Components of culture in health for medical students' education

Racial biases in clinical practice and medical education: a scoping review

INTRODUCTION

Health inequalities represent a major challenge in contemporary medicine, with some attributed to racial biases. Recently, in the United States, a call to combat discrimination in the field of health has resonated, particularly in the context of the COVID-19 crisis, in which minorities have been disproportionately affected. These calls echo recommendations from the Institute of Medicine dating back to 2001, urging the fight against inequalities in access to health care. In France, inequalities based on presumed origin persist, yet medical education on these issues is virtually nonexistent.

MATERIALS AND METHODS

We conducted a scoping review literature review in accordance with the JBI recommendations for scoping review writing and applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to explore existing conceptual and educational data on racial biases in medicine. The inclusion criteria were interventional studies or evaluations of existing educational programs in medical training addressing the fight against racial biases in clinical settings published in French or English between 2003 and 2023. Six databases were systematically consulted.

RESULTS

Out of 748 initial studies, 28 were included in our study. The median number of participants in the studies was low, interventions were diverse, and participants were generally well received, most of whom were self-selected. No study has evaluated the clinical impact of these interventions. The highlighted concepts included levels of racism, cultural competence, cultural humility, and critical race theory.

DISCUSSION

The authors most frequently referred to institutionalized racism, demonstrating the systemic nature of these issues. At an individual level, implicit and unconscious biases were most often emphasized. It appears that the concept of "race" is a sociopolitical construct without supporting biological determinants. Humility is central to this field of study, as it encourages questioning of individual or collective medical practices. In France, the context, including the prohibition of ethnic statistics, may hinder the objectification of discrimination. Immersion and virtual patient scenarios emerged as potential solutions for evaluating the clinical impact of interventions. A more horizontal medical pedagogy seems better suited to teach these sensitive issues.

Biases towards different patients groups. How do they differ during medical education?

OBJECTIVE

This cross-sectional study was a first to attempt to assess how biases towards age, gender and sexual orientation differ during the years of undergraduate medical education.

METHODS

600 medical students from the first, third and sixth year of study participated in the study. Three questionnaires were used: The Ambivalent Sexism Inventory scale (ASI), the Fraboni Scale of Ageism (FSA) and the Homophobia scale (HSc).

RESULTS

Results showed statistical significant differences between the three groups in the total scores of ageism and homophobia. Students in the last year of studies reported more ageist and more homophobic biases than students in the first year of their studies.

CONCLUSIONS

Our results demonstrate a need for education to reduce/address/mitigate bias in medical students. Τhe finding that biases increase in students who are farther along in their education needs further investigation. This warrants particular attention to determine if this is a change due to the medical education process itself.

PRACTICE IMPLICATIONS

Medical education should teach students about diversity and acceptability with updated curriculums and designed interventions.

Racism in medicine: A qualitative study on the impact of discussion among medical students

Background: This study evaluated the impact of the Racism in Medicine Summit on student perceptions of various topics related to racism in medicine. The Summit was organized at the Wayne State University School of Medicine (WSUSOM) to educate students, faculty and staff on how structural racism affects the residents of Detroit and the historical relationship between healthcare and vulnerable populations. The Summit aimed at providing context for what students in Detroit will encounter as physicians-in-training and the skills they will need to master while working within similar communities.  Methods: Qualtrics surveys were created and distributed via email to attendees before and after the event. Responses were obtained via Likert scale and open-text questions.  Results: A total of 342 out of 445 participants (77%) completed both the pre- and post-survey. Quantitative analysis in post-survey responses revealed more familiarity among participants regarding specific instances of racism in the history of medicine, greater extent of thinking the history of racism impacts present-day Detroit residents, greater extent of thinking that racism influences medical care and/or medical outcomes, and belief that racism is reflected in medical research, compared to pre-survey responses (p < 0.001). Participants also reported more often considering racial or societal influences when studying medicine and more knowledge of what they can do to combat racism as a student and physician (p < 0.001).  Qualitative analysis revealed seven themes among participants: the history of racism in medicine, personal reflection, racism in research, bias and microaggression, actions to take against racism, resources for anti-racist education, and racism in medical education.  Conclusions: Demonstrable changes in medical student attitude and awareness surrounding topics of racism and healthcare were achieved after the Racism in Medicine Summit. This can serve as a model for other medical schools to raise awareness about racism in medicine.

Utilization of Health Care Services and Common Disease Diagnoses among University Students: An Analysis of 35,249 Students from Thailand

The health care services for university students are important to improve student health and well-being. Analyzing the database of health conditions in the health service system will identify common health problems, which could be useful in further appropriate and specific health service planning. This study aims to investigate the utilization of health care services and common disease diagnoses among university students enrolled at Chiang Mai University during the academic year of 2018. A retrospective study was carried out using health data from the electronic health records (EHR) database of the university hospital. Ethical procedures were followed. Out of the overall 35,249 students in the academic year 2018, 17,284 students (49.03%) had visited an outpatient department (65,150 outpatient department visits), and 407 students (1.15%) had been admitted to the hospital (458 inpatient department admissions). The proportions of utilization between each field of education and training were similar across both groups. The top five categories of diagnosis, for both outpatient department visits and inpatient department admissions, differed between gender. Some of the most common diseases included trauma and injury conditions, respiratory diseases, and mental health. The conclusion of the study is that integration of a health promotion program with preventive methods, especially regarding traffic injury, transmitted diseases, mental health support, and safe environments are essential for university students. A general overview of utilization and common diseases among university students, which is still lacking in the literature, could be useful as a platform to enhance health care services for common diseases.

