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Dental Students’ Attitudes Toward Treating Diverse Patients: Effects of a Cross-Cultural Patient-Instructor Program

Key words: culture, diversity, dentistry, education, attitudes

Submitted for publication 01/31/08; accepted 06/25/08

	Abstract

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This article describes the effects of a cross-cultural patient-instructor (PI) program on dental students’ attitudes toward diversity. PIs were individuals from the community trained to portray specific simulated patients who presented cross-cultural challenges to students. Dental students interviewed PIs during two rotations, one in their junior and one in their senior year. Using a retrospective pretest-posttest design, after completing each rotation, students reported their likelihood of engaging in certain desirable diversity thoughts and actions before versus after each PI rotation. Seventy-three students completed the first cross-cultural rotation, and eighty-two students completed the second. Each rotation improved students’ diversity-related attitudes. The first rotation, in their junior year, had slightly greater effect on these outcomes than the second rotation, in their senior year. Students also reported very positive evaluations of the course. These findings suggest that students’ attitudes toward diversity can be modified. PIs are a creative way to promote cross-cultural patient care with health professions students, making them more open to thinking about, discussing, and engaging in patient-oriented, diversity-related activities.

Dentists are not immune to communication problems with patients from other cultures. Koerber et al. compared orthodontic resident communication with minority and European American patients.⁹ They found that residents used more close-ended questions, were in less agreement with, and were more task-oriented with their minority patients than with their European American patients, among other differences.

Based on this and related literature, education to improve communication in cross-cultural encounters has been recommended for all health care providers.¹⁰ We have documented that most dental students appreciate the importance of patient culture in the provision of dental care, yet many enter their clinical years lacking knowledge about the cultures of patients they are likely to treat in practice,¹¹ as well as the skills necessary to effectively engage in cross-cultural interactions with their patients.¹² Cross-cultural communication has therefore become a focus of the undergraduate dental curriculum at the University of Connecticut School of Dental Medicine (UConn SDM).

One component of this curriculum is the patient-instructor rotations. Patient-instructors teach communication skills in standardized role-playing scenarios. This learning environment is safe for patients because they are actors and safe for students because they are given feedback about their cross-cultural communication skills in a supportive and constructive manner. We and others have demonstrated that PIs are an effective way of teaching cross-cultural communication skills to dental and medical students.^12–14 That is, PIs have been shown to improve interviewing techniques and the elicitation and delivery of pertinent information. However, the effect of cross-cultural PI teaching on students’ attitudes about diversity is unknown. Furthermore, students’ reactions to the use of PIs for teaching cross-cultural skills per se are not well described. The aims of the study reported in this article were to 1) investigate the PI program’s effect on students’ self-reported diversity-related attitudes and 2) report student satisfaction with the program.

	Methods

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Patient-Instructors
The UConn SDM patient-instructor rotations have been described in detail in an article that appeared in the December 2007 issue of the Journal of Dental Education.¹² Briefly, patient-instructors (PIs) are individuals from the community who are drawn from diverse racial, ethnic, and socioeconomic groups. They typically work on a part-time basis and are paid an hourly wage. Because the UConn School of Medicine has a longstanding PI program, the SDM PIs are usually hired through word-of-mouth from current PIs. PIs have various backgrounds, but are often current or retired teachers, actors, and health care professionals.

PIs are trained extensively to portray fictional patients with specific histories and presentations, and they also receive training in how to evaluate student performance. Evaluation of students is based on a predetermined checklist of topics the student is expected to cover during the interview, as well as a standardized rating scale of communication style. These have been described previously.¹² The fictional patient case history is written to include a chief complaint, medical, dental, and social histories, and cultural characteristics that are likely to broaden students’ communication skills. Challenging cultural characteristics might include beliefs about oral health and use of alternative healing strategies, differences in cultural values, attitudes toward health care providers, English as a second language, and insurance status. These case characteristics are consistent with a recent review by Schouten and Meeuwesen that identified several key predictors of culture-related communication problems, including cultural differences in explanatory models of health and illness, differences in cultural values, cultural differences in patients’ preferences for doctor-patient relationships, racism/perceptual biases, and linguistic barriers.¹⁵

Depending upon the case, the student might be expected to address the need for an interpreter, assess the patient’s beliefs about the cause and course of the presenting problem, assess the patient’s practices for treating the problem, invite the patient to include additional health care decision makers (e.g., family members) in treatment planning, assess any beliefs that might interfere with treatment, and address any insurance or financial issues. PIs for the programs reported here included individuals from Central and South America, eastern Europe and the former Soviet Union, Africa, India, and Asia. Development of the cases is an iterative process, with both the faculty and PIs contributing to the case.

