AMSA's 2015 Annual Convention
Join Us Next Spring
in Washington, DC!

February 26 - March 1, 2015 

Cultural Competence Goes to School

STUDENTS LEARN THAT UNDERSTANDING DIFFERENCE IS A PART OF MEDICAL EDUCATION.

The New Physician November 2005
The summer between first and second year—when options for what might be your last substantial break until retirement stretch before you—can create a cacophony of temptations in your mind. Travel to Costa Rica? No. Volunteer? No, wait: Lounge by the pool? Ah, no. Stockpile sleep for future wakeful nights on an ER rotation? Yeah, that’s it.


Zachary Child rejected them all. Instead, he built a Web site.


OK, so it wasn’t exotic. And it wasn’t relaxing. And two years later, he sure could use some of that sleep as he moves between cases on a busy orthopedics rotation. But that summer, Child, now a fourth-year at the University of Nevada School of Medicine (UNSOM), created something that physicians and students benefit from daily: a Web site with downloadable tools that help them communicate with and better treat their Spanish-speaking patients. The Focused Medical Spanish site is located at medspanish.med.unr.edu.


Child could see his own need for some basic Spanish-language skills, especially while studying medicine in the West. “In Las Vegas, 60 percent of my patients spoke no English at all on rotations last year,” he says. Having a minimal Spanish vocabulary, it made taking histories tough. “I would begin to assess a patient, and I was rapidly outstripped…. I could understand the questions, but I couldn’t always give an answer.


“The problem that medical students face—and that physicians face and paramedics face—is the need for time. The gold standard is learning Spanish, of course.”
But for students at UNSOM with already-packed schedules, that wasn’t going to happen. “I don’t know where you’re going to fit a lot of cultural competency into the curriculum,” Child says. “We got some, but it was basically superficial.”


His Web site helps bridge that gap, allowing students to better relate to patients in their native language. “You start talking to someone in their own language, and it’s really impossible to think of them as…whatever the stereotype is. That’s so huge.”


Child’s efforts are just one example of the ways medical schools—and their students—are making efforts to graduate new physicians with an understanding of other cultures. But with overcrammed student schedules, little legislative guidance and resistance from some faculty and students who don’t understand the need, many schools have found that initial steps move ahead slowly.


CULTURAL COMPETENCE


Child may not have noticed a lot of cultural-competence instruction at UNSOM because it’s a relatively new concept in medical education. When he began medical school in 2002, the Liaison Committee on Medical Education (LCME), which accredits allopathic medical schools, had mandated only two years before that cultural competence be addressed in the curriculum. And even cultural-competence advocates have brought the issue to light only since the 1990s.


Many schools are just now feeling their way as they anticipate upcoming reaccreditation procedures, which occur on a rolling basis. And they may not be feeling much of a heavy hand on this issue from the LCME yet, which has so far only asked schools in their reaccreditation evaluations if they teach cultural competence and how they address it. The committee and its parent organization, the Association of American Medical Colleges (AAMC), recently rolled out a new evaluation tool to help schools assess where in the curriculum the subject is addressed and how. According to Robert Eaglen, Ph.D., LCME assistant secretary, this spreadsheet computer program will soon become part of the required documentation schools must submit with their reaccreditation materials.


The LCME standards call for faculty and students to “demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases and treatments.” While they are vague in the eyes of some faculty, the standards as written do have the benefit of allowing schools to define their own paths to creating culturally competent students.


A few ideas are constant across different schools. Most try to tie the issue into already-established courses and learning tools, believing that cultural competence, like patient safety or the physician–patient relationship, can’t be separated from other patient-care instruction. “We didn’t want to say, ‘OK, now you’ve learned all this stuff, and now we’re going to teach you about cultural competence,’ because that implies it’s not a natural part of patient care,” says John George, Ph.D., professor of family and community medicine at the Pennsylvania State University (PSU) College of Medicine, of the school’s four-year, integrated cultural-competence education.


At the University of Pittsburgh School of Medicine, cultural-competence instruction is woven throughout the four-year curriculum also for this reason, and because repetition is key to learning, says Dr. Jeannette South-Paul, medical director of the university medical center’s community health services division. “Remember, medical students are at a vulnerable part of their training. They will remember what they see frequently.”


Beginning with first-year orientation, Pitt students are required to attend three half-day workshops, each dealing with a different aspect of diversity: race, gender and sexual orientation. Later that year, students learn how to handle cultural differences in the interviewing process. The second year brings a 30-minute lecture on health disparities, and in the third year, students have a 90-minute discussion on cultural issues as part of a pre-clerkship didactics day. They can opt for further exposure during their fourth year in an elective offered through the school’s Center for Integrative Medicine.