Fostering cultural responsiveness in physiotherapy: curricula survey of Australian and Aotearoa New Zealand physiotherapy programs

BACKGROUND

Developing cultural responsiveness among physiotherapists is considered essential to promote quality and equity in healthcare provision for our culturally diverse populations. The aim of this study was to evaluate how entry-level physiotherapy programs in Australia and Aotearoa New Zealand (NZ) design curricula to foster the development of cultural responsiveness in physiotherapy students. Further, the challenges of integrating educational content and approaches, and the perceptions of the effectiveness of these curricula were also explored.

METHODS

A cross-sectional telephone survey with closed and open-ended questions, was conducted with 18 participants representing 24 entry-level physiotherapy programs (82% of all programs) in Australia and NZ between May and September 2017. Data were analysed descriptively in the form of frequencies, percentages or ratios as appropriate. Open-ended responses were thematically analysed.

RESULTS

Results suggest variability in the structure, and teaching and assessment methods used across all programs. The majority of programs appeared to rely on didactic teaching methods, along with knowledge based and implicit assessment methods. The main challenges reported were that cultural responsiveness was thought to be perceived by academic staff as unimportant and that the curriculum was perceived to be 'overcrowded'. Participants also felt there was room for improvement despite perceiving the curriculum to be effective at fostering cultural responsiveness.

CONCLUSION

Results provide insight into the educational content and approaches integrated in entry-level physiotherapy curricula in Australia and NZ, and suggest opportunities for further research and development to foster cultural responsiveness among physiotherapy students.

'Fostering transformative learning, self-reflexivity and medical citizenship through guided tours of disadvantaged neighborhoods'

BACKGROUND AND OBJECTIVES

Medical school curricula increasingly seek to promote medical students' commitment to redressing health disparities, but traditional pedagogical approaches have fallen short of this goal. The objective of this work was to assess the value of using community-based guided tours of disadvantaged neighborhoods to fill this gap.

METHODS

A total of 50 second-year medical students participated in a guided tour of disadvantaged public housing neighborhoods in Richmond, Virginia. Students completed self-reflexive writing exercises during a post-tour debriefing session. Student writings were analyzed to assess the tour's effect on their awareness of poverty's impact on vulnerable populations' health and wellbeing, and their personal reactions to the tour.

RESULTS

Student writings indicated that the activity fostered transformative learning experiences around the issue of poverty and its effects on health and stimulated a personal commitment to working with underserved populations. Themes from qualitative analysis included: increased awareness of the extent of poverty, enhanced self-reflexive attitude towards personal feelings, biases and misperceptions concerning the poor, increased intentional awareness of the effects of poverty on patient health and well-being, and, encouragement to pursue careers of medical service.

CONCLUSIONS

This pilot demonstrated that incorporating self-reflexive learning exercises into a brief community-based guided tour can enhance the social consciousness of medical students by deepening understandings of health disparities and promoting transformative learning experiences.

Protecting the health of medical students on international electives in low-resource settings

BACKGROUND

Increasingly, medical students from developed countries are undertaking international medical electives in developing countries. Medical students understand the many benefits of these electives, such as the opportunity to develop clinical skills, to gain insight into global health issues and to travel to interesting regions of the world. However, they may be much less aware of the risk to their health and wellbeing while abroad. Compounding this problem, medical students may not seek advice from travel medicine practitioners and often receive inadequate or no information from their medical school prior to departure.

METHODS

The PubMed database was searched for relevant literature relating to the health of medical elective students. Combinations of the following key words were used as search terms: 'international health elective', 'medical student' and 'health risks'. Articles were restricted to those published in English from 1997 through June 2017. A secondary review of the reference lists of these articles was performed. The grey literature was also searched for relevant material.

RESULTS

This narrative literature review outlines the risks of clinical electives in resource-poor settings which include exposure to infectious illness, trauma, sexual health problems, excessive sun exposure, mental health issues and crime. Medical students may mitigate these health risks by being informed and well prepared for high-risk situations. The authors provide evidence-based travel advice which aims to improve pre-travel preparation and maximize student traveller safety. A safer and more enjoyable elective may be achieved if students follow road safety advice, take personal safety measures, demonstrate cultural awareness, attend to their psychological wellbeing and avoid risk-taking behaviours.

CONCLUSION

This article may benefit global health educators, international elective coordinators and travel medicine practitioners. For students, a comprehensive elective checklist, an inventory of health kit items and useful web-based educational resources are provided to help prepare for electives abroad.

Measuring Medical Students' Preparedness and Skills to Provide Cross-Cultural Care

Purpose: Cross-cultural education is an integral and required part of undergraduate medical curricula. However, the teaching of cross-cultural care varies widely and methods of evaluation are lacking. We sought to better understand medical students' perspectives on their own cultural competency across the 4-year curriculum using a validated survey instrument.

Methods:We conducted an annual Internet-based survey at Harvard Medical School with students in all 4 years of training, for four consecutive years. We used a tool previously validated with residents and slightly modified it for medical students, assessing their (1) preparedness, (2) skillfulness, and (3) perspectives on the educational curriculum and learning climate.

