Special Theme: Cultural Competence: SPECIAL THEME ARTICLES
Applying Theory to the Design of Cultural Competency Training for Medical Students: A Case Study
Crandall, Sonia J. PhD; George, Geeta MPH; Marion, Gail S. PA, PhD; Davis, Steve MA
Dr. Crandall is associate professor, Dr. Marion is associate professor, and Mr. Davis is research instructor, Department of Family and Community Medicine, Wake Forest University School of Medicine; Winston-Salem, North Carolina; Ms. George is behavioral science research coordinator, Department of Behavioral Science, The University of Texas M. D. Anderson Cancer Center, Houston.
Correspondence should be addressed to Dr. Crandall, Department of Family and Community Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157; e-mail: 〈email@example.com〉. Reprints are not available.
The authors thank Dr. Liza Cariaga-Lo, assistant dean, Yale University Graduate School, for her initial contributions to cultural competency training at WFUSM and the Promoting, Reinforcing, and Improving Medical Education (PRIME) project for funding the development of the course. PRIME is managed by the American Medical Student Association Foundation and funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine and Dentistry.
Although literature suggests that providing culturally sensitive care promotes positive health outcomes for patients, undergraduate medical education currently does not provide adequate cultural competency training. At most schools, cultural competency, as a formal, integrated, and longitudinal thread within the overall curriculum, is still in its infancy. In this article, the authors summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine. Evaluation of the results indicate that the course was successful in improving knowledge, attitudes, and skills related to cultural competence as well as bringing about positive changes in the medical school's approach to cultural competency training. Also discussed are the implications of the outcomes for the development of culturally competent physicians and how using appropriate theory can help achieve desired outcomes.
Undergraduate medical education does not adequately prepare future physicians to understand how culture influences a patient's perception of disease and how perceptions affect treatment and, ultimately, quality of care.1 Evidence suggests that providing culturally sensitive care promotes positive health outcomes for patients.2,3,4,5,6 Although some cross-cultural medical education curricula date back to 1970,7 requiring cultural competency as a comprehensive curricular thread in undergraduate medical education is mostly still in its infancy.8,9,10 However, medical educators and accreditation bodies are increasingly recognizing cultural competency as critical to the professional development of physicians.10 The Liaison Committee on Medical Education has taken a position in their accreditation standards that “The faculty and students must 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. Medical students must learn to recognize and appropriately address gender and cultural bias in themselves and others, and in the process of health care delivery.”11 The American Medical Student Association's Promoting, Reinforcing and Improving Medical Education project (AMSA PRIME) has solicited requests for proposals from schools to pilot a cultural competency curriculum using the association's established core competencies. The Accreditation Council of Graduate Medical Education and the Council on Graduate Medical Education are increasingly emphasizing the importance of cultural competency and will soon establish guidelines. Guidelines and competencies have already appeared for residency programs.12,13 The National Board of Medical Examiners will ultimately focus on cultural competency skill as one requirement for passing licensing exams.
In this article, we summarize the current practice of cultural competency training within medical education and describe the design, implementation, and evaluation of a theoretically based, year-long cultural competency training course for second-year students at Wake Forest University School of Medicine (WFUSM).
A REVIEW OF CURRENT PRACTICES
An abundance of resources exist to assist medical schools, other health professions schools, and health care institutions to develop a culturally competent healthcare workforce.14 Although most institutions have implemented some form of cultural competency training, the types of educational and assessment activities vary widely. Cultural competency educational initiatives in medical education traverse the continuum from undergraduate medical education through continuing medical education (CME) and include language training,15,16 lectures and interactive sessions,17,18,19,20 workshops,21 student clerkships,22 elective courses,23 immersion programs,15,16 components within broader residency curricula,24 month-long rotations for residents,25 cultural teaching objective structured clinical examinations (OSCEs),26 longitudinal curricular experiences,27,28 and short immersion CME programs.29 Generally, programs offer more than one type of experience, for example, language training combined with immersion15,16 or “classroom” sessions accompanied by clinical experiences23,25,27,30; some include service learning via community-based projects.16,22,27 Usually, these experiences include attention to the role of ethnic and cultural issues in patient care either broadly defined or specific to populations living in the local geographic regions.
