Mihalic, Angela P. MD; Dobbie, Alison E. MD; Kinkade, Scott MD
By 2050, it is projected that fewer than 50% of the persons living in the United States will identify themselves as non-Hispanic white. Additional estimates predict that by 2050, 24% of the population will be ethnically Hispanic, and 15% will be black.1 Between 1990 and 2000, the number of Americans with a first language other than English grew by 47%, and the population with limited English proficiency increased by 53%.2 Yet, only 15.2% of current medical students identify themselves as members of minority groups that are underrepresented in medicine (i.e., black, Hispanic, and American Indian).3 Therefore, future generations of minority children born in our rapidly diversifying population may receive health care from physicians whose ethnic, linguistic, and/or cultural backgrounds often differ from their own. These cultural differences may adversely affect physicians' understanding of their minority patients' needs. In turn, this misunderstanding may reduce quality of care, jeopardize patient safety, and contribute to health care disparities.4
Health care beliefs, expectations of the physician–patient relationship, and acceptance of Western medicine vary widely across cultures. Culturally competent health care fosters respect for the patient's health beliefs, enhances the physician–patient relationship, and encourages collaborative management of the patient's illness.5,6 In addition, culturally effective care can increase compliance and improve patient safety and clinical outcomes.7
Cultural sensitivity may be especially important in the care of children.4 Acknowledging this importance, several national pediatric associations have issued policy statements regarding cultural competence in medical education. In 1999, the American Academy of Pediatrics (AAP) published a policy statement defining culturally effective health care and describing its importance in pediatrics.8 In 2002, in their General Pediatric Clerkship Curriculum and Resource Manual, the Council on Medical Student Education in Pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA) cited cultural sensitivity and tolerance as essential medical student characteristics.9 In 2004, the AAP published a second policy statement promoting the development of curricula across the spectrum of medical education to provide the knowledge and skills for culturally effective pediatric care.10 In its 2005 report, Cultural Competence Education for Medical Students, the Association of American Medical Colleges (AAMC) introduced the Tool for Assessing Cultural Competence Training. This tool provides a mechanism for medical schools to map and track cultural competence teaching content across all four years of their curricula.11
Despite these national policy statements and interventions, a 2006 PubMed search revealed no manuscripts describing the teaching and learning of culturally competent pediatric care within U.S. pediatric clerkships. Most reported cultural competence curricula do not address pediatric issues,12,13 and most occur in the first two years of medical school rather than within the clinical clerkships.14,15 As part of the educational scholars program of the Pediatric Academic Societies (PAS)/APA, we conducted a national survey of pediatric clerkship directors to investigate the current state of cultural teaching in U.S. pediatric clerkships. (The PAS Educational Scholars Program is a three-year faculty development program that includes didactic sessions, workshop participation and review, and a longitudinal, mentored, educational research project.) In this article, we report the survey's findings and provide recommendations to promote the teaching of culturally competent pediatric care.
In April 2006, we surveyed all 125 U.S. pediatric clerkship directors concerning the teaching of culturally competent/culturally effective pediatric care within their clerkships and elsewhere in the medical school curriculum.
We designed an online questionnaire using content from a literature search that we carried out, the 1999 and 2004 AAP policy statements,8,10 the AAMC cultural competence education report,11 the family medicine cultural competency curricular guidelines,16 and the report Child Health in the Multicultural Environment.17 A multidisciplinary panel of 12 clinician educators at our institution pilot tested the questionnaire for content, clarity, usability, and length. The PAS educational scholars program faculty also provided valuable input. The COMSEP executive committee approved the questionnaire and distributed it electronically via their listserve. Our institutional review board awarded the study exempt status.
Questionnaire content and delivery.
In our questionnaire, we inquired about the presence or absence of cultural competence teaching in U.S. pediatric clerkships. Where curricula existed, we asked about curricular content, teaching and learning methods, and evaluation strategies. We also solicited clerkship directors' attitudes regarding the importance of cultural competence teaching, and we asked about local factors that facilitated or hindered them in developing cultural competence curricula. Finally, we inquired whether cultural issues related to children were taught elsewhere in the medical school curriculum. Question types were multiple choice/single best answer, checklists, five-point Likert-type scales, and free-text responses. We used simple, descriptive analyses to report the responses. We distributed the questionnaire electronically via Survey Monkey though the COMSEP listserve. We attached a PDF version for respondents who preferred a paper version. We sent the questionnaire a second time after one week. After two weeks, we sent personal electronic reminders to nonresponders.
