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Cultural Competence Training in US Medical Schools
... Studies note that health professionals report a lack of access to training that would help them meet the needs of LGBT clients and, even when training is available, it may not be mandatory (see Champaneria & Axtell, 2004;Lyons et al., 2010;Price et al., 2005). For example, one concern across some health professions (e.g., nursing or medicine) is that the evidence for the effectiveness of cultural competence training is lacking in methodological rigor in the design and evaluation of the trainings (Price et al., 2005). ...
... For example, one concern across some health professions (e.g., nursing or medicine) is that the evidence for the effectiveness of cultural competence training is lacking in methodological rigor in the design and evaluation of the trainings (Price et al., 2005). Similarly, although there has been a sharp increase in cultural competence curricula in medical schools from 1991 to 2000, difficulties remain with the assessment of the knowledge acquired during the cultural competence training of physicians (Champaneria & Axtell, 2004). In addition, the lack of a requirement that all students enroll in these prescribed trainings and cross-sectional evaluation designs add additional challenges. ...
A central part of providing evidence‐based practice is appropriate cultural competence to facilitate psychological assessment and intervention with diverse clients. At a minimum, cultural competence with lesbian, gay, bisexual, and transgender (LGBT) people involves adequate scientific and supervised practical training, with increasing depth and complexity across training levels. To further this goal, we offer 28 recommendations of minimum standards moving toward ideal training for LGBT‐specific cultural competence. We review and synthesize the relevant literature to achieve and assess competence across the various levels of training (doctoral, internship, postdoctoral, and beyond) in order to guide the field toward best practices. These recommendations are aligned with educational and practice guidelines set forth by the field and informed by other allied professions in order to provide a road map for programs, faculty, and trainees in improving the training of psychologists to work with LGBT individuals.
... What solutions can, then, be presented to tackle possible cultural malpractice, implicit bias, and, at the same time, provide a quality intercultural health service? Proper training would be a logical answer and counselling psychology graduate programmes in North America are required by the American Psychological Association to include cultural competence in the overall training (20). However, it would appear that this is relatively unique as, globally, few other accreditation or licensing boards make such requirements (21). ...
As healthcare systems are challenged to respond to the linguistic and cultural diversity that accompanies migrations, a common response is the deployment of the figure of the ‘intercultural mediator’ (ICM). This chapter will explore some of the key issues related to intercultural mediation that complicate the ICM being an effective component of interculturally competent mental health care. We provide a background of the rationale for the existence of the ICM and outline some of the serious factors, both conceptual and practical, which complicate matters, and explore the specific role possibilities for effective functioning in mental health care settings.
... 1 Although the concept of cultural competence (CC) made its way into the literature in the early 1990s, it was not until the IOM's report that CC became widely implemented into undergraduate medical education (UME) in hopes of combating health disparities. [2][3][4] Along with this trend, the Liaison Committee on Medical Education has made cultural competence a requirement in all undergraduate medical curriculums in the USA. 5 CC can be defined as a healthcare provider's (eg, a physician) understanding of how their own culture and the patient's culture can influence the patient-physician relationship along with the patient's health, behaviors, and decisions, and applying this knowledge to communicate with patients more effectively to deliver personalized care and ensure the best health outcomes. 6 It has been 15 years since the IOM's report and CC training made its way into medical education and little has changed. ...
Cultural competence (CC) training has become a required part of medical education to create future physicians dedicated to decreasing health disparities. However, current training seems to be inadequate as research has demonstrated gaps between CC training and clinical behaviors of students. One aspect that is potentially contributing to this gap is the lack of physician education of CC. Without it being something not only taught in the classroom, but also modeled and taught in the clinical setting, CC will continue to be a theoretical concept instead of a skill set that changes the way that future physicians interact with patients and make decisions about patient care. To change this, we propose the implementation of a Train the Trainer model in which the preclinical professor in charge of CC education trains Clerkship and Residency Directors who then can train and supervise the physicians and residents in their departments on CC to better implement it into the formal and informal curriculum of clerkships.
... However, Benn, Dagkas, and Jawad (2011) note the continuing gap between research on education and educational practice. One common approach to enhancing cultural sensitivity in professional practice is increased attention to knowledge of other cultures in curricula and courses (Champaneria & Axtell, 2004). Whatman et al. (2017) argue that including indigenous knowledge in the PETE curriculum could stimulate the kind of disruption and friction essential to growth in the discipline. ...