Medical educators are challenged to integrate cultural competency training into content-laden curricula and assure that these educational experiences are valuable and achieve targeted outcomes. Regardless of the abundance of information about the importance of teaching cultural competency and the multitude of resources available, published literature on the outcomes of cultural competency training in the medical education curricula are scarce. Combining terms relevant to cultural competency training and program evaluation, we searched WilsonWeb (12 databases that cover business, science, education, humanities and social sciences), PubMed, Medline, CINAHL, Social Services Abstracts, and ERIC and found little published medical education literature describing program evaluation for cultural competency training in terms of achieved learning outcomes.
A THEORETICAL FRAMEWORK FOR CULTURAL COMPETENCY TRAINING
We used two communication theories to inform the design, implementation, and evaluation of a new year-long culture and diversity course for second-year students at WFUSM. Howell describes levels of communication competence that help educators reflect on where learners may be in any situation.31 In The Empathic Communicator, he explains how learners transition from one level to the next.32 Learners at Level 1 (unconscious incompetence) do not recognize that they are miscommunicating. As they move into Level 2 (conscious incompetence), learners recognize their mistakes, but they are generally unable to correct or resolve the problem. Howell writes, “The third level [conscious competence] adds understanding … knowing what you do and why it works or does not work.” The fourth level (unconscious competence) and fifth level (unconscious supercompetence) are where experts' function and skillful interaction appear effortless. Experts are able to modify their interactions with others as needed without thinking about them. Morell et al. observe that “As with any new learning, students must recognize their need to learn before they can embrace new knowledge, [skills, and attitudes]. Students who do not recognize this need are ‘unconsciously incompetent’ and must move to ‘conscious incompetence’ before learning will occur.”33 Creating awareness of students' “incompetence” must occur in a safe environment, carefully facilitated by the faculty.
Bennett offers a model of intercultural sensitivity that describes six developmental stages varying from ethnocentrism (denial, defense, minimization) to ethnorelativism (acceptance, adaptation, integration).34,35 Although other models36,37,38,39 and successful teaching approaches38,40,41,42,43,44 for cultural competence exist, Bennett's model is particularly practical. Bennett built his model on established concepts and addressed stages of development with greater specificity, which allows “educators to diagnose stages of development for individuals or groups, to develop curriculum relevant to particular stages, and to sequence activities in ways that facilitate development toward more sensitive stages.”35 Culhane-Pera and colleagues adapted Bennett's model in residency education and collapsed the stages into five levels ranging from Level 1, “in which physicians have no insight about the influence of culture on medical care, to Level 5, in which they integrate attention to culture into all areas of their professional lives.”27
Howell's levels of competence and Bennett's developmental model interrelate and provide useful tools for developing curriculum to assess cultural competence in medical students. Table 1 provides a comparison of the two models and the Culhane-Pera et al. adaptation of the Bennett model. In planning the Culture and Diversity Course at WFUSM, we used Howell's and Culhane-Pera et al.'s frameworks to design course objectives and educational experiences and to help determine changes in students' knowledge, skills, and attitudes from the beginning to the end of the course.
DEVELOPMENT OF THE CULTURE AND DIVERSITY COURSE AT WFUSM
WFUSM was one of the three original schools to be awarded an AMSA PRIME contract for culture and diversity. WFUSM's approach was to create a year-long elective course titled “Culture and Diversity” for second-year students, with the intent of using the year to experiment with content and activities and have the students help to identify experiences that could be integrated into the four-year curriculum. The course was not intended to be a permanent stand-alone offering. This pilot was the prelude to developing a four-year curriculum in multicultural medicine. Twelve students (five men, seven women) out of a class of 113 volunteered to participate in the pilot course. All students completed the year-long course. They were offered credit for a non-clinical elective rotation, which met one of their graduation requirements. This group was more ethnically diverse (58% minority—Korean, Russian, African American, Chinese, Hawaiian, and Caucasian) than the second-year class (20% minority).