Procedures
Students conduct clinical interviews with the patient-instructors during a mock appointment. Students are aware that the encounter is simulated, and they are also aware that their performance is being evaluated. Each PI evaluates the content and process of the interview, as well as the student’s ability to elicit and appropriately respond to cultural aspects of the case. Then, the patient-instructor gives the student immediate, individualized, and detailed feedback about his or her interviewing skills, interpersonal style, and ascertainment of information specific to that case. During feedback, student strengths and weaknesses are discussed from the perspective of both student and PI, and students are given the opportunity to role-play again the most important weaknesses. Clinical dental and behavioral science faculty preceptors observe students in real time via audiovisual equipment, and they also provide feedback to students at the end of each rotation during a small group debriefing session.

At the beginning of their junior year, students participate in an introductory PI rotation. They interview three patient-instructors (twenty minutes each) over the course of an afternoon. This exercise orients the student to the PI experience and helps attenuate anxiety about the exercises in general. These cases offer the student the chance to practice basic interviewing skills. However, these scenarios do not have a cross-cultural emphasis and therefore are not the focus of this article. In the spring of their junior year, students participate in their first cross-cultural PI rotation. Students interview four new PIs who present the student with cross-cultural communication challenges. In the fall of their senior year, students participate in their second cross-cultural PI rotation. Students interview five new diverse patient-instructors who present different cross-cultural communication challenges from those the students experienced in the junior year. In each rotation, students interview PIs in a round-robin session, so that the difficulty of each case is counterbalanced across students.

Data collection for this study occurred as follows. In the spring of their junior year, students completed their first cross-cultural PI rotation in a half-day experience. At the conclusion of that rotation, students completed questionnaires. The questionnaires included a retrospective pretest, a posttest, and a satisfaction survey. This same procedure occurred again when students completed their second cross-cultural PI rotation in the fall of their senior year. Evaluation of this program was approved by the University of Connecticut Institutional Review Board (IRB).

Study Design
This investigation employed a retrospective pretest-posttest design. The retrospective design was specifically chosen in order to account for a phenomenon in self-report research called "response shift." In essence, response shift posits that people may adjust how they self-report a given construct, such as attitudes toward diversity, when they encounter relevant new information about that construct.¹⁶ The self-report may change due to a) a redefinition of the concept (e.g., reconceptualization of what diversity actually is); b) a change in values (e.g., change in the perceived importance of diversity); and/or c) a change in internal standards of measurement (e.g., applying a new yardstick for measuring one’s own diversity-related attitudes). Learning experiences are designed to transmit new skills, knowledge, or understanding with which the participants are originally unfamiliar. Therefore, traditional pretests can yield biased results. Response shift has occurred when, after a class, learners express a sentiment to the effect of "Before this class, I didn’t realize how much I didn’t understand." When this occurs, it can be difficult to detect improvement using a typical pretest-posttest design. Therefore, assessing the effects of an intervention that may produce response shift requires specific assessment approaches.

Among the many response shift assessment approaches available, the retrospective posttest design approach is one of the most commonly used.¹⁷ This quasi-experimental design was first described by Campbell and Stanley.¹⁸ This design is a well-established method in the education discipline that is also gaining wider use in the social sciences. Most recent research has covered the application of this method to testing the effectiveness of achieving program outcomes when interventions such as training programs are implemented. The retrospective post-test accounts for changes in definition, values, and internal standards of measurement. At the posttest session, participants fill out the self-report measure twice. First, they report how they perceive themselves at the present (conventional posttest). Immediately after (i.e., less than a minute later), they also provide a judgment about their baseline level (retrospective posttest). By taking the pretest and posttest in temporally close succession, it is assumed that these measures will be completed with respect to the same definition, values, and internal standard of measurement. Essentially, the participants find out during the learning experience what they know or don’t know and then can give accurate pretest as well as posttest estimates.¹⁹

This study design is widely used for program evaluation, wherein learners tend to overestimate their baseline ability. For example, Pratt et al. investigated the effects of a child abuse prevention program on behaviors of new mothers.²⁰ Results showed that when response shift bias was present, traditional pretest-posttest comparisons resulted in an underestimation of program effects. Similarly, Lamb and Tschillard compared a traditional pretest-posttest design with a retrospective pretest-posttest design in their ability to evaluate a teacher training program.¹⁹ Results suggest that the traditional pretest underestimated the impact of the workshop on participants’ learning.

