.
Summary The United States is changing rapidly both in terms of diversity and health care delivery. The health-care system is shifting rapidly to address the new demands of a diverse patient population. To plan for these enhancements of health care delivery, the ACGME and the American Board of Family Medicine released a new standard for evaluating resident physicians and residency programs. Known as the Family Medicine Milestone Project, this set of 22 behaviorally anchored rating scales lists different levels of skills and behaviors that are desirable for resident physicians to display at various stages of their training. One such
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Milestone, PROF-3, measures to what extent the resident physician: ‘‘Demonstrates Humanism and Cultural Proficiency.’’22 As articulated by the ACGME, resident physicians must have the skills to communicate clearly and negotiate mutually agreeable treatment plans with their patients in a context of trust, respect, and capacity to navigate differences and conflicts.7 The role for medical educators is clear and essential. It becomes incumbent upon educators to understand the changing needs of society, be aware of their own biases, and acquire the skills necessary to deliver culturally responsive care. Doing so will begin to eliminate health disparities and cultivate true patient-centered care. Authors’ note This article is presented at the Forum for Behavioral Sciences in Family Medicine in Chicago, IL on 18–21 September 2014.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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