The course was designed considering the 27 core competencies outlined by AMSA PRIME45 and the goals for the curriculum at WFUSM, specifically effective communication, self-directed independent learning, critical thinking and problem solving, and facility with technology. The course incorporated interactive lectures, videos, simulation, demonstration, role-plays, workshops, patient interviews (including interviews using interpreters), community-based service–learning, and online problem-based learning cases. These strategies are those commonly used in cultural competency training in medical education.7,15,16,17,18,19,20,21,22,23,24,25,27,28,30
We designed the course's goals using Howell and Bennett's developmental theories.27,32,35 Our aim was to help students move from unconscious incompetence (Howell's Level 1) to conscious incompetence, and in some instances to conscious competence (Howell's Levels 2 and 3). We used Culhane-Pera et al.'s adaptation of Bennett's model to help move students from a stage of denial or minimal emphasis on culture (Bennett's Stages 1, 2 and 3) to “acceptance of the role of cultural beliefs, values, and behaviors on health, disease and treatment”27 (Culhane-Pera et al.'s Level 3; Bennett's Stage 4). We also planned the course's goals around a broad definition of culture to include the influences of race/ethnic diversity, social class, racism, disability status, and sexual orientation on health status.
The course consisted of 20 two-to-three–hour sessions during the year (March 2000–February 2001). The session presenters included local, national, and international experts on cultural influences on health as well as contacts provided via the Culture and Diversity Advisory Group convened when the AMSA PRIME project was initiated. Students were assigned readings for each session, which were identified by either the course director or the session content expert. Table 2 is an example of one session's outline.
Assignments included a critical and reflective journal entry for each session, an interview with an individual culturally different from the student and an essay that reflected on the interview using Purnell's 12 cultural domains,39 observed interviews using interpreters, and a self-directed service-learning project. The reflective journal provided students the opportunity to respond to the concepts covered in each session and reflect on how they related to the practice of medicine generally and how students could incorporate the concepts in their experiences with patients. The interviews allowed students not only to practice skills learned in the sessions but also to become more comfortable interviewing patients whose first language was not English. Finally, the service-learning project helped students to learn about the types of resources available in the community, identify a need, and design a project to assist with meeting that need.
EVALUATION OF THE WFUSM PROGRAM
To evaluate the theory-based curriculum development process and the educational value of WFUSM's Culture and Diversity Course, students were asked to complete a self-report questionnaire during the first and last sessions of the course. The Multicultural Assessment Questionnaire (MAQ) is a 16-item Likert-scale instrument designed by Culhane-Pera and colleagues27 that consists of specific knowledge, skill, and attitude objectives that help learners to achieve Stage 4 of Bennett's model.34,35 As Table 1 shows, Bennett's Stage 4 corresponds to Level 3 in the Culhane-Pera et al. adaptation. Achievement of Level 3 was believed to be an appropriate level of cultural competence for second-year students. Although no reliability and validity data were available on the MAQ, one objective for the program evaluation was to determine its reliability for use within an undergraduate medical education setting. We felt that the MAQ had face validity. The questionnaire developers gave us permission to use the instrument. We obtained IRB approval for this curriculum evaluation.
