standardized patients to enhance cross-cultural sensitivity
Ellen Buenconsejo-Lum, Gregory G. Maskarinec
of Family Practice and Community Health, University of Hawai'i John
A. Burns School of Medicine, Hawai'i, USA
To prepare family practice residents for an international rotation,
and simultaneously to address recent mandates for objective standardized
evaluation of residents, the authors have initiated a series of standardized
patients (SPs) specifically designed to teach and evaluate cross-cultural
issues. These cases supplement the authors' existing cross-cultural
Methods: Two SP cases, based on actual presentations of patients
from the Marshall Islands who presented to the authors' outpatient
clinic, are used to provide an ethnographic exploration of other cultural
models of illness and to examine the narrative foundations of the
illness experience. These SPs were piloted on the intern class of
Results: Increased cross-cultural sensitivity and improved
residents' communication skills.
Conclusion: The authors have found that using standardized
patients specifically designed to teach cross-cultural issues, is
a very powerful addition to existing evaluation strategies. Standardized
patients can be designed not only as evaluation tools, but also as
teaching tools and group discussion points for sensitive patient care
The Family Practice Residency Program at the University of Hawaii requires
its residents to undertake two international rotations in the Republic
of the Marshall Islands (RMI) during postgraduate years 2 and 3 (PGY-2
and PGY-3). To prepare residents for this international rotation and simultaneously
to address recent mandates from the American Association of Medical Colleges
and the Accreditation Council for Graduate Medical Education (ACGME)2
(see Table 1) we have piloted
a series of objective standardized learning experiences (OSLEs) that emphasize
cross-cultural sensitivity and are intended to supplement our existing
In doing this we are seeking to supplement findings that standardized
patients (SPs, defined as people who are trained to portray a clinical
scenario for teaching or research purposes)3,4
are an effective means
to assess components of interviewing, physical examination, communication
skills and certain clinical tasks.5,6
We urge other programs to use OSLEs
to address the following important issues:
appropriateness and effectiveness of interventions;
relevant values and practices involved in end-of-life decision-making,
including attitudes toward suffering and death, understanding of advance
directives and their relevance, and the possibility of unaddressed spiritual
concerns of patients and their families;7
accuracy and efficacy of patient-physician communication;
to avoid medical errors that may involve cross-cultural misunderstandings;
possibilities of complementary and alternative medicine use by patients
in specific diagnostic categories (including chronic pain disorders
and anxiety disorders);
quality and equity of care delivered to underserved populations.
nationwide expertise and experience with standardized patients, there
is a paucity of literature in the use of standardized patients to teach
and assess cultural competency. Therefore, we believe that our efforts
will prove useful to other departments struggling to develop similar programs.
To measure more accurately residents' skills in cultural sensitivity,
we needed to create a safe, standardized learning environment and use
a teaching and evaluation method that more accurately assesses desired
skills and qualities for family physicians.
In order to do this in our pilot program, we created standardized patient
cases, based on real patient scenarios commonly encountered in our outpatient
clinic, seeking to provide cross-cultural training within a clinical framework
in the following three areas:
of other cultural models of illness;8,9
of illness narratives;10,11
of discourse analysis.12,13
Our assessment instruments are based on the Toronto Consensus Statement14
and the Kalamazoo Consensus Statement,15 emphasizing rapport-building,
active listening, agenda-setting, information management, appreciating
the patient's perspective, and reaching common ground.16
Our program simulates an entire 15-minute patient encounter and the standardized
patients are trained to react to the physician as a 'real' patient might.
For example, if a physician is rushed and appears uninterested in the
patient, then the patient may not answer the physician's questions very
well, because no rapport or trust has been established. In our program,
each case and the relevant expectations are adjusted to evaluate what
a first-year family practice resident (or whomever is being tested) should
be able to perform in a 15-minute office visit. Residents are expected
to complete the entire office visit (focused history, physical examination,
patient counselling) in 15 minutes, then discuss with a faculty member
(who has been watching the encounter on video monitor) for 2 minutes in
front of the patient. After the faculty member has taught one teaching
point, the resident then has 5 minutes to 'wrap-up' the visit. Depending
on the teaching point, this 5-minute 'wrap-up' session may include gathering
more information, redoing a portion of a physical exam, or negotiating
a more patient-centered and culturally appropriate treatment plan with
the patient. After this approximately 25-minute session, the resident
then has 15 minutes to complete their progress note and clinic encounter
form (on which they are graded). During this time, the SPs also have 15
minutes to complete their evaluation of the resident. After the resident
has completed both cases, they also complete a self-assessment form. The
final competency scores ('grades') are comprised of scores and written
feedback given on the evaluation forms completed by the faculty and the
SPs, accurate completion of the progress note and clinic encounter form
(billing and coding). The competency scores are then compared with the
resident's self-assessment scores. All scores are tracked longitudinally.
