The U.S. Census Bureau’s 2014 National Projections estimated that by 2044, more than half of all Americans will belong to a racial/ethnic minority group and by 2060 one in five of the nation’s population will be foreign-born [1]. The Surgeon General’s Supplement to the Report on Mental Health: Culture, Race and Ethnicity in 2001 sparked increased awareness of and interest in health disparities and the relationship of culture and mental health [2]. An individual’s cultural background influences the presentation of mental health symptoms, care-seeking behaviors, treatment expectations, and communication between patients and providers.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes a revised Outline for Cultural Formulation (OCF) that assesses culture across four domains: (1) Cultural identity of the individual, (2) Cultural conceptualizations of distress, (3) Psychosocial stressors and cultural features of vulnerability and resilience, and (4) Cultural features of the relationship between the individual and the clinician; and a fifth section summarizes this information into an overall cultural assessment [3]. In an effort to guide clinicians in the use of the OCF, the DSM-5 Cross-Cultural Issues Subgroup developed the Cultural Formulation Interview (CFI) as a standard, semi-structured interview with 16 questions and probes to facilitate gathering information from the patient on cultural issues [4].

The CFI can be used with cultural minorities in an effort to address healthcare disparities and it can also guide the care of mainstream population by eliciting their person-centered, cultural views of illness and treatment. The Psychiatry Milestones Project from ACGME (Accreditation Council of Graduate Medical Education) specifies milestones for several aspects of cultural competence [5]. Residency programs will need to create methods to document attainment of these cultural competence milestones. We propose the use of an objective standardized clinical examination (OSCE) as an effective tool to teach trainees how to use the CFI to assess patients’ cultural views of illness and treatment and properly use interpreters. By participating in this OSCE, trainees can demonstrate acquisition of milestones with patients from mainstream and diverse ethno-racial and sociocultural backgrounds and the ability to formulate a clinical diagnosis taking sociocultural issues into account. They can also demonstrate professionalism by showing compassion, respect for others, and sensitivity and responsiveness to a diverse population.

Methods

Seventeen psychiatry residents and fellows (PGY-1 through PGY-6) in the University of Massachusetts Medical School (UMass) psychiatry residency program participated in two small-group culturally appropriate assessment OSCE exercises designed to practice exploration of cultural and religious aspects of the patient’s symptoms using the CFI. Culturally appropriate assessment was defined as a patient evaluation that takes into account the patient’s cultural and ethnic background, beliefs, social context, their role in the therapeutic relationship, and the patient’s attitude towards care. Two English-speaking standardized patients portrayed case 1. Due to a shortage of Spanish-speaking standardized patients (SPs), two volunteers with backgrounds in health and mental health were trained to become SPs and portrayed case 2. Two professional Spanish-speaking medical interpreters also donated their time and services.

Prior to this exercise, 25 % of participants had participated in three or more didactic sessions on cultural psychiatry, 62.5 % had one to two sessions and 12.5 % did not recall any sessions. Trainees received a copy of the CFI and guidelines for the appropriate use of interpreters provided by the UMass Interpreter Services office. They received a copy of the CFI to use during the interview. The group was divided into eight subgroups of 2–3 and each subgroup was assigned to interview one of the SPs and observe their peers interviewing the other SP. A two faculty members, a visiting expert on cultural psychiatry (RLF), and the creator of the OSCE observed the interviews via closed-circuit video and used the CFI questionnaire to evaluate the interview content.

Case 1

An English-speaking middle-aged man was brought to the hospital by his pastor, with pain, burning with urination, and fever. He was diagnosed with pyelonephritis and admitted for intravenous fluids and antibiotics. However, the patient refused treatment and claimed, “The Lord will heal me.” Per the medical team, he exhibited psychotic symptoms and acted bizarrely. The team requested a psychosomatic medicine consultation for evaluation of capacity to refuse treatment. His “bizarre behavior” included praying, praising the Lord repetitively, suspiciousness, and reports of auditory hallucinations.

The goals for this case were for trainees to ask about particular beliefs relating to his refusal of treatment, identify normative behavior, such as praying, praising the Lord vs. psychotic behavior, such as paranoia and disorganization; identify the need to obtain collateral information from community members, determine appropriate interventions and level of care, and present a cultural formulation.

Case 2

A Spanish-speaking middle-aged woman was brought to the emergency mental health by ambulance for evaluation of loss of consciousness. The patient had been at a family gathering when her oldest son was disrespectful to her and they began arguing. The patient started to yell and physically attacked her son, punching him in the arms. She began to shake and fell to the floor, losing consciousness shortly thereafter. Her landlord called 911 and she was taken to the emergency department where she was medically cleared and sent to the emergency mental health for further evaluation.

The goals for this case were for trainees to correctly identify a cultural syndrome (ataque de nervios), determine the level of intervention needed and treatment plan, correctly use a Spanish-language interpreter, and present a cultural formulation.

