Moving the Needle Forward in Health Disparities: An Education Initiative Moving the Needle Forward in Health Disparities: An Education Initiative Moving the Needle Forward in Health Disparities: An Education Initiative Project Summary Both trainees and medical staff at Mayo Clinic Arizona (MCA) have traditionally had remarkably limited exposure to underserved and/or vulnerable populations. Interwoven in this gap is a lack of understanding and appreciation of the impact of health disparities, social determinants, implicit bias and cultural humility of providers on patient health, healthcare seeking, trust in the healthcare system and willingness to participate in clinical trials. This health disparities initiative represents an innovative curricular program that aims to better prepare healthcare workers to deliver optimal care and develop patient rapport through a patient-centric approach to understand reflective of our societys rapidly shifting demographics. This, in turn, will provide trainees and staff the tools necessary to recruit these patients to important clinical trials. The disparities and equity-based curriculum will include quarterly didactic lectures, online interactive modules and group discussions. Curricular and clinical efforts are interdependent and ultimately will provide the didactic and hands-on context needed to fully understand issues related to health disparities and treating socially, economically and culturally diverse patients. This program will be initially piloted to oncology providers and trainees in Arizona with the goal of broadening the program to include all oncology providers including nurses and midlevel providers at the tri-site level. We anticipate that this curriculum will be easily adapted within a variety of graduate medical education programs and provide critical continuing education for all current medical- and study staff members. Specific project aims and objectives: Presently there is no formal training in healthcare disparities and equity, cultural humility, implicit bias or social determinants of health at the GME level or the CME level for medical and research staff at MCA. This area of study has become increasingly important in our era of healthcare delivery and is vastly under-recognized and under-appreciated. By contrast, the Mayo Clinic School of Medicine (MCSoM) has recognized the value in conveying this content knowledge to their medical students, formally designating these topics as mandatory curricular offerings. As part of MCSoMs partnership with Arizona State Universitys (ASU) College of Health Solutions, students are required to complete an 18-credit Certificate in the Science of Health Care Delivery program that includes coursework covering the social determinants of health, health disparities, health policy, and the role of physician leadership and advocacy to increase health equity. Notably, the program now also includes a course covering unconscious bias, which has recently been integrated into the Liaison Committee on Medical Education (LCME) accreditation standards. Much of this content has been iteratively co-developed and delivered in the medical school classroom over the past two years at the MCSoM Arizona campus by ASUs Professor Swapna Reddy, JD, MPH. Beyond these curricular offerings, all MCSoM faculty and students are also required to read Blindspot: Hidden Biases of Good People and complete the Implicit Association Test (IAT) prior to the first day of medical school. In this way, MCSoM has demonstrated a commitment toward improving disparities based content in medical education, developing the core health equity competencies of both students and faculty and becoming a national leader in preparing future physicians to tackle some of these difficult issues. Unfortunately, this curriculum has not translated into the educational programs offered to our oncology investigators and staff (nor other post-graduate GME training) and, as such, a vital portion of education and clinical development are missing. Many of our cancer center staff practice in or interact with communities of need from a wide array of socioeconomic and culturally diverse backgrounds. The ability to understand patients socioeconomic and cultural backgrounds, health literacy and other social determinants that impact their health will be vital for our trainees and staff to be able to give compassionate, comprehensive care to all patients as well as to establish relationships and rapport with patients to be able to recruit them into available studies. Aim 1 To establish a curriculum to provide oncology providers, trainees and allied medical/research staff with a foundational understanding of disparities in health and health care delivery, social determinants of health, implicit bias and cultural humility. Aim 2 To deliver a multi-modality curriculum through the use of quarterly didactic in-person lectures, online modules, group discussions and problem-based learning activities. Aim 3 To evaluate the efficacy and impact of the curriculum through the use of pre- and post- validated measures of specific clinical and personal competencies as well as online module assessments. Objectives: 1. To better understand the social, economic and systemic factors that contribute to health inequity in the U.S and locally; 2. To identify how the lack of cultural humility and biases exacerbate