cultural competence small- group reflection exerciseculturalmeded.stanford.edu/pdf...

Cultural Competence

Small- Group Reflection Exercise:

Increasing Awareness of Cultural Stereotypes

FACILITATORS GUIDE With Instructions

Christopher N. DeGannes, M.D., FACP Assistant Professor, Howard University College of Medicine, General Internal

Medicine Kamilah Woodson-Coke, Ph.D.

Assistant Professor, Howard University School of Nursing Tanya Bender Henderson, Ph. D.

Assistant Professor, Howard University School of Business, Marketing Kathy Sanders-Phillips, Ph.D.

Professor, Howard University College of Medicine, Pediatrics

Acknowledgements: This project was supported in part by a grant award from the National Institutes of Health (NIH), National Heart, Lung and Blood Institute, K07 HL-04-012. The authors

gratefully acknowledge the assistance of Andrea King in preparation of this manual.

Small Group Reflection Exercise: Increasing Awareness of Cultural Stereotypes

DeGannes CN, Woodson-Coke K, Henderson T, Sanders-Phillips K. 2

TABLE OF CONTENTS Goals and Specific Learning Objectives 3 Introduction 4 Purpose 4 Background 4 Rationale 4 Description 4 Feedback 5 Outline and Small Group Exercise Instructions 6 Small Group Exercise Details 8 Length of Time, Group Size, Number of Facilitators 8 Required Materials 8 Options 8 References 9 Appendix A. Group Headers for Posters (formatted for printing) 11



GOALS & OBJECTIVES GOALS:

1. That healthcare providers will increase their awareness of unconscious

cultural stereotypes.

2. That healthcare providers will increase their awareness of the impact of unconscious cultural stereotypes on patient care.

3. That healthcare providers will reduce the influence of unconscious cultural stereotypes on medical decision-making.

SPECIFIC LEARNING OBJECTIVES:

1. By the end of the reflection exercise, each participant will agree that he/she is more aware of unconscious cultural stereotypes.

2. By the end of the reflection exercise, each participant will agree that he/she

is more aware of the potential impact of unconscious stereotypes on patient care.

3. By the end of the reflection exercise, each participant will agree that he/she

is more aware of the influence of unconscious stereotypes on medical decision-making.



INTRODUCTION I. PURPOSE The purpose of the Small Group Reflection Exercise is to increase the awareness of unconscious stereotypes, and the negative impact of such stereotypes on the quality of healthcare provided. II. BACKGROUND Racial and ethnic disparities in health and healthcare exist in the U.S.2 There is a robust literature demonstrating that racial and ethnic minorities have lower life expectancy, fewer years of health life, increased rates of death from preventable diseases, and overall poorer indicators of health.2-8 Additionally, minority groups have decreased access to healthcare unrelated to insurance status, and are less likely to be referred for routine screening tests or specialized procedures9-18 While these disparities primarily came to public attention following the IOM report “Unequal Treatment” in 2002, disparities in health and healthcare have been cited by the Surgeon General since as early as 1979.19-22 The causes of health disparities are complex and multi-level. Although, disparities in health and healthcare are somewhat ameliorated when socioeconomic status and level of education are controlled for, they are not eliminated and cannot be explained by these factors alone.22 Evidence suggests that conscious and unconscious stereotypes, biases, and assumptions made by healthcare providers play a significant role in the decreased referral rates for specialized care. Work by Schulman and colleagues demonstrated with videotaped simulated patients of differing gender, age, and race portraying a scripted case of chest pain, that African-American women were referred less for cardiac intervention than their white counterparts presenting with the same complaints.15 Similarly Ayanian’s group demonstrated that African-American patients with renal failure were referred less by their nephrologists for renal transplantation.16 When their nephrologists were asked their perception of the causes of the disparities in referral rates for renal transplantation, physicians responded “patient preference”.18 Yet evidence documents that African-American and White patients want renal transplantation at the same rates.17 These findings suggest that unconscious or conscious stereotypes, assumptions, or biases on the part of provider impact medical decision-making regarding referral for specialized care. III. RATIONALE Due to the findings that conscious and unconscious stereotypes play a significant role in contributing to racial and ethnic disparities in health and healthcare, several authorities recommend cultural competence training for healthcare providers.22-29 The first step in effective cultural competence training is increasing learners’ awareness of: racial and ethnic disparities; the presence of unconscious personal stereotypes, biases, and assumptions; and the impact of such stereotypes on healthcare delivery.31-33

