Dr. Flores is assistant professor of pediatrics and public health, Boston University Schools of Medicine and Public Health; founder and co-director, Pediatric Latino Clinic, Boston Medical Center; consultant, Center for MassHealth Evaluation and Research, University of Massachusetts School of Medicine, Worcester; and Robert Wood Johnson Minority Medical Faculty Development Scholar. Ms. Gee is a medical student, Boston University School of Medicine. Ms. Kastner is research coordinator, Division of Pediatric Emergency Medicine, Boston Medical Center.
Correspondence and requests for reprints should be addressed to Dr. Flores, Division of General Pediatrics, Boston Medical Center, 91 East Concord Street, Maternity 419, Boston, MA 02118; e-mail: 〈firstname.lastname@example.org〉.
The authors thank Deborah Danoff, MD, for her assistance during several phases of the study, and Gregory Lawson, for providing information about US medical schools for the multivariate analysis. Supported by grants from the Robert Wood Johnson Minority Medical Faculty Development Program (#030878) and an Institutional Research Training Grant of the Health Resources Services Administration (HRSA).
Presented in part at the annual meetings of the Association for American Medical Colleges, Washington, DC, November 3, 1996, and the Pediatric Academic Societies, Washington, DC, May 4, 1997.
The United States and Canada rapidly are becoming more diverse. Racial and ethnic minorities comprise 28% of the U.S. population1 and 15% of the Canadian population.2 It is estimated that by 2000, minorities will outnumber whites in at least three states and the District of Columbia.3 In eight of the ten largest American cities, ethnic minority groups already outnumber whites.4 In addition, more than 31 million Americans are unable to speak the same language as their health care providers.5
Numerous studies have documented that culture (including language) can profoundly influence health care. Culture has been shown to affect access, adherence, health status, continuity of care, preventive screening, doctor-patient communication, analgesia adequacy, use of harmful remedies, immunization rates, and prescription practices.6
Despite the importance of culture in health care and the growing diversity of the United States and Canada, little is known about the teaching of cultural issues in medical schools. Only one published study has examined this topic. Lum and Korenman7 found that in 1991–92, most U.S. medical schools did not have courses on cultural sensitivity. Their study, however, had a 78% response rate, and they did not survey Canadian medical schools or examine in detail the format, content, and timing of courses. The objectives of our study, therefore, were to (1) determine the number of U.S. and Canadian medical schools that have separate courses on cultural issues; (2) examine the format, content, and timing of courses; and (3) investigate whether the cultural issues of major ethnic groups are taught in these courses.
For 1996 to 1998, we attempted to contact by telephone the deans or assistant deans of students and/or the directors of courses on cultural issues at all 126 U.S. (excluding Puerto Rico) and all 16 Canadian medical schools. When telephone contact failed, we also e-mailed and faxed the deans and course directors. Up to eight calls per school were made for initial non-responders to increase the likelihood of a response.
Study Design and Survey
The study design was a cross-sectional telephone survey. The survey instrument consisted of the following questions and requests: (1) Does your school offer a course on cultural sensitivity or multicultural issues? (2) If so, is the course incorporated into the curriculum as a separate required course or elective, or as part of a larger course? (3) Please briefly describe your course. (4) In which year(s) of medical school is the course taught? (5) How many years has the course been in existence? (6) Which ethnic groups are addressed in the course?
The survey took five to ten minutes to complete. We also requested supplemental course materials (syllabi or handouts).
A course was considered to meet the qualifications of teaching about cultural issues if it had one or more of the following topics as a central focus: culture, cultural differences, ethnicity, race, or language and its relation to health care.
Data were entered and bivariate analyses performed using Epi Info 6.03.8 Major ethnic/racial groups in a U.S. medical school's region were identified using data from the Statistical Abstract.4 Multiple logistic regressions were done in a stepwise fashion using True Epistat9; two dependent variables were examined: course of any kind offered on cultural issues; and separate course offered on cultural issues. Independent variables examined in multivariate analyses included: medical school ownership (public versus private); age of school in years, endowment in dollars, percentage of women students, percentage of minority students, class size, and preference given to applicants from the inner city.
All medical schools that were successfully contacted agreed to participate in the study. Only eight U.S. schools and one Canadian school did not respond to repeated contacts, for a response rate of 94% for each country (118/126, and 15/16, respectively). We were unable to determine why the nine schools chose not to participate in the study.