After completing the OSCE, each subgroup of trainees were assigned a specific subsection of the outline for cultural formulation for one of the two patients and asked to present it to the faculty, residents, and fellows so that by the end of the session, the entire CFI had been presented and discussed for each patient by the entire group. Trainees received feedback from the visiting cultural psychiatry expert and other faculty on their interviewing styles and use of the CFI. Trainee participants were surveyed about their comfort with the use of the Cultural Formulation Interview, self-perception of competence working with medical interpreters, and their practice of exploring cultural and religious issues with patients before and after the exercise. Sixteen participants completed the 7-question survey within a week of the exercise but one refrained from answering questions. The survey was conducted using a 5-point Likert scale (strongly disagree to strongly agree). The average number of participants who responded with “agree” or “strongly agree” to statements assessing comfort level with cultural interview skills and competence with the use of interpreters before and after the OSCE were compared using paired t tests using STATA 13.0 (College Station, TX) statistical software.

Results

Sixteen of seventeen residents completed both the pre- and post-test surveys. Results of the paired t tests (N = 16) show that the mean level of comfort with the Cultural Formulation Interview differed before (M = 3.56, SD = 1.2) and after (M = 4.06, SD = 0.68) the course (t = 3.16, df = 15, p = 0.01, 95 % CI for mean difference = 0.163–0.837). On average, the level of comfort was 0.5 points higher after the course. There were no significant changes in the level of interpreter use competency before and after the course (M = 4.19; SD = 0.66 vs. M = 4.38, SD = 0.50). 62.5 of the participants reported exploring the relationship of cultural and religious background to the patient’s symptoms, diagnosis. and treatment prior to this exercise. One hundred percent of the participants reported planning to explore this relationship in patient encounters after having participated in the OSCE.

Three fourths of participants planned to make changes to their practice after participating in the OSCE and 87.5 % found the OSCE format to be effective for teaching cultural formulation and proper use of interpreters. Trainees also provided feedback on the exercise and suggestions for improvement. They reported enjoying the variety of the cases, the group interview format, observing colleagues in an active environment, using the CFI, and the visiting professor’s debriefing and group discussion. Participants suggested that this exercise would have been helpful in the beginning years of training. Some, despite finding the CFI useful, raised concerns about how to implement this interview given the time constraints in clinical encounters. Faculty feedback indicated that the exercise helped them appreciate the importance of teaching these topics and helping trainees feel comfortable exploring cultural and religious aspects of patient care.

Discussion

Psychiatrists should understand how psychiatric symptoms differ among diverse populations. Although there are no standardized teaching and assessment methods for learning cultural humility [6], several curricula, interviewing approaches, and treatment planning formats that take patients’ and families’ culture into account have been published [7]. OSCEs have been used in other specialties and at the undergraduate level as an objective way to assess and develop these skills [8]. The UMass cultural OSCE prompted trainees to distinguish between normative religious beliefs and psychotic symptoms, and to correctly identify a cultural syndrome by exposing participants to cases that were relevant to their practice.

Despite theoretical information available in training and informal discussions about cultural issues during rounds or lectures, asking patients about their cultural background, immigration status, and religious beliefs can be out of the comfort zone for many trainees [9].

OSCE participants felt more comfortable using the Cultural Formulation Interview following the OSCE and noted plans to explore cultural issues with their patients after having the opportunity to practice these interviewing skills in a non-clinical setting. Trainees appreciated the opportunity to learn and practice the use of the CFI with standardized patients in a small-group format. However, they raised concerns about time needed during clinical encounters to implement this interview. The DSM-5 field trial of the CFI found that completion of the CFI takes about 20 min; however, it can be used within a 50-min intake because some of the information would have been gathered in other components of the traditional interview (HPI, PMH, family history, and social-developmental history). Despite the perceived time demand, conducting a culture-focused, person-centered interview early in care could reduce missed visits and non-adherence later. This hypothesis, however, still needs to be empirically tested.

The CFI-based assessment is pertinent to a number of milestones, including those subsumed by PC2 Psychiatric Formulation and Differential Diagnosis, those included in level 3 of the MK1 subcompetency in Development Through the Life Cycle, in MK2 Psychopathology, and in level 3 of ICS 2 Information Sharing. Based on the success of this exercise with residents and fellows, the UMass training leadership will explore including a similar OSCE experience in the intern orientation curriculum. However, as most trainees reported plans to make practice changes following this exercise, repeating a version of it with senior residents without the instructional or didactic portion may also be helpful in assessing achievement of cultural psychiatry milestones.

Implications for Educators

• The opportunity to practice how to inquire about cultural issues with standardized patients may help trainees feel more comfortable in exploring these issues during their patient encounters.

• The culturally appropriate assessment objective structured clinical examination may benefit in documenting resident achievement of specific culturally-related milestones in psychiatry training.

• The culturally appropriate assessment objective structured clinical examination is a useful tool for trainees to practice and become familiar with the use of the Cultural Formulation Interview.