There is a growing body of research on cultural diversity, discrimination and racism in physical education teaching and practice. However, although ‘cultural diversity’ is a central concern in research, curriculum and policies of higher education, it is not clear how and in what ways students and teachers should consider cultural diversity. Drawing on qualitative interviews with teachers and students in a Norwegian physical education teacher education (PETE) programme, we investigate how and in what ways students and teachers regard cultural diversity in that context. We suggest that cultural diversity is not sufficiently understood when it is assumed that knowledge about particular positions or identity categories (white, black, minority, majority) is fixed. Our findings indicate that cultural diversity is visible in movement and in bodily resonance between people. These findings present a strong argument for recognition of the relational, embodied and social aspect of cultural diversity in PE.
... 1 The changing U.S. demographics drive the need for trained physicians able to deliver high-quality care to socioculturally diverse patients. 1,[7][8][9] Residency training is an important opportunity to train resident physicians on high-quality cross-cultural care, including educational content on health and healthcare disparities. 10 Previous studies of residents have shown them to not feel well prepared to provide cross-cultural care with associated factors, including limited training and role modeling. ...
Purpose: Training residents to deliver care to increasingly diverse patients in the United States is an important strategy to help alleviate racial and ethnic disparities in health outcomes. Cross-cultural care training of residents continues to present challenges. This study sought to explore the associations among residents' cross-cultural attitudes, preparedness, and knowledge about disparities to better elucidate possible training needs.
Methods: This cross-sectional study used web-based questionnaires from 2013 to 2014. Eighty-four internal medicine residency programs with 954 residents across the United States participated. The main outcome was perceived preparedness to care for sociocultural diverse patients.
Key Results: Regression analysis showed attitude toward cross-cultural care (beta coefficient [β]=0.57, 95% confidence interval [CI]: 0.49–0.64, p<0.001) and report of serving a large number of racial/ethnic minorities (β=0.90, 95% CI: 0.56–1.24, p<0.001), and low-socioeconomic status patients (β=0.74, 95% CI: 0.37–1.10, p<0.001) were positively associated with preparedness. Knowledge of disparities was poor and did not differ significantly across postgraduate year (PGY)-1, PGY-2, and PGY-3 residents (mean scores: 56%, 58%, and 55%, respectively; p=0.08).
Conclusion: Residents' knowledge of health and healthcare disparities is poor and does not improve during training. Residents' preparedness to provide cross-cultural care is directly associated with their attitude toward cross-cultural care and their level of exposure to patients from diverse sociocultural backgrounds. Future studies should examine the role of residents' cross-cultural care-related attitudes on their ability to care for diverse patients.
... In the US the Institute of Medicine recommended that all health professionals receive training in cultural competency [39]. At an undergraduate level the majority of medical schools in the US have incorporated cultural competency training in their curriculum [40]. Training in cultural competence involves teaching students how sociocultural factors, such as ethnicity, religion and sexual orientation interplay with healthcare provision [41]. ...
Purpose:
The aim of this study was to develop an instrument (University of Auckland General Practice Report of Educational Environment: UAGREE) with robust psychometric properties that measured the educational environment of undergraduate primary care. The questions were designed to incorporate measurements of the teaching of cultural competence.
Methods:
Following a structured consensus process and an initial pilot, a list of 55 questions was developed. All Year 5 and 6 students completing a primary care attachment at Auckland University were invited to complete the questionnaire. The results were analysed using exploratory factor analysis and confirmatory factor analysis resulting in a 16-item instrument.
Results:
Three factors were identified explaining 53% of the variance. The items' reliability within the factors were high (Learning: 0.894; Teaching: 0.871; Cultural competence: 0.857). Multiple groups analysis by gender; and separately across ethnic groups did not find significant differences between groups.
Conclusion:
UAGREE is a specific instrument measuring the undergraduate primary care educational environment. Its questions fit within established theoretical educational environment frameworks and the incorporation of cultural competence questions reflects the importance of teaching cultural competence within medicine. The psychometric properties of UAGREE suggest that it is a reliable and valid measure of the primary care education environment.
... Current frameworks primarily aim to integrate context-based, experiential learning about diversity (e.g., on axes of gender, race, class, age, sexuality, and ability) into medical education, seemingly motivated by the sense that exposing practitioners to simulations or descriptions of experience with diverse patients will result in less discrimination against marginalized groups in practice. Yet it remains unclear how to understand the mechanisms by which exposure in educational settings could change the practices of care providers or how best to chart improvements cultural competence programs provide (Champaneria and Axtell 2004). One of the most common "measures" of improved cultural competence in health care practice is physician or student self-reported increases in confidence and comfort (Kumas-Tan et al. 2007), but this metric seems inherently limited as it fails to address how unconscious assumptions and biases about queer and trans patients may persist. ...
