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Academic Medicine:
doi: 10.1097/ACM.0b013e318253d6c6
Cultural Competence

Cultural Competence Springs up in the Desert: The Story of the Center for Cultural Competence in Health Care at Weill Cornell Medical College in Qatar

Elnashar, Maha; Abdelrahim, Huda; Fetters, Michael D. MD, MPH, MA

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Author Information

Ms. Elnashar is director, Center for Cultural Competence in Health Care, Weill Cornell Medical College, Doha, Qatar.

Ms. Abdelrahim is trainer and medical interpreter, Center for Cultural Competence in Health Care, Weill Cornell Medical College, Doha, Qatar.

Dr. Fetters is director, Japanese Family Health Program, and associate professor, Department of Family Medicine, University of Michigan Health System, Ann Arbor, Michigan.

Correspondence should be addressed to Ms. Elnashar, Weill Cornell Medical College in Qatar, Education City, PO Box 24144, Doha, Qatar; telephone: (974) 4492-8344; fax: (974) 4492-8322; e-mail: mse2002@qatar-med.cornell.edu.

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Abstract

The authors describe the factors that led Weill Cornell Medical College in Qatar (WCMC-Q) to establish the Center for Cultural Competence in Health Care from the ground up, and they explore challenges and successes in implementing cultural competence training.

Qatar’s capital, Doha, is an extremely high-density multicultural setting. When WCMC-Q’s first class of medical students began their clinical clerkships at the affiliated teaching hospital Hamad Medical Corporation in 2006, the complicated nature of training in a multicultural and multilingual setting became apparent immediately. In response, initiatives to improve students’ cultural competence were undertaken. Initiatives included launching a medical interpretation program in 2007; surveying the patients’ spoken languages, examining the effect of an orientation program on interpretation requests, and surveying faculty using the Tool for Assessing Cultural Competence Training in 2008; implementing cultural competence training for students and securing research funding in 2009; and expanding awareness to the Qatar community in 2010. These types of initiatives, which are generally highly valued in U.S. and Canadian settings, are also apropos in the Arabian Gulf region.

The authors report on their initial efforts, which can serve as a resource for other programs in the Arabian Gulf region.

Research demonstrates that people with cultural backgrounds outside the mainstream of society generally have less access to health care and worse health care outcomes compared with others in the community.1,2 These disparities highlight the need for more training in cultural competence in the health care field. The 14 U.S. standards on culturally and linguistically appropriate services3 offer a guide for health care institutions that provide multilingual and multicultural services to diverse patient populations. Further, the U.S. Liaison Committee on Medical Education (LCME) sets specific objectives (ED-21, ED-22) targeting cultural competence education.4 Although the United States and Canada have seen substantive efforts in the development of cultural competence training and curricula, such initiatives have received limited attention in the Arabian Gulf region.

A paucity of literature is available to inform approaches to cross-cultural issues and cultural competence in health care settings in the Gulf region. In February 2009, a search of PubMed’s extensive database of medical literature, of Academic Medicine’s archive, and of MedEdPORTAL’s depository of curricular resources using the key words “Arabic culture,” “cultural competence,” “cultural awareness,” “cultural sensitivity,” “health care,” “medical field,” “medical education,” and “Qatar”/”Gulf Region”/”Arab world” yielded few articles. A complete review of the literature is beyond the scope of this article; however, in brief, the most informative articles identified by our search mainly address challenges facing Arab Americans or Arab Canadians. Teebi and Teebi,5 for example, discuss the most prevalent demographic, genetic, and moral issues of Arab patients in the United States and Canada, and they urge health care providers to become acquainted with Arab culture so that they can be better equipped to provide excellent-quality health care to their Arab patients. Hammoud and colleagues6 describe Arab Americans’ challenges regarding health care access and delivery, summarize cultural influences on the health of Arab patients, and make recommendations for providing culturally sensitive health care. Also, using qualitative data from focus groups convened in the United Arab Emirates (UAE) to identify the health care needs of Emirati women of childbearing age, Winslow and coworkers7 suggest ways to enhance the delivery of culturally sensitive care. Finally, Fiester8 addresses providing patient-centered care in cases of serious cultural conflict; she emphasizes meeting patients on their own terms and respecting their values.

