Global migration patterns have forever changed the racial, ethnic, cultural, and linguistic character of the United States.1,2 One consequence of the nation's rapid multicultural transformation is that interpretations of contemporary health care experiences are often reflections of the different cultural viewpoints about health and the health care delivery system that exist among patients and providers. For example, patients' opinions of the use of complementary and alternative healing practices, spiritual healers, and community-based support mechanisms as primary sources for health maintenance or healing can be at odds with the perspective of those U.S. providers whose explanations and approaches to health and illness originate in training heavily infused with the principles of biomedicine and technology.3,4,5,6,7
Fundamental mismatches in culturally mediated health belief systems between patients and providers in the current health care system are occurring alongside the well-publicized differentials in health outcomes across racial and ethnic groups in the United States. Over the last decade, substantial research and educational efforts have been directed towards untangling the relationships between culture and health in order to reverse these differentials. Many health policy experts, and most recently the Institute of Medicine, suggest that a well-conceptualized focus on culture in medical education could serve as one of several important national strategies to eliminate racial and ethnic health disparities.4,8,9,10,11,12,13,14,14A
Responding to the call to teach about culture in the undergraduate medical curriculum requires creating learning materials and learning environments that equip students with knowledge, skills, and experiences about culture and health that have clinical applicability for all patient populations. For example, part of this educational process includes providing students with information that deepens their understanding of the concept of culture in health, the power dynamics inherent in cultural interactions, and the reality that culture is ever-changing and thus cannot be reduced to stereotypic descriptions of population groups' cultural health beliefs, norms, behaviors, and values.7 It also includes the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients' health outcomes.15,16,17,18 The companion piece to this article (which appears next in this issue of Academic Medicine), by Dr. Marjorie Kagawa-Singer and Ms. Shaheen Kassim-Lakha, covers these content areas in detail, and is an example of the kind of foundation information needed to carry out this educational process.
In this article, I seek to make the practical contribution of identifying core components of the topic of culture in health that should be incorporated into undergraduate medical education. Over the past two decades, residency programs, hospitals, community organizations, and medical schools have developed courses and programs focused on cross-cultural, or multicultural, education in health.3,4,5,6,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 The rich lessons from these bold and sometimes risky endeavors have strengthened the educational content and materials for teaching about culture in health. These pioneering contributions to cross-cultural curriculum development, combined with a review of the social science, education, and biomedical literature, form the basis of the synthesis reflected in the core components discussed in the following pages.15,16,25,34,35,36,37,38,39,40,41,42,43,44,45
When presented as thoughtfully prepared instructional material throughout the four-year curriculum, these core components on culture could provide medical students of all sociocultural backgrounds and identities the opportunity to learn both the theory and the application of the concepts of culture in health. How these components are introduced, sequenced, integrated, and reinforced within the existing four-year biomedical curricula is a matter to be worked out by creative leadership within each institution.
THE CORE COMPONENTS
The core components of teaching about culture in health in undergraduate medical education are described below and summarized in Table 1.
Why learn about the impact of culture in health and health care delivery? Students deserve a cogent, well-researched articulation of why it is necessary to include education about culture in the biomedical training program. Briefly, elements of the rationale include:
▪ the ever-changing demographic patterns in the United States;
▪ literature indicating negative health outcomes when culture is dismissed as an influencing factor in health;
▪ the use of health care systems other than biomedicine, such as complementary and alternative medicine, by large numbers of patients;
▪ evidence that increasing provider education about culture in health can contribute to reducing racial and ethnic differentials in health outcomes; and
▪ adherence to the legislative, regulatory, and accreditation mandates requiring that providers be knowledgeable about the applications of culture in health and health care delivery.5,8,9,37
Several excellent review articles, with detailed justifications and explanations for this rationale, can be used as the basis for the education section. Presenting the rationale and providing conditions for student and faculty discussion and debate about the legitimacy of the rationale can set a compelling stage for ongoing study.