Results: Of 2592 possible survey responses, we received 1561 (60% response rate). Fourth-year students had significantly higher scores than first-year students (p<0.001) for all but one preparedness item (caring for transgender patients) and all but one skillfulness item (identifying ability to read/write English). Less than 50% of students felt adequately prepared/skilled by their fourth year on 8 of 11 preparedness items and 5 of 10 skillfulness items. Lack of practical experience caring for diverse patients was the most frequently cited challenge.

Conclusions: While students reported that preparedness and skillfulness to care for culturally diverse patients seem to increase with training, fourth-year students still felt inadequately prepared and skilled in many important aspects of cross-cultural care. Medical schools can use this tool with students to self-assess cultural competency and to help guide enhancements to their curricula focusing on cross-cultural care.

The Roles of Counseling Psychologists in Reducing Health Disparities

This article presents an overview of the health disparities problem that exists among individuals from ethnic minority and low-income backgrounds and their majority counterparts. The argument is made that the involvement of counseling psychologists in addressing this health disparities problem presents an opportunity for the field to remain true to its commitment to prevention, multiculturalism, and social justice while becoming more competitive in the health care and health promotion fields. This article highlights the prevalence of health disparities and identifies the primary factors contributing to these disparities. In addition, the roles and approaches that counseling psychologists can adopt to help alleviate this problem are specified.

Guidelines for Teaching Cross-Cultural Clinical Ethics: Critiquing Ideology and Confronting Power in the Service of a Principles-Based Pedagogy

This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the "social sciences versus bioethics" debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences (such as the critique of the universality of the Euro-American construct of "autonomy") within (rather than in opposition to) a principles-based framework for clinical ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed.

Reactions to Diversity: Using Theater to Teach Medical Students about Cultural Diversity

Training medical students to understand the effects of culture and marginalization on health outcomes is important to the future health of increasingly diverse populations. We devised and evaluated a short training module on working with diversity to challenge students' thinking about the role of both patient and practitioner culture in health outcomes. The workshop combined didactic teaching about culture as a social determinant of health using the cultural humility model, interactive exercises, and applied theater techniques. We evaluated changes in the students' perceptions and attitudes over time using the Reaction to Diversity Inventory. There was initial significant improvement. Women and students with no past diversity training responded best. However, scores largely reverted to baseline over 12 months.

Intercultural Competency in Public Health: A Call for Action to Incorporate Training into Public Health Education

Due to increasing national diversity, programs addressing cultural competence have multiplied in U.S. medical training institutions. Although these programs share common goals for improving clinical care for patients and reducing health disparities, there is little standardization across programs. Furthermore, little progress has been made to translate cultural competency training from the clinical setting into the public health setting where the focus is on population-based health, preventative programming, and epidemiological and behavioral research. The need for culturally relevant public health programming and culturally sensitive public health research is more critical than ever. Awareness of differing cultures needs to be included in all processes of planning, implementation and evaluation. By focusing on community-based health program planning and research, cultural competence implies that it is possible for public health professionals to completely know another culture, whereas intercultural competence implies it is a dual-sided process. Public health professionals need a commitment toward intercultural competence and skills that demonstrate flexibility, openness, and self-reflection so that cultural learning is possible. In this article, the authors recommend a number of elements to develop, adapt, and strengthen intercultural competence education in public health educational institutions.

How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College

BACKGROUND

Global health educational programs within U.S. medical schools have the opportunity to link their "global" focus with local circumstances by examining the challenges underserved communities face in the United States.

AIM

Students in Weill Cornell Medical College's Global Health Clinical Preceptorship (GHCP) learn history-taking and physical examination skills while gaining exposure to local health care disparities and building cultural competency.

METHODS

First-year medical students in the program are placed in the office of a physician who works with underserved patient populations in New York City. Students receive an orientation session, shadow their preceptors one afternoon per week for seven weeks, complete weekly readings and assignments on topics specific to underserved populations, attend a reflection session, and write a reflection paper.

RESULTS

In three years, 36% of first-year students (112 of 311) opted into the elective GHCP program. Students reported gaining a better understanding of the needs of underserved patient populations, being exposed to new languages and issues of cultural competency, and having the opportunity to work with role model clinicians.

CONCLUSIONS

The GHCP is a successful example of how global health programs within medical schools can incorporate a domestic learning component into their curricula.

O ensino das ciências sociais em saúde: entre o aplicado e o teórico

Os modelos de ensino de ciências sociais e da clínica são insuficientes para as necessidades prático-reflexivas quando aplicados à saúde. O objetivo deste artigo é refletir sobre os desafios e as perspectivas do ensino de ciências sociais para profissionais da saúde. Na década de 1950 iniciou-se o importante movimento de aproximação das ciências sociais com o campo da saúde, no entanto prevalecem relações de fraca credencial, devido: baixo status profissional dos cientistas sociais na área da saúde; localização pouco clara dos profissionais de ciências sociais no campo da saúde; pequena importância atribuída pelos estudantes às ciências sociais; reduzido número de profissionais e a colonização das ciências sociais pela cultura biomédica no campo da saúde. Dessa maneira, aos profissionais das ciências sociais aplicadas à saúde ainda é colocada a necessidade de construir uma identidade, mesmo após seis décadas de presença neste campo, pois sua condição ambivalente os tem fixado como presença parcial, incompleta e virtual, exigindo estratégia complexa de sobrevivência na fronteira entre as ciências sociais e a saúde.