This paper draws on findings from qualitative interviews with queer and trans patients and with physicians providing care to queer and trans patients in Halifax, Nova Scotia, Canada, to explore how routine practices of health care can perpetuate or challenge the marginalization of queers. One of the most common "measures" of improved cultural competence in health care practice is self-reported increases in confidence and comfort, though it seems unlikely that an increase in physician comfort levels with queer and trans patients will necessarily mean better health care for queers. More attention to current felt discomfort in patient-provider encounters is required. Policies and practices that avoid discomfort at all costs are not always helpful for care, and experiences of shared discomfort in queer health contexts are not always harmful.
... Ethics training as a part of medical education shows great variability in terms of content, timing, and form. (26,27).This is crucial as medical schools do produce a limited but important addition of public health professionals (28,29). ...
Ethics is a discipline, which primarily deals with what is moral and immoral behavior. Public Health Ethics is translation of ethical theories and concepts into practice to address complex multidimensional public health problems. The primary purpose of this paper was to conduct a narrative literature review-addressing role of ethics in developing curriculum in programs and schools of public health, ethics-related instruction in schools and programs of public health and the role of ethics in developing a competent public health workforce.
An open search of various health databases including Google scholar and Ebscohost yielded 15 articles related to use of ethics in public health practice or public health training and the salient features were reported.
Results indicated a variable amount of ethics' related training in schools and programs of public health along with public health practitioner training across the nation. Bioethics, medical ethics and public health ethics were found to be subspecialties' needing separate ethical frameworks to guide decision making.
Ethics based curricular and non-curricular training for emerging public health professionals from schools and programs of public health in the United States is extremely essential. In the current age of public health challenges faced in the United States and globally, to have an ethically untrained public health force is arguably, immoral and unethical and jeopardizes population health. There is an urgent need to develop innovative ethic based curriculums in academia as well as finding effective means to translate these curricular competencies into public health practice.
... Our results are congruent with other projects aimed at multi-cultural medical education1314151618,27,313233, and more specifically, health care for refugees [27,28]. These studies support the proposition that student attitudes about refugees change following coursework or clinical encounters with refugees. ...
There are growing numbers of refugees throughout the world. Refugee health is a relatively unstudied and rarely taught component of medical education. In response to this need, a Refugee Health Elective was begun. Medical student perceptions toward cultural aspects of medicine and refugee health before and after participation in the elective were measured.
Preliminary questionnaires were given to all preclinical students at the academic year commencement with follow-up questionnaires at the refugee elective's conclusion. Both questionnaires examined students' comfort in interacting with patients and familiarity with refugee medical issues, alternative medical practices, and social hindrances to medical care. The preliminary answers served as a control and follow-up questionnaire data were separated into participant/non-participant categories. All preclinical medical students at two Midwestern medical schools were provided the opportunity to participate in the Refugee Health Elective and surveys. The 3 data groups were compared using unadjusted and adjusted analysis techniques with the Kruskall-Wallis, Bonferroni and ANCOVA adjustment. P-values < 0.05 were considered significant.
408 and 403 students filled out the preliminary and follow-up questionnaires, respectfully, 42 of whom participated in the elective. Students considering themselves minorities or multilingual were more likely to participate. Elective participants were more likely to be able to recognize the medical/mental health issues common to refugees, to feel comfortable interacting with foreign-born patients, and to identify cultural differences in understanding medical/mental health conditions, after adjusting for minority or multilingual status.
As medical schools integrate a more multicultural curriculum, a Refugee Health Elective for preclinical students can enhance awareness and promote change in attitude toward medical/mental health issues common to refugees. This elective format offers tangible and effective avenues for these topics to be addressed.
... a for this training incorporate language training, interactive workshops, and adjunct clinical experiences in foreign countries or in North American regions with majority ethnic populations 5,6,8,27-31 Discussions about ethical and cultural traditions related to health beliefs improve students' understanding of the patient's outlook on health care. 5,6,8,24,27 Another component in current professional graduate education is the use of the humanities—such as art and literature—to foster cultural competency. 24-26 Despite existing curricula, as described above, cultural competency training for college students interested in health careers is scarce and lacks in formal evaluation methods ...
The diverse US population requires medical cultural competency education for health providers throughout their pre-professional and professional years. We present a curriculum to train pre-health professional undergraduates by combining classroom education in the humanities and cross-cultural communication skills with volunteer clinical experiences at the University of California, Los Angeles (UCLA) hospital.
The course was open to a maximum of 15 UCLA junior and senior undergraduate students with a pre-health or humanities major and was held in the spring quarters of 2002--2004. The change in students' knowledge of cultural competency was evaluated using the Provider's Guide to Quality and Culture Quiz (QCQ) and through students' written assignments and evaluations.