disparities for vulnerable patient populations; 3. To demonstrate improved physician leadership skills; 4. To demonstrate improved cultural humility after having the opportunity to work with patients from different backgrounds; 5. To develop skills that improve quality and patient centered care. By way of these three Aims, this project effectively moves the needle forward on both health equity and GME/CME for Mayo Clinic Cancer Center providers, trainees and allied medical/research staff. Significance of project: Despite advances in medical science and education in the United States, significant health disparities persist. Social determinants of health including socioeconomic status, insurance coverage, access to care, language, health literacy, social capital, and trust in health systems play a significant role in the health outcomes of communities.1 In an attempt to make a significant impact in health equity, it is vital to understand how these determinants impact patients lives and contribute to their health. Additionally, physicians themselves must recognize and confront their own biases and need for cultural humility, not only to meet the social mission of medicine, but also in an effort to elevate the quality and responsiveness of care.2 This initiative is critical for the education of medical staff providers, trainees and research staff at Mayo Clinic Cancer Center as it represents an innovative opportunity to gain both clinical and curricular education in an effort to better prepare them to provide high quality, patient-centered care and form relationships necessary for study recruitment. Description of the project: A multi-platform, case-based curriculum will be formatted whereby online modules and in-person lectures will be delivered on the topics of health- and healthcare disparities, cultural humility, implicit bias and social determinants of health. Online modules will include multimedia tools such as interactive videos, lectures and assessments. In-person lectures will utilize didactic presentations, use of selected sections of the novel Blind Spot, group discussions and problem-based learning activities. This curriculum will be leveraging successful similar educational programs in medical education both at the Mayo Clinic School of Medicine and at a national level in medical education .3-5 Specifically, the content delivery would include four (4) quarterly iterative curricular sections that would include A.) a one hour lunch time interactive discussion and B.) a correlative case based multimedia online module. Topics for each section are: Quarter Topic General Description 1 Social Determinants of Health What are social determinants of health? How do they impact the lives of patients and communities? How do they impact health outcomes? Why is it important for health care providers, researchers and systems to understand the social determinants of underrepresented communities? How can a deeper understanding of social determinants aid in recruitment and participation of underrepresented communities in clinical trials? Arizona-Based Case Study illustration. 2 Cultural Competency & Humility What is cultural competency? What is cultural humility? What are the roles of each in the context of interacting with underrepresented communities? How do each impact the relationship between patient/community member and provider/researcher? How can improving cultural competency and humility build, improve and sustain trust between patients/community members and the scientific community? How can a deeper understanding of cultural competency and humility aid in the recruitment and participation of underrepresented communities in clinical trials? Arizona-Based Case Study 3 Health Literacy What is health literacy? How does the concept impact patients and communities? How can health care providers/researchers/systems work with patients/community members to improve health literacy? How can a deeper understanding of health literacy aid in the recruitment and participation of underrepresented communities in clinical trials? U.S. Based Case Study 4 Unconscious Bias in Health Care What is unconscious bias? How does it differ from explicit bias? What is the impact of unconscious bias on patient outcomes, scientific research, providers and health systems? Effective interventions for unconscious bias in health care. How can a deeper understanding of unconscious bias aid in the recruitment and participation of underrepresented communities in clinical trials? IAT Administration U.S. Based Case Study Online Modules: The online modules will include multimedia tools such as interactive videos, lectures and assessments. Online modules are intended to complement the in-person presentations and offer learners the opportunity to gain a deeper understanding of each of the quarterly topics. To this end, each module will include: at least 2 "thought piece" topical articles, 1-2 short topical videos (news pieces, short documentary clips or recorded faculty discussions) to review, and a multiple choice quiz. All curricula components will, whenever possible, use cancer-related examples of disparities in health and screening. The overall online platform should include an optional discussion board on which learners can regularly post comments, articles, relevant current event clips, local lecture series, etc. for those interested to continue engagement