The Arabian Gulf region contains pockets of “extremely high-density multicultural settings,” which we define as geographic locations with people from greater than 100 cultures living in close proximity (e.g., within one city). Examples can be found in the UAE, Kuwait, and Bahrain. Qatar, which is situated on a peninsula in the Arabian Gulf, also has locales that qualify as extremely high-density multicultural settings. Qatar is undergoing rapid modernization, fueled by the discovery of the world’s third-largest natural gas field9 within its borders. The country’s prosperity draws enormous numbers of expatriate workers from around the globe to support infrastructural expansion. The Qatari capital, Doha, is said to have speakers of 190 languages. This tremendous diversity creates a mélange of cross-cultural challenges in health care settings.

To develop a health care workforce to meet Qatar’s health needs, the Qatar Foundation for Education, Science, and Community Development partnered with Cornell University in 2001 to establish Weill Cornell Medical College in Qatar (WCMC-Q),10,11 a branch campus of the Weill Cornell Medical College in New York. WCMC-Q, Qatar’s only medical school, provides a slightly condensed, typical U.S. curriculum (six total years of basic science education followed by clinical training). Clinical training occurs at the teaching hospital of Hamad Medical Corporation (HMC),12 the country’s premier public health care provider, whose patient population is extremely culturally diverse.

Although WCMC-Q educators have aimed since the school’s founding to prepare medical students to provide world-class, culturally appropriate health care in a highly diverse environment, cultural competence is a virtually unknown concept in this region. Herein, we describe the medical interpretation and cultural competence activities undertaken at WCMC-Q, which led, in turn, to the development of the Center for Cultural Competence in Health Care (CCCHC). We also provide insights for other medical educators engaged in cultural competence educational initiatives.

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Medical Interpretation Services

Recognizing a need for interpretation services

When the first WCMC-Q clinical clerkships began in June 2006, it quickly became clear that medical students needed interpreters to be able to communicate with many of their patients—specifically those who speak hardly any English or Arabic, Qatar’s official languages. At that time, medical interpretation services were available at HMC only through a “language bank,” a database listing employees and their spoken languages. Students, physicians, and other personnel rarely used the language bank for several reasons, including a lack of training and competition with other work demands. Most interpretation happened haphazardly through “incidental interpreters,” which we define as bilingual or multilingual individuals untrained in medical interpretation who can speak a patient’s language and who happen to be present to interpret for health care providers when interpretation is needed. Incidental interpreters could include family members, medical students, nurses, clerks, other staff, or even strangers. Using incidental interpreters posed potential risks, stemming from errors in interpretation, breach of confidentiality, ethical conflicts, minimal familiarity with medical terms, insensitivity to gender issues, and the provision of unsolicited advice.13,14

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Establishing a medical interpretation program

In March 2007, recognizing the impracticality of students’ relying on incidental interpreters and the language bank, then-associate dean for clinical curriculum Dr. Nounou Taleghani instituted, in collaboration with the HMC Medical Education Department, a medical interpretation program for medical students (Table 1). She arranged for free professional medical interpretation training for 25 interpreter candidates from the community who had responded to a newspaper ad and had been carefully interviewed and selected by the associate dean and representatives of human resources. Experts from the Seattle Cross Cultural Health Care Program15 administered a didactic and interactive training program in June 2006 that lasted 40 hours (8 hours per day for 5 consecutive days). All candidates passed the course. The training aimed to develop a pool of professional medical interpreters fluent in English plus at least one other language commonly spoken in Qatar: Arabic, Hindi, Tamil, or Urdu. Since that initial training, HMC has hired three of those trained on a trial basis, and WCMC-Q has hired both a specialist (M.E.) to lead the interpretation program and an Arabic medical interpreter (H.A.) who helps with program operations.