Trainees displayed a statistically significant improvement in scores on the QCQ. Participants' written assignments and subjective evaluations confirmed an improvement in awareness and a high motivation to continue learning at the graduate level.
This is the first evaluated undergraduate curriculum that integrates interdisciplinary cultural competency training with patient volunteering in the medical field. The didactic, volunteering, and writing components of the course comprise a broadly applicable tool for training future health care providers at other institutions.
... [2][3] It has become a widely used tool in medical education both for teaching and evaluation and is now part of the national board examination. [4][5] Despite much literature on the teaching of cultural competence in general, [6][7][8][9][10] information about using OSCEs for cultural competence evaluation and training is mostly anecdotal with few published studies. 11,12 We are aware of no research that describes the perspectives of medical students on such an experience. ...
Objective structured clinical examinations (OSCEs) use standardized patients (SPs) to teach and evaluate medical students' skills. Few studies describe using OSCEs for cultural competence education, now a Liaison Committee on Medical Education accreditation standard for medical schools. We designed an OSCE station emphasizing cross-cultural communication skills (ccOSCE) and interviewed students to better understand and improve upon this tool.
Two investigators conducted semistructured interviews with 22 second-year Harvard medical students who completed the ccOSCE. Three investigators coded and analyzed the interview transcripts by using qualitative methods to explore students' perspectives on the station and its focus on cultural competence.
Themes that emerged pertinent to design and implementation of the station were grouped into four categories: learning goals, logistical issues, faculty feedback, and SPs. Students were positive about the overall experience. They appreciated the practical focus on nonadherence. Some found the learning goals complex, and others felt the format promoted stereotypes. Logistical issues included concerns about marginalizing cross-cultural care by creating a separate station. Faculty feedback was helpful when specific about sociocultural issues students did or did not explore well. Students found SPs realistic but inconsistent in how easily they revealed information.
Designing a ccOSCE experience is challenging but feasible. Students' perspectives highlight a tension between presenting cultural competence in a dedicated station (potentially marginalizing the topic and promoting stereotypes) and spreading it across stations (limiting opportunity for focused teaching). Learning goals should be clear, concise, and effectively communicated to faculty and SPs so their feedback can be standardized and specific.
... Recognizing the importance of educating health care professionals to provide culturally and linguistically responsive care, the Liaison Committee on Medical Education has added cultural competence as a standard for accrediting medical schools (Liaison Committee on Medical Education 2004). Multiple cross-cultural curricula have been developed across medical schools and residency programs with a growing emphasis on developing a set of skills in caring for patients from a range of diverse backgrounds rather than simply providing culture-specific (and often stereotypic) information (Tervalon and Murray-Garcia 1998;Carrillo et al. 1999;Flores et al. 2000;Nunez 2000;Green et al. 2002;Whitcomb 2002;Betancourt et al. 2003;Betancourt 2004;Champaneria and Axtell 2004;Harris et al. 2004;Beach et al. 2005;Kripalani et al. 2006). Eliciting cross-cultural factors (including literacy, use of interpreters, health beliefs, alternative/complementary medicine) have been added into existing communication skills training as well as discussions of cultural and social factors embedded into case-based learning. ...
Medical schools use OSCEs (objective structured clinical examinations) to assess students' clinical knowledge and skills, but the use of OSCEs in the teaching and assessment of cross-cultural care has not been well described.
To examine medical students' reflections on a cultural competence OSCE station as an educational experience.
Students at Harvard Medical School in Boston completed a 'cultural competence' OSCE station (about a patient with uncontrolled hypertension and medication non-adherence). Individual semi-structured interviews were conducted with a convenience sample of twenty-two second year medical students, which were recorded, transcribed, and analysed.
Students' reflections on what they learned as the essence of the case encompassed three categories: (1) eliciting the patient's perspective on their illness; (2) examining how and why patients take their medications and inquiring about alternative therapies; and (3) exploring the range of social and cultural factors associated with medication non-adherence.
A cultural competence OSCE station that focuses on eliciting patients' perspectives and exploring medication non-adherence can serve as a unique and valuable teaching tool. The cultural competence OSCE station may be one pedagogic method for incorporating cross-cultural care into medical school curricula.
Teaching cultural sensitivity to healthcare professionals is critical in providing appropriate care todiverse patient populations. Constantly increasing U.S. immigrant population and growing numbers ofinternational medical graduates practicing in the U.S. bring the issue of appropriate cross-culturaltraining to the forefront of addressing health disparities.Cultural competence training of healthcare professionals and provision of culturally sensitive patientcare is the responsibility of healthcare leadership.1 Acquiring awareness and knowledge about culturaldifferences requires focused development of skills to communicate with patients from diverse cultures;this is a process developed through professional training and experience.2 Few professionalcontinuous education programs have been offered to prepare mentors and role models in the field ofhealthcare to ensure culturally sensitive approach in patient service.