IV. DESCRIPTION The following Small Group Reflection Exercise was developed from an exercise that is used in social science training programs,34,35 but is not known by the authors to be in use in the education of medical students, residents, or



physicians. The exercise is designed to increase participants’ awareness of unconscious stereotypes they might have about different cultural groups. Through self- and group reflection participants additionally become more aware of the potential influence of unconscious stereotypes on healthcare delivery. a. Group Discussion: The exercise begins with personal Introductions where participants are asked to introduce themselves by name and state their self-identified race, ethnicity, and culture. Following these opening Introductions, a Group Discussion of “what are race, ethnicity, and culture?” is stimulated. In groups of 10 to 15 students with 1 facilitator students are encouraged to discuss this question. To stimulate a more robust discussion, facilitators may opt to show a ‘trigger’ video such as the Robert Phillips section from the “Worlds Apart” series. Note: the use of a trigger video, or this particular video is NOT a required component of the exercise. b. Reflection Exercise: Following the Introductions and Group Discussion on race, participants are asked to write stereotypes they are aware of for various racial, cultural and ethnic groups on Post-it® notepads and then place these written stereotypes on posters with the names of these groups that are hung on the walls of the room. Note: it is recommended that posters be hung on the walls before the small group convenes. After completing this section each poster with the name of a different racial, cultural, or ethnic group will have several written stereotypes attached to it. Each participant is then assigned a poster(s) and is asked to read out loud the name of the racial, ethnic, or cultural group and the stereotypes attached to its poster. Participants may read 1 or several posters; however, it is recommended that all participants read at least 1 poster. After each poster is read out loud reflection begins. Participants are asked to reflect on:

1. Were any stereotypes posted on the groups that you identify with, or belong to?

2. Did you notice any stereotypes that you personally have for any of the groups posted?

3. Were positive as well as negative stereotypes posted? 4. How might positive stereotypes be problematic? 5. How did the experience of writing and hearing the stereotypes read aloud

feel? 6. How might these written stereotypes impact medical decision-making when

caring for persons of the represented groups? c. Group Discussion: Following a brief period of reflection, participants are invited to share their reflections with the group. d. Cool-Down Session: Participants are reminded of the purpose of the exercise: to increase their awareness of unconscious stereotypes and their potential influence on medical decision-making and healthcare delivery in an effort to ultimately reduce racial and ethnic disparities in health and healthcare. V. FEEDBACK



This exercise is an effective first step in any cultural competence curriculum. When conducted in multiple small group sessions with a total of 114 medical students, after completing the exercise 49% agreed and 44.7% strongly agreed (93.7% combined) that they were more aware of the influence that unconscious stereotypes and assumptions had on providing effective patient care.42 Additionally, after completing this exercise 41.7% agreed and 49% strongly agreed (90.7% combined) that they were more aware of stereotypes and assumptions they personally had or made about groups different from themselves.42



OUTLINE AND INSTRUCTIONS Note: all times listed are suggestions.

I. Trigger Video (optional): (15 min) a. Show the Robert Phillips video from the Words Apart series – or –

other b. See “Required Materials” on pg. 8 for ordering instructions

II. Introductions: (10 – 15 min) a. Have participants introduce themselves by name and state their

identity (self-identified): race, ethnicity, culture, bloodline, other

III. Open Group Discussion: (45 min) a. What are race, ethnicity, & culture? b. Participants may also share their impressions/reflections on the

Robert Phillips video, or other trigger video if shown.

IV. Break (optional): (5 min)

V. Reflection exercise: (60 min) a. Exercise:

i. Post signs of various groups on the walls. (see “Tips” below) ii. Participants think of stereotypes they personally hold, know

of, or have heard of for each group and write the stereotype on a Post-it.®

iii. Participants then walk around the room and stick the Post-it® note with the written stereotype(s) on the poster it relates to.

iv. Participants read the stereotypes placed on each poster aloud. Each participant should read 2 to 3 posters.

b. Discussion: i. How does hearing these stereotypes about each group make

you feel? ii. What is it like to hear these stereotypes about the group(s)

you identify with? iii. Were positive as well as negative stereotypes posted? iv. How might positive stereotypes be problematic?

c. Self-reflection: (5 – 10 min) i. Do you see any stereotypes of various groups posted that you

personally hold or believe? ii. Do you see any stereotypes of various groups that you wish

to comment on? iii. Participants are asked if anyone would like to share their

reflections with the group. Note: these reflections may be personal or shared within the group.

d. Discussion: i. How do (or might) these perceptions affect healthcare?