The promise and paradox of cultural competence

Cultural competence has become a ubiquitous and unquestioned aspect of professional formation in medicine. It has been linked to efforts to eliminate race-based health disparities and to train more compassionate and sensitive providers. In this article, I question whether the field of cultural competence lives up to its promise. I argue that it does not because it fails to grapple with the ways that race and racism work in U.S. society today. Unless we change our theoretical apparatus for dealing with diversity to one that more critically engages with the complexities of race, I suggest that unequal treatment and entrenched health disparities will remain. If the field of cultural competence incorporates the lessons of critical race scholarship, however, it would not only need to transform its theoretical foundation, it would also need to change its name.

Cultural competency in health care and its implications for pharmacy part 3A: emphasis on pharmacy education, curriculums, and future directions

Culture influences patients' beliefs and behaviors toward health and illness. As the U.S. population becomes more diverse, a critical need exists for pharmacy education to incorporate patient-centered culturally sensitive health care knowledge and skills into the curriculum. Nursing was the first profession to incorporate this type of learning and training into its curriculums, followed by medicine. Pharmacy has also made great progress to revise curriculums, but inconsistency exists in depth, breadth, and methods across pharmacy colleges. This article addresses important aspects of pharmacy education such as curriculum development, incorporation of educational innovations and techniques into the teaching of patient-centered culturally sensitive health care across the curriculum from didactic to experiential learning, assessment tools, and global education. A preliminary model curriculum with objectives and examples of teaching methods is proposed. Future directions in pharmacy education, teaching and learning scholarship, postgraduate education, licensure, and continuing education are also presented.

Why isn't evidence based practice improving health care for minorities in the United States?

Achieving health equity by improving the health care of all racial/ethnic groups is one of the key goals of Healthy People 2020. The implementation of evidence based practice (EBP) has been a major recommendation to achieve health equity in hopes of eliminating the subjectivity of clinical decision making. However, health disparities among racial/ethnic minorities are persistent in spite of the adoption of standardized care based on evidence. The EBP with racial and ethnic minorities is often seen as a possible cause of health and health care disparities. Three potential issues of using EBP to reduce health disparities have been identified: (1) a lack of data for EBP with ethnic/racial minority populations; (2) limited research on the generalizability of the evidence based on a European-American middle-class; and (3) sociocultural considerations in the context of EBP. Using EBP to reduce disparities in health care and health outcomes requires that nurse professionals should know how to use relevant evidence in a particular situation as well as to generate knowledge and theory which is relevant to racial/ethnic minorities. In addition, EBP implementation should be contextualized within the sociocultural environments in which patients are treated rather than solely focusing on the health problems.

Recent developments in health care law: culture and controversy

This article reviews recent developments in health care law, focusing on controversy at the intersection of health care law and culture. The article addresses: emerging issues in federal regulatory oversight of the rapidly developing market in direct-to-consumer genetic testing, including questions about the role of government oversight and professional mediation of consumer choice; continuing controversies surrounding stem cell research and therapies and the implications of these controversies for healthcare institutions; a controversy in India arising at the intersection of abortion law and the rights of the disabled but implicating a broader set of cross-cultural issues; and the education of U.S. health care providers and lawyers in the theory and practice of cultural competency.

Self-assessment and students' study strategies in a community of clinical practice: a qualitative study

BACKGROUND

Self-assessment is recognized as a necessary skill for lifelong learning. It is widely reported to offer numerous advantages to the learner. The research evaluated the impact of students' and supervisors' self-assessment and feedback training on students' perceptions and practices of self-assessment. Moreover, it evaluated the effect of self-assessment process on students' study strategies within a community of clinical practice.

METHODS

We conducted a qualitative phenomenological study from May 2008 to December 2009. We held 37 semi-structured individual interviews with three different cohorts of undergraduate medical students until we reached data saturation. The cohorts were exposed to different contexts while experiencing their clinical years' assessment program. In the interviews, students' perceptions and interpretations of 'self-assessment practice' and 'supervisor-provided feedback' within different contexts and the resulting study strategies were explored.

RESULTS

The analysis of interview data with the three cohorts of students yielded three major themes: strategic practice of self-assessment, self-assessment and study strategies, and feedback and study strategies. It appears that self-assessment is not appropriate within a summative context, and its implementation requires cultural preparation. Despite education and orientation on the two major components of the self-assessment process, feedback was more effective in enhancing deeper study strategies.

CONCLUSION

This research suggests that the theoretical advantages linked to the self-assessment process are a result of its feedback component rather than the practice of self-assessment isolated from feedback. Further research exploring the effects of different contextual and personal factors on students' self-assessment is needed.

Living and working with the people of 'the bush': a foundation for rural and remote clinical placements in undergraduate medical education

BACKGROUND

The Australian Government's policies and programmes to redress the medical workforce shortage in rural and remote areas focus on recruitment of rural students and provision of rural clinical placements. The University of Notre Dame's Rural and Remote Health Placement Programme (RRHPP) uses an additional approach to address this issue.

AIM

This article describes the RRHPP undertaken by all medical students in the first 2-years of their course and examines the educational worth of this approach.

METHOD

Data were obtained from curricular documents, publications about the RRHPP and evaluation questionnaires administered to students and supervisors.

RESULTS

The RRHPP provides students with opportunities to develop a patient- and community-centred perspective on the health issues of rural and remote populations by having them live and work with people in these areas prior to clinical placements. It is based on sound educational principles and underpinned by participation of rural/remote communities as experts and equal teaching partners. The RRHPP is valued and perceived by a majority of students and placement hosts as a useful strategy to develop medical students' understanding of the rural/remote community context and its impact on health.