This chapter addresses the unique challenges of stimulating cultural competency within the realm of undergraduate medical education, with the aim of developing an intentional awareness among future physicians such that their perspective in diagnosis and medical management of diverse populations based upon race, gender, creed, sexual orientation, etc. that take cultural differences into account and potentially lead to daily patient encounters that are as satisfying and beneficent.
Purpose:
To determine physician assistant (PA) students' perceived levels of preparedness to treat patients from culturally diverse backgrounds.
Methods:
An online survey with quantitative and qualitative components was distributed to students at 8 PA programs in different geographic locations of the United States. The survey used a modified version of the previously validated Self-Assessment of Perceived Level of Cultural Competence Questionnaire and evaluated PA students' knowledge, skills, encounters, attitudes, awareness, and abilities regarding cultural competence, as well as students' evaluation of these components of their education. Descriptive statistics were generated using SPSS software, and qualitative findings were analyzed for common themes.
Results:
PA students rated their attitudes, awareness, and abilities about cultural competence as significantly greater than their cultural knowledge, skills, and encounters. Second-year students and racial minority students reported higher personal ratings for levels of cultural competence. Most PA students reported being well prepared (39%) or moderately prepared (46%), compared to those who did not feel at all prepared (15%). Students indicated that specific classes focusing on cultural topics, discussions about cultural issues, and clinical experiences were the most useful for promoting cross-cultural education.
Conclusion:
While PA students perceive cultural competence to be important, they appear to be deficient in the areas of cultural knowledge, skills, and encounters. Integrating cultural competence courses, cultural discussions, and clinical rotations involving diverse patient populations should be encouraged throughout PA training as they may strengthen students' preparedness to provide cross-cultural care.
This phenomenological study describes the experiences of primary care physicians trained in the United States who participated in an international clinical immersion rotation during medical school or residency. Five central themes emerge relating to their experience: (a) Participants chose the international rotation for developmental purposes. (b) The lifestyle in their destination country was different than in the U.S., and this had an impact on participants. (c) There were positive outcomes for participants and their future practice. (d) Harmful external forces (at the rotation site) shortened patients’ lifespans and had a negative impact on their quality of life. And, (e) participants wonder whether they have chosen the right profession. The process of participating in the immersion experience helped participants grow, think, and feel in new ways, both professionally and personally. They developed observational skills by living in the same environment as their patients. They learned resourcefulness as they solved practical problems with no one to support them. They became more confident through their daily work and by being considered “the doctor.” They learned to adapt to the ways of people and cultures that “slow down” and live at a different pace compared to people in the U.S. One particularly significant observation is that they described changes and awareness consistent with growth in cultural competence, even though this was not their primary intention. The essence of the immersion experience is a constellation of developmental growth areas for primary care physicians who participated, but evidence of possible cultural competence development is at the forefront. Adviser: Gina S. Matkin
Introduction:
Racially/ethnically diverse children with disabilities experience increased risk for health care disparities when compared to non-Hispanic White children with disabilities or racially/ethnically diverse children without disabilities. The purpose of this study was to progress culturally congruent health care by exploring cultural competence (CC) for an interdisciplinary leadership training program designed to improve services for children with disabilities. The study also sought to bridge a gap in the literature by including the perspectives of diverse health care consumers.
Method:
Q-methodology was used to support participant groups' sorting of CC training outcomes by importance to identify factors of CC.
Results:
Data collected from 51 participants were subjected to a by-person factor analysis that yielded six factors explaining 50% of variance.
Discussion:
Findings validate some common elements of existing CC models and provide new perspectives regarding potentially overlooked aspects of CC, with many new perspectives provided by racially/ethnically diverse parents of children with disabilities.
Medical professionalism faces distinctive challenges in the 21st century. In this chapter, we review the history of professionalism, address specific challenges physicians face today, and provide an overview of efforts to address these issues, including behavioral and virtue ethics approaches. First, we discuss core features professions share and the development of codes of medical ethics that guide the practice of western medicine. Second, we address challenges related to the doctor-patient relationship, continuity of care, cultural competence, conflicts of interest, and the regulation of quality of care through maintenance of certification. We then explore three cultural trajectories that have deeply influenced medical practice: the technologic imperative, physicians' collective neglect of structural factors impacting medicine, and the rise of commercialism. Finally, we describe efforts to address these challenges, focusing on the Physician Charter developed by the American Board of Internal Medicine and widely endorsed by medical boards and societies internationally.