The SP program is obviously different from a traditional objective structured
clinical exam (OSCE) which comprises multiple testing stations: the student
is asked to complete a specific task (obtain a focused history, complete
an expanded abdominal exam, interpret an EKG [electrocardiogram], etc.)
at each station.
The scores from the SP experiences, in conjunction with the competency-based
360-degree evaluation system (see Addendum) are used to monitor the resident's
progress through the six core competencies, over time.
of the cases
The two cases used were performed by actual ethnic Marshallese healthcare
workers who are familiar with healthcare in the RMI as well as the conditions
at our clinic (to which many of the Marshallese patients living in Hawaii
come for their care). (see Boxes 1 and 2) They
were explicitly instructed to respond to the residents' approach and questioning
in traditional Marshallese ways. If they did not feel comfortable with
the doctor, they would not share information or would answer 'yes' and
'no' and not elaborate. If the resident used medical jargon, the SPs were
told to prompt the resident only once to speak in simpler terms ('what
does that mean?'). The SPs evaluated the residents not only on the core
competencies, but also in their ability to translate medical jargon into
words and phrases appropriate for patients for whom English is not their
Competency scores were based on the resident's interaction and performance
during all parts of the OSLE - interview, physical examination, patient
counselling/interaction, presentation to faculty, receptivity to preceptor
feedback, accuracy and legibility of progress notes and encounter forms
(billing sheet). Scores were derived as follows.
completion of each session, SPs completed the first side of the evaluation
form, circling descriptions that best reflected the resident's performance.
evaluators had a 'checklist' which was used to generate a feeling of
how well the resident did on each portion for immediate management,
short-term management and long-term management (if appropriate), case
presentation and progress note/encounter form documentation. This checklist
was not used to generate 'percent completion', but was helpful to compare
how well each resident did in comparison to each other. After reviewing
the progress notes and encounter forms, the faculty member completed
the evaluation form.
on how many descriptors were circled in each column, the faculty member
and SP evaluators then assigned a competency score for each of the six
addition to the competency rating, faculty members and SPs were asked
if they would refer a family member or return to this physician for
their care. 'No' answers needed to be explained in the comment section.
patients were also asked to evaluate the resident on their English/non-medical
language skills on a scale of 1-9 (9 being the highest).
resident's self-assessment form is essentially the same as the faculty
evaluation form. Currently, residents complete one self-assessment form
for both SP cases.
and written comments were compiled for each resident, which was then reviewed,
along with the videotapes, by both the resident and faculty advisor. Composite
averaged scores (scores by faculty and SPs) are compared with the resident
self-assessment score for all faculty members to analyze and to facilitate
comparison between residents. General trends are also noted on the summary
scores and averages sheet (Table
For these two cases, residents had more difficulty in communicating with
these patients. Both SPs commented that the residents often incorrectly
assumed that the patient understood more English than they actually did
and did not clarify with the patient often enough to assure understanding
and proper communication. SP1 (irritable bowel case) was very straightforward,
but many residents were quick to assume that a 'yes' answer actually meant,
'Yes, that symptom is there' versus 'Yes, I don't really understand the
Residents who were able to speak without medical jargon and who took time
to explain their questions were better able to make a correct assessment
of the situation. For SP2 (advanced cervical cancer), she was able to
detect which residents felt very uncomfortable and she rated them lower
because she felt they were communicating ineffectively. Residents that
took the time to explain female anatomy, where the cancer was, how it
might be contributing to her symptoms, what the next steps would be and
who checked to see how the patient was reacting to the news, were rated
very highly by the patient.
We found our cross-cultural standardized patient program to be effective
in the following ways:
allows for early observation
of resident performance in a standardized setting;
allows for targeted
interventions to assist the resident in improving their skills in one
or more areas;
allows all faculty
members to observe resident performance and determine group recommendations
helps to identify areas
in the residency curriculum which need improvement;
allows for large group-review
of different cultural models of illness and wellness; and
allows for 'safe' patient
feedback to the resident physicians.