An exploration of culture as encompassing beliefs, behaviors, attitudes, and practices that are learned, shared, and passed on by members of a group should serve as the starting point in answer to this section's basic question: What is culture? Excellent definitions in the social science literature can be used to invite students to think through the meaning of culture for individuals and population groups in health, clinical practice, research, and health care delivery systems. It is important to illustrate in this process how culture and definitions of cultural identity are dynamic and ever-changing. For example, exploring the complexity of each individual as a cultural being with multiple affiliations based on common characteristics such as age, disability, or gender identity can give texture and everyday context to the implications of culture for health outcomes.7,10,11,12,14,15,16,19,22,23,24,25,26,28,29,31,32,40,41,49,50,51
Similarly, the opportunity exists here to explore how health care systems operate as cultural systems, by learning the definitions and distinguishing features of the three prominent health care systems used by patients in the United States today: biomedicine, complementary and alternative medicine (CAM), and integrative medicine. For example, instruction could include a review of the current definitions and content of CAM, learning sessions that engage students to develop strategies for gathering, assessing, and utilizing data on CAM in the clinical encounter, followed by observations and dialogue with CAM practitioners. This kind of exposure prepares students to interact while having at least introductory knowledge and a measure of respect with increasing numbers of patients who use other health systems in combination with the Western-based biomedical health system for their health care.7,15,16,25,41,43
This component should also clarify the definitions and meaning of the many words and terms used in the discussion of culture in health care such as sociocultural, multicultural, cultural competence, race, ethnicity, gender, socioeconomic status, diversity, and diverse populations. This requirement for definitions throughout the culture basics section is a way to establish a common language in the national conversation within medical education about issues of culture in health. Teaching and dialogue on these basic culture topics form the building blocks for ongoing learning about the role of culture in the health care setting.5,22,27,31,49
Presenting and analyzing data on the health status of all population groups along with close examination of the United States' dynamic demographic changes demonstrates the urgency of understanding the role of culture in health. These materials offer endless venues for critical thinking among medical students and instructors about the sources and meanings of the links between data on differential health status and culture. For example, are the group classifications in data presentations such as “black,” “white,” “Hispanic,” and “other”—which are currently used in well respected, peer-reviewed research studies—based on biological, cultural, or social classifications? What do the terms biological, cultural, and social mean in health care research and clinical practice today? Why does it make a difference, when conducting, reporting, and explaining research data about groups today, to be clear about the meanings of these terms? How do we begin to untangle the contributions of culture when reviewing current health data on cardiovascular disease, diabetes, or organ transplants, where the racial and ethnic differentials are so stark? Asking questions like these and formulating teaching materials that encourage debate and group learning can highlight for students the importance of a disciplined study of the role of culture in health.14,38,42,48,52,53
Review of the data on health status, over time and in the historical context of longstanding social inequities in the United States, is an equally important facet of this component. Thoughtful historical presentations of the current health epidemics of HIV/AIDS, hepatitis C, and diabetes, and careful instructional presentation of the Tuskegee syphilis studies can show students how the complex relationships of historical forces, economics, politics, geography, legal, and cultural systems affect health care delivery systems, influence health status, and shape health outcomes.2,7,10,11,12,15,22,26,29,32,49,50,51,54
Clinical Encounter: Knowledge, Tools, and Skills
Three distinct yet related segments focused on culture in the clinical encounter are included here: (1) learning about core cultural issues, (2) learning interviewing approaches and methods that elicit information about the patient's social and cultural context, and (3) demonstrating the effective use of the principles and practices associated with the participation of medical interpreters in the clinical encounter.
Core cultural issues
Core cultural issues are universal themes that operate within cultural groups, such as gender roles and positions of authority within a family system; views about birth, dying, advance directives, and death; etiology and the meaning of illness; religion and spirituality; folk illnesses and practices of traditional healers.7,15,16,22,41,50 Such core cultural issues can have implications for clinical care and health outcomes. Using complex, textured examples of these themes from many cultural groups as illustrations, students can begin to witness and understand the dynamic and ever-changing nature of cultures that occur within cultural groups. The educational point here is to present basic knowledge about core cultural issues with examples that alert students to the kinds of key cultural issues that may arise in the clinical encounter.1,20,21,22,26,27,28,29,30,31,35,36,44,49,50,55,56 Emphasizing core cultural issues avoids the problematic approach of presenting detailed lists of traits or characteristics associated with particular cultural groups as knowledge items for students. Sophisticated students and teachers react negatively to such listings in coursework because of the potential to take this information and make assumptions about the cultural beliefs of individual patients without engaging in the careful exploration with each individual about his or her particular cultural belief system and to what extent cultural beliefs are important for each individual in the health care encounter.20,22,26,30,32,49
