In her 1997 book, The Spirit Catches You and You Fall Down, Anne Fadi-man describes in vivid detail an unfolding tragedy as doctors and other health professionals who were raised and educated in the United States struggle to care for a Hmong child.
Fadiman's account is at times painful to read, not because of its prose, but because the sequence of events that she describes is so maddening, and the tragic outcome seems so preventable. The truly remarkable lesson contained in her narrative is that it is likely that the health professionals caring for the child and the child's family would share that view, but would see the events through very different lenses. As she so aptly concludes, the tragedy was the result of the collision of two cultures!
Fadiman's book has contributed greatly to the growing recognition that medical schools and residency programs must do a much better job than in the past in preparing doctors to care for patients from the many diverse cultures that are now represented in this country. But the story she tells is so stark that those who see it as a good point of reference for course work on “cultural competence” run the risk of overlooking the more nuanced examples of the cultural clashes that occur in medicine on a much more frequent basis.
Abraham Verghese's 1994 book, My Own Country, tells a very different kind of story, but one that catches some of the nuances and is extremely important in thinking about the meaning of cultural competence in medicine. In his book, he recounts his own experience in caring for patients with AIDS when they first appeared among the residents of a community in a mountainous region of eastern Tennessee. His story is revealing in that he describes how the inhabitants of the region responded to the afflicted patients—a cultural clash of sorts, even though the patients and the community residents were all native-born Americans. The story has an additional cultural dimension to it. Verghese first came to the United States in 1973 after leaving an Ethiopian medical school because of civil unrest in that country. He eventually completed his medical school studies in India in the late 1970s, and then returned to the United States for additional training and to pursue his career goals.
The books written by Fadiman and Verghese would certainly be among the useful reference materials for faculty developing course work in cultural competence. But in preparing to peruse those materials, faculty would undoubtedly be wondering how to approach the topic. Indeed, they would almost certainly find themselves asking several fundamental questions, such as, What is meant by cultural competence? What are the domains of cultural competence that should receive attention in the course work designed for medical students and resident physicians? These and other questions are plaguing medical educators across this country. Indeed, I am certain that they are challenging medical educators throughout the world.
This issue of Academic Medicine features a set of papers that give insights into the kinds of issues that medical educators will have to be sensitive to as they design relevant course work and plan the clinical rotations that medical students and resident physicians should experience. The six papers cover a range of topics. Three of them raise important issues about the constructs that are used in defining the meaning of culture, and how culture may or may not relate to the various clinical conditions that physicians encounter in the course of their daily work. The other three focus directly on how cultural issues are represented in the design and conduct of the medical school curriculum. One of the important points made by the papers is that faculty must be sensitive to the ways that diversity is represented in the curriculum, and that schools must put in place mechanisms to ensure that this occurs.
As valuable as the collection of papers is in raising important issues related to cultural competence, they do not answer the fundamental question that medical educators confront in designing curricula: What are the domains of culture competence that should receive attention in medical school and residency program curricula? Readers should be aware, however, that a project is now under way at the Association that should provide an answer to that question. With funds provided by a grant from the Commonwealth Fund, the Association has convened an expert panel on cultural competence. The panel members have been charged to determine the domains of cultural competence that should be represented in the medical school curriculum, and to set forth learning objectives for each of the domains. The project will be completed in the next few months.
Once the work of the panel is done, the background papers prepared for the panel and the results of the panel's deliberations will be published in Academic Medicine. That issue of the journal will provide the medical education community with additional guidance on issues that need to be considered in designing and conducting educational experiences that are intended to ensure that future practitioners—medical students and residents—will be prepared to care for the diverse population of this country. Equally important, both the papers in the current issue and those that will appear in the future will provide guidance on actions that individual physicians, medical groups, hospitals, and health plans might taken to assist current practitioners to improve the care now being provided to persons from different cultures. Hopefully, this guidance will help foster changes in the education of doctors and other health professionals that will ensure that the kind of tragic story told by Anne Fadiman will not repeat itself in the future!