This is in keeping with the use of patient-centered communication skills
which may lead to improved patient and physician satisfaction, and better
An unexpected finding was the ability to detect which resident physicians
had a tendency to over-rate or under-rate themselves compared to the evaluators'
assessment (refer to bold-type results in Table 2). When this was discussed
and reflected upon by all of the faculty, this did in fact, correlate
with faculty observation of the residents' presentations and self-confidence
in the actual clinical setting.
Our 'pilot' cases were intentionally difficult, with multiple psychosocial
issues. More advanced and skilled residents should, in theory, be able
to elicit more history from SPs who trusted them. While none of our interns
were able to elicit everything on the checklist, it was very clear to
all observers which residents had better communication skills and rapport;
the SPs rated those physicians higher who tended to discuss at least two
hidden issues with the patient. Interns were overwhelmed, not by the complexity
of the cases, but by the 15-minute time restriction, though they were
aware that the rationale for this was to mimic future practice. We did
allow 15 minutes after the patient visit for SPs to complete the evaluations
and for residents to complete their progress notes. This does not allow
for true measure of residents' performances in a busy clinical setting,
but the faculty members felt that it was more important for the SPs to
have time to adequately assess the residents.
For the Marshallese cases, the core faculty member met with one of the
SPs ahead of time to ensure accurate portrayal and issues in the standardized
cases. The Marshallese healthcare workers were very pleased with the cases
and felt they accurately reflected common medical and social issues for
Marshallese, either in the RMI or in Hawaii. They also thought this an
excellent way to help better prepare our residents for their cultural
immersion/mandatory rural rotations in the RMI in the PGY-2 and PGY-3
We have only had two completed OSLEs (four cases), but in that short time
(3 months) have noticed overall improvement in the performance of four
of the interns. Their documentation on the progress notes and encounter
forms, in particular, were more thorough and complete. We feel that this
is probably due to more consistent clinic supervision and feedback by
the faculty member, as well as direct feedback on the OSLE progress notes.
More of the residents were able to pick up patient cues and address hidden
messages, although they had a more difficult time because of the communication
style of Marshallese patients.
feel that our SP program has been successful in meeting our need to evaluate
effectively our cross-cultural curriculum, as well as evaluating residents'
progress toward achieving the ACGME core competencies. The group discussion,
based on case scenarios (problem-based learning) tends to be a more effective
curricular method for teaching cross-cultural issues to our residents
and faculty members, as well as for teaching other medical topics.
We have found that using SPs to teach and evaluate cross-cultural issues
are a very powerful addition to existing evaluation strategies. Standardized
patients can be designed not only as evaluation tools, but also as teaching
tools and group discussion points for sensitive patient-care issues.
development of these cases was funded in part by a Health resources and
Services Administration, Bureau of Health Professions Academic Administrative
Units grant award to the University of Hawai'i John A. Burns School of Medicine
Department of Family Practice and Community Health.
of the most commonly used methods for evaluating a resident's performance
in a given area is through a 360-degree evaluation. 360-degree evaluations
consist of measurement tools completed by multiple people who come into
contact with the subject, such as supervisors, peers, nurses, clinic staff,
and patients and families. Most 360-degree evaluation processes use a
survey or questionnaire to gather information about an individual's performance
on several topics, including teamwork, communication, management skills
and decision-making, and include rating scales to assess how frequently
a behavior is performed (e.g. a scale of 1-5, with 5 meaning 'all the
time' and 1 meaning 'never'). The ratings are summarized for all evaluators,
by both topic and overall.
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1 Programs that train resident physicians for any specialty are now
required by the Accreditation Council for Graduate Medical Education to
document educational outcomes and graduate physicians competent in six
Patient Care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health
B. Medical Knowledge about established and evolving biomedical,
clinical, and cognate (e.g. epidemiological and social-behavioral)
sciences and the application of this knowledge to patient care
C. Practice-Based Learning and Improvement that involves investigation
and evaluation of their own patient care, appraisal and assimilation
of scientific evidence, and improvements in patient care
D. Interpersonal and Communication Skills that result in effective
information exchange and teaming with patients, their families, and
other health professionals
E. Professionalism, as manifested through a commitment to carrying
out professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population
F. Systems-Based Practice, as manifested by actions that demonstrate
an awareness of and responsiveness to the larger context and system
of health care and the ability to effectively call on system resources
to provide care that is of optimal value.