(Knowing that individuals within the group of participants present will be in positions of power as providers within the healthcare system.)

VI. Cool-Down Session



a. Participants are reminded of the purpose of the exercise, and allowed to share any last thoughts.

Tips: o Hang posters with group headings on the walls of the small-group room

before participants enter to begin the session. o It is helpful to recommend that students write the name of the group in the

lower right hand corner of the each Post-it® note to facilitate placement of the stereotype on the correct poster.

o When assigning participants to small groups it is recommend that these small groups deviate from any small group assignments used in other courses (anatomy lab, or other) or other areas of work to avoid potential sub-grouping within the small group discussion.

Suggested Group Headings for posters:

• Race/Ethnicity: 1. African-American 2. West Indian 3. African 4. White 5. Latino 6. Asian 7. Native American 8. East Indian 9. Arab 10. Middle Eastern

• Linguistic: 1. Non-English speaking

• Age: 1. Elderly

• Religion: 1. Jehovah Witness

• Religion (cont’d)

2. Muslim 3. Christian 4. Jewish 5. Scientologist 6. Hindu

• Insurance: 1. Medicaid 2. Private Insurance 3. No Insurance

• Gender: 1. Men 2. Women

• Sexual Preference: 1. Gay 2. Lesbian 3. Bisexual 4. Transgender

Note: total – 27 groups



DETAILS Length of time: 150 minutes Group size: 10 – 15 students Facilitator(s): 1 facilitator, no prior training necessary Note: the above details are recommended REQUIRED MATERIALS • Poster Board* (Post-it® flipchart pages, newsprint, or other)

o Used for poster background • Printer paper

o Used to print header with group title for each poster • Scotch Tape or Glue stick

o Used to affix group header to poster background • Notepads† (Post-it® pads)

o Used for students’ written stereotypes that will be placed on designated poster.

• Pens • “Worlds Apart” video series (optional)

o Order separately from Fanlight Productions; available at: http://www.fanlight.com/catalog/films/912_wa.php

OPTIONS: * - For a greater impact, you may choose to use posters with photos of persons and/or

images (maps, flags, cultural items, etc.) representative of each group. † - Post-it® notepads are preferred as they are self adhesive.



REFERENCES 1. Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum development for medical education, a

six-step approach. Baltimore: Johns Hopkins University Press, 1998. 2. National Institutes of Health. Addressing Health Disparities: The NIH program of Action. What

Are Health Disparities? Available at: http://healthdisparities.nih.gov/whatare.html. last accessed Sept. 25, 2006.

3. Arias E, Anderson RN, Hsiang-Ching K, et al. Deaths: Final data for 2001. National Vital Statistics Report, vol 52, No. 3. Hyattsville, Md: National Center for Health Statistics; 2003.

4. Erickson P, Wilson R, Shannon I. Years of health life. Healthy People 2000 Statistical Notes. Atlanta, Ga, and Hyattsville, Md: CDC, National Center for Health Statistics; 1997.

5. National Center for Health Statistics. Health, United States, 2003. Hyattsville, Md: NCHS; 2003. 6. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States,

2004. MMWR Morb Mortal Wkly Rep 2006;53(53):33. Available at: http://www.cdc.gov/mmwr/PDF/wk/mm5353.pdf. last accessed Sept. 25, 2006.

7. District of Columbia State Health Profile. State Center for Health Statistics Administration; DC Dept. of Health; 2003. Available at: http://app.doh.dc.gov/services/administration_offices/schs/pdf/SHPFinal.shtm. Last accessed Oct. 3, 2006.

8. National Center for Health Statistics. Health, United States, 2005 with Chartbook on Trends in the Health of Americans. Hyattsville, Md: 2005. Available at: http://www.cdc.gov/nchs/data/hus/hus05.pdf. last accessed Sept. 25, 2006.

9. Peterson ED, Shaw LK, DeLong ER, et al. Racial Variation in the Use of Coronary Revascularization Procedures. NEJM 1997;336:480-6.

10. Bach PB, Cramer LD, Warren JL, et al. Racial Differences in the Treatment of Early-Stage Lung Cancer. N Engl J Med 1999;341:1198-205.

11. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: Results from the HIV Cost and Services Utilization Study. JAMA 1999;281(24):2305-2315.

