Effectiveness of a Social Justice Curriculum Intervention on Cultural Competency among Internal Medicine Residents

doi:10.21203/rs.3.rs-3426316/v1

Download PDF

Research Article

Effectiveness of a Social Justice Curriculum Intervention on Cultural Competency among Internal Medicine Residents

https://doi.org/10.21203/rs.3.rs-3426316/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Introduction:

There is a nationwide need to include social justice topics in medical education to reduce health disparities of culturally diverse patients. Cultural competence acts as a link between cultural diversity and social justice to foster health equity among patients. We implemented a Social Justice in Medicine curriculum in the Internal Medicine residency program to prepare cultural competencies for social justice among residents. We sought to investigate the impact of curriculum implementation on residents' cultural competency.

Methods

The social justice in medicine included a variety of educational strategies including online curriculum modules, immersive clinical experiences in continuity clinics, community engagement, a lecture series (Social Determinants of Health, social injustices, resident activism etc.), and the use of reflective practices (bias assessments, group discussions). We conducted a pre-post quasi-experimental study to evaluate the effect of implementation of an educational intervention on competency as measured by the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals - Revised, a 25-item 4-point Likert scale. This instrument assesses cultural awareness, knowledge, skill, encounters, and desire. The effect size was summarized with mean difference (MD) and 95% confidence interval (CI).

Results

A total of 40 residents participated in the study. Overall 11.7% relative improvement in cultural competency was observed following the intervention (MD = 7.7; 95%CI: 4.72, 10.68, p < 0.001). The intervention improved all the domains of competency including awareness (MD = 0.93; 95%CI: -0.02, 1.87), p = 0.05), knowledge (MD = 2.20; 95%CI: 1.33, 3.07, p < 0.001), skill (MD = 1.90; 95%CI: 1.12, 2.68, p < 0.001), encounters (MD = 1.10; 95%CI: 0.23, 1.97, p = 0.014), and desire (MD = 1.58; 95%CI: 0.80, 2.35, p < 0.001).

Conclusions

The implementation of social justice in medicine curriculum improved the cultural competencies among internal medicine residents in our study. Future longitudinal studies are required to investigate challenges, barriers, and modes of implementation strategies in a larger setting.

social justice

medical education

healthy equity

cultural competence

American Board of Internal Medicine's (ABIM) charter of professionalism details the promotion of social justice as a core principle of medicine that can be achieved by working to eliminate discrimination in healthcare. (1) Increasing physician cultural competency has a significant impact on promoting social justice in medicine. Social justice in medicine focuses on addressing systemic inequities and disparities in healthcare access and outcomes, with the goal of ensuring that all individuals have equal opportunities to achieve optimal health. (2) In medical education, cultural competence refers to the knowledge, attitudes, and skills that enable healthcare professionals to communicate with and understand their patient's culturally diverse health beliefs and practices. (2, 3) When healthcare providers possess cultural competency, they can better understand and respond to the diverse needs and experiences of their patients, particularly those from marginalized and underserved communities. This, in turn, leads to more equitable healthcare practices and improved health outcomes. The Institute of Medicine report titled Unequal Treatment recommended that all healthcare professionals receive training in cultural competence in order to promote social justice and decrease racial or ethnic disparities in healthcare. (4) However, the integration of a social justice in medicine curriculum and its effects through a designed study is not evaluated in any US schools. Moreover, the healthcare system located in underserved and border regions presents a unique set of challenges with limited healthcare access in the community as a result of the constant flow of migrants. A greater understanding of social injustices in medicine and approaches to overcome these challenges would help residents serve our communities better. The mission of the Social Justice Curriculum is to train and prepare the next generation of clinicians committed to caring for disadvantaged and vulnerable populations. Therefore, we implemented a Social Justice in Medicine curriculum to prepare culturally competent residents committed to social justice. The purpose of this study was to assess the effectiveness of social justice instruction on cultural competency among Internal Medicine residents in one academic year.

