Racial disparities in surgical care impact millions in the US each year. Compared to whites, black patients are more likely to experience negative outcomes across a wide range of procedures. The National Institutes of Health and American College of Surgeons summit on surgical disparities identified improving patient-provider communication through the development of cross-cultural training programs as the first priority in their national agenda for surgical disparities research. The Institute of Medicine recommends cultural competency training as a solution to address healthcare disparities, and medical schools are now required to incorporate cultural competency training as part of their curricula. However, there is limited evidence that such programs effectively impact clinical outcomes or health disparities. Furthermore, medical students and residents continue to feel unprepared to treat culturally diverse patients, and surgical training does not have any formalized cultural competency curriculum. Through an extensive review of existing cultural competency programs, we identified 3 major barriers to current approaches: (1) a lack of tailored curriculum content; (2) an inability to incorporate culture/system change; (3) a limited focus on skills training. Reflecting these barriers, we propose an innovative paradigm shift to cultural competency training called cultural dexterity, which emphasizes context specific training and the development of skills to apply knowledge to practice, with a focus on lasting institutional culture change. Based on extensive research with surgeons, patients, and experts, we developed a cultural dexterity curriculum called PACTS (Provider Awareness and Cultural Dexterity Toolkit for Surgeons) that incorporates novel educational approaches such as a flipped classroom model, spaced-education, and performance tracking to improve knowledge, skills and attitudes related to provider-patient trust, working with patients of limited English proficiency, informed consent, and pain management. The proposed trial will include implementing the curriculum at 8 surgical residency programs to examine the change in resident and patient outcomes using surveys and a simulated clinical encounter prior to the intervention. After the baseline tests, 4 of the 8 sites will receive the PACTS curriculum and be tested at the end of the year. They will be retested one year later to see whether they retained the improvements. The other 4 sites will receive their standard residency curriculum so outcomes can be compared after receiving the PACTS curriculum in the following year. We will examine whether the PACTS curriculum results in improvements in resident knowledge, attitudes and skills, patient satisfaction and clinical outcomes compared to the standard residency curriculum. If the curriculum demonstrates improvements, the research team will work with representatives of national organizations to disseminate the program to surgical residency programs nationally. Such training will improve the communication skills of the next generation of surgeons and serve as an important step for mitigating surgical disparities.

Public Health Relevance

Improving the ability of providers to provide cross-cultural care is a necessary development in the effort to improve patient-centered care and reduce healthcare disparities. The trial will test the effectiveness of a novel cultural dexterity curriculum (PACTS) in improving surgical residents? knowledge, attitudes, and skills in caring for patients of diverse cultural backgrounds. The added dimension of measuring patient satisfaction and clinical outcomes in response to the intervention, which has not been done previously, will provide evidence to support the connection between cultural dexterity and patient outcomes, and reinforce the anticipated impact of this initiative.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Dagher, Rada Kamil
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Brigham and Women's Hospital
United States
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