Table 1
Table 1
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Conducting a language survey and raising student and faculty awareness of professional interpreters’ indispensability

Along with hiring trained medical interpreters, we also sought to identify the languages spoken most commonly among patients, to raise student and faculty awareness of the need for such professionals, and to develop an orientation program on professional interpretation.

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Determining patients’ spoken languages.

The 2007 population data from Qatar’s Permanent Population Committee suggested that 45% of the overall Qatari population spoke Arabic,16 but the languages spoken commonly among the remaining 55% were unknown. Thus, to determine the languages needed in recruiting future medical interpreters, we conducted a two-month survey of non-Arabic-speaking patients at HMC outpatient clinics in 2008 (Table 1). The WCMC-Q Office of Research Compliance deemed that this survey and all others mentioned in this article did not require ethical review or approval under Qatari or U.S. regulations for protection of human research subjects. Nurses helped to administer the surveys to randomly selected patients at check-in. Our results showed that of 1,600 respondents, 1,408 (88%) spoke South Asian languages: 21.2% spoke Hindi, 19.5% spoke Urdu, 14.7% spoke Malayalam, 9.5% spoke Tagalog, 7.2% spoke Bengali, 4.5% spoke Nepali, 3.5% spoke Pashto, 3.1% spoke Tamil, 2.3% spoke Sinhalese, 1.5% spoke Farsi, and 1.1% spoke Telugu. The survey results allowed us to make data-driven arguments regarding the need for additional interpretation services and cultural competency efforts.

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Creating orientation sessions on medical interpretation.

Because a campaign to illustrate the importance of professional medical interpretation was needed, we developed orientation sessions for medical students and their preceptors at HMC. Over the course of 18 months, beginning in January 2008, we offered 12 sessions ranging from 30 to 60 minutes during which we emphasized the importance of using medical interpreter services for clear patient–provider communication (Table 2).

Table 2
Table 2
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Developing an educational DVD on medical misinterpretation.

In addition to the orientation sessions, the interpretation program team, led by a fourth-year student under the supervision of Dr. Taleghani, developed an educational DVD, entitled “Medical Misinterpretation.” Many medical students and faculty were unaware of the compelling advantages of medical interpreter services; thus, the 2008 video clarified the importance of using professional medical interpreters in medical encounters when the patient and provider have no language in common. The five-minute DVD contains three scenarios of medical interviews to illustrate (1) the difficulty patients and doctors face if they do not speak the same language, (2) the risks of using family members as interpreters (they may provide misleading or incomplete information on the basis of assumptions they make about the patient’s medical history), and (3) the increased effectiveness of medical encounters when a professional medical interpreter is present.

To evaluate the effectiveness of the DVD, students completed a questionnaire before and after viewing it. The whole session (watching the DVD, completing both the pre- and postquestionnaire, and discussion) took about 20 minutes. The questionnaire measured students’ awareness of the essentiality of engaging trained medical interpreters for medical encounters with patients who do not speak the same language as the provider. Results on items addressing the value and appropriateness of using professional medical interpreters improved from the previewing to the postviewing questionnaires.

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Medical interpretation requests: Unexpected outcomes

Despite our efforts to orient students to the medical interpreter program and to emphasize the importance of engaging interpreters when appropriate, initial interest in the medical interpretation program, which we measured by tracking the number of requests made for interpretation services (Table 3), was far less than we had anticipated. Programmatic issues may partly explain students’ apparent reluctance to use the service initially. For example, medical interpreter hours were restricted to 7:00 AM to 3:00 PM. In addition, we discovered that some faculty members were steering students toward English-speaking patients, believing that non-English speakers would overburden the students. Lastly, informal communications revealed that students’ infrequent use of interpretation services was also due to their unfamiliarity with the function of professional medical interpreters, their concerns that interpretation takes too much time, and, especially, their lack of awareness of the influence that culture has on medical decision making. This last finding led to our understanding that a more comprehensive effort to develop cultural competence was needed.