Study design: We developed and implemented a social justice curriculum in the internal medicine residency program at Texas Tech University Health Sciences Center El Paso. The TTUHSC El Paso is the primary tertiary care center located on the US-Mexico border. There is no academic medical institution in a radius of 300 miles which poses unique challenges for social justice in medicine. This study employed a pre-posttest quasi-experimental design to examine the changes in the cultural competency levels among Internal Medicine residents throughout a year-long curriculum. We invited all the 40 residents in the internal medicine to participate in this study.

Components of curriculum intervention: We established a curriculum focused on developing the cultural competence needed to address health inequities in the clinical setting. The social justice curriculum was developed based on multiple components focusing on improving knowledge of social aspects, community and inherent biases, interactions and engagement with the community, and ethical training and skill developments. Instructional methods included a broad structured learning curriculum through a dedicated speaker series, instructional modules, and community outreach.

Resident scholarly curriculum: Residents completed courses from the Institute of Healthcare Improvement (IHI) online curriculum on Introduction to Patient-Centered Care (PFC 101), Introduction to the Triple Aim for Populations (TA 101), and Improving Health Equity (TA 102).

Formal lectures: Another highlight of the curriculum included the Social Justice Speaker Series. Community, national, and international social justice in health champions discussed key topics of their expertise with residents throughout the academic year. Topics included the social determinants of health, social justice in the ICU setting, implicit bias training, the effect of government policies on health care, resident activism, etc. Reflective practices such as bias assessments and group discussions were used to create a more impactful curriculum.

Resident community outreach: Residents provided informational lectures to the community in Spanish and English on the management of common preventable ailments such as diabetes and hypertension. The aim was to further resident engagement with the community and foster relationships. The residents also volunteered their time once a week at Rota Care, the free walk-in clinic dedicated to serving patients without insurance or legal documentation. Additionally, the resident continuity clinic at Texas Tech provided regular opportunities to learn about and actively combat the health disparities faced by uninsured and undocumented patients.

Satisfaction survey and feedback: After each formal lecture, residents were asked to provide feedback on the speaker and their learning experience through a survey.

Outcome assessment: We used the paper version of the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals - Revised (IAPCC-R) developed by Dr. Josepha Campinha-Bacote. The IAPCC-R is a validated self-assessment tool specifically designed for healthcare professionals and graduate students in allied health fields. It comprises 25 questions that effectively measure five essential cultural constructs: desire, awareness, knowledge, skill, and encounters. Each question is scored using a 4-point Likert scale, resulting in a range of scores from 25 to 100. The Q1-Q25 groped into different domains is included in a Supplementary Table 1. These scores indicate the level of cultural proficiency, cultural competence, cultural awareness, or cultural incompetence exhibited by the healthcare professional. Notably, higher scores signify a greater level of cultural competence. (5)

Statistical analysis: We computed the overall competency scores and the individual construct scores as per the specified instructions at baseline and post-intervention. The scores data were described with mean and standard deviation (SD) while categorized data were presented with frequency and percentages. The pre-post comparisons of the total score and each construct score were carried out using a two-sided paired t-test. We summarized the effect size using the mean differences (MD) in each score along with a 95% confidence interval (CI). In addition, we also computed relative percent improvements at post-intervention by subtracting post to pre-intervention scores and dividing by the pre-intervention score for each construct and overall score separately. We further validated findings by removing subject data with missing observations. We also compared the proficiency level on each question between pre and post-intervention using a McNemar’s test to determine which specific question might be critical for improvements. The satisfaction and feedback survey was summarized with descriptive statistics using frequency and percentages. P-values less than 5% were considered statistically significant results. All the statistical analyses were conducted using STATA 17.1.