Hill and Betz argue that both the conventional pretest and the retrospective pretest entail some source of bias and that the choice depends on the goals of the researchers.²¹ Among the many considerations is the nature of the questionnaire. Asking respondents to reveal sensitive information (e.g., attitudes toward diversity) is "at best unrealistic (i.e., [respondents] will not report openly) and at worst offensive." Second, if having participants reflect on the content of the program is important, then a retrospective pretest may be preferable. Completing retrospective ratings at posttest provides participants an opportunity to reflect on how much they have learned or changed. Comparing "then" and "now" ratings may reinforce feelings of efficacy and become a part of the learning experience of the program. A retrospective test is therefore useful for providers who want to promote this type of reflection at the end of a program. More generally, if a goal of evaluation is to describe change as experienced subjectively by intervention participants, a retrospective pretest is more appropriate. Conventional pretests may better capture change in objective skills, knowledge, or behaviors. Retrospective tests, on the other hand, explicitly and implicitly ask respondents to report how much they think they have changed between then and now.²² If the aim is to understand how participants feel about their personal growth, the retrospective test provides a more direct assessment of these factors.

Outcome Measures
Two student outcomes are described in this article. First, we investigated changes in students’ diversity-related attitudes and behaviors, which were measured with a self-report scale. Second, we investigated student satisfaction with the program, which was measured with a different self-report scale.

Diversity-Related Attitudes and Behaviors.
A cross-cultural training evaluation measure developed by Welch was used to evaluate the effect of the PI program on students’ diversity-related attitudes.²³ The measure is designed to retrospectively evaluate the effect of cross-cultural training programs. Students responded to the question "PRIOR to the patient-instructor program, how likely were you to engage in the following activities or mental processes?" Then they immediately responded to the question "IN THE FUTURE, how likely do you think you will be able to engage in the following activities or mental processes?" Sample items are "incorporate or initiate discussions of diversity-related issues into your teaching, work, or practice" and "feel at ease with people of diverse backgrounds." Responses are on a six-point Likert scale, with 1=extremely unlikely and 6=extremely likely. Responses were summed and averaged, with higher scores indicating desirable attitudes. Two reverse-scored items (items for which a high score indicates negative diversity attitudes, rather than positive diversity attitudes) were omitted because they showed poor reliability with the other six items. The resulting six-item scale showed good internal consistency; coefficient alpha in this sample for the PRIOR scale was .80 and for the FUTURE scale was .79.

Student Satisfaction.
A twelve-item survey designed by one of the authors (CAP) was used to assess student satisfaction with rotations. Sample items included "the patient-instructor encounters were a good way for me to improve my interviewing skills" and "the patient-instructor encounters provided useful feedback on my skills." Responses were provided on a five-point Likert scale, with higher scores indicating greater satisfaction. Responses were summed and averaged. Coefficient alpha in this sample was .93, indicating excellent internal consistency.

Analyses
The PI rotations are required at the University of Connecticut School of Dental Medicine. Two graduating classes completed both cross-cultural rotations. One graduating class averaged twenty-five years of age, 54 percent were female, 61 percent were from New England, and the class had the following racial/ethnic composition: 66 percent white, 12 percent black, 10 percent Asian/Pacific Islander, 7 percent Hispanic, and 5 percent other or did not report. Another graduating class averaged twenty-six years of age, 37 percent were female, 47 percent were from New England, and the class had the following racial/ethnic composition: 63 percent white, 13 percent black, 3 percent Asian/Pacific Islander, 13 percent Hispanic, and 8 percent other or did not report. The first cross-cultural rotation was completed by a total of seventy-three students; the second cross-cultural rotation was completed by a total of eighty-two students.

To investigate differences in student diversity attitudes, a 2 (PRIOR to the program vs IN THE FUTURE) by 2 (first rotation vs second rotation) repeated measures ANOVA was performed, with diversity attitude scores as the dependent variable. To evaluate student satisfaction, an ANOVA was performed, with rotation as the independent variable and student satisfaction scores as the dependent variable. Evaluation of potential differences between graduating classes on the attitudes and behaviors scale was investigated. No differences were found, so further analyses collapsed the two classes into one group. Evaluation of assumptions of normality and skewness were satisfactory. Data were analyzed using SPSS.

	Results

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Overall, students held desirable attitudes toward diversity (M=4.4, SD=0.8, range 1–6). This indicates that, overall, students rate themselves as "somewhat likely" to "very likely" to engage in diversity-related thoughts and behaviors.

Figure 1 shows the mean diversity attitude scores for the two cross-cultural PI rotations. Analysis showed a significant main effect for the PI program on diversity scores, F(1,153)=130.97, p<.05. Students’ desirable diversity attitudes were lower prior to the PI program than were projected for the future. Analysis showed a trend for an interaction of the PI program by rotation, F(1,153)=3.69, p=.06, indicating a tendency for students to improve differently across the two rotations. Students’ diversity attitudes improved marginally more on their first rotation (M=4.3 past vs M=4.0) than on their second rotation (M=4.5 vs M=4.9).

