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The Impact of Cultural Dexterity Training on Surgical Residents’ Knowledge, Cross-Cultural Care, Skills, and Beliefs: The PACTS Trial
Douglas Smink1, *Gezzer Ortega2, *Brittany Dacier2, *Emil Petrusa3, *Yu-Jen Chen2, *Namra Shaikh4, *Benjamin Allar2, *Maria Chun5, *Alexander Green3, *Katharine Caldwell6, *Rachel Atkinson2, *Emma Reidy2, *Olubode Olufajo7, L.D. Britt8, *Molly Brittain8, *Jorge Zárate Rodriguez6, *Sandra Swoboda9, Edward Cornwell7, *Kenneth Lynch10, *Paul Wise6, David Harrington10, *Tara Kent11, John Mullen3, *Pamela Lipsett9, Adil Haider4
1Department of Surgery, Brigham and Women's Hospital, Boston, MA; 2Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; 3Department of Surgery, Massachusetts General Hospital, Boston, MA; 4Aga Khan University, Karachi, Pakistan; 5Department of Surgery, University of Hawaii, Honolulu, HI; 6Department of Surgery, Barnes-Jewish Hospital, St. Louis, MO; 7Department of Surgery, Howard University Hospital, Washington, ; 8Department of Surgery, Sentara Norfolk General Hospital, Norfolk, VA; 9Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; 10Department of Surgery, Rhode Island Hospital, Providence, RI; 11Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA

OBJECTIVES: Healthcare disparities directly impact surgical care and negatively influence outcomes. Cross-cultural training of healthcare providers has been identified as a way to limit outcome disparities, however there is little evidence of their effectiveness in Surgery. This study examines the impact of the Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents’ knowledge, cross-cultural care, skills, and beliefs.
METHODS: The PACTS curriculum was designed to improve knowledge, perceived preparedness to provide cross-cultural care, skills, and beliefs of clinically active surgical residents in post-graduate years (PGY) 1-5. The curriculum focuses on building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. PACTS was a randomized crossover trial with an intention to treat analysis at 8 academic general surgery residencies in the United States: 4 were randomized to the Early Sites Group (“ESG?, receiving the PACTS curriculum between Periods 1 and 2), and 4 were randomized to the Delayed Sites Group (“DSG?, receiving the PACTS curriculum between Periods 2 and 3). Residents were assessed before and after the intervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs using published and novel surveys. Analysis used chi-square and Fisher’s exact tests to evaluate within- and between-intervention group differences before and after the curriculum. The PACTS curriculum occurred during the COVID-19 pandemic and during a time when health equity awareness was heightened, so the curriculum was expanded from 12 to 18 months and shifted to a virtual format during Periods 2 and 3.
RESULTS: Of the 406 residents enrolled in the study, 315 were exposed to the complete PACTS curriculum. Demographics included male (50.2%), PGY1-2 (57.5%), White (51.8%), Asian (15.2%), Black (10.8%) and Hispanic (8.25%) residents. ESG residents had higher Knowledge scores after the PACTS curriculum, though this was not statistically significant (71.3% to 74.3%, p = 0.0661). ESG residents’ Cross-Cultural Care (79.6% to 88.2%, p<0.0001), Self-Assessed Skills (74.5% to 85.0%, p<0.0001), and Beliefs (89.6% to 92.4%, p=0.0028) improved after the PACTS curriculum. DSG resident scores pre- to post-PACTS (Period 2 vs Period 3) showed minimal improvements in all 4 domains. At Period 2, ESG residents had a modest improvement in all 4 assessment areas when compared to DSG residents; the increase in Beliefs was statistically significant (ESG 92.4% vs DSG 89.9%, p=0.0199).
CONCLUSION: Training the next generation of culturally dexterous surgeons is a necessary step in mitigating surgical disparities. The PACTS curriculum is a comprehensive tool that equips surgical residents with the skills needed to care for a diverse patient population.

Table 1. Resident Assessment Evaluation at Early Sites, and Comparison of Early and Delayed Sites
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