Qualitative Analysis of a Cultural Dexterity Program for Surgeons: Feasible, Impactful, and Necessary

Operating on A Bias: A Review of Cultural Competency Curricula in Surgical Residencies and a Call for Systemic Change

BACKGROUND

Several factors contribute to surgical outcome disparities, including structural racism and implicit bias. Research into how surgical residency programs intervene on Cultural Complications via education remains sparse. We review the literature for how surgical residency programs use education to combat staff and patient exposure to Cultural Complications.

METHODS

We searched PubMed, SCOPUS, and Google Scholar for curricula aimed at improving cultural competency in surgical residencies. OBGYN curricula were included. Non-US studies were excluded.

RESULTS

Studies were organized by intervention type: Didactic, Grand Rounds, and M&M. The most common interventions were Didactics, with Grand Rounds being the least common. Target measures improved anywhere from 20-88%.

CONCLUSIONS

The common types of cultural competency curricula are clear, and certain interventions show improvement in trainees' education. Scarcity of data on these curricula does not necessarily indicate their lack of existence but does suggest additional research is needed into curricular interventions and how they may address cultural complications.

Health Disparities Curricula in General Surgery Residency Programs: A Critical Scoping Review

INTRODUCTION

In 2021, the structural determinants of health (SDOH) were added to the Accreditation Council of Graduate Medical Education common program requirements for all accredited residency programs, including general surgery. In this study, we sought to explore the current scope of, and concepts used in, health disparities curricula for general surgery residents, specifically investigating how general surgery residents learn about health disparities and the SDOH.

METHODS

We searched PubMed, EMBASE, Education Research Complete (EBSCOhost), and Web of Science Core Collection using keywords related to health disparities and the SDOH. Inclusion criteria consisted of all studies published after 2005 that discussed health disparities curricula for Accreditation Council of Graduate Medical Education-accredited general surgery residency programs. Five thousand three hundred seventeen articles were screened using a two-phase process. Data extraction and analysis was performed using critical review methods.

RESULTS

Seventeen articles were identified. Within these articles, seven unique health disparities curricula were found. All seven of the identified curricula employed cultural frameworks as methods to mitigate health disparities. Three curricula, all published after 2011, included education on the SDOH. A wide variety of educational methods were utilized; in-person didactics was the most common.

CONCLUSIONS

In the current literature, culture continues to play a large role in health disparities training for general surgery residents. Though further efforts are needed to understand the methods used in programs that have not published scholarly work, it is imperative to ensure that residents are provided with the sociopolitical perspective needed to understand the SDOH and serve all patients, including those affected by health disparities.

Prevalence of and Barriers to Health Disparities Education Among Otolaryngology Residency Curricula

Objective

To assess the prevalence of health disparities curricula in otolaryngology residency programs and identify implementation barriers.

Study Design

Cross-sectional survey.

Setting

National otolaryngology residency programs.

Methods

A survey based on published literature discussing the incorporation of health disparities curricula, educational design, quality, barriers to implementation, and patient demographics was sent to US otolaryngology residency program directors (PDs). Otolaryngology programs excluded from consideration included those of osteopathic recognition, programs outside of the United States, and military programs. In excluding osteopathic, international, and military-based residency programs from our survey, we aimed to maintain sample homogeneity and focus our analysis on allopathic programs due to potential variations in demographic compositions and practice settings. This decision was made to ensure a more targeted examination of health disparities within a specific context, aligning with our research objectives and resource constraints. Anonymous survey results were collected and analyzed to determine the prevalence of health disparities curricula as well as their effectiveness and standardization across residency programs.

Results

A total of 24 PDs (response rate, 23%) responded to the survey. Half of the PDs reported having a health disparities curriculum, among whom only 25% felt the quality of their curriculum was very good or excellent. All institutions with an explicit health disparities educational program reported having developed their own curriculum, 75% of which changed annually. However, 92% of these programs reported not measuring outcomes to assess their curriculum's utility. The most reported barriers to curriculum development for all programs included insufficient time (63%), limited teaching ability specific to health disparities education (54%), and faculty disinterest in teaching (33%).