Table 3
Table 3
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The CCCHC

A major milestone in our work was achieved by establishing the CCCHC.

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Steps toward implementing cultural competence training

The idea for the center grew out of a series of efforts and successes in cultural competence activities (Table 1), including founding the medical interpreter program. Below, we chronologically highlight additional activities that set the stage for CCCHC’s establishment.

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Piloting a cultural competence presentation.

After various discussions, Dr. Taleghani suggested that we create a pilot presentation for students on the effects of culture on health care. In early 2009, a professor of medical ethics invited us to give a four-hour presentation on communication barriers and cross-cultural issues in health care as part of his Medicine, Patients, and Society course. The students received the presentation well; in informal, postclass discussions and through formal, written evaluations, they recommended implementing cultural competence training the year before clinical clerkships begin. Their suggestion encouraged us to examine the curriculum and the potential to integrate a formal cultural competence training program.

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Assessing the existing curriculum.

To assess the scope of cultural competence training in the clinical curriculum, we used Survey Monkey (Palo Alto, California) to administer to clinical faculty members the Tool for Assessing Cultural Competence Training (TACCT) which was developed by and is available from the Association of American Medical Colleges.17 Results revealed that faculty were covering few of the cultural competence training objectives. The existing curriculum focused on U.S.-related health care facts (e.g., disparity factors, health insurance plans, health care access by ethnicity). Essential local cultural and health data were lacking, and we focused on these gaps in developing and evaluating the cultural competence training.

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Developing a cultural competence training proposal.

Our next task was to design cultural competence training for medical students. We developed the overarching framework on the basis of the Accreditation Council for Graduate Medical Education’s six competencies18 and the five TACCT domains: (1) cultural competence rationale, context, and definition, (2) key aspects of cultural competence, (3) understanding the impact of stereotyping on medical decision making, (4) health disparities and factors influencing health, and (5) cross-cultural clinical skills.17 We read Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competence Training,19 along with all relevant sources cited in that book. We also examined data produced by various official Qatari bodies (e.g., the Supreme Council for Family Affairs, Permanent Committee of the Population, HMC, and Qatar Islamic Cultural Center). Such sources helped us to refine our training objectives and to customize the material to the local environment. The local sources helped us to include the following:

* Local case studies and demographic data (e.g., data published in HMC’s annual report);

* Pertinent cultural topics (e.g., Islamic scholars’ views on vital health matters); and

* Traditional healing practices specific to Qatar and the region (e.g., herbal medicine, Islamic healing procedures for heart and mind ailments, and traditional surgical treatments such as cauterization, bone setting, and cupping).20

Ultimately, we chose 24 topics for our training sessions (each one an hour in length), to be taught over the course of the first three years of medical school (List 1). We designed the training not only to cover the diverse sociocultural norms of Qatar and the people in its health care system but also to train students to be culturally proficient, enabling them to work anywhere they might practice in the future.

List 1
List 1
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Obtaining approval to implement training and launching the CCCHC.

In November 2008, after reviewing the TACCT survey results, evaluating our training proposal, and taking into account the LCME accreditation standards mandated for cultural competence training in U.S. medical schools,4 the WCMC-Q Clinical Curriculum Committee agreed to implement the training starting in the 2009–2010 academic year.

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The official launching of CCCHC

Thankfully, leaders at our institution embraced the importance of cultural competence and fully supported our efforts. In April 2009, the dean of WCMC-Q approved expanding the medical interpretation program to become the CCCHC, a new center tasked with providing not only interpreting but also training and consultation services to the WCMC-Q community and its affiliates. In addition to medical interpretation services, the main scope of CCCHC’s work would include training health care providers (students, residents, staff) to be culturally competent and to function effectively as individuals amid cultural differences.

