How to Create a Culturally Competent PA

Cultural competency — the ability to interact effectively with people of different cultures and socio-economic backgrounds — is a part of the Carroll University PA program’s DNA. In September 2010, while the curriculum was still under development, the program received a five-year Health Resources and Services Administration (HRSA) grant for nearly $970,000 to design, implement, and evaluate a cultural competency thread.

Carroll’s Dean of the College of Natural Sciences & Health Sciences Jane Hopp, PhD, and her team spent the next year and a half developing the curriculum. The focus on cultural competency made sense for Carroll. The university emphasizes service in a “diverse and global society,” and within the Wisconsin region where the university is found, there’s a strong primary care need for underserved populations.

Carroll’s faculty began by looking at models from medical and PA schools that taught cultural competency — why reinvent the wheel? But the traditional approach — an allotted number of hours within the curriculum followed by an elective — left faculty at these programs reporting disappointing results. The lessons didn’t seem to make an impact.

“I think one of the defining moments for me was when those in existing curriculum said that the students never owned it,” Hopp said.

So Carroll set out to develop their own model with the help of experts and consultants from across the country. They decided that the cultural competency thread would be woven throughout the 24-month program and given equal weight to other areas of study. They also began pulling in campus resources, including the learning commons, library, and career services.

“We can’t just be an island of cultural competency, just kind of sprinkling it in,” said Program Director Barbara Bahrke, MT ASCP, MPAS, PA-C.

Teaching Cultural Competency

Upon beginning the program, each student completes a self-assessment about their own cultural identity. Before they can truly grasp the intricacies of another culture, the reasoning goes, the students must first recognize and understand their own.

“We all have cultural biases, whether we realize it or not,” Bahrke said.

Second-year student Joe Steiner agrees. “One very important lesson that I learned was how past experiences were largely responsible for shaping the way I saw others,” he said.

First-year student Krista Morin gained a better understanding of her personal discomforts and biases. “I realized that my experiences with individuals from lower socioeconomic statuses have been nearly exclusively somewhat paternalistic, charity-based situations,” she said. “This limited exposure affects how I view individuals in that demographic.” Through the cultural competency training, Morin worked to develop true relationships with people whose backgrounds were different from her own.

Carroll recently went from a general admissions process to a holistic admissions process, but that didn’t change the need for self-assessment. “It’s interesting how a more diverse student population doesn’t mean that they’re more culturally aware,” Hopp said. “They know their culture, but they don’t know anybody else’s culture.”

When exposing students to topics relating to culture, faculty employ multiple approaches. Guest speakers come to the classroom to share their experiences — everything from working at an underserved health clinic to how to best work with interpreters.

Students research and give presentations to each other about different religions and ethnicities, and how those aspects of culture affect a patient’s health. At the nearby Hispanic Resource Center, students lead education seminars for the community.

Students also participate in several simulations, including one on poverty designed by the nonprofit organization Hunger Task Force. They receive the profile of a low-income patient and, as that patient, they must purchase food to feed their family while overcoming obstacles, like relying on public transportation.

“I think it’s a real aha moment for students because it’s a day in the life of their patients,” said Associate Professor Barbra Beck, PhD. “I think they start to see the big picture.”

Bahrke doesn’t see cultural competency as any less important than the medicine component of a PA’s job. “There have been a lot of studies that show being a culturally competent provider improves patient outcomes,” Bahrke said. “You can’t just write a prescription and say, ‘Off you go.’”

Just because the importance of cultural competency is clear to faculty, doesn’t mean that’s always the case with students. Bahrke recalled one student in Carroll’s inaugural class who wanted to concentrate on the science and thought cultural competency was “nonsense.” But in the end, she said “he did a 180,” receiving the highest score on the program’s OSCE, which weighs cultural competency equal to medical knowledge.

Today Carroll’s focus on cultural competency is emphasized during the admission process, so students generally know what to expect. “We still do get students who are so obsessed with learning the medicine that we have to sort of mold them a little bit,” Bahrke said. “As they get into clinical rotations, they see why we did it the way we did.”

First-year student Allison Levra doesn’t struggle to see the value. “They have given us the tools to really individualize patient care and think outside the box,” she said.

One of the biggest lessons Levra learned through her training? “Before we label [patients] as non-compliant and assume it is because they don’t care about their health or didn’t want to listen to medical advice, it is vital that we take a step back and assess the situation.”

When it’s time for clinical rotations, the students have the opportunity to put into practice what they’ve learned. “Preceptors often remark that Carroll students possess a unique ability to meet with patients comfortably and confidently no matter their cultural backgrounds,” Hopp said.

John Jenkins, PA-C, a recent graduate of the program, said he most often “taps into” his cultural thinking when dealing with non-compliant or difficult patients. For example, “Numerous times men have been resistant to hernia repair because they believe it will make them impotent,” he said. “If you never ask why they don’t want a repair or educate them on the procedure, they will continue to follow their ill-informed views.”

To date, more than 60 percent of the program’s graduates have chosen to work in underserved or rural locations. As word has gotten out about Carroll’s emphasis on cultural competency, the program has begun attracting applicants with an interest in working with underserved communities, so that percentage could further increase.

The Next Phase

Though the program’s HRSA funding ends this August, the faculty has no intention of winding down the cultural competency thread — just the opposite. They’re in the process of developing a more-formalized health literacy initiative that will teach students how to recognize when patients are at risk for low health literacy, how to approach those patients about it, and how to empower them in their health care.

“The PA model is inherently designed to improve health literacy rates in clinical practice,” said Bahrke. “One of the most important roles of the PA is patient education.”

Though cultural competency training has been a core focus for Carroll since the program’s inception, Hopp still thinks it’s possible for already established programs to incorporate the topic into their curriculum.

“Instead of adding something, think about how you can stay the same and shift materials around that might also decompress some courses, while also introducing this concept,” Hopp said. She suggests that a good time for doing this may be before re-accreditation.

Bahrke notes that emphasizing cultural competency and health literacy training is timely — the Affordable Care Act’s Medicare Shared Savings Program calls for accountable care organizations to emphasize and design reimbursement based on patient outcomes rather than the number of patients seen. Carroll University’s PA program, she said, “is answering that call.”