Conclusion

Very few of the surveyed otolaryngology residency programs have implemented a health disparities curriculum. A comprehensive and standardized health disparities curriculum would be beneficial to ensure that residents can confidently develop competency in health disparities, aligning with the Clinical Learning Environment Review mandate and Accreditation Council for Graduate Medical Education expectations.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

Educational Outcomes of Diversity Curricula in Graduate Medical Education

Background

Education is an important step toward achieving equity in health care. However, there is little published literature examining the educational outcomes of curricula for resident physicians focused on diversity, equity, and inclusion (DEI).

Objective

Our objective was to review the literature to assess the outcomes of curricula for resident physicians of all specialties focused on DEI in medical education and health care.

Methods

We applied a structured approach to conducting a scoping review of the medical education literature. Studies were included for final analysis if they described a specific curricular intervention and educational outcomes. Outcomes were characterized using the Kirkpatrick Model.

Results

Nineteen studies were included for final analysis. Publication dates ranged from 2000 to 2021. Internal medicine residents were the most studied. The number of learners ranged from 10 to 181. The majority of studies were from a single program. Educational methods ranged from online modules to single workshops to multiyear longitudinal curricula. Eight studies reported Level 1 outcomes, 7 studies reported Level 2 outcomes, 3 studies reported Level 3 outcomes, and only 1 study measured changes in patient perceptions due to the curricular intervention.

Conclusions

We found a small number of studies of curricular interventions for resident physicians that directly address DEI in medical education and health care. These interventions employed a wide array of educational methods, demonstrated feasibility, and were positively received by learners.

Cultural Competency Curricula in US Graduate Medical Education: A Scoping Review

BACKGROUND

Cultural competency training provides participants with knowledge and skills to improve cross-cultural communication and is required for all graduate medical education (GME) training programs.

OBJECTIVE

The authors sought to determine what cultural competency curricula exist specifically in GME.

METHODS

In April 2020, the authors performed a scoping review of the literature using a multidatabase (PubMed, Ovid, MedEdPORTAL) search strategy that included keywords relevant to GME and cultural competency. The authors extracted descriptive data about the structure, implementation, and analysis of cultural competency curricula and analyzed these data for trends.

RESULTS

Sixty-seven articles met criteria for inclusion, of which 61 (91%) were focused exclusively on residents. The most commonly included specialties were psychiatry (n=19, 28.4%), internal medicine (n=16, 23.9%), and pediatrics (n=15, 22.4%). The shortest intervention was a 30-minute online module, while the longest contained didactics, electives, and mentoring programs that spanned the entirety of residency training (4 years). The sample sizes of included studies ranged from 6 to 833 participants. Eight (11.9%) studies utilized OSCEs as assessment tools, while 17 (25.4%) conducted semi-structured interviews or focus groups. Four common themes were unique interventions, retention of learning, trainee evaluation of curricula, and resources required for implementation.

CONCLUSIONS

Wide variation exists in the design, implementation, and evaluation of cultural competency curricula for residents and fellows.

Healthcare Disparity Education for Surgical Residents: Progress Made, More Needed

BACKGROUND

Healthcare disparities are an important determinant of patient outcomes yet are not standardized within surgical resident education. This study aimed to determine the prevalence and design of current healthcare disparities curricula for surgical residents and included a resident-based needs assessment at a single institution.

STUDY DESIGN

A national survey evaluating the presence and design of healthcare disparities curricula was distributed to general surgery program directors via the Association of Program Directors in Surgery Listserv. A related survey was administered to all general surgery residents at a single academic institution.

