Improving Culturally Dexterous Care for Surgical Patients: The PACTS Trial

Key Learning Points

1. Racial disparities in surgical care the United States contribute to inequities in health outcomes.
2. Training healthcare team members in cultural dexterity can improve communication with patients from diverse sociocultural backgrounds.
3. 30% of patients receiving care at the 8 large, academic medical centers participating in the trial reported that they did not receive culturally dexterous care, with Black patients more likely to report poorly dexterous care than White patients.
4. The Provider Awareness and Cultural Dexterity Toolkit for Surgeons Curriculum is a curriculum specifically designed to provide surgical residents with training on cultural dexterity to improve their ability to communicate more effectively with patients of diverse cultural backgrounds.

Racial disparities in health outcomes persist in the United States. In the past two years, these disparities have been thrown into even starker relief by the pandemic. The glaring disparity in rates of COVID-19 infection has highlighted the structural racism and inequities in healthcare experienced by those from low-income, racial, or ethnic minority groups.¹ Across the country, people of color continue to experience worse access to care, lower standards of care, and worse outcomes from a multitude of disease processes. Specific examples of inequity in surgical care are also overwhelming. Non-White patients have been shown to have less access to high-volume oncologic surgical care,² lower rates of revascularization with correspondingly higher rates of primary amputation for vascular disease,³ and lower rates of graft survival after organ transplantation.⁴ While these disparities remain impactful and discouraging, national efforts are underway to attempt to address them in surgery.

In 2015, the American College of Surgeons (ACS) established a task force to develop a research agenda to combat racial disparities in surgical care.⁵ One key recommendation of this task force was to improve the cultural competency of surgical providers. Sociocultural differences between patients and physicians have been shown to lead to patient dissatisfaction and poor health outcomes.^6–8 Previous work has demonstrated that training healthcare team members in cultural competency can improve communication with patients from diverse sociocultural backgrounds. This ability to adapt to the unique needs of each patient to provide patient-centered care can be termed “cultural dexterity.” ⁹ Cultural dexterity does not require physicians to memorize information about many different cultural practices. Instead, healthcare professionals focus on identifying their own biases, recognizing structural, societal, and/or institutional barriers to care, and developing skill sets to improve bidirectional communication between healthcare team members and patients.

While surgical residents receive extensive training in the management of countless diseases and the performance of multiple operations, no formal national curriculum exists to assist surgical residents in the development of skills essential for effective interpersonal communication, such as emotional intelligence and active listening. In addition, residents currently receive little to no training in cultural dexterity, which is designed to help residents communicate more effectively with patients of diverse cultural backgrounds. This is despite the fact that the Accreditation Council on Graduate Medical Education (ACGME) had added to the Common Program Requirements for Residency that “…residents must receive training and experience in…understanding of healthcare disparities” and participate in “…activities aimed at reducing healthcare disparities.” ¹⁰ To address this need, the Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) consortium was established to develop and study such a curriculum. PACTS is a National Institute on Minority Health and Health Disparities funded (R01MD011685), multi-institutional trial designed to develop and assess a cultural dexterity curriculum for surgical residents. The curriculum is founded on three pillars of cultural dexterity: empathy, curiosity, and respect. We implemented the curriculum over 12 to 18 months at 8 participating residency programs and followed a “flipped classroom” model, consisting of: online, self-paced e-learning modules, case explorations, resident evaluation through objective structured clinical exams (OSCEs), and spaced education. The PACTS values are incorporated throughout the curriculum as residents learn to explore patients’ perspectives, be open to different perspectives, and demonstrate understanding (Figure 1). In the case explorations, residents role play as patients and clinicians working through challenging communication scenarios to improve their ability to explore different perspectives and receive feedback on their ability to demonstrate understanding.

The PACTS curriculum focuses on four main aspects of culturally dexterous care: building trust, optimizing communication with patients with limited English proficiency, informed consent, and management of pain. These areas of focus were chosen after a multi-institutional qualitative interview of patients, surgical residents and faculty focused on identification of areas in need of improvement in cross-cultural care. Residents are first exposed to foundational concepts through online modules. These online modules are interactive and include early exposure to important terms and animated vignettes to demonstrate how foundational concepts relate to real clinical scenarios. In small groups proctored by a faculty member, residents role-play realistic clinical scenarios and practice specific skills, such as effective use of an interpreter and of the “teach back” method to obtain informed consent. Residents discuss personal and/or larger institutional factors that serve as barriers to care, and they share solutions and best practices that they have found effective in mitigating these factors. Following online and small group learning, residents then undergo spaced learning, consisting of case-based vignette questions, over the ensuing four weeks.

While the PACTS trial is still ongoing, baseline data obtained as a part of the trial show that over 30% of patients receiving care at the 8 large, academic medical centers participating in the trial reported that they did not receive culturally dexterous care, with Black patients more likely to report poorly dexterous care than White patients.¹¹ The PACTS trial has demonstrated a need to improve the cultural dexterity of surgical teams. This improvement is necessary to benefit not only patients but also diverse providers. Black surgical residents participating in the PACTS trial reported four times higher levels of perceived discrimination daily,¹² a finding concordant with other studies demonstrating physicians of color experience significant discrimination in their work environments.¹³ Studies are currently ongoing to evaluate how the interventions of the PACTS trial have been successful in leading to improved understanding of the lived experiences of individuals from racial and ethnic minority groups, which is essential to making our surgical training environment more welcoming and inclusive.

Resident physicians care for surgical patients in all areas of the hospital. They are frequently the first face of surgical care that patients see, rounding on a patient daily, managing their pain, and performing informed consent. They lead discussions with patient’s families and navigate difficult conversations about operative complications or goals of care. Growing numbers of residents in surgery are members of historically marginalized groups.¹⁴ While physicians of color are more likely to provide critical access care to racial and ethnic minority groups,¹⁵ it is important that we do not expect these physicians to shoulder this burden alone. It should be our expectation that all residents are able to provide culturally dexterous care to patients of all backgrounds.

We globally assess residents with respect to their interpersonal and communication skills. However, it is critical that we more specifically assess their skills in communicating with patients with limited English language proficiency and those with distrust or historically poor experiences with the healthcare system. Just as we teach residents how to perform the steps of an operation safely and competently and how to communicate with the operating room staff, we must also teach them how to effectively communicate with—and gain the trust of—patients of diverse backgrounds, employing the core values of curiosity, respect, and empathy. We hope that the results of the PACTS trial will demonstrate the effectiveness of our cultural dexterity curriculum in improving our patients’ perception of the care that they receive and perhaps even of their actual surgical outcomes. Furthermore, we look forward to the day when this curriculum is offered to all surgical residents across the country as we seek to eliminate the disparities in healthcare that exist in our country and across the globe.

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Katharine E. Caldwell, Department of Surgery, Washington University School of Medicine, Saint Louis, MO

Jorge G. Zarate Rodriguez, Department of Surgery, Washington University School of Medicine, Saint Louis, MO

Paul E. Wise, Department of Surgery, Washington University School of Medicine, Saint Louis, MO

Emma Reidy, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA

Gezzer Ortega, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA; Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

John T. Mullen, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Douglas S. Smink, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA; Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

PACTS Trial Research Group