A total of 40 residents including 23 males and 17 females were included in this study. All residents completed all the questions in the competency instrument except for a few questions. Overall 11.7% relative improvement in cultural competency was observed following the intervention (MD = 7.7; 95%CI: 4.72, 10.68, p < 0.001). The intervention improved all the constructs of competency including awareness (MD = 0.93; 95%CI: -0.02, 1.87, p = 0.05), knowledge (MD = 2.20; 95%CI: 1.33, 3.07, p < 0.001), skill (MD = 1.90; 95%CI: 1.12, 2.68, p < 0.001), encounters (MD = 1.10; 95%CI: 0.23, 1.97, p = 0.014), and desire (MD = 1.58; 95%CI: 0.80, 2.35, p < 0.001). The highest improvement was noticed in knowledge (19.7%) followed by cultural skills (16.7%), cultural desire (11.1%), and cultural encounters (9.4%). The least improvement was in cultural awareness (Supplementary Table 1). The results were unchanged in the sensitivity analysis after removing the missing data (Supplementary Table 1). The competent and proficient levels were found to be significantly higher in post-intervention compared to pre-intervention (75% vs. 35%, p < 0.01) (Fig. 1).

Among individual question analyses, two-thirds of cultural competency questions in the proficiency level showed a significant improvement after curriculum intervention. Questions 1, 2, 3, 15, and 18 from cultural awareness did not show any change in the proficiency level while questions 6, 8, 10, 11, and 12 in cultural knowledge, questions 5, 9, 20, 21, and 22 in cultural skill, and questions 4, 7, 13, 19, and 24 in cultural desire did not show significant improvements in the proficiency level (Supplementary Table 2). For some questions, the proficiency level post-intervention was greater than 70%, and for most questions, cultural desire post-intervention achieved a 70% or higher proficiency level (Supplementary Table 2).

Additionally, post-lecture, residents were asked to provide feedback through a survey, and the results revealed positive responses from the participants (Fig. 2). Out of those who responded, 44% strongly agreed that the lectures were useful, 62% strongly agreed that the lectures were engaging, 59% strongly agreed that the lectures were informative, and 63% strongly agreed that the lectures were empowering. These survey findings reflect the effectiveness of the intervention and its positive impact on the residents' perception of the lectures.

The results of the TTUHSC-EP Internal Medicine Residency Program’s Social Justice in Medicine curriculum showed a significant improvement in residents' cultural competency. The post-test scores indicated improvements in all domains including cultural awareness, knowledge, skill, and desire among residents. These findings suggest that the educational strategies, such as the immersive clinical experiences, community engagement, and lecture series, were effective in enhancing residents' cultural competency. This is a promising outcome, as culturally competent healthcare providers are better equipped to understand and address the unique healthcare needs of culturally diverse patients. Post-lecture resident satisfaction was high, indicating that residents valued the teaching and found it engaging, informative, and empowering. This curriculum contributes to the larger goal of reducing health inequities and improving healthcare outcomes for culturally diverse patient populations.

The nationwide push to include social justice topics in medical education to reduce health disparities of culturally diverse patients has been championed by many medical schools. Similar to our study, multiple academic institutions have established a social justice program. The Warren Alpert Medical School at Brown University offers multi-year scholarly concentration programs in advocacy, activism, and caring for underserved communities. (6) Harvard Medical School has a compulsory course in social medicine and global health, with additional elective courses and fieldwork opportunities. (7) The University of Michigan Medical School focuses on social justice through site visits, case discussions, projects, conferences, and an elective program in global health and disparities. (8) The University of New Mexico School of Medicine provides early community health immersion experiences, scholarly projects, and instruction in social justice-related issues. (9) The University of Vermont College of Medicine emphasizes integration and progression from learner to teacher, with competency-based evaluation and participation in public health projects. (10) Stanford School of Medicine has implemented a Social Justice and Health Equity Curriculum Thread to address anti-racist education and health equity, making it a permanent part of their curriculum. (11) Lastly, the Human Rights and Social Justice Scholars Program (HRSJ Scholars Program) at Mount Sinai School of Medicine pairs medical students with faculty mentors and allows them to engage in a social justice research project, working alongside community organizations. This program offers a comprehensive curriculum emphasizing health equity, human rights, and social justice. (12). In addition, some internal medicine residency programs adapted newly developed social justice/ health equity/ health advocacy curriculums. When present, they were often separate tracks that residents could opt to take such as the health equities track at the University of California San Francisco, Albert Einstein College of Medicine, University of Texas at Austin, University of Connecticut, etc. Only a handful of programs including Virginia Mason Franciscan (18) and Stony Brook (19) incorporated Social Justice and Health Equity topics into the curriculum for all internal medicine residents. However, these studies have not conducted an educational research study to assess their implementation strategies on any outcomes.