RESULTS

One hundred forty-six program directors completed the survey, with 68 (47%) reporting an active curriculum. The most frequently taught topic is regarding patient race as a healthcare disparity, found in 63 (93%) of existing curricula. Fifty-two (76%) of the curricula were implemented within the last 3 years. Of the 78 (53%) programs without a curriculum, 8 (10%) program directors stated that their program would not benefit from one. Thirty-four (45%) of the programs without a curriculum cited institutional support and time as the most common barriers to implementation. Of the 23 residents who completed the survey, 100% desired learning practical knowledge regarding healthcare disparities relating to how race and socioeconomic status affect the clinical outcomes of surgical patients.

CONCLUSIONS

Less than half of general surgery training programs have implemented healthcare disparities curricula. Resident preferences for the format and content of curricula may help inform program leaders and lead to comprehensive national standards.

Language Proficiency and Survival in Pancreatic Cancer: a Propensity Score-Matched Analysis

BACKGROUND

Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC.

METHODS

A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status.

RESULTS

Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation.

CONCLUSIONS

In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.

Perceived Discrimination Among Surgical Residents at Academic Medical Centers

BACKGROUND

Residents of color experience microaggressions in the work environment, are less likely to feel that they fit into their training programs, and feel less comfortable asking for help. Discrimination has been documented among surgical residents, but has not been extensively studied and largely remains unaddressed. We sought to determine the extent of perceived discrimination among general surgery residents.

MATERIALS AND METHODS

Residents who were enrolled in a randomized controlled trial investigating a cultural dexterity curriculum completed baseline assessments prior to randomization that included demographic information and the Everyday Discrimination Scale (EDS). Data from the baseline assessments were analyzed for associations of EDS scores with race, ethnicity, sex, socioeconomic level, language ability, and training level.

RESULTS

Of 266 residents across seven residency programs, 145 (55%) were men. Racial breakdown was 157 (59%) White, 45 (17%) Asian, 30 (11%) Black, and 12 (5%) Multiracial. The median EDS score was seven (range: 0-36); 58 (22%) fell into the High EDS score group. Resident race, fluency in a language other than English, and median household income were significantly associated with EDS scores. When controlling for other sociodemographic factors, Black residents were 4.2 (95% CI 1.62-11.01, P = 0.003) times as likely to have High EDS scores than their White counterparts.

CONCLUSIONS

Black surgical residents experience high levels of perceived discrimination on a daily basis. Institutional leaders should be aware of these findings as they seek to cultivate a diverse surgical training environment.

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum

OBJECTIVE

Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum.

DESIGN, SETTING, AND PARTICIPANTS

Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method.

RESULTS

Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors.

CONCLUSIONS

Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.

Refusal of colorectal cancer surgery in the United States: Predictors and associated cancer-specific mortality in a Surveillance, Epidemiology, and End Results (SEER) cohort

Introduction

This study aims to understand patient factors associated with refusal of surgery for nonmetastatic colorectal cancer and the associated cancer-specific mortality.

Methods

Patients diagnosed with nonmetastatic colorectal cancer between 2004 and 2015 from the Surveillance, Epidemiology, and End Results Program were included.

Results

A total of 152,731 (99.4%) patients underwent surgery, and 983 (0.6%) refused surgery. Independent predictors of refusal included male sex, older age, minority race, single relationship status, being uninsured, more recent date of diagnosis, having an earlier stage of diagnosis, and rectal versus colon cancer. Refusing surgery for nonmetastatic colorectal cancer increased cancer-specific mortality (adjusted hazard ratio 5.10, 95% confidence interval 4.62–5.62).

Conclusion

Most patients diagnosed with nonmetastatic colorectal cancer undergo surgery in the United States. However, refusal of surgery is increasing and associated with higher cancer-specific mortality. A better understanding of surgical decision making in colorectal cancer is urgently needed.

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Most patients diagnosed with nonmetastatic colorectal cancer undergo curative surgery.

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Refusal of surgery for nonmetastatic colorectal cancer is increasing.

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Sociodemographic and clinical factors are independently associated with refusal of surgery.

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Patients who refuse surgery have an increased cancer-specific mortality.

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A better understanding of surgical decision making in colorectal cancer is needed.