of competency in these six areas will help assure that physicians are prepared
to practice medicine in the changing health care delivery system.
back to text
2 Objective standardized learning experiences summary scores
average (resident self-rating)
Patient Care: Resident provides compassionate care that is effective
for the promotion of health, prevention, treatment, and at the end
Medical Knowledge: Resident demonstrates knowledge of biomedical,
and social sciences and applies that knowledge effectively to patient
Practice-Based Learning and Improvement: Resident uses evidence and
methods to investigate, evaluate, and improve his/her patient care
Communication and Interpersonal Skills: Resident demonstrates these
skills and maintains professional and therapeutic relationships with
patients and the healthcare team
Professionalism: Resident demonstrates behaviors that reflect an ongoing
commitment to continuous professional development, ethical practice,
sensitivity to diversity and responsible attitudes
Systems-Based Practice: Resident demonstrates both an understanding
of thecontexts and systems in which health care is provided and applies
knowledge to improve and optimize health care
SP1 and SP2, Marshallese women with irritable bowel syndrome and
new diagnosis of advanced cervical cancer. The evaluators' average
is listed in bold and is compared to the resident self-rating, in parentheses.
R, resident. Rating: 1-4 = below; 5-7 = meets; 8-9 = exceeds expectations.
§R1 and R6 excused from the second OSLE. Their scores reflect only
the first OSLE cases (Filipino female with poorly controlled diabetes
mellitus, hypertension, no drug coverage and Catholic, married, 'hidden'
victim of domestic violence). Bold-type results: resident physicians with
a tendency to over-rate or under-rate themselves compared to the evaluators'
1: 38 years-old, married Marshallese female who lives in a rural
area on Oahu with her family (husband and three children). She is
complaining of abdominal pain, suffering from alternating constipation
and diarrhea. History and review of systems, if elicited correctly
by the resident, point clearly to irritable bowel syndrome. The
patient is 'a little' (VERY) worried about finances because her
mother is coming from the RMI to 'visit', which for all intents
and purposes, means that she plans to relocate to Hawaii permanently.
The patient's mother is a poorly controlled diabetic with severe
end-organ damage, who will undoubtedly have large medical costs
and hospitalizations. Because of the Marshallese patients' relationship
with the United States, they are not considered immigrants, so have
no access to special Immigrant Health Insurance programs. Unless
they plan to live and remain in Hawaii and have lived at the same
address for over 6 months, they are not eligible to apply for the
state Medicaid program. The patient's husband is the sole wage earner
for the family and his job provides medical coverage for his immediate
family, but his income is barely enough to pay for all household
expenses and the rising prescription co-payments and 'family plan'
medical insurance premiums. Residents are assessed on: ability for
resident to elicit sensitive history (bowel movements, abdominal
pain, sexual history) in a manner appropriate for Marshallese patients;
ability for resident to adjust to a situation where there might
be conflicts between the patient and doctor because the doctor is
male/female, younger versus older.
2: 48-year-old-married Marshallese female who lives in a small semirural
community on Oahu with her family. She is here to follow-up on the
Pap smear result from two weeks ago (which was her first Pap smear
ever, since she recently arrived from the RMI several years ago
and there are no cancer screening programs for the general population
in the RMI). At the last visit, the patient was complaining of some
bloating and vaginal bleeding (mild), so the resident did a Pap
smear and pelvic examination. After the end of the last visit, the
resident seemed very concerned and made sure that the patient kept
this follow-up appointment so that they could discuss the results
of the test. That resident is not here today but in the RMI on rotation,
so the patient is seeing a new doctor, whom she has never seen before.
The patient suspects something is wrong, as that is why she bothered
to show up to the doctor two weeks ago. Today's doctor will need
to give the patient the diagnosis of advanced cancer of the cervix
and discuss some general treatment plans (referral to another physician[s],
more tests for staging, therapy in stages [surgery, chemotherapy,
radiation therapy or all three]). The resident should also begin
discussions with the patient regarding end-of-life issues. The resident
will not be doing a physical exam. Residents are assessed on: ability
for resident to deliver very bad news (advanced cervical cancer)
in a manner appropriate for Marshallese patients (who are not accustomed
to discussing anything related to female or male anatomy, sexual
issues); ability for resident to adjust to a situation where there
might be conflicts between the patient and doctor because the doctor
is male/female, younger versus older; ability for resident to discuss