Effective and skillful interviewing is a cornerstone of excellent clinical practice. Arthur Kleinman's Explanatory Model and other variations on this theme such as LEARN,57 BATHE,17 and SMARTS32 offer students several approaches and methods to respectfully elicit each patient's story of wellness or illness, through core cultural issues and a defined social context. These approaches guide effective and respectful communication and negotiation of clinical diagnoses and treatment options with patients. It is also important to reinforce that these are interviewing approaches, not dogma, and that each patient is the expert on how little or how much culture has to do with each clinical encounter. Teaching students these interviewing models as a discrete skill set is essential. The role of the provider is (1) to thoughtfully and respectfully elicit this information from the patient alone or in partnership with interpreters, (2) to skillfully utilize social and cultural profiles when interviewing patients, and (3) to consider how the cultural beliefs of the patient will be incorporated into the provider's decision-making processes when negotiating treatment and referral plans with patients and families.9,20,22,26,27,28,30,31,32,33,44,49,55,56,58,59,60
Patients who speak a language other than English as their primary language are at a distinct disadvantage in the health care setting in the United States. Few physician providers are fluent in a language other than English and capable of conducting a complete clinical visit with a patient who speaks another language without the assistance of an interpreter. Title VI of the civil rights legislation of 1964 makes it illegal to provide health care services without interpretation services when the patient speaks a language other than English. While establishing interpreter services is an institutional matter, skillful partnership with interpreters in the health care setting is an instructional matter of great importance. Three elements are key in this instruction: (1) exposing students to the roles that translators/medical interpreters from a local community may play as cultural brokers and “truth tellers” in the clinical setting; (2) teaching the code of ethics that guides the work of language and interpretative services in health care; and (3) demonstrating how to establish an effective working relationship with medical interpreters in the clinical encounter, from pre- and post-medical interview discussions with the interpreter, to guidance from the interpreter about cultural beliefs and practices in the community, and to how to physically position the interview triad of patient, provider, and translator in the room for optimal communication. Formal instruction and training in these areas can greatly reduce the provider's inability to communicate with and provide adequate health care for patients who speak languages other than English, while reinforcing the fact that it is against the law to fail to provide such services.61,62,63,64
Provider Focus: Clinician Attitudes and Behaviors
This component is aimed at highlighting the importance of standardizing instruction in medical education that can shape providers' attitudes and behaviors so that providers' own negative biases, prejudices, and stereotypes about cultural groups become insignificant factors in the health care encounter. When providers become aware of these factors, they can clearly and honestly determine when they are differentially closing the doors to resources in biomedicine for distinct patient populations.8
Extensive literature now documents that providers would do well to change their stereotypic attitudes and behaviors when engaged in clinical encounters with patients from population groups with which they may be unfamiliar. When providers act on biased or stereotypic views of patients the results are manifest in the delivery of differential preventive services, clinical resources, and life-saving diagnostic procedures and treatments. Unexamined provider bias, whether conscious or unconscious, supports the continuation of what I see as deathly differentials for diverse populations.20,21,27,28,49,55,56
In order to be fully able to participate in the elimination of health care disparities, and to provide the highest quality of care to all patients, students need the opportunity to examine and understand their own multifaceted cultural identities, their perspectives and views on the culture of biomedicine, and the ways in which these elements may influence their attitudes and behaviors in health care settings. Learning to use self-assessment and self-reflective processes and tools can set a standard for students that can assist them throughout their professional lives to interface in each clinical encounter with humility, compassion, and confidence.22,49
Several features exist in this learning process for students. First, students are encouraged to acknowledge and describe their own individual, often multidimensional cultural identities and those of peers, patients, and communities, the influence of cultural identity and the culture of biomedicine on their health belief systems, and the sources of potential conflict and compatibility that arise from these influences in health care settings.22,35,36,47 Second, students are encouraged to identify potential or actual sources of bias, prejudice, and discrimination that arise from their lived experiences and to remediate identified limitations though anti-bias, anti-isms training with a focus pertinent to health care. Finally, students are encouraged to utilize these self-reflection tools and skills in their lifelong work as health clinicians, researchers, and scholars, and as part of their personal participation as health professionals in the elimination of health care disparities.28,33,49,56 Willingness to engage in these processes and activities is linked to understanding and accepting the power and privilege inherent in the role of physicians today and, consequently, understanding the ability to either introduce differential care or eliminate differential care at the interfaces of communication, diagnosis, treatment options, referrals, follow-up, and resource allocation with patients.10,17,59,60 Success in this segment depends on combining baseline knowledge components with opportunities to practice individual self-assessment, ongoing dialogue, and analysis of clinical cases.