throughout the four quarters. Modules will be managed by Professor Reddy and her study manager. Modules will be delivered using Blackboard which is currently in use by the MCSoM. Literature supports that infusing this type of curriculum in the education of future health care providers leads to an improved patient-physician relationship, and consequently improved patient outcomes.6 The AMA has most recently attempted to recognize and address unconscious personal biases through a similarly-structured GME Competency Education Program. This program has worked to help physicians not only acknowledge their own susceptibility to implicit biases, but also practice evidence-based perspective-taking techniques through interactive modules. Development of a physicians cultural humility and management of biases are indispensable tools with which emerging education programs seek to equip the emerging workforce.6 Audience: This curriculum will be widely available and applicable to all Cancer Center staff including GME trainees, medical and research staff. Specifically, all physicians, trainees and staff involved in MCCC clinical trials including consultant oncologists, radiation oncologists and consultants and trainees in medical, radiation and surgical oncology and gastroenterology will be recommended to participate in this program. These lectures will be recorded and also be available to those unable to attend in person using video-conferencing. This will be piloted at the Arizona campus and thereafter if successful can be made available to trainees and staff at all three Mayo Clinic Cancer Center sites as well as could be made available to other institutions to facilitate their GME/CME curricula in healthcare disparities. Anticipated Outcomes: We expect participants to demonstrate an improved understanding of the factors that contribute to inequity in our healthcare system and to gain the tools necessary to address and overcome these factors with patients both as patient advocates and physician leaders. All graduates of the program, those who successfully participate in all in-person/remote and online module offerings, will earn a Certificate in Health Care Disparities created and distributed by ASU College of Health Solutions. Significance to Mayo Clinics Educational Mission: As discussed above, we are committed to providing both trainees and staff with the highest level of training which will culminate in them becoming excellent clinical providers. We have identified a significant gap in both training and CME for both medical and research staff which, if filled, would round out their overall experiences and help them to be better providers. There is a significant portion of our population to whom our providers have minimal exposure on a routine basis and, hence, minimal understanding. Plan for evaluating the outcomes of the project: We will be using multiple, validated instruments as well as pre- and post-lecture testing. Participants will complete the Jefferson Scale of Empathy7, the CCCHP instrument (Cross-Cultural Competence of Healthcare Professionals (CCCHP))8and the IAT 9-11 to assess providers cultural awareness and experience and preparedness with working with different cultures. The Jefferson Scale of Empathy is a 20-item scale designed to assess empathy in healthcare professionals (Appendix A). The CCCHP is a 32-item self-reported scale which delivers a comprehensive assessment of health professionals cultural competence (Appendix B). The IAT is an online instrument developed by Harvard University used to help detect preferences or aversions to certain attributes and has been used to measure implicit bias in physicians.12 Paper questionnaires (CCCHP and Jefferson Scale of Empathy) will be completed before the first lecture (pre-) and after the last lecture (post). These will be mandatory for all trainees attending the lectures and optional, but encouraged, for medical, nursing, midlevel and research staff. Time during the first lecture will be set aside to complete these brief instruments and they will be distributed and collected by Professor Reddy and her study manager/s who will be attending at the Phoenix location and from video conferenced location on the Scottsdale campus. The data will be collated and entered into a database formulated and managed by Professor Reddys team. The completion and analysis of these questionnaires also supports a robust research component to this project as we expect to glean valuable, publishable data from this experience. Program Deliverables: The improvement in understanding of healthcare disparities will be evaluated at the end of each year and, partially, at the end of each lecture via pre- and post-lecture assessments. We anticipate an improvement in scores on all instruments indicating higher levels of cultural competency and empathy and lower levels of implicit bias and improved knowledge of the concepts as demonstrated by higher post-lecture scores. An annual report will be created collating assessment results, mapping of the process and identifying challenges as well as best practices to create scalable programs for future trainees as well as other GME and CME programs at MCA with similar gaps in knowledge and experience.
|Effective start/end date||1/31/20 → 7/31/21|
- Mayo Clinic: Cancer Center (MCCC): $15,001.00
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