suggested that most students were able to identify CAM as
alternative approaches to Western medicine, while culture was
consistently discussed in the context of differences in values,
beliefs, practices and social norms among different groups.
Despite these study limitations, our findings reinfo rce
existing literature about the power of the hidden curricu-
. For example, although role-modeling was not iden-
tified as an explicit clerkship learning objective, it emerged as a
powerful influence on learning, both negatively and positively.
Similarly, the concept of the culture of medicine was not part of
the clerkship’s formal objectives, yet it consistently appeared in
students’ written and discussion comments. Without the addi-
tion of the RP components, these and other influential dimen-
sions would have remained submerged.
We note that a few key ingredients are necessary to achieve
desired goals. First, students benefit from having interdisci-
plinary faculty facilitate discussions. While physician faculty
may add real-world credibility, “outsider” pers pect ives of
faculty trained in the social sciences and philosophy expands
their understanding of clinical issues. Second, the lack of
evaluative function of participating faculty creates an environ-
ment of safety and openness. Third, we found an incremental
approach of pedagogical value. Although our model runs the
risk of being perceived as “repetitive” or “redundant”, circling
back to clinical experiences through different modalities
(written, oral) and in different settings (individual vs. facilitated
group reflection) reduces the burden of multi-tasking, and
encourages Socratic self-discovery. We believe that this
approach is essential to stimulating critical thinking as
opposed to rote regurgitation and adopting “politically correct”
postures. This approach may allow students to develop practice
styles that incorporate carefully considered ethical conclusions
about interactions across cultures rather than simply imitating
faculty or residents. We believe that this model of RP, woven into
an existing curriculum, addresses the need for “critical con-
in the continuum of cultural competency training
toward the development of self-awareness. However, because
faculty themselves do not consistently practice RP at our
institution, we are not certain if adoption of RP as a habit by
physicians might enhance the effectiveness of our curriculum.
Finally, as noted in the Program Description, facilitator skills
needed to conduct the reflective practice sessions are easy to
acquire and maintain and no specific training is necessary.
In summary, integration of a brief RP curriculum occupying
only 2 hours of a required clerkship was feasible and highly
acceptable to students, and associated with more complex and
nuanced understanding and useful problem-solving of chal-
lenges frequently arising in cross-cultural encounters.
We speculate that this integrated model can be easily
incorporated into most clerkships to promote critical thinking
and consciousness about addressing health disparities
through improved quality of cross-cultural encounters. The
RP curriculum addresses content that is difficult to teach in
stand-alone blocks. What remains to be discovered is what
amount and quality of longitudinal exposure across clinical
training is needed to foster and maintain the practice of self-
reflection for lifelong learning.
Acknowledgements: This project was supported by a grant from the
National Institutes of Health (NIH), National Heart, Lung and Blood
Institute, award# K07 HL079256-01 “An Integrative, Evidence-based
Model of Cultural Competency Training in Latino Health across the
Continuum of Medical Education” (2004–9) and from the Association of
American Medical Colleges (AAMC) grant initiative “Enhancing Cultur-
al Competence in Medica l Schools” (2 005–8) supported by the
California Endowment. The contents are solely the responsibility of
the authors and do not necessarily represent the official views of the
NIH or AAMC. The authors gratefully acknowledge the invaluable
contributions of Loretta Garcia and Jennifer Encinas for data collection
and management, and the support of clerkship director David
Conflict of Interest Statement: None disclosed.
Corresponding Author: Desiree Lie, MD, MSED; UCI - Department
of Family Medicine, University of California, Irvine, School of
Medicine, 101 The City Dr South, Bldg 200, Rm 512, Orange, CA
92868, USA (e-mail: email@example.com).
1. Smith WR, Betancourt JR, Wynia MK, et al. Recommendations for
teaching about racial and ethnic disparities in health and health care.
Ann Intern Med. 2007;147(9):654–65.
2. Kumagai AK, Lypson ML. Beyond cultural competence: critical con-
sciousness, social justice, and multicultural education. Acad Med.
3. Kagawa-Singer M, Kassim-Lakha S. A strategy to reduce cross-cultural
miscommunication and increase the likelihood of improving health
outcomes. Acad Med. 2003;78(6):577–87.
4. Hill CLA, MN PNR. Designing and evaluating interventions to eliminate
racial and ethnic disparities in health care. J Gen Intern Med. 2002;17
5. Rosen J, Spatz ES, Gaaserud AM, et al. A new approach to developing
cross-cultural communication skills. Med Teach. 2004;26(2):126–32.
6. Reynolds P, Kamei RK, Sundquist J, Khanna N, Palmer EJ, Palmer T.
Using the PRACTICE mnemonic to apply cultural competency to genetics
in medical education and patient care. Acad Med. 2005;80(12):1107–13.
7. American Association of Medical Colleges, Tool for Assessing Cultural
Competence Training (TACCT). http://www.aamc.org/meded/tacct/
start.htm. Accessed November, 2009.
8. Lie DA, Boker J, Cleveland E. Using the tool for assessing cultural
competence training (TACCT) to measure faculty and medical student
perceptions of cultural competence instruction in the first three years of
the curriculum. Acad Med. 2006;81(6):557–64.
9. Lie DA, Boker J, Crandall S, DeGannes CN, Elliott D, Henderson P, et
al. Revising the Tool for Assessing Cultural Competence Training (TACCT)
for curriculum evaluation: Findings derived from seven US schools and
expert consensus’. Medical Education Online. July 2008;13. http://www.
med-ed-online.org/volume13.php. Accessed November, 2009.
10. Haidet P, Hatem DS, Fecile ML, Stein HF, Haley HL, Kimmel B, et al.
The role of relationships in the professional formation of physicians: case
report and illustration of an elicitation technique. Patient Educ Couns.
11. Street RL Jr, O’Malley KJ, Cooper LA, Haidet P. Unders tanding
concordance in patient-physician relationships: personal and ethnic
dimensions of shared identity. Ann Fam Med. 2008;6(3):198–205.
12. Kelly PA, Haidet P. Physician overestimation of patient literacy: a potential
source of health care disparities. Patient Educ Couns. 2007;66(1):119–22.
13. Shapiro J, Lie DA, Gutierrez D, Zhuang G. That never would have
occurred to me”: a qualitative study of medical students’ views of a
cultural competence curriculum. BMC Med Educ. 2006;6:31.
14. Shapiro J, Morrison EH, Hollingshead J. Self-perceived attitudes and
skills of cultural competence: a comparison of family medicine and
internal medicine residents. Med Teach. 2003;25:327–29.
15. Branch WT Jr. Use of critical incident reports in medical education. A
perspective. J Gen Intern Med. 2005;20(11):1063–7.
16. Kind T, Everett VR, Ottolini M. Learning to connect: students’
reflections on doctor–patient interac tions. Patien t Educ Couns .
17. Fischer MA, Harrell HE, Haley HL, Cifu AS, Alper E, Johnson KM,
Hatem D. Between two worlds: a multi-institutional qualitative analysis
of students’ reflections on joining the medical profession. J Gen Intern
S124 Lie et al.: Reflective Practice for Cross-cultural Encounters JGIM