One hundred U.S. pediatric clerkship directors responded to our survey, a response rate of 80%. The response rate was consistent across all AAMC regions; central, 22 schools (71%); northeastern, 27 schools (77%); western, 14 schools (82%); and southern, 36 schools (86%). Fifty-nine (60%) of respondents taught at public medical schools, and 39 (40%) taught at private schools. Eighty-eight respondents (88%) had six- or eight-week clerkships. Clerkship group sizes ranged from fewer than 10 students (18%), 10–20 students (39%), 20–30 students (32%), to over 30 students (11%). There was no association between size or length of clerkship and provision of cultural teaching.
Of the 98 respondents who reported the presence or absence of a cultural competence curriculum, 24 (24.5%) offered such a curriculum, and 74 (75.5%) did not. Two respondents failed to answer the question on presence or absence of a cultural curriculum.
Attitudes toward teaching culturally competent care of children.
On a five-point Likert scale from strongly disagree to strongly agree, most respondents agreed or strongly agreed that teaching culturally competent care is important (91%), that such care enhances the physician/patient/family relationship (99%), and that culturally competent care improves patient outcomes (90%). Ninety-three (93%) clerkship directors agreed or strongly agreed that their students saw culturally diverse patients. However, only 72 (72%) agreed or strongly agreed that their faculty had the skills to teach culturally competent care, and 82 (82%) agreed or strongly agreed that their faculty role-modeled such care.
Cultural curricular content.
The content of the 24 reported curricula is summarized in Table 1. The five most commonly taught cultural knowledge topics were health beliefs, health care disparities and access to care, legal and ethical cultural issues, influence of faith or religion on health care, and the social and historic contexts of communities. The most commonly taught skills were linguistic differences (use of medical translators), culturally effective medical interviewing and communication, and recognizing, eliciting, and negotiating different core cultural issues. The top five attitudinal areas taught were appreciation for diverse health beliefs; socioeconomic factors and health; impact of race on health care delivery; self-reflection to understand one's personal culture, biases, and tendency to stereotype; and impact of gender on health care delivery. Only four respondents (16%) taught the culture of American medicine, and only two respondents (8%) covered ethnopharmacology (the study of differences in response to drugs by varied racial and ethnic groups) or cultural issues of refugees/foreign-born adoptees.
Cultural teaching and learning methods.
Of the 24 schools with a cultural curriculum, the most common teaching and learning methods were didactic lectures (63%), experiential learning through community activities (58%), and small-group discussions (54%). Other reported methods included Web-based learning (29%), standardized patients (21%), videos (21%), and specially designed clinical experiences (21%). Three schools used directed readings (13%), and two reported problem-based learning (8%).
Evaluation methods for assessing cultural competence.
Of the 24 programs teaching cultural competence curricula, only 14 (58%) reported any evaluation methods (described in Table 2). The most common evaluation methods were student surveys, clinical case presentations, and standardized patient experiences. Other reported evaluation methods included written and online case exercises, videotaped and audiotaped clinical encounters, reflective journals and portfolios, and an objective structured clinical exam.
Facilitating factors and challenges in developing curricula.
Twenty-four respondents reported factors that facilitated cultural curricular development, and 95 reported challenges and barriers to curriculum development. These factors are summarized in Figure 1. The 24 respondents with a curriculum reported that the top factors that facilitated its development were a culturally diverse patient population, faculty interest, faculty expertise, culturally diverse clinic/hospital staff, culturally diverse student group, and culturally diverse faculty. The top three challenges that hindered or prevented curricular development were lack of protected time for program development, lack of grant support/funding, and lack of faculty expertise.
Cultural competence teaching outside the pediatric clerkship.
Many of the 100 respondents reported that, in their institutions, students learn cultural aspects of child health in courses other than the pediatric clerkship. The most common settings were the preclinical clinical medicine course (60%), a preclinical human behavior course (56%), or other clinical clerkships (34%). Respondents from only 10 institutions reported a preclinical course specifically addressing culturally competent care, and only nine reported having a fourth-year elective devoted to culturally competent care.
