In last month's editorial, I noted that medical schools face a major challenge in designing educational experiences to help their students learn how to develop effective relationships with patients who differ from them racially, ethnically, or in other ways. The magnitude of the challenge relates primarily to the fact that it is not yet clear how best to teach students how to begin acquiring the knowledge, skills, and attitudes they will need to accomplish this. There can be little doubt that it will require a great deal of work by members of the medical education community to meet this challenge. The set of 12 papers devoted to cultural competence that appears in this month's journal provides clear evidence that that work is well under way. Taken together, these papers underline the complexity of that work, and present four important issues that deserve comment.
First, two of the papers—one by Wright and Carrese and one by Tang et al.—indicate that when it comes to addressing issues related to cultural competence, there is at present a disconnect of sorts in the clinical environment between the learners (medical students and residents) and the clinical faculty who teach and mentor them. The learners are, as a group, much more diverse than the clinical faculty, who are largely white men who studied medicine at a time when very few women or minorities attended medical school. Medical schools and residency programs must recognize, therefore, that this difference may affect the interactions that occur in the clinical environment between individual learners and individual teachers. As a result, the efforts of medical schools and teaching hospitals to promote cultural competence may be affected adversely.
Second, four of the papers—those by Peña Dolhun et al., Drouin et al., Crandall et al., and Tervalon—suggest general topics, or content domains, that should be covered in a “cultural competence curriculum.” The paper by Peña Dolhun documents the variation in the content offered by 19 schools that had implemented such a curriculum. The results of their study underscore the need for medical educators to reach a consensus on the content that should be covered in educating medical students about cultural competence before determining how to integrate appropriate learning experiences into the educational program.
Third, Betancourt emphasizes in his paper the importance of evaluating the learning experiences that are designed to promote cultural competence. He makes an extremely important point: Integrating cultural competence learning experiences into the curriculum in not an end in and of itself. While it is certainly important to document that students or residents have learned the content presented in the curriculum, the real tests of the effectiveness of the learning experiences are whether or not what is learned affects positively the interactions that occur between doctors and their patients, and whether these interactions produce improved clinical outcomes. In that regard, the paper by Began is of particular interest. The results of her study suggest that integrating relevant content into learning exercises conducted during the preclinical years of the curriculum will not have a lasting impact on students if those lessons are not reinforced during their clinical education.
Finally, three of the papers—those by Kagawa-Singer and Kassim-Lakha, Taylor, and Wear—challenge us to think more broadly about the nature of the cultural complexities and dissonances that may be encountered in the clinical arena, and indeed to ponder the meaning of cultural competence itself. Taylor points out that the culture of medicine as a profession has an impact on the ways that doctors interact with their patients. This aspect of cultural competence needs to be appreciated, since it potentially affects all patients, not simply those who differ from their doctors by race, ethnicity, or other cultural experience. And Wear challenges us to recognize that socioeconomic differences are themselves important in creating cultural dissonances between doctors and their patients—once again, regardless of differences in race, ethnicity, and other cultural influences.
Wear goes on to argue that physicians will not become truly culturally competent until they experience firsthand the reality of the socioeconomic status of the disadvantage individuals they care for, and she suggests that engaging in actions to address and perhaps ameliorate the impact of being economically disadvantaged is also a necessary element of cultural competence. With regard to her first point, the paper by Crampton is of interest. He discusses the value of having medical students in New Zealand spend a one-week immersion experience with a Maori tribe—an experience that allows students to gain a true perspective on the realities of a disadvantaged and culturally distinct population.
There are some important lessons to be learned from all these papers. First, medical schools must establish cultural competence learning objectives that define the relevant knowledge, skills, and attitudes they expect their students to possess before graduation. Second, they must design educational experiences that will allow students to achieve those learning objectives. In this regard, they must be particularly aware of the need to provide relevant experiences in the clinical years of the curriculum. Those experiences should include home visits or other outreach strategies to expose students directly to the circumstances faced by many of their patients who are socioeconomically disadvantaged. Third, since participating in these learning exercises may present a challenge for some members of the clinical faculty, schools must establish faculty development programs (workshops, seminars, etc.) that will allow faculty members to understand how to be effective in their assigned roles. And finally, schools must establish methods for assessing not only that students have learned relevant material, but also that they apply what they have learned in their interactions with patients. Needless to say, what is involved here is much more than just providing information about the various racial, ethnic, and cultural groups that produce the extraordinary diversity that exists in this country.
In closing, I want to note the important contributions made to the body of work presented in this issue of the journal by anthropologists and other scholars, who are not seen as being in the mainstream of clinical medicine. In my view, these contributions are good examples of how a critically important aspect of clinical medicine can benefit from the intellectual rigor and perspectives that those in other disciplines can bring to bear on the issue. Given the magnitude and complexity of the challenge facing the medical education community as it strives to integrate effective cultural competence educational experiences into the medical education continuum, it is essential that the voices of all who can aid this effort be heard. As I noted last month in this column, we will continue to publish papers on cultural competence because of its critical importance to doctors and their patients, and will continue to invite scholars from all relevant disciplines to submit papers to us on this topic.