The Pitt lectures and workshops nudge students to think about diversity issues and how they might respond to patients from different backgrounds, and also offer a framework in which students can continue to self-develop, believes fourth-year Jamie Ann Cavallo. In the end, cultural competence can’t be forced. “It’s an effort that needs to come from the student,” she says.


Some understanding also comes from experience, says South-Paul. “For those of us who have had a lot of patient care—and I’ve had a lot of patient care—we’ve seen how cultural aspects affect you.”
That’s why relating instruction to real life is essential, says Marie Dent, Ph.D., associate professor of community medicine at Mercer University School of Medicine. “The key to cultural competence is to always make sure you can tie it so students can see how that is going to be clinically relevant—‘How is this going to make me a better physician?’”


Often, Mercer students see the significance during their second year, when they spend a required 10 weeks in the community working with a local physician. There, they identify two families and study the effects health and wellness have on them, following up with the families in their third and fourth years.


Faculty also try to address social and cultural issues concerning health care by working other exercises into instruction as time allows, Dent says. Through a grant from the American Medical Student Association (AMSA) Foundation, Mercer developed an exercise to help students better understand poverty and another to help them create a “cultural genogram” for their patients. This tool helps them assess any cultural differences a patient might have in his genealogy that would affect how he views health care. “It is a way of giving students a structure of what questions to ask and what information to gather [while taking a history],” Dent says.


CONVINCING THE UNINITIATED


Not every student is enthusiastic about cultural competence, however. South-Paul hears complaints about Pitt’s cultural-competency instruction as early as the first-year workshops, which she says is “remarkable.”
“There’s a segment that says, ‘This is baloney,’ and ‘We’ve already had this lecture three times,’ and ‘Why do we have to do it again?’”


But faculty members say usually the majority is on board with the idea—so much so at PSU that a student group secured a grant that enabled the school to review its problem-based learning cases for first- and second-years, rewriting them to eliminate stereotypes. For example, George says, the school added more examples of women and reworked a sickle-cell anemia patient from a person of color on welfare to a white lawyer.


More often, the challenge for schools is convincing administrators and faculty that cultural competence has a place in the medical school curriculum—many of them far pre-date the new concept. “Clearly, some faculty are sensitive to such issues, and some are not. So students will be exposed to a range of perspectives,” Eaglen says.


So, in some respects, cultural-competence education depends on faculty development, he says. And that’s not always easy. South-Paul agrees: “You need a goal champion.”
Having the LCME require some type of cultural-competence education has helped convince some skeptics, as have some state regulations. New Jersey and California now require physicians to prove their cultural competence for state licensure. “How you get people interested in issues is—I hate to say this—is legislative. But the reality is, saying, ‘If you don’t meet this, then we won’t pay you for it,’ [helps convince physicians],” South-Paul says.


MEASURING THE EFFECTS


So, does all this time and effort to include cultural competence really produce better physicians? Absolutely, say advocates. But others, including some students, think the message is missing the mark. For the past several years, the LCME has used the AAMC Graduation Questionnaire to measure whether students think they’re prepared to deal with cultural differences in their exam rooms. Between 20 percent and 25 percent say no.


Jennifer Neuwalder, a second-year at Tufts University School of Medicine, may be part of that percentage when she graduates. “I wish I could tell you that Tufts had a great cultural-competency program, but it doesn’t,” she says. Describing a two-hour, cultural-competence orientation workshop as “OK,” she’s more troubled by the lack of interest in cultural issues she sees in some of her professors. “I tried to ask a lot of questions in our human growth and development class last year to address cultural differences, but I was largely disappointed by the responses I received…. When I asked the lecturer about carrying an infant a lot for at least the first year and about ‘co-sleeping,’ both of which are the norm in most non-Western cultures, she immediately dismissed both practices as ‘dangerous.’”


Instead, Neuwalder looks at her cultural-competence education as her own responsibility, talking about issues with friends and family members and reading. That’s not necessarily a bad thing, says George. “I think students should take initiative if they don’t feel they’re getting adequate information.”


At Mercer, students have taken their interests beyond the school’s official offerings, twice securing AMSA grants to pay for a tutor to help them with medical Spanish. Pitt student Cavallo says she thinks it would be a great idea if students would come together on their own during the fourth year to share their real-life experiences on the wards, learning from successes and failures. “I think it could be a more efficient and even more meaningful exercise if it was initiated by the students,” she says.


Looking back on the progress in the five years since the LCME created the accreditation standards, Eaglen predicts it will be another five until even 90 percent of medical students report their cultural-competency exposure was adequate. But that’s a number he says he can live with.
Jennifer Zeigler is a freelance writer near State College, Pennsylvania. Direct questions and comments about this article to tnp@www.amsa.org.