Like our study, several medical training programs have also explored the impact of social justice curricula and cultural competency training in medical education. Inspired by like-minded students at the Weill Cornell Medical College, Rockefeller University, and Memorial Sloan Kettering Tri-Institutional (Tri-I) MD-PhD Program, students from the Washington University School of Medicine Medical Scientist Training Program and the Tri-Institutional MD-PhD Program organized journal clubs focused on social justice and anti-racism. A total of 21 students were invited to participate, with 17 students attending at least one meeting. The students completed pre- and post-surveys using Google Forms to assess their perspectives on cultural competency, racism, comfort discussing race, systemic racism, history of racism in St. Louis, microaggressions, empowerment to combat racism, knowledge of Black pioneers in science and medicine, and dealing with microaggressions. The results demonstrated that even the 5-week curriculum, which employed an empowered leadership approach, positively impacted participants' perception of important subjects and equipped them with actionable steps to address these issues. (13)

Another study conducted by Ambrose et al. at the University of Hawai‘i John A. Burns School of Medicine (JABSOM) introduced the Social Justice Curriculum Program (SJCP) for medical students as an addition to the traditional biomedical curriculum. The SJCP had three components including self-directed learning and didactics, implementation and action, and self-reflection and personal growth. The participants identified areas that needed improvement in three dimensions: theoretical foundations in social justice (Didactics), SJ research and presentation (Implementation), and prior SJ experience (Foundations). Approximately one-third of the students were interested in focusing on developing SJ knowledge. In terms of preferred learning methods, group discussions, independent reading, and lectures were the most favored. Group discussions were particularly popular, chosen by 87% of participants. For implementation, community-based service and clinical experience were the preferred learning methods, with almost 95% of participants preferring community-based service to apply their learning. (14) Taking lessons from JABSOM, TTUHSC-EP prioritized community-based learning. Residents had weekly opportunities to volunteer at the free clinic in addition to organizing health advocacy camps at community events.

Similar to our study, The Geisel School of Medicine developed a comprehensive curriculum that includes 55 hours of content divided into classroom work and experiential learning. The curriculum emphasizes addressing health disparities, evaluating student competencies, and engaging in community outreach. (15) The group noted that while standard written exams are appropriate measures of student competency for some social justice concepts, competency in addressing social determinants of health disparities would be better evaluated by self-reflection sessions and presentations to peers and the community. (6) In addition to community outreach, the TTUHSC- EP curriculum also included an immersive self-reflection session followed by group discussions. These published studies at other medical training programs align with our social justice study findings, collectively highlighting the effectiveness of social justice curricula and cultural competency training in medical education. They underscore the importance of incorporating diverse educational strategies, such as didactic sessions, experiential learning, reflective practices, and community engagement, to enhance healthcare professionals' cultural competence and promote health equity among diverse patient populations.

While medical school education has worked to incorporate Social Justice topics into their curriculum, training during internal medicine residency is lacking. A survey of medicine residents in Canada revealed that while involvement in health advocacy was common during high school and undergraduate studies, 76% of residents reported no current engagement in advocacy activity. (16) Tulane University's internal medicine residency noted that their residents desired but lacked opportunities for training to become physician advocates and health equity champions. (17) To address this, the program developed an Advocacy and Leadership Track for a few interested residents every year. No objective metric was used to compute the success of the track; however, they noted that when resident tasks were action-oriented, attendance was greater than when meetings were simply educational. Resident physicians are well-positioned to be champions for vulnerable populations. A potential barrier to effectively engaging resident interest in social justice in medicine lies in the formidable challenges posed by demanding resident schedules and the increasing appeal of fellowship training programs, which may divert their attention toward research for fellowship applications. In order to address this issue, TTUHSC-EP internal medicine residency faculty encouraged residents to develop research ideas aligned with their chosen specialties while also incorporating the crucial aspect of health equity. Residents have formulated various quality improvement (QI) projects that seamlessly integrate their fellowship interests with the promotion of health equity and social justice.