View larger version (6K): [in this window] [in a new window]   Figure 1. Prior and future diversity attitudes by rotation

In each analysis, when graduating class was entered as a covariate, it was unrelated to the respective outcome.

	Discussion

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Our main findings are the following: 1) each PI rotation resulted in improved diversity-related attitudes and behaviors; 2) improvement was marginally greater during the first rotation; 3) some of the improvement after the first PI rotation was lost, but still remained above baseline levels; and 4) students reported overall high satisfaction with the cross-cultural PI experience that decreased from the first rotation to the second.

The cross-cultural PI program is designed not only to teach facts about specific cultures that students are likely to encounter, but also to increase sensitivity to and appreciation for cultural differences. Compared to before the PI program, after the PI program students reported improved attitudes toward diversity such as noticing the influence of stereotypes on their own thoughts, feelings, and behaviors. This is likely the product of discussing the patient’s culture as it relates to oral health and oral health care in the context of a clinically relevant encounter.

Previous reports have documented positive student reactions to and satisfaction with PI programs.²⁴ Our findings show that students report decreasing, though overall positive, satisfaction with the program from their junior year to senior year. This is consistent with a report by Croft et al. that showed that students found patient-instructor experiences more enjoyable and more valuable earlier in their academic curriculum.²⁵ The decline in student satisfaction found in our study may reflect several factors, including increasing difficulty of the cases across rotations, boredom with the program over time, or decreased receptivity to feedback from PIs.

Limitations
There are several limitations to this study that should be noted. First, we relied on student self-report, and there was no objective measure of students’ diversity-related behavior. Improved attitudes may not necessarily lead to improved diversity-related behaviors with patients, colleagues, or others. Second, the time frame for the posttest was immediately following the PI session. Thus, long-term effects on attitudes are unknown. Third, while the surveys were anonymous, social desirability may nonetheless have influenced responses. On a related note, because we collected anonymous surveys, we were not able to investigate predictors of change in attitudes. We cannot say, for example, whether men vs. women or foreign-born vs. United States-born dental students benefited most from the PI program. Fourth, these results may not generalize to other students. Specifically, the University of Connecticut PI program occurs in the context of diversity-related, didactic, small group seminar and clinical experiences. Thus, these other curriculum components may also be affecting attitudes such that the effect of a cross-cultural PI program in isolation could be very different from that reported here. Finally, like all research designs, the retrospective pretest design entails some sources of bias. Hill and Betz state that retrospective pretests are vulnerable to motivational biases, i.e., systematic cognitive biases.²¹ Respondents may be motivated to report personal growth (present "now" self better than "past" self) and to justify the effort that they put into the program by reporting benefits. These biases may have been present in our study. Despite these limitations, strengths of this study include 1) its unique focus on diversity-related attitudes, 2) its use of a retrospective design that accounts for response shift, and 3) its observation of two classes of students over two rotations.

In conclusion, a cross-cultural PI program improved dental students’ attitudes toward diversity and was evaluated positively by students. Future research should investigate the effects of PI training on students’ directly observable diversity-related behaviors with patients in clinic.

Practice Implications
Improving student attitudes toward diversity is at least as important as improving their cross-cultural communication skills. Dentists in a teaching role should be aware that attitudes are modifiable, and that the curriculum can be presented in a way that is satisfactory, and indeed enjoyable, to students. Patient-instructors are one method for promoting culturally sensitive patient care.

	Author Information

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Dr. Wagner is Associate Professor, Division of Behavioral Sciences and Community Health, School of Dental Medicine; Dr. Arteaga is Associate Clinical Professor, Division of Prosthodontics and Operative Dentistry, School of Dental Medicine; Dr. D’Ambrosio is Associate Professor and Chair, Division of Oral Medicine, School of Dental Medicine; Dr. Hodge is Associate Professor, Division of Behavioral Sciences and Community Health, and Associate Dean, Office of Community and Outreach Programs, School of Dental Medicine; Dr. Ioannidou is Assistant Professor, Division of Periodontology, School of Dental Medicine; Dr. Pfeiffer is Professor, Department of Medicine and Director, Clinical Skills Assessment Program, School of Medicine; and Dr. Reisine is Professor, Associate Dean for Research, Chair of Division of Behavioral Sciences and Community Health, and Head of Department of Oral Health and Diagnostic Sciences, School of Dental Medicine—all at the University of Connecticut Health Center. Direct correspondence and requests for reprints to Dr. Julie Wagner, Division of Behavioral Sciences and Community Health, MC3910, School of Dental Medicine, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030; 860-679-4508 phone; 860-679-1342 fax; juwagner{at}uchc.edu.

This study was supported through a grant from the Robert Wood Johnson Foundation.

	REFERENCES

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