12. Schneider EC, Zaslavsky AM, Epstein AM. Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care. JAMA 2002;287:1288-1294.

13. Trivedi AN, Zaslavsky AM, Schneider EC et al. Trends in the Quality of Care and Racial Disparities in Medicare Managed Care. N Engl J Med 2005;353:692-700.

14. Ayanian JZ, Udvarhelyi IS, Gatsonis CA, et al. Racial Differences in the Use of Revascularization Procedures After Coronary Angiography. JAMA 1993;269:2642-6.

15. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med 1999;340:618-26.

16. Epstein AM, Ayanian JZ, Keogh JH, et al. Racial Disparities in Access to Renal Transplantation: Clinically appropriate or due to underuse or overuse. N Engl J Med 2000;343:1537-44.

17. Ayanian JZ, Cleary PD, Weissman JS, et al. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med 1999;341:1661-9.

18. Ayanian JZ, Cleary PD, Keogh JH, et al. Physicians’ beliefs about racial differences in referral for renal transplantation. Am J Kidney Dis 2004;43:350-7.

19. US Public Health Service, Office of the Surgeon. Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. DHEW (PHS) Publication No. 79-55071; 1979.

20. US Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: Dept. of Health and Human Services, DHHS (PHS) Publication No. 91-50212; 1991.

21. US Dept of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health, 2 vols. Washington, DC: Government Printing Office; 2000.

22. Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.

23. U.S. Dept. of Health and Human Services, OPHS, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC. 2001.

24. Missing Persons: Minorities in the Health Professions. A Report of the Sullivan Commission on Diversity in the Healthcare Workforce. The Sullivan Commission. 2004. Available at: http://www.aacn.nche.edu/Media/pdf/SullivanReport.pdf. last accessed Sept. 25, 2006.



25. American College of Physicians Position Paper. Racial and Ethnic Disparities in Health Care. Ann Intern Med. 2004;141:226-232.

26. Functions and Structure of a Medical School. Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Liaison Committee on Medical Education. 2006. Available at: http://www.lcme.org/functions2006june.pdf. last accessed Sept. 25, 2006.

27. Betancourt JR. Eliminating Racial and Ethnic Disparities in Health Care: What is the Role of Academic Medicine? Acad Med. 2006;81:788-792.

28. Brach C, Fraserirector I. Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model. Medical Care Research and Review. 2000;57(Suppl 1):181-217.

29. AAMC. Cultural Competence Education for Medical Students. AAMC, Washington, D.C. 2005. Available at: http://www.aamc.org/meded/tacct/culturalcomped.pdf. last accessed Sept. 25, 2006.

30. Lie D, Boker J, Cleveland E. Using the Tool for Assessing Cultural Competence Training (TACCT) to Measure Faculty and Medical Student Perceptions of Cultural Competence Instruction in the First Three Years of the Curriculum. Acad Med. 2006;81:557-564.

31. Betancourt JR. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med. 2003;78:560-9.

32. Tervalon M. Components of culture in health for medical students’ education. Acad Med. 2003;78:570-6.

33. Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588-94.

34. The Southern Poverty Law Center. Teaching Tolerance. Available at: http://www.tolerance.org/teach/magazine/index.jsp Accessed November 15, 2006.

35. Stay Connected. Promoting Understanding (Reducing Prejudice). Available at: http://www.aces.edu/teens/stayconnected/insessionactivities.htm Accessed November 15, 2006.

36. Culhane-Pera KA, et. al. A Curriculum for Multicultural Education in Family Medicine. Fam Med 1997;29:719-23.

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40. Pena Dolhun E, Munoz C, Grumback K. Cross-cultural education in U.S. medical schools: development of an assessment tool. Acad Med. 2003;78:615-22.

41. Crosson JC. et. al. Evaluating the Effect of Cultural Competency Training on Medical Student Attitudes. Fam Med 2004;36:199-203.

42. DeGannes CN, Woodson-Coke K, Henderson T, Sanders-Phillips K. Developing a Cultural Competence Curriculum Using Best Practices. Manuscript in preparation.



APPENDIX

A. Poster Headers (formatted for printing) i. Instructions for using formatted poster headers:

1. print pages with headers 2. fold in half and affix to poster background

African-American

West Indian

African

Latino

Native American

East Indian

Middle Eastern

Non-English Speaking

Jehovah Witness

Muslim

Christian

Jewish

Scientologist

Elderly

Medicaid

Private Insurance

No Insurance

Lesbian

Bisexual

Transgender

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