Limitations

One of the main limitations of our study is its quasi-experimental design. In addition, we did not collect background information on residents to explain heterogeneity in the findings. It should be noted that our curriculum was designed with consideration for the characteristics of its internal medicine residents and may not easily apply to all medical trainees. We did not assess the long-term improvements in the competency outcomes. Moreover, the long-term sustainability and adaptability of our intervention strategy in different residency programs were also not evaluated in our study. Future expansion for comparing efforts at other residency programs may lead to institutional-level improvements. Collaborative efforts between faculty members and institutional support are crucial, especially for smaller residency programs with limited resources. To ensure the success and longevity of the program, student leadership and peer mentoring are vital components that require effective communication and planning between students and the institution. Involving community partners not only fosters mutual accountability but also facilitates knowledge exchange, strengthening the curriculum's effectiveness. One of the major strengths of our study is the multifaceted components of intervention including knowledge improvement, bias reduction, community engagement, ethics, and skill development. In addition to the comprehensiveness of our program, structure and the length of our educational program yielded robust outcomes. Our intervention program is useful for particularly underserved regions.

Conclusions

The implementation of a multicomponent curriculum on social justice in medicine improved the cultural competencies among internal medicine residents in our study. Overall, the residents were highly satisfied with the different components of our intervention program. The study demonstrates a proactive effort to equip healthcare professionals with the essential knowledge, skills, and attitudes needed to tackle health disparities and enhance healthcare outcomes for diverse patients. Our culturally appropriate social justice curriculum needs to be promoted in other residency programs and schools to improve the quality of health care. Future longitudinal studies are required to investigate challenges, barriers, and modes of implementation strategies in a larger setting with larger sample sizes.

Ethics approval and consent to participate- TTUHSC El Paso IRB number E23006. The IRB acknowledged that this project meets the criteria for exemption from formal IRB review in accordance with 45 CFR 46.104(d). All experimental protocols were reviewed and approved for exemption by the TTUHSC El Paso IRB Committee. Informed consent was obtained from all subjects.

Consent for publication- Not applicable

Availability of data and materials-

The datasets generated and/or analyzed during the current study are not publicly available per compliance with IRB regulations but are available from the corresponding author on reasonable request. All extracted data was recorded in a Microsoft Excel document with columns representing recorded variables and each row representing individual subjects. Any identifier, including the name of the subject, biographical information, etc. was not recorded in our master list. The excel file has been saved in the secured Texas Tech Computer of the PI. Paper surveys during the study have been kept in the secured and locked office of the PI.

Competing interests- The authors declare that they have no competing interests

Funding- This study was funded by the 2023 Internal Medicine SEED Grant by Texas Tech University El Paso.

Authors' contributions- BT and AM wrote the manuscript and conducted the literature review. DM, PH, AH, BE, and ADeoker developed the project idea and executed the curriculum. PH and A.Dwivedi analyzed and interpreted the patient data and assisted in manuscript development. A. Deoker critically reviewed and approved the article and is the article’s guarantor. All authors reviewed and approved of the whole manuscript.

Acknowledgments- Collaborating authors:

Bhavi Trivedi, Adriana Mares, Debabrata Mukherjee, Priya Harindranathan, Aimee Hechanova, Brian Edwards, Alok Dwivedi, Abhizith Deoker