CONCLUSION

This community participatory approach benefits medical students and rural/remote communities.

Competencies for undergraduate community-based education for the health professions--a systematic review

BACKGROUND

Community-based education (CBE) along with competency approach is increasingly becoming popular. However, there appears to be lack of evidence on CBE competencies for undergraduate curriculum, therefore this systematic review attempted to identify and categorize CBE competencies to determine the ones used frequently.

AIMS

The systematic review aimed at identifying and categorizing CBE competencies implemented in nursing and medical schools to inform all stakeholders of health professional's education.

METHOD

A systematic review of electronic databases including MEDLINE, CINAHL, and ERIC and manual search of four medical education journals was carried out. Search was restricted to original research, published in English language between January 2000 and December 2009.

RESULTS

Nineteen studies fulfilled the search criteria. The competencies identified were categorized under six themes: Public Health; Cultural Competence; Leadership and Management; Community Development; Research; and Generic Competencies. Moreover, a number of clinical competencies were also found to be overlapping with CBE.

CONCLUSIONS

The literature on CBE competencies is limited in number and in its geographical span as most of the studies found was from developed countries; to expand the efforts to other institutions and countries, core competencies for CBE must be recognized and disseminated widely for its integration in health professionals' curriculum.

Self-assessment of intercultural communication skills: a survey of physicians and medical students in Geneva, Switzerland

BACKGROUND

Physicians working with multicultural populations need to know how to elicit the patient's understanding of the illness; determine the patient's sociocultural context and identify any issues that might affect care; communicate effectively across patient-provider social and cultural differences; and collaborate effectively with an interpreter. Skills self-assessment can contribute to identifying training needs and monitoring skills development in these areas.

METHODS

As part of a larger study exploring the knowledge, attitudes and practices of Geneva physicians and medical students regarding the care of immigrant patients, we asked respondents to self-rate their ability to perform a range of common yet challenging intercultural communication tasks.

RESULTS

Overall, respondents rated themselves less competent at intercultural tasks than at basic medical skills and less competent at specific intercultural communication skills than at general intercultural skills. Qualified doctors (as opposed to students), those with greater interest in caring for immigrants, and those who rarely encountered difficulties with immigrants rated themselves significantly more competent for all clinical tasks. Having a higher percentage of immigrant patients and previous cultural competence training predicted greater self-rated intercultural communication skills.

CONCLUSION

Our self-assessment results suggest that students and physicians should be provided with the opportunity to practice intercultural skills with immigrant patients as part of their cultural competence training. To strengthen the validity of self-assessment measures, they should ideally be combined with more objective methods to assess actual skills.

Global Longitudinal Pathway: has medical education curriculum influenced medical students' skills and attitudes toward culturally diverse populations?

BACKGROUND

The Pathway represents a longitudinal program for medical students, consisting of both domestic and international experiences with poor populations. A previous study reported no significant attitudinal changes toward the medically indigent between Pathway and non-Pathway students.

PURPOSE

The purpose of this study was to investigate and differentiate the skills and attitudes of Pathway and non-Pathway students in working with culturally diverse populations by conducting quantitative and qualitative analyses.

METHODS

Selected items from a cultural assessment were analyzed using independent t-tests and a proportional analysis using approximation of the binomial distribution. In addition, a qualitative assessment of non-Pathway and Pathway students was conducted.

RESULTS

A statistically significant difference was found at the end of Years 2, 3, and 4 regarding student confidence ratings, and qualitative results had similar findings.

CONCLUSIONS

Clear and distinct differences between the two studied groups were found indicating the root of this increased confidence may have developed due to exposure to the Pathway program.

Cross-cultural undergraduate medical education in North America: theoretical concepts and educational approaches

BACKGROUND

Cross-cultural undergraduate medical education in North America lacks conceptual clarity. Consequently, school curricula are unsystematic, nonuniform, and fragmented. This article provides a literature review about available conceptual models of cross-cultural medical education. The clarification of these models may inform the development of effective educational programs to enable students to provide better quality care to patients from diverse sociocultural backgrounds.

SUMMARY

The approaches to cross-cultural health education can be organized under the rubric of two specific conceptual models: cultural competence and critical culturalism. The variation in the conception of culture adopted in these two models results in differences in all curricular components: learning outcomes, content, educational strategies, teaching methods, student assessment, and program evaluation.

CONCLUSIONS

Medical schools could benefit from more theoretical guidance on the learning outcomes, content, and educational strategies provided to them by governing and licensing bodies. More student assessments and program evaluations are needed in order to appraise the effectiveness of cross-cultural undergraduate medical education.

Using clinical vignettes to assess doctors' and medical students' ability to identify sociocultural factors affecting health and health care

BACKGROUND

Methods are needed for assessing clinicians' cultural knowledge frameworks.

METHOD

We used a mail survey containing four short clinical vignettes to explore respondents' ability to identify sociocultural factors affecting health and health care. Participants included 299 physicians working at the University Hospitals of Geneva, 156 private physicians, and all 134 local medical students in their clinical years. Twenty-one sociocultural "domains" were identified through inductive coding of responses. For each vignette, we obtained the sum of codes as a measure of the respondent's awareness of sociocultural factors that might affect care in this particular situation. As internal consistency was reasonably high (0.68), we computed a single total score as the sum of responses given to all four vignettes.

