Reflections on culture: views on script concordance testing

Abstract

Context and setting The socio-cultural curriculum at the University of Michigan Medical School was designed as a longitudinal programme to allow the fluid development of students’ cultural awareness on issues of religion, race, socio-economic status and health disparities. Why the idea was necessary Although numerous cultural competency assessment methods have been introduced, few have explored students’ perceptions of the assessment and the manner in which it may contribute to their understanding of cultural issues. Through discussing the assessment process, we hoped to gain insight into the impact of the exercise on student attitudes toward diagnosis when culture is introduced. What was done The Script Concordance Test (SCT) was designed to assess students’ clinical reasoning via clinical vignettes. In the case scenario developed by the University of California Los Angeles, the SCT provides options for changing the diagnosis or treatment once the cultural background of the patient is introduced. A total of 171 students completed the SCT at the end of Year 3 using a single case of a 45-year-old patient returning for a follow-up office visit for hypertension. Approximately 3 weeks after the completion of the exercise, students were asked to participate in a focus group to discuss the exercise. Specifically, students were asked to share their overall thoughts about the exercise, to compare their clinical decisions with those suggested by a panel of experts and to discuss whether there was anything they would have done differently in completing the test. Eleven students (two male, nine female) participated in two focus groups. Evaluation of results and impact A thematic analysis of the focus group transcripts revealed that the exercise caused students to consider how culture influenced interpersonal interactions. For instance, a student commented: ‘You wouldn’t really change your management based on a patient’s culture, but I would change the way I ask certain questions or I might change what I ask or how I ask it.’ Additionally, the exercise prompted reflections such as: ‘When I was answering the questions, I was thinking, “Would this really have an impact on me? Should this have an impact on the decision I make?” It was more of an internal battle rather than [about] whether I knew the right answer or not.’ The exercise also helped students to realise that treatment plans are not based solely on an individual’s cultural background. One student noted: ‘Ethnicity shouldn’t be a main determining factor in the way that you take care of patients. A lot of standards of care you should really do for everyone.’ Finally, the analysis suggested that students recognised that when creating a patient treatment plan: ‘You consider their culture, where they’re coming from, their place in the world… just all of these different factors about them that may influence their ability to agree to the plan and actually work with you as a partner.’ We believe the SCT provided students with the opportunity to assess their clinical reasoning skills, to consider the processes used to diagnose individuals with similar symptoms but different cultural backgrounds and thereby to identify personal bias.