Texas Tech University El Paso

4800 Alberta Avenue

El Paso, Texas 79905

Medical professionalism in the new millennium. A physician charter. Ann Intern Med. 2002;136(3):243. 10.7326/0003-4819-136-3-200202050-00012.
Schiff T, Rieth K. Projects in medical education: Social Justice in Medicine a rationale for an elective program as part of the medical education curriculum at John A. Burns School of Medicine. Hawaii J Med Public Health. 2012;71(4 Suppl 1):64–7. PMID: 22737646; PMCID: PMC3347740.
Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C, Jenckes MW, Feuerstein C, Bass EB, Powe NR, Cooper LA. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43(4):356–73. 10.1097/01.mlr.0000156861.58905.96. PMID: 15778639; PMCID: PMC3137284.
Betancourt JR, Green AR, Commentary. Linking cultural competence training to improved health outcomes: Perspectives from the field. Acad Med. 2010;85(4):583–5. 10.1097/acm.0b013e3181d2b2f3.
About The IAPCC-R. https://transculturalcare.net/iapcc-r/. Accessed October 9, 2023.
Caring for Underserved Communities, Warren Alpert Medical School. https://education.med.brown.edu/scholarly-concentrations-program/caring-underserved-communities. Accessed October 9, 2023.
Resources for Racial and Social Justice., Harvard Medical School. https://hms.harvard.edu/about-hms/campus-culture/diversity-inclusion/resources-racial-social-justice. Accessed October 9, 2023.
Diversity &. Health Equity Curricular Requirements and Opportunities, University of Michigan School of Medicine. https://medicine.umich.edu/medschool/education/md-program/curriculum/diversity-health-equity. Accessed October 9, 2023.
Race, Justice S. University of New Mexico https://ascas.unm.edu/academics/department/race-social-justice.html. Accessed October 9, 2023.
Vermont Medicine Magazine., Fostering Socially Conscious Clinicians. http://www.med.uvm.edu/vtmedicine/summer_2021/fostering_socially-conscious_clinicians. Accessed October 9, 2023.
Social Justice & Health Equity Curriculum Thread. https://med.stanford.edu/md/discovery-curriculum/social-justice-and-health-equity.html. Accessed October 9, 2023.
Mount Sinai Students Recognized for Social Justice Program in East Harlem - Icahn School of Medicine at Mount Sinai. http://www.mssm.edu/about-us/news-and-events/mount-sinai-students-recognized-for-social-justice-program-in-east-harlem. Accessed October 9, 2023.
Lemieux M, Chaturvedi S, Juarez Diaz E, Barbar L, Bui M, Isakov D, et al. The Time is now: Student-driven implementation of Social Justice and anti‐racism focused curricula in medical scientist training program education. FASEB BioAdvances. 2021;3(6):439–48. 10.1096/fba.2020-00112.
Ambrose AJ, Andaya JM, Yamada S, Maskarinec GG. Social justice in medical education: strengths and challenges of a student-driven social justice curriculum. Hawaii J Med Public Health. 2014;73(8):244–50. PMID: 25157325; PMCID: PMC4142578.
Coria A, McKelvey TG, Charlton P, Woodworth M, Lahey T. The design of a medical school social justice curriculum. Acad Med. 2013;88(10):1442-9. 10.1097/ACM.0b013e3182a325be. PMID: 23969356.
Stafford S, Sedlak T, Fok MC, Wong RY. Evaluation of resident attitudes and self-reported competencies in health advocacy. BMC Med Educ. 2010;10:82. 10.1186/1472-6920-10-82. PMID: 21087495; PMCID: PMC2999597.
Andrews J, Jones C, Tetrault J, Coontz K. Advocacy training for residents: Insights from Tulane’s Internal Medicine Residency Program. Acad Med. 2019;94(2):204–7. 10.1097/acm.0000000000002500.
Virginia Mason Franciscan Health Social Justice Curriculum. https://www.vmfh.org/residencies-fellowships-and-training/post-graduate-residency-programs/internal-medicine-residency/social-justice-curriculum. Accessed October 9, 2023.
Social Justice and Health Equity Education. https://renaissance.stonybrookmedicine.edu/medicine/residency/curriculum/social_justice_health_equity. Accessed October 9, 2023.

No competing interests reported.

SupplementaryTables.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Effectiveness of a Social Justice Curriculum Intervention on Cultural Competency among Internal Medicine Residents

Status:

Version 1

Abstract

Introduction:

Methods

Results

Conclusions

Figures

Introduction

Methods

Results

Discussion

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1