RESULTS

Reponses correlated with factors that might be expected to impact clinicians' awareness of sociocultural factors affecting care. Medical students, females, respondents who had received cultural competence training, those with greater interest in caring for immigrant patients, and those with high self-assessed skills at exploring psychosocial and migration-related issues scored higher on the vignettes.

CONCLUSIONS

Brief clinical vignettes appear to be a relevant and feasible method for exploring physicians' knowledge of social and cultural factors affecting health and health care.

Using medical students to enhance curricular integration of cross-cultural content

We hypothesized that an interested medical student group would be helpful in reviewing tutorial cases and giving relevant feedback on the curricular integration of cross-cultural content using case triggers in a preclinical gastrointestinal pathophysiology course. Self-selected student leaders (n = 9) reviewed pre-existing problem-based learning tutorial cases (n = 3) with cross-cultural triggers, and provided narrative feedback to course faculty. The cases were modified and used for the entire class in the following 2 years. Participating course students' comments and teaching faculty feedback were also noted. Outcomes were a change in case content, student global evaluations of the course, and self-reported faculty comfort with teaching the cases. All three tutorial cases were reviewed by a separate group of 2-3 students. Major and minor revisions were made to each case based on the student feedback. These cases were used in 2007 and 2008 and were the major change to the course during that time. Overall course evaluation scores improved significantly from 2006 to 2008 (p = 0.000). Tutors (n = 22 in 2007; n = 23 in 2008) expressed relief during tutor meetings that students had reviewed the cases. A general framework for eliciting student feedback on problem-based cases was developed. Student feedback, consisting of self-selected students' case reviews and solicited course and tutor comments, added value to a curricular reform to improve the integration of cross-cultural content into a problem-based learning curriculum. Our study underscores the fundamental link between teachers and students as partners in curricular development.

Reinforcing cultural competency concepts during introductory pharmacy practice experiences

OBJECTIVES

To incorporate cultural competency concepts into various introductory pharmacy practice experiences (IPPE) at the University of Missouri - Kansas City, School of Pharmacy.

DESIGN

A 6-week series, titled "Becoming a Culturally Competent Provider" was developed to provide IPPE students with the opportunity to apply theory regarding cultural competency in a clinical context.

ASSESSMENT

Pre- and post-intervention attitude survey instruments were administered to 25 students in the spring semester of 2009. Several activities within the series were associated with reflection exercises. Student presentations were evaluated and formal feedback was provided by faculty members. A course evaluation was administered to evaluate the series and determine areas of improvement.

CONCLUSION

A special series on cultural competency resulted in positive changes in students' attitudes, highlighting the importance of reinforcing cultural competency concepts during IPPEs.

Humanities in undergraduate medical education: a literature review

PURPOSE

Humanities form an integral part of undergraduate medical curricula at numerous medical schools all over the world, and medical journals publish a considerable quantity of articles in this field. The aim of this study was to determine the extent to which the literature on humanities in undergraduate medical education seeks to provide evidence of a long-term impact of this integration of humanities in undergraduate medical education.

METHOD

Medline was searched for publications concerning the humanities in undergraduate medical education appearing from January 2000 to December 2008. All articles were manually sorted by the authors. Two hundred forty-five articles were included in the study. Following a qualitative analysis, the references included were categorized as "pleading the case," "course descriptions and evaluations," "seeking evidence of long-term impact," or "holding the horses."

RESULTS

Two hundred twenty-four articles out of 245 either praised the (potential) effects of humanities on medical education or described existing or planned courses without offering substantial evidence of any long-term impact of these curricular activities on medical proficiency. Only 9 articles provided evidence of attempts to document long-term impacts using diverse test tools, and 10 articles presented relatively reserved attitudes toward humanities in undergraduate medical education.

CONCLUSIONS

Evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse. This may pose a threat to the continued development of humanities-related activities in undergraduate medical education in the context of current demands for evidence to demonstrate educational effectiveness.

Measuring Physicians’ and Medical Students’ Attitudes Toward Caring for Immigrant Patients

It is generally believed that culturally competent clinical practice depends in part on the development of positive attitudes toward the care of immigrant patients. However, few tools exist to measure such attitudes in physicians. The authors operationalized ‘‘culturally competent attitudes’’ to include a high level of interest in caring for immigrant patients, an acceptance of the responsibility of doctors and hospitals to adapt to immigrant patients’ needs, and the opinion that understanding the patient’s psychosocial context is particularly important when caring for immigrant patients. The authors then assessed these attitudes and opinions among a sample of 619 Geneva doctors and medical students using a self-administered questionnaire and explored their association to respondents’ personal characteristics and professional experience. The authors found that both personal characteristics and professional experience were associated with attitudes toward caring for immigrant patients. In particular, the perceived importance of understanding the psychosocial context when caring for migrants was higher among medical students, women, Swiss nationals, those with greater interest in caring for immigrant patients and those who had received training in cultural competence. However, it is unclear whether cultural competence training and clinical context lead to the development of more positive attitudes or whether medical students and physicians who already have positive attitudes are more likely to participate in such training.

Disparities education: what do students want?

BACKGROUND

Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners' opinions are vital to the development of future curricula.

DESIGN

Qualitative research using focus group methodology.

OBJECTIVES

Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.

PARTICIPANTS

Study participants were first year medical students with an interest in health disparities (n = 17).

APPROACH

Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.

MAIN RESULTS

The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.

CONCLUSIONS

While many of the students' opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.