The medical community has hailed the recent movement to provide patient-centered care as a progressive step forward in meeting the needs of the very diverse patient population of the United States. Stakeholders in all arenas of U.S. medicine-professional organizations, public advocacy groups, hospital administration, medical school leadership, insurance carriers, and nursing-have embraced the focus on patient-centered care. But, although the community universally endorses the ideal of patient-centered care, the ethical obligations it entails have only just begun to be explored. One of the most difficult circumstances in which to provide patient-centered care is when there is a deep cultural conflict-that is, when the values and priorities of the patient and his or her family are in direct opposition to those of the clinical team. Given the mandate to provide care that is "culturally and linguistically appropriate," the author asks what obligations providers have to meet patient demands when doing so is inconvenient, challenging, or, at the extreme, offensive and contrary to clinical values. The author examines the tension that occurs when culturally sensitive patient-centered care disrupts the workflow of the service, requires acknowledging antithetical, unsupportable values, or entails discriminatory or ad hominem practices that constitute a personal insult or affront to the provider. The strategy the author has invoked for this analysis is to search for common values that might provide a bridge between patients and providers who are in deep cultural conflict.
Cultural competency is gaining recognition as an essential strategy by which to address health care disparities. A closer examination of medical school curriculums was undertaken to determine how the need for cultural competency and humility (CCH) training in medical education is being addressed.
A MEDLINE review of published literature regarding CCH training in medical education was performed. Additionally, key informant interviews with influential faculty members from prominent medical institutions were completed.
Many academic medical institutions recognize the need for CCH and have successfully integrated it into the first 2 years of their curriculums. However, there seems to be a uniform deficit in CCH training in the third and fourth years of their education.
Recognizing the need for CCH training during the third and fourth years of medical education, we explored the issues inherent to the integration of CCH training in clinical education. Using surgery as a model, we established a set of recommendations to assist clerkship directors and curriculum committees in their efforts to ensure CCH training in the last 2 years of medical education.
In 2007, the Alaska Division of Public Health issued their first-ever fish consumption advisory to reduce exposure to methylmercury. Interestingly, they utilized a toxicity level in their calculations of risk that is four times higher than the U.S. Environmental Protection Agency's (EPA) level, arguing that the EPA's calculation is "inappropriately restrictive" for Alaskans. This article explores the institutional reasoning and scientific calculations behind the state's fish consumption advice, with special attention paid to the consequences for Alaska Natives. I argue that a discourse of "Alaskan exceptionalism" is utilized by the health department to justify their assessment of risk. Although this exceptionalist discourse is intended to accommodate the unique lifestyles of Alaskan citizens, it may actually serve to undermine the very lifeways and traditions that it presumes to preserve. This article contributes insights into the ways that states can influence the social and material reproduction of communities through the deployment of "cultural difference" during the risk-assessment process.
The present study reviewed the published literature to examine the effects of international health electives (IHEs) on medical student learning and career choice.
A systematic literature review was conducted to identify key English-language articles on IHEs, using PubMed journal databases for the period 1990--2009. Article inclusion for this review was vetted by a rigorous evaluation of each article's study methods, content, and data quality. Pooled or aggregate information from 11 key articles, including information on type and duration of IHE, study and comparison group characteristics, and measured outcomes such as self-reported changes in cultural competency, clinical skills, and specialty choice, were extracted and summarized.
Findings suggest that having IHE experiences contributed to a more well-rounded training for medical students; students reported being more culturally competent and were more likely to choose a primary care specialty and/or a public service career.
Although IHE experiences appear to have educational benefits, the quality and availability of these electives vary by institution. Barriers to ensuring that students attain a safe and rich experience include the lack of consistent categorical funding, safety concerns when traveling, and limited faculty experience and resources to support and guide students during their rotations abroad.
Tobacco-related morbidity and mortality disproportionately burdens America's most vulnerable populations, and many physicians in the USA are untrained in smoking cessation skills with patients of various literacy levels and races and ethnicities. An anonymous survey was administered to 860 second year and 827 fourth year students at 12 medical schools. A faculty representative at each of the schools completed an assessment of the curriculum and rated medical students' knowledge and skills for cultural competency. Report of experience in tobacco counseling for persons of various literacy levels and ethnicities rose from 42% (second year students) to 82% (fourth year students) and 48% (second year students) to 91% (fourth year students), respectively. However, only 37% of second year students and 40% of fourth year students reported that they had ever been taught to employ culturally competent strategies for tobacco cessation. This study found that almost two thirds of students in 12 medical schools reported no exposure to teaching about cultural competency and tobacco cessation, and approximately one third reported no practical experience with tobacco cessation counseling persons of various races and ethnicities. Effective cultural competency training for tobacco control should include teaching the social constructs of race, ethnicity, and socio-cultural concepts within a medical context. Additionally, students should receive supervised clinical opportunities to practice counseling, including opportunities to discuss and reflect on their experiences.