Our survey demonstrates that despite the AAP policy statements on culturally effective pediatric care, and despite widespread agreement about the importance of teaching such care within the pediatric clerkship, only 25% of U.S. programs currently offer such teaching. Clerkship directors believed that some cultural competence teaching happened through the “informal curriculum” during inpatient and outpatient clinical experiences and by role modeling by residents and faculty. Unfortunately, the literature suggests that this may not be the case. Few faculty and residents have received faculty development in culturally sensitive care, and they may not have the knowledge, skills, and attitudes to role model effectively.18,19
Few clerkship directors reported teaching about working with interpreters. Because of the rapidly increasing numbers of Americans with limited English proficiency, and the tendency to inappropriately use children as interpreters, working well with interpreters is vital to promote effective patient–physician communication and to reduce medical error.4 Few clerkships included studies on the U.S. culture of medicine that might prompt students to examine U.S. medical norms and expectations. Without such self-reflection regarding their own cultural values, biases, and assumptions, it may be more challenging for students to appreciate patients' cultural positions and effectively negotiate the therapeutic relationship.
Almost no clerkship directors taught issues related to refugee medicine. This is surprising, considering the increasing influx of refugees into the United States, the high percentage of children among those refugees, and the multiple medical and psychological problems typically experienced by this population.17
Most reported teaching and learning methods were traditional lectures and case-based discussions. Relatively few clerkships used Web-based learning methods or standardized patients to convey content. A few clerkships reported experiential learning activities within communities to enhance students' cultural learning.20,21 This type of learning activity was also reported in 2005 by Sidelinger et al,21 who described a community–academic partnership aimed at teaching culturally effective pediatric care in pediatric residency training programs in New York and California. These programs included cultural immersion experiences using local community leaders as teachers.
Fewer that half of the clerkship directors who teach culturally competent care reported that they evaluate their programs, and none have reported outcome measures in the peer-reviewed literature. This lack of reported outcomes inhibits dissemination and sharing of effective curricular materials. Also, reported evaluation methods addressed only low-level outcomes measures, such as students' satisfaction with the curriculum and attitudes towards cultural competency. No survey respondent described evaluation methods that demonstrated changes in learners' behavior in the clinical setting with families from different cultures.
The main reported challenges to developing a cultural competence curriculum are common across other content areas and include lack of time, money, and expertise. Responding directors expressed concern over lack of time in the clerkship to teach cultural competence as well as lack of available curricular materials.
Surprisingly, almost all respondents reported that students learn cultural aspects of child health in courses other than the pediatric clerkship. This contradicts our experience, and our findings from the literature, that preclinical cultural curricula typically focus on adult topics. Therefore, we question the extent to which the preclinical curricula in those other courses really covered cultural topics specific to children.
Our study yielded an excellent response rate of 80%. Although 70% is generally considered an acceptable response rate for generalization, we postulate that our nonresponders are more likely than our responders to not have a cultural competence curriculum. Therefore, our study results may overestimate the amount of cultural competence teaching that is occurring in U.S. pediatric clerkships.
U.S. pediatric clerkship directors generally agree with the national pediatrics associations that it is important to teach about culturally competent care, but few deliver such teaching, and almost none evaluate it. Common barriers include lack of time, money, faculty expertise, and easy access to validated teaching materials.
We present the following recommendations to promote the teaching of culturally competent pediatric care within U.S. clerkships.
* First, medical educators should provide interested faculty with opportunities to gain content, teaching, and evaluation skills in cultural competency. Suggested strategies for faculty development include workshops at national meetings on pediatric cultural competence and culturally sensitive pediatric care.
* Second, faculty need protected time to develop, implement, evaluate, and disseminate curricular materials and evaluation tools. In the absence of major external funding sources such as the Health Resources and Services Administration Title VII funds, we recommend that U.S. medical schools promote and support the teaching of culturally competent care from internal resources.
* Third, skilled faculty should develop validated teaching materials and should disseminate them through national presentations, peer-reviewed publications, and online resources such as the AAMC MedEdPORTAL.22 These materials should include more Web-based interactive cases, particularly cases concerning the use of interpreters and refugee medicine. Dissemination of these teaching materials will likely enhance the overall teaching of culturally sensitive health care of children in U.S. pediatric clerkships. In addition, we encourage the increased or expanded use of community partnerships to promote experiential learning that will augment traditional teaching methods.
We currently lack outcomes data from most pediatric cultural curricula. Most reported evaluations have focused on the low-level outcomes of cultural attitudes and skills. No study has yet demonstrated that cultural teaching interventions influence students' behavior in real patient settings or that they have improved patient care outcomes. Further studies should focus on these higher levels of evaluation. Teaching interventions that change behavior are vital if we are to graduate physicians who are competent to provide culturally sensitive pediatric care to the changing U.S. population.
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