Teaching cultural diversity: current status in U.K., U.S., and Canadian medical schools

In this paper we present the current state of cultural diversity education for undergraduate medical students in three English-speaking countries: the United Kingdom (U.K.), United States (U.S.) and Canada. We review key documents that have shaped cultural diversity education in each country and compare and contrast current issues. It is beyond the scope of this paper to discuss the varied terminology that is immediately evident. Suffice it to say that there are many terms (e.g. cultural awareness, competence, sensitivity, sensibility, diversity and critical cultural diversity) used in different contexts with different meanings. The major issues that all three countries face include a lack of conceptual clarity, and fragmented and variable programs to teach cultural diversity. Faculty and staff support and development, and ambivalence from both staff and students continue to be a challenge. We suggest that greater international collaboration may help provide some solutions.

Long-term effectiveness of patient-centered training in cultural competence: what is retained? What is lost?

PURPOSE

To determine whether the effects of a patient-centered cultural competence curriculum could be sustained for one year.

METHOD

In 2006, 57 fifth-year medical students at National Taiwan University were randomly assigned either to a group that received training in patient-centered cross-cultural communication skills or one that received no training. Students' scores on objective structured clinical exams (OSCEs) were compared in the realms of exploring (1) patient perspectives and (2) social factors related to illness, immediately after training (OSCE1) and one year after training (OSCE2).

RESULTS

Regarding students' exploration of patient perspectives, the intervention group scored significantly higher than the control group at OSCE1, but there was a significant decrease from OSCE1 to OSCE2 in the intervention group and no significant difference between the intervention and control group at OSCE2. Regarding students' exploration of social factors related to illness, the intervention group scored significantly higher than the control group at OSCE1, with a nonsignificant decrease from OSCE1 to OSCE2 in the two groups, such that the intervention group again scored higher than the control group in OSCE2.

CONCLUSIONS

The effect of a patient-centered cultural competence training curriculum on students' exploration of social factors related to illness was sustained to a significant degree after one year, whereas the effects on students' exploration of patient perspectives were not. Further research is needed to determine the extent to which additional training can prevent the loss of student skills.

Empowering students with cultural competence knowledge: randomized controlled trial of a cultural competence curriculum for third-year medical students

BACKGROUND

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.

PURPOSE

To determine the impact of formal cultural competence teaching on third-year medical students' knowledge of cultural competence.

METHOD

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.

RESULTS

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).

CONCLUSIONS

Third-year medical students in the intervention group were significantly empowered with cultural competence knowledge when compared to the control group.

Towards effective evaluation and reform in medical education: a cognitive and learning sciences perspective

Health professions education is dealing with major transformations in light of the changing nature of the health care delivery system, including the use of technology for "just in time" delivery of care, evidence-based practice, personalized medical care and learning, as health professionals strive to integrate biomedical advances and clinical practice. This has forced the medical education community to reassess the current teaching and learning practices and more importantly, the evaluation of the medical education process. There have been recent advances in cognitive and learning sciences theories, some of which can inform medical educators about best teaching and learning practices and their impact on the evaluation process. An understanding of these theories provides a sound rationale for choosing specific instructional strategies and choosing evaluation measures that assess the curricular objectives. The review begins with an overview of evaluation and assessment in education, followed by an overview of major theories from the cognitive and learning sciences. Next, the role of cognitive and learning sciences theories in informing the process of medical education evaluation is discussed, including its impact on student learning, performance and professional competence, as well as recommendations for reform of medical curricula based on such theories. The paper continues with the elaboration of current trends in health sciences education, particularly medical education, and available evidence for the impact on student learning and performance as well as areas where more research is needed.

Building and maintaining trust in a community-based participatory research partnership

Although intervention research is vital to eliminating health disparities, many groups with health disparities have had negative research experiences, leading to an understandable distrust of researchers and the research process. Community-based participatory research (CBPR) approaches seek to reverse this pattern by building trust between community members and researchers. We highlight strategies for building and maintaining trust from an American Indian CBPR project and focus on 2 levels of trust building and maintaining: (1) between university and community partners and (2) between the initial project team and the larger community. This article was cowritten by community and academic partners; by offering the voices of community partners, it provides a novel and distinctive contribution to the CBPR literature.

Revising the Tool for Assessing Cultural Competence Training (TACCT) for curriculum evaluation: Findings derived from seven US schools and expert consensus

BACKGROUND: The 67-item TACCT currently used for needs assessment has potential for evaluating evolving cultural competence (CC) curricula. PURPOSE: To validate a shortened, more practical TACCT measure. METHODS: The 67-item TACCT was administered to students and course directors at 7 US schools. Course directors and students reported which of 67 TACCT items were taught. Intraclass correlation coefficients (ICC) examined faculty-student agreement. Under-addressed content was identified. A new and shortened TACCT configuration was proposed and validated with expert educator input. RESULTS: Across-school faculty and student response rates ranged from 75% to 100%. Aggregate ICC was 0.90 (95% CI: 0.84, 0.94) for the 67-item TACCT demonstrating faculty-student agreement. Experts agreed on reduction from 67 to 42 items and domain revision from five to six domains to match under-addressed content. Item analysis showed high internal consistency for all 6 new domains and the total revised 42-item TACCT. CONCLUSIONS: A shorter, more practical TACCT measure is valid and reliable and focuses on under-addressed CC content. Use for curricular evaluation is suggested.

