The Provider Awareness and Cultural Dexterity Toolkit for Surgeons Trial

Study Overview
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Brief Summary
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This study is designed to test the impact of a new curriculum, called Provider Awareness Cultural Dexterity Toolkit for Surgeons (PACTS), on surgical residents' cross-cultural knowledge, attitudes, and skills surrounding the care of patients from diverse cultural backgrounds, as well as clinical and patient-reported health outcomes for patients treated by surgical residents undergoing this training.

Detailed Description
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In order to improve overall health outcomes of minority patients, undergoing surgical care, the National Institute on Minority Health and Health Disparities (NIMHD) collaborated with the American College of Surgeons (ACS) and prioritized to evaluate the effect of improvement in culturally dexterous care on surgical outcomes for patients from disparity populations. Poor outcomes in patients are attributed to poor patient-provider communication which may lead to treatment errors, inadequate pain management, less patient-centered care, decreased adherence to treatment plans, and worse overall clinical outcomes. Additionally, studies have shown that some surgeons have pro-White implicit biases, which are unconscious, automated preferences that individuals may not even be aware of. Historically, formal training in cultural competency is generally integrated into medical education at the undergraduate level but it rarely continues up to the post-graduate level. Few surgical programs have attempted to incorporate cross-cultural communication skills into their educational paradigms, and the approaches to doing so have been inconsistent. In order to add the surgical context in post-graduate level medical education, the investigators adopted a novel approach to cross-cultural communication for surgical trainees, known as cultural dexterity. Cultural dexterity refers to a set of skills and cognitive practices used to maximize communication across multiple dimensions of cultural diversity and deviates from the concept of cultural competency in that it does not demand that learners associate certain practices and behaviors with individuals based on generalizations. Study design: Cross-over, cluster-randomized trial Study Procedures: Curriculum Administration The PACTS curriculum incorporates contemporary learning practices such as the flipped classroom model, team-based learning. It consists of e-learning modules, interactive sessions in which residents will apply concepts from the e-learning modules to roleplay scenarios constructed in a team-based learning format. Residents will be given detailed, scripted prompts for the role-play sessions followed by structured feedback from peers and facilitators. Outcome Measurement Patients To evaluate patients' satisfaction and clinical quality related to PACTS training, the investigators will administer surveys to patients treated by residents to determine satisfaction with pain management, communication, trust-building, and comprehension of the informed consent discussion two months before and after the intervention is implemented. Patient satisfaction will be assessed using elements of the validated Pain Treatment Satisfaction Scale (PTSS). Clinical surgical outcomes obtained from the NSQIP database will be assessed for each patient participant before and after the PACTS curriculum is implemented to measure individual outcomes such as length of stay, postoperative complications, unplanned reoperations, and 30-day morbidity/mortality. Residents To evaluate the impact of PACTS on surgical residents' knowledge and attitudes about caring for diverse patients, the investigators will use a pre- and post-test in the form of validated instruments that assess knowledge, attitudes, and self-reported skills on a Likert-type scale. Resident skills will also be objectively assessed through an Objective Structured Clinical Examination (OSCE) that will be created by the study staff and administered immediately before the intervention and 3 months after the intervention has been completed. The OSCE uses 5-point Likert scale questions to evaluate resident performance across multiple domains. These may be administered virtually or in-person. A Standardized Patient evaluator and a third-party trained impartial observer will evaluate the residents on these domains, and the resulting numerical scores will be averaged. It will serve both a summative and educational purpose in this context. Residents will be required to take a knowledge survey before and after receiving the PACTS curriculum or standard training. Attitudes regarding the importance of facing cross-cultural health care situations will be assessed across multiple domains using a novel survey instrument that is based on a survey that was used in a similar curriculum aimed at medical students, as well as the Values and Belief Systems domain.

Official Title
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The Provider Awareness and Cultural Dexterity Toolkit for Surgeons Trial

Conditions
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Resident Knowledge and Attitudes Regarding Cross-cultural Care, Interpersonal and Communication Skills in Patient-clinician Encounters, Patient-reported Satisfaction With Resident Physicians Involved in Their Care, Patients' Clinical Health Outcomes After Surgery

Intervention / Treatment
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* Other: PACTS curriculum


Participation Criteria
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Eligibility Criteria
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*Eligibility Criteria for Residents: Inclusion Criteria: All residents in the general surgery program at Johns Hopkins University, Brigham and Women's Hospital, Brown University, and Eastern Virginia Medical School, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Howard University, and Washington University in St. Louis. Exclusion Criteria: Non-surgical residents at Johns Hopkins University, Brigham and Women's Hospital, Brown University, and Eastern Virginia Medical School, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Howard University, and Washington University in St. Louis. Eligibility Criteria for Patients: Inclusion Criteria: Admitted to surgical service under the care of a participating resident; Able to recognize resident as the main care provider from a photo; Able to consent as determined by a cognitive screen for capacity to give informed consent Fluent in English or Spanish. Exclusion Criteria: Admitted to Intensive Care; Mentally impaired and/or not oriented to person/time/ place.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: Sites will be assigned to an early intervention/retention assessment group or a delayed intervention group (control) for examination of the effectiveness of the intervention as well as learner retention.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Early Intervention / Retention Group<br>The investigators will assess the residents' knowledge, attitudes, and skills prior to and after the PACTS curriculum administration at half the sites (Early Intervention/Retention Group). Follow-up testing will be conducted after one year to evaluate learner retention. Further, the investigators will test post-exposure effect retention in the Early Intervention Group at the end of year 2. | Other: PACTS curriculum<br>* The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care. The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment.<br>|
| Active Comparator: Delayed Intervention Group<br>The investigators will conduct baseline testing prior to the standard residency curriculum, and administer the PACTS curriculum the following year. Both between- and within-group differences will be examined based on curriculum exposure in intervention year 1 as well as within-group differences for the Delayed Intervention Group at the end of year 2. | Other: PACTS curriculum<br>* The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care. The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in residents' questionnaire scores from pre- to post-PACTS curriculum | The effect of PACTS curriculum on surgical residents' questionnaire scores measuring knowledge and attitudes about caring for culturally diverse patients | Year 2 and Year 3 | 
| Objective Structured Clinical Examination scores | Standardized Patient observers will evaluate surgical residents on multiple dimensions of cultural dexterity and communication skills using Likert-type scales. | Year 2 and year 3 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patients' self-reported satisfaction scores | An adapted version of the CAHPS Pain Treatment Satisfaction Scale will be used to assess patients' (1) satisfaction with pain management, (2) satisfaction with communication including specific measures for LEP, (3) trust, and (4) comprehension of informed consent. | Year 2 and Year 3 | 
| Patients' clinical outcomes: length of stay | NSQIP metrics for each patient participant capturing length of stay in days | Year 2 and 3 | 
| Patients' clinical outcomes: surgical complications | NSQIP metrics for each patient participant capturing complications experienced as a result of surgical procedure | Year 2 and 3 | 
| Patients' clinical outcomes: 30-day morbidity, mortality, and complications | NSQIP metrics for each patient participant capturing 30-day quality measures | Year 2 and 3 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Medical education, Patient-reported Satisfaction, Patient-reported outcomes, Cultural dexterity, Cross cultural care, Resident physician education