Although education about culture, race and ethnicity has increasingly been viewed as an important addition to the medical undergraduate curriculum, internationally the evidence of its effectiveness is mixed. Research to date fails to show why. We chose to explore how contrasting approaches to learning about cultural diversity impacted on medical students. The views of second year students towards teaching about cultural diversity at two UK medical schools, with differently structured curricula, were explored using a series of focus groups (7). The findings, using a methodology based on a combination of grounded theory and thematic analysis identified two potentially competing views espoused by the students at both sites. First, they claimed that although cultural diversity was important, their medical schools marginalised and failed to adequately support effective teaching. Second, in contrast, they claimed that the medical school was an 'inappropriate' setting for successful teaching about cultural diversity. Students did not consider the subject matter to be of central relevance to biomedicine. They felt it should be learnt experientially in the workplace and socially among peers. These narratives represent two potentially conflicting standpoints, which might be understood through the sociological concept of 'habitus', where students conform to the institution's dominant values in order to succeed. The tensions identified in this study cannot be ignored if effective learning about race, ethnicity and culture is to be achieved. Early introduction to understanding the delivery of health care to diverse populations is needed. This should be accompanied by more open collaborative debate between tutors and students on the issues raised.
Formal training in cultural competence for health care providers has become vital as the US population continues to become increasingly culturally diverse. However, a low percentage of medical schools offer formal training in this area, and there is a lack of curriculum evaluation reported in the literature.
To determine the impact of formal cultural competence teaching on third-year medical students' knowledge of cultural competence.
Data from 109 third-year medical students during the period of November 2001 to February 2004 were analyzed in the study. The intervention was a comprehensive cultural competence curriculum, and the primary outcome measure was the change score in cultural competence knowledge demonstrated by the medical students after completing a precourse and postcourse 40-item multiple-choice questionnaire.
Forty-seven medical students in the control group and 62 medical students in the intervention group completed both the pretest and posttest. The overall knowledge scores in the intervention group increased by 19%, compared to a 4% increase in the controls (p < .01).
Third-year medical students in the intervention group were significantly empowered with cultural competence knowledge when compared to the control group.
National health care quality measures suggest that racial and ethnic minority populations receive inferior quality of care compared to whites across many health services. As the largest insurer of low-income and minority populations in the United States, Medicaid has an important opportunity to identify and address health care disparities.
Using 2006 Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA), we examined quality of care for cancer screening, diabetes, and asthma among all eligible non-dual North Carolina Medicaid recipients by race and ethnicity.
In comparison to non-Latino whites, non-Latino African Americans had higher rates of screening for breast cancer (40.7% vs. 36.7%), cervical cancer (60.5% vs. 54.6%), and colorectal cancer (25.5% vs. 20.6%) and lower rates of LDL testing among people with diabetes (61.8% vs. 65.7%) and appropriate asthma medication use (88.7% vs. 97.0%). A1C testing and retinal eye exam rates among people with diabetes were similar. Smaller racial/ethnic minority groups had favorable quality indicators across most measures.
Comparability of findings to national population-based quality measures and other health plan HEDIS measures is limited by lack of case-mix adjustment.
For the health services examined, we did not find evidence of large racial and ethnic disparities in quality of care within the North Carolina Medicaid program. There is substantial room for improvement, however, in cancer screening and preventive care for Medicaid recipients as a whole.
Tort reform emerged as a major issue in the culture wars during the 2004 presidential election and continues to be a heavily debated issue today. While a community’s sense of social justice should dictate the values used to assess and shape tort law, different communities have widely varying perspectives of social justice. This article reflects on the potential impact of the culture wars on medical malpractice law and litigation and emphasizes the most critical criteria for assessing medical malpractice reform is how well the legal system protects, affirms, and restores the human dignity of both patients and health care providers. The article reasons there is not a one-size fits all medical malpractice tort system, and in order to prioritize human dignity, it is essential to take into account the cultural, social, and religious diversity within America and shift the focus from economic to dignitary priorities. Finally, the article discusses the profound health care consequences of illiteracy and low health literacy.