Cultural competence in health care and its implications for pharmacy. Part 1. Overview of key concepts in multicultural health care

Pharmacists are caring for more individuals of diverse age, gender, race, ethnicity, socioeconomic status, religion, sexual orientation, and health beliefs than in previous decades. Not all residents of the United States equally experience long life spans and good health. Health disparities in various cultures have been documented. One critical aspect of reducing health disparities is moving health care providers, staff, administrators, and practices toward increased cultural competence and proficiency. Effective delivery of culturally and linguistically appropriate service in cross-cultural settings is identified as cultural competence. Culture is a dynamic process, with people moving in and out of various cultures throughout their lives. The failure to understand and respect individuals and their cultures could impede pharmaceutical care. Incongruent beliefs and expectations between the patient and pharmacist could lead to misunderstandings, confusion, and ultimately to drug misadventures. Models and frameworks have been developed that provide descriptions of the process by which individuals, practice settings, and organizations can become culturally competent and proficient. This article, the first in a five-part series, presents an overview of issues related to cultural competence in health care with an emphasis on the pharmacy profession. Also provided are definitions for cultural competence and related terms, a brief overview of health disparities and challenges to the common morality, and a discussion of models and frameworks that describe pathways to cultural competence and proficiency.

Cultural diversity teaching and issues of uncertainty: the findings of a qualitative study

BACKGROUND

There is considerable ambiguity in the subjective dimensions that comprise much of the relational dynamic of the clinical encounter. Comfort with this ambiguity, and recognition of the potential uncertainty of particular domains of medicine (e.g.--cultural factors of illness expression, value bias in diagnoses, etc) is an important facet of medical education. This paper begins by defining ambiguity and uncertainty as relevant to clinical practice. Studies have shown differing patterns of students' tolerance for ambiguity and uncertainty that appear to reflect extant attitudinal predispositions toward technology, objectivity, culture, value- and theory-ladeness, and the need for self-examination. This paper reports on those findings specifically related to the theme of uncertainty as relevant to teaching about cultural diversity. Its focus is to identify how and where the theme of certainty arose in the teaching and learning of cultural diversity, what were the attitudes toward this theme and topic, and how these attitudes and responses reflect and inform this area of medical pedagogy.

METHODS

A semi-structured interview was undertaken with 61 stakeholders (including policymakers, diversity teachers, students and users). The data were analysed and themes identified.

RESULTS

There were diverse views about what the term cultural diversity means and what should constitute the cultural diversity curriculum. There was a need to provide certainty in teaching cultural diversity with diversity teachers feeling under considerable pressure to provide information. Students discomfort with uncertainty was felt to drive cultural diversity teaching towards factual emphasis rather than reflection or taking a patient centred approach.

CONCLUSION

Students and faculty may feel that cultural diversity teaching is more about how to avoid professional, medico-legal pitfalls, rather than improving the patient experience or the patient-physician relationship. There may be pressure to imbue cultural diversity issues with levels of objectivity and certainty representative of other aspects of the medical curriculum (e.g.--biochemistry). This may reflect a particular selection bias for students with a technocentric orientation. Inadvertently, medical education may enhance this bias through training effects, and accommodate disregard for subjectivity, over-reliance upon technology and thereby foster incorrect assumptions of objective certainty. We opine that it is important to teach students that technology cannot guarantee certainty, and that dealing with subjectivity, diversity, ambiguity and uncertainty is inseparable from the personal dimension of medicine as moral enterprise. Uncertainty is inherent in cultural diversity so this part of the curriculum provides an opportunity to address the issue as it relates to patient care.

Integrating cultural competency into the undergraduate medical curriculum

CONTEXT

A significant movement is underway to develop standardised curricula that provide medical students with a fundamental knowledge of cultural sensitivity.

METHODS

This paper reviews the recent initiative to integrate cultural competency training into the curricula of American undergraduate medical institutions.

RESULTS

Despite these initiatives, few medical institutions have achieved a comprehensive curriculum providing for continued cultural experiences and assessment of related skill sets. The article proposes a framework for the introduction of continued instruction in and assessment of cultural competency within the undergraduate medical education.

CONCLUSIONS

The described components of cultural competency education in the undergraduate medical curricula provide a framework to facilitate early and continued exposure to experiences designed to promote cultural sensitivity.

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

PURPOSE

To compare faculty and student perceptions of cultural competence instruction as measured by the AAMC's Tool for Assessing Cultural Competence Training (TACCT) as part of a comprehensive curricular needs assessment.

METHOD

In 2005, 25 basic science and clinical course directors and 92 third-year medical students at the University of California, Irvine, School of Medicine were asked to indicate which of 67 separate items listed on the TACCT describing knowledge, skill, and attitude about cultural competence were covered during the first three years of the curriculum. The mean percentage of "yes" responses to each item was computed and compared for both faculty and students.

RESULTS

Response rates were 100% (25/25) for course directors and 75% (69/92) for students. Students systematically perceived that cultural competence instruction occurred more often in the curriculum (range of 28% to 93% "yes" responses) compared to the faculty (range of 8% to 64%). However, faculty and students demonstrated a high level of concordance (intraclass correlation coefficient = 0.89 across all items) in their perceptions about instruction, as measured by their relative rank orderings of the 67 TACCT items. Students and faculty identified clusters of TACCT items pertaining to health disparities, community partnerships, and bias/stereotyping as least likely to be presented.

CONCLUSIONS

Faculty and third-year students at one medical school responded congruently about the relative degree to which cultural competence instruction occurred. The TACCT can be used to identify significant gaps in cultural competence training and inform curricular revision. Further studies involving other schools are warranted.