Course Format, Duration, and Timing
Only 8% of U.S. and no Canadian medical schools taught cultural issues to medical students in separate courses (Table 1). Most schools (U.S., 87%; Canadian, 67%) presented cultural issues as a few lectures incorporated into larger courses or electives; the numbers of such lectures ranged from one to three. Cultural issues were taught in electives by 16% of U.S. but no Canadian schools. Canadian schools were significantly more likely than were U.S. schools to offer no instruction on cultural issues (27% versus 8%, respectively; p =.04).
Most courses (both separate and integrated) in U.S. and Canadian medical schools had been taught for less than six years (Table 1). A surprisingly large proportion of schools reported teaching courses for more than 15 years. Several schools in each nation stated that they were uncertain how long the courses had been taught.
The most common format for teaching cultural issues in both countries was case-based instruction (Table 1). Didactic and group-learning formats were used more often in U.S. schools, whereas problem-based learning was more common in Canadian schools. Cultural issues were taught as part of clinical clerkships in 6% of U.S. schools, but in no Canadian school.
Most courses on cultural issues were taught in the first two years of medical school in both countries (Table 1). Canadian schools reported substantially more often that they taught about cultural issues in the third and fourth years of medical school. For example, about three fourths of Canadian schools said that they taught about culture in the third year, compared with about one fourth of U.S. schools. About two thirds of U.S. schools taught about culture for only one to two years, whereas almost three fourths of Canadian schools taught about culture for three to four years. Cultural issues were taught only in the first two years by 61% of U.S. and 27% of Canadian schools. Of note, 20% of U.S. and 36% of Canadian schools reported teaching about culture in all four years of medical school.
Course Coverage of Specific Ethnic/Racial Groups
Most U.S. and Canadian medical schools did not address the specific cultural issues of the largest non-white ethnic groups (Table 1). More than two thirds of U.S. schools did not teach about African American cultural issues, and close to three fourths failed to teach about Latino cultural issues. More than 80% of U.S. schools did not provide instruction about cultural issues of either Asians/Pacific Islanders or Native Americans. The specific cultural issues of the largest non-white ethnic group in a given medical school's state were taught by only 35% of U.S. schools.
More than two thirds of Canadian schools did not teach about cultural issues of either of the nation's two largest non-white ethnic groups, Native Canadians and Asians/Pacific Islanders (Table 1). Significantly more Canadian than U.S. schools (27% versus 7%, p =.03) provided no instruction about the specific cultural issues of any non-white ethnic group.
Multiple logistic regression analyses revealed that none of the seven independent variables (medical school ownership, age of school, endowment, percentage of women students, percentage of minority students, class size, and preference given to those from the inner city) was significantly associated with either of the two outcome variables (having any instruction about cultural issues and having a separate course on cultural issues).
It is surprising that most U.S. and Canadian medical schools do not teach about specific cultural issues of the largest minority groups. In the United States, there are 33 million African Americans, 31 million Latinos, almost ten million Asians/Pacific Islanders, and two million Native Americans,1 but cultural issues of these groups are taught by only 17% to 28% of U.S. medical schools. In Canada, there are 1.2 million Asians (of Chinese, Southeast Asian, Japanese, or Korean descent) and 1.1 million Native Canadians,2 but cultural issues of either group are taught by only 27% of Canadian medical schools. Greater cultural understanding might help to eliminate the often dramatic ethnic disparities in health and use of health services that exist in both countries, such as significant racial differences in cardiac procedures.10,11 Although cultural competency is a relatively new field, medical school course directors already have several available resources for teaching about cultural issues, including textbooks12,13 and cultural competency models.6 Another important but underutilized educational resource is citizens and faculty from major ethnic groups residing in a medical school's surrounding communities. By providing patients' and clinicians' perspectives on culture and health care, these community members can have a key impact on medical students.
Many studies6 document that culture can affect doctor—patient communication, access to health care, health status, and the use of health services, but very few U.S. and no Canadian medical schools offer separate courses about cultural issues. It is also concerning that most schools teach about cultural issues in only one to three lectures in larger courses during the preclinical years. Because culture can profoundly influence clinical care and because the ethnic diversity of patients will only increase, we recommend that medical schools consider teaching cultural issues in a separate, devoted course. Part of this course or the entire course might be given during the medical students' clinical years, so that students can directly and immediately apply the principles. A comprehensive course on cultural issues might consist of presentation of a cultural competency model, skills for using interpreters, folk illnesses, sessions on cultural issues of major ethnic groups, and analysis of cases. We believe that adequate instruction on these essential concepts can be accomplished only in a semester-long (or longer), separate, required course.