Race is important in medicine. In order to correct the inequality in healthcare racial minority people can expect to receive, a new rhetorical stance is needed so that we can place our discourse in a productive arena. Most recommended solutions argue for increased education on "cultural competence" for physicians. Who will educate the educators? What rhetorical stance will work? A requirement for physicians to learn about cultural and linguistic competence will not get us to fairness in medical care, independent of race. That's because race is not the problem. There's nothing wrong with our race. Other disciplines within academe must contribute to students' understanding and treatment of race in America if we are to seriously address disparities in medical care.
Social work practice has become more complex and complicated, as social workers wade through the burgeoning call for empirical evidence, the demand to deliver services in shorter periods and with restricted resources. In substance abuse treatment organizations, implementing evidence-based, culturally competent treatment initiatives can seem counter-intuitive to program staff and are subsequently not administered or administered in a way that sabotages the integrity of the intervention. This paper examines cultural competence and explores the meaning of meta-cultural competency that is, the organization's culture, the client's cultural background, and how these factors are interpreted by practitioners within the organizational network.
The aim of this study was to evaluate a culturally effective health care (CEHC) curriculum integrated into the real-time clinical experience of a third-year medical student pediatric clerkship.
The intervention group (n = 22) and the nonintervention group (n = 69) consisted of students who were assigned to one of two sites for their clerkship. Students did not volunteer for the curriculum. A curriculum in 2002 was developed based upon a local needs assessment of students and parents, key CEHC concepts and experts' input. Learning strategies included incorporation of CEHC issues into clinic precepting, attending rounds, and written histories. Evaluation methods were preintervention and postintervention knowledge tests and Likert-type attitudinal surveys, and a final objective structured clinical exam (OSCE; nonintervention group, n = 22, intervention group, n = 22).
Pretest knowledge scores were similar in both groups. The post-test scores were significantly different. The intervention group demonstrated higher gain in the knowledge scores (42% vs 5%; P < .001). The intervention group demonstrated significantly higher gains in observed role modeling (85% vs 31%; P = .01), self-perceived skill (82% vs 19%; P < .001), and attitude (21% vs 0%; P = .02), but not in self-perceived knowledge domains (65% vs 15%; P = .14) on the attitudinal survey. The intervention group performed significantly better in the folk (83% vs 70%; P = .02) and language (75% vs 63%; P = .01) OSCE stations and had a significantly higher total OSCE score (79% vs 68%; P = .01).
A CEHC curriculum, stressing clinical relevance, was successfully incorporated into the real-time experience of a third-year medical student pediatric clerkship. Students demonstrated significant gains in knowledge, attitudinal domains, and clinical skills.
In this article, we examine the apparent resistance of elderly Russian Jewish émigrés to the dominant U.S. biomedical model of diabetes treatment. Cultural competence on the part of medical professionals who make assumptions about Russian culture tends to be based on particularly American values of self-control and individual agency. The American consumer model of health care incorporating risk, individual responsibility, autonomy, and choice, when applied to elderly Russian Jewish émigrés, results in a reading of different values and choices as failed self-management or noncompliance. This article argues for a more reflexive understanding of U.S. biomedical culture as a replacement for the current "sound bite" model of cultural diversity.
As the United States becomes more multicultural, physicians face the challenge of providing culturally sensitive and appropriate health care to patients with differing health beliefs and values. While a few schools are providing cultural-sensitivity training in response to the changing patient population, the pervasiveness of such training has not been thoroughly reported.
In 1991-92, all 126 U.S. medical schools were surveyed regarding their implementation and plans for future implementation of cultural-sensitivity training. The t-test was used to compare data from those schools that offered separate, formal cultural-sensitivity courses with data from the schools that did not offer such courses.
Of the 126 schools surveyed, 98 (78%) responded. Only 13 of the responding schools offered cultural-sensitivity courses to their students, and all but one of these courses were optional. These 13 schools reported a greater perceived likelihood that their students would have contact with African-American patients (t = 2.88, p < .05). Despite the few courses offered and the common perception that recent graduates were only "somewhat prepared" to provide culturally sensitive clinical services, only 33 schools were planning to implement new courses.
The results indicate needs for more cultural-sensitivity training and for further studies to determine the most effective type of training for students.
Cultural competence in the provision of health care is a very important area of investigation and is receiving recognition at multiple levels. Minority groups constitute a significant and growing percentage of our population. However, there has been no commensurate increase in the number of minority physicians. There is a tremendous need for medical professional schools and health care organizations to implement formal cultural competence training for current and future health professionals. In this article, we present the findings of an extensive literature review that describes how several factors have brought the need for cultural competence to the forefront. These factors include a greater appreciation for the impact of culture on health, changes in U.S. demographics, increased awareness in health care disparities, and modifications in legislative and accreditation mandates.