Community teachers in culture curricula bring the daily expressions of cultural factors in health care to life in the context of the priorities of community members' carrying out their jobs, obtaining food and shelter, and dealing with other life stressors. Specifically, the daily experiences of community members, shared in teaching settings, locate culture in the context and quality of life and health in that moment, for that community, in that uniquely complex interface of culture, health, and society. An exploration of the content and meaning of the term community, by students, teachers, and community members, must occur in order to proceed in a useful manner.
When community experts and patients from the immediate hospital or medical school community participate as educators they often bring to the teaching experience compelling local information and vivid personal stories that invite students to “listen and learn” about the context, complexities, nuances, quality, and consequences of cultural factors from the patient's point of view in encounters with the health care systems and health care personnel.6,20,26,28,32,38,47,49
Similarly, course work that immerses medical students in community-based clinics or nonprofit community organizations can expose students to the multiple paradigms at play in the lives of patients. This includes the often-underplayed positive, asset-based, healing conditions that are well recognized in communities despite pervasive conditions of limited financial and/or political resources. Experiential short-term instruction of this nature, if well supervised, can close the loop “from theory to practice” in the culture portions of the curriculum, with students actively integrating the formal classroom instruction in a contemporary health care workplace.6,20,24,26,28,44,49 However, multiple short-term exposures to community-based experiences are not inherently enlightening and can run the risk of placing the student in the position of spectator, not participant, thus reducing the impact of the experience to something akin to a walk through a museum filled with cultural artifacts. Long-term engagements in community-based settings are far preferable for medical student education. Placements of this type encourage students to foster ongoing relationships with community members and help students gain a deeper sense of responsibility and accountability to actively participate in community-led problem solving and advocacy efforts. Community teachers and community-based experiences can provide the bridge for medical students to understand the depth and breadth of the role of culture in health care, which are often obscured in the limited window of a single clinical encounter or even a series of clinical encounters with patients.
Achieving partnership between community members and medical educators for teaching purposes is not easy. For some students and faculty, the fact that the source of wisdom, knowledge, and expertise on matters of culture and health can reside outside the biomedical model of health is often difficult—if not impossible—to accept. Nonetheless, working closely with community members in teaching partnerships can help students and faculty alike re-examine and redirect their often-inappropriate assumptions of superior knowledge and their often-inappropriate exercise of power and control with regard to issues of culture and health care.1,2,12,20,21,26,30,33,49,50,52,54
Institutional Culture and Policies
Visible institutional leadership can send the message that the study of culture in undergraduate medical education is not only important but also here to stay. The creation of curricula and environments that support critical dialogue on the potentially contentious issues of culture, race, racism, ethnicity, gender, class, sexual orientation, disability, language, and immigration is not a minor matter. Student resistance to studying these issues in medical school finds quick and comfortable companionship in institutions that marginalize or undermine efforts to construct these educational venues. Seemingly simple matters such as remaining silent on the issue of senior-level faculty members' using outdated medical terminology to describe current social phenomena in infectious disease epidemics such as HIV–AIDS or hepatitis can create an undercurrent of wonder among students and faculty alike about whether or not an institution is truly committed to a fully contemporary look at the role of culture in health.
The institutional leadership in undergraduate medical education must commit time and money to developing the teaching materials, environments, and partnerships that are necessary to make the study of culture in medical education a reality. Several other institutional processes should simultaneously be present and include (1) formal and unapologetic efforts to expand the social and cultural composition of faculty, employees, and students; (2) training for all faculty in the issues of culture in health; and (3) careful institutional review of clinical practice patterns to identify and redress existing institutional processes of patient discrimination in diagnosis, treatment, referral, or resource allocation. This parallel process of institutional education, self-reflection, and redirection is an essential requirement in elevating the standards for education in the area of culture and health for medical students.12,20,26,28,30,32,33,42,44,45,49,51,54,55,56
These components offer a start for including material on the impact of culture on health in undergraduate medical school curricula. Elements of the topics lend themselves to lecture format, while others call for an interactive teaching method with emphasis on debate, dialogue, and exploration. As is the case with biomedical instruction for adult learners in medical education, the proper balance of teaching methods for issues of culture in health care will also be at the heart of whether or not students learn, remember, and use this new knowledge in their practices of medicine. Medical educators and the leadership in medical schools have the obligation to meet the urgent challenge of formally preparing medical students to practice in this century, with knowledge about the role and impact of culture in health care in order for these providers of tomorrow to improve the health of all Americans.
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