All 12 enrolled students completed the pre- and post-course administrations of the MAQ. Paired t-tests were used to analyze differences between pre- to post-course results on the knowledge (six items), skill (six items), and attitude (four items) sections of the MAQ. Cronbach's alpha was calculated at both assessments to determine internal consistency of the MAQ items. Cronbach's alphas were 0.88 (pre-course) and 0.89 (post-course). Table 3 shows the pre- and post-course results for the knowledge, skill, and attitude sections of the MAQ. Means for each section were significantly different, which indicates that students believed their knowledge, skills, and attitudes improved dramatically, and they achieved Level 3 competence during the year-long course. Effect sizes were large, which denotes that there was little or no overlap between the pre- and post-course distributions of the scores. An effect size of 2.0 indicates a non-overlap of 81.1%.46 The large effects were important findings because this pilot project had a small number of students enrolled in the course. Differences for each of the 16 items were statistically significantly from pre- to post-course (Bonferroni adjusted p < .003), which would be expected given the large effect sizes.
LESSONS LEARNED FROM THE PILOT PROGRAM
Results from the evaluation of our pilot program provide encouraging evidence that medical students' knowledge, skills, and attitudes related to cultural competency can be positively changed. Further studies are needed to evaluate whether these changes persist over time. Additionally, it will be important to examine whether such self-reported changes correlate with students' actual behaviors during clinical encounters (through, for example, unannounced standardized patients on a clinic schedule). Future curricula might include immersion programs, which are receiving positive feedback from learners.16
The program evaluation was limited by the small number of students (volunteers) participating in the year-long course. Selection bias is inherent in a volunteer group. Self-reports may be questioned because participants may think the changes are better than they really are. Changes in knowledge, skills, and attitudes are multifaceted and may not directly result from the intervention (course).
Despite these limitations, a principal strength of this curriculum development process was our use of a theoretical framework for designing and evaluating an educational program. Further, the outcomes suggest that the MAQ may be a reliable instrument for examining cultural competency among medical students. Additionally, as a result of the Culture and Diversity Course at WFUSM, the Dean of Medical Education convened a Cultural Competency Theme Team (CCTT) consisting of individuals who direct curriculum components. The CCTT's task is to critically review the four-year curriculum and propose integration of culturally relevant education throughout all phases. The students' journals from the course will provide one source of information for designing those activities. To date, nine problem-based cases in the first two years have been identified. They are being revised to include task questions that will generate learning issues relevant to the “culture” of the patient. First- and second-year courses (medical interviewing in the first year and medicine as a profession in the first and second years) as well as areas in the third and fourth years have been identified for integration of appropriate activities. The course director for the medical interviewing course is a member of the CCTT, and a new session on cultural sensitivity, titled “The Patient's Perspective and Cross Cultural Communication,” was implemented in that course. The Standardized Patient Assessments (SPAs) in years one and two provide opportunities to develop scenarios in which culturally relevant issues affect the presentation of the case. The patients and the faculty who directly observe the SPAs must be trained to assess and provide feedback to the learners.
Another positive outcome involves the Clinical Performance Exam, which is held in June for rising fourth-year students. This exam's case base now includes a new scenario presenting a middle-aged Latino man who has limited English proficiency. This case was pilot tested in 2001. Students are assessed on their ability to ascertain culturally relevant information.
CONTRIBUTION OF THE THEORIES
When using the theoretical models we discuss, educators must initially determine the level of competency desired appropriate to the developmental stage of the learners. For second-year medical students, Levels 2 and 3 (awareness and understanding) of Howell's model32 and Level 3 (acceptance) of the Culhane-Pera et al.27 adaptation of Bennett's model34 were apt levels and achievement at these levels guided the pre- and post-course assessments. First-year students should be expected to achieve levels different from fourth-year students. As is the case for other required competencies within any professional education program, as learners gain experience, higher levels of achievement (Level 4 or 5) of cultural competency objectives should be expected. An example of a higher-order objective might be for the learner to incorporate “help me understand” questions into every aspect of the patient–clinician communication process.47 The theoretical frameworks used to design WFUSM's Culture and Diversity Course provide effective models for multicultural education and outcomes assessment for undergraduate, graduate, and continuing medical education.
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