Three potential limitations of this study should be noted. It is possible that the reported courses of some medical schools participating in this study may not have corresponded to the actual courses taught. The study results, therefore, may overestimate the prevalence, content, and ethnic coverage of courses on cultural issues. Because the study findings, however, already indicate that the teaching of cultural issues in medical schools is not adequate, such overestimates would not alter the conclusions. A second potential limitation is that the people we interviewed may not always have been aware of all courses in which cultural issues were taught. It is therefore possible that some courses were overlooked in which a lecture or component was devoted to cultural issues. This might have led to an underestimation of the number of schools offering any instruction on cultural issues, but would not affect this study's findings regarding the limited number of schools offering separate courses focusing on cultural issues. A third limitation is that, as with other surveys that do not have a 100% response, non-response bias may have distorted the findings. Because response rates were high (94% for both countries), however, the results could change by no more than 6% with full response by all schools, which still would not substantially alter the conclusions.
It is not clear why most Canadian medical schools have lagged behind their American counterparts in teaching cultural issues. Canadian schools significantly more often offer no course on cultural issues and no instruction about the specific cultural issues of any non-white ethnic group. These findings are particularly surprising given the recent creation of a new territory, Nunavut, in which 85% of the residents are Inuit.14 These results are also of concern in light of data that show the multilingual nature of Canada is growing as a result of increased immigration. In 1996, for example, 4.7 million Canadians, or 16% of the total population, reported a mother tongue other than English or French, a 15% increase from 1991.15 This increase was 2.5 times faster than the overall growth rate of the Canadian population. The greater recognition of diversity and the growing multilingual population in Canada suggest that a critical priority for medical schools should be teaching cultural issues to future Canadian physicians.
Fewer U.S. medical schools teach cultural issues now compared with earlier in the decade. A 1991 study7 found that 13% of U.S. schools had separate cultural sensitivity courses, compared with 8% in our study. It is disturbing that the teaching of cultural issues in U.S. and Canadian medical schools is inadequate and may be getting worse, particularly given the rapid growth of diversity in both countries and mounting evidence on the important effects of culture in clinical care. Our findings suggest that a required medical school course on cultural issues would reverse these disturbing trends, and ensure that we train culturally competent physicians able to provide quality care, with improved communication and patient satisfaction.
2. Official Release and Media Relations Section, Communications Division, Statistics Canada. 1996 Census: ethnic origin, visible minorities. In: Currie D (ed). Statistics Canada, The Daily, catalogue 001E, February 17, 1998. 〈http://www.statcan.ca/Daily/English/980217/d980217.htm
4. U.S. Bureau of the Census. Statistical Abstract of the United States: 1998. 118th ed. Washington, DC: U.S. Department of Commerce, 1998.
5. Woloshin S, Bickell N, Schwartz L, Gany F, Welch G. Language barriers in medicine in the United States. JAMA. 1995;273:724–8.
6. Flores G. Culture and the patient—physician relationship: achieving cultural competency in health care. J Pediatr. 2000:136;14–23.
7. Lum C, Korenman S. Cultural-sensitivity training in U.S. medical schools. Acad Med. 1994;69:239–41.
8. Dean AG, Dean JA, Coulombier D, et al. Epi Info, Version 6: A Word Processing, Database, and Statistics Program for Epidemiology and Microcomputers. Atlanta, GA: Centers for Disease Control and Prevention, 1994.
9. Gustafson TL. True Epistat. Version 5.0. Richardson, TX: Epistat Services, Inc., 1994.
10. Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary revascularization procedures. Are the differences real? Do they matter? N Engl J Med. 1997;336:480–6.
11. Schulman KA, Berlin JA, Harles W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–26.
12. Harwood A (ed). Ethnicity and Medical Care. Cambridge, MA: Harvard University Press, 1981.
13. American Medical Association. Culturally Competent Health Care for Adolescents. A Guide for Primary Care Providers. Chicago, IL: American Medical Association, 1994:39–67.
14. DePalma A. In new land of Eskimos, a new chief offers help. New York Times. 1999:April4:A4.
15. Official Release and Media Relations Section, Communications Division, Statistics Canada. 1996 Census: Mother tongue, home language and knowledge of languages. In: Currie D (ed). Statistics Canada, The Daily, catalogue 001E, December 2, 1997. <http://www.statcan.ca/Daily/English/971202/d971202.htm