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Evaluating and improving training

In September 2009, we began providing cultural competence skills training to medical students, teaching them about the effective use of medical interpreters, and preparing them for delivery of high-quality care in multicultural settings. In tandem with implementing the new training, we developed questionnaires for students to complete both before and after their exposure to the cultural competence curriculum. We have collected student responses on the preexposure questionnaire and will administer the postexposure questionnaire after the first cohort of students complete their clinical training in 2013. We have also administered questionnaires to students after each of the modules to examine their satisfaction with the learning experiences and to make improvements as necessary.

We have implemented three major curricular enhancements based on some of the recommendations (Table 4) students have written in their open-ended responses:

Table 4
Table 4
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Recommendation 1: Use more local case studies in future training. Solution: Because there is a limited number of local published case studies, we plan to develop a research proposal to collect real-life case studies for students and residents to use as learning tools.

Recommendation 2: Use an interactive workshop format rather than lectures. Solution: We are increasing the number of activities and discussions for the next academic year; for example, we include various role-playing activities, Web-based exercises, video clips, and small-group activities.

Recommendation 3: Include in-depth information on various cultural groups. Solution: Although initially we intentionally included no detailed cultural information to avoid stereotyping, we are adding general information on the main cultural groups in Qatar. Moreover, we continue to encourage our students to develop the curiosity, respect, and empathy essential for providing patient-centered care, and we explicitly discuss the risk of stereotyping (List 1).

Overall, students’ evaluations of our modules have been positive (Table 5). We believe our training format has achieved remarkable success and fulfilled its educational objectives.

Table 5
Table 5
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Research agenda

In addition to providing cultural competence training and medical interpreters, the CCCHC has developed a research agenda. The lack of local published research on culture’s effects on medicine, the undervaluing of professional medical interpretation services, and the dismissal of the relevance of culture to clinical care accentuated the need to demonstrate through research the clinical importance of cultural differences. Thus, we sought opportunities to conduct research to add more rigor to our work and to help us gain the respect of medical school and hospital colleagues.

The advocacy of the senior associate dean of education led to a funded, collaborative research project among WCMC-Q, HMC, and University of Michigan Health System. Our investigative team submitted a proposal to the Qatar National Research Fund’s National Priority Research Program,21 a research-funding mechanism similar to the U.S. National Institutes of Health. We hypothesized that developing a culturally and linguistically adapted, self-administered instrument for patients to assess health care quality could inform quality improvement efforts and empower individuals who are disadvantaged by linguistic and cultural differences. In 2009, we received a three-year, $1,001,965 (U.S.) grant for our proposed project, “Providing culturally appropriate health care services in Qatar: Development of a multilingual patient cultural assessment of quality instrument.”22 Currently ongoing, our survey instrument was inspired by the Consumer Assessment of Health Care Providers and Systems program,23 a product of the U.S. Agency for Healthcare Research and Quality. When the project is complete, our instrument will be available in Arabic, English, Hindi, and Urdu (chosen according to the results of our survey of languages commonly spoken among patients), and it will allow patients to evaluate the quality of the health care they receive. Our analysis will focus on cultural differences to inform our efforts for serving the needs of the diverse cultural groups.

Although further details of the investigation will be reported elsewhere, the significance of the project lies in the collaboration of two leaders of the cultural competence initiative (M.E., H.A.), other WCMC-Q and HMC local investigators, and an international expert on cultural influences in decision making from the University of Michigan (M.D.F.). The scope and magnitude of the project add to the legitimacy of CCCHC’s efforts.

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Successes, Lessons Learned, and Going Forward

The cultural competence training is ongoing; the first medical school class to complete their cultural competence training will graduate in 2013. However, thus far, the annual feedback received from students has been positive (Tables 4 and 5). The largest gain CCCHC has earned is validation. Local media have repeatedly provided favorable coverage of CCCHC’s activities, including the National Priority Research Program grant and WCMC-Q students’ use of HMC’s medical interpretation services to improve patients’ care.24 Weill Cornell Medicine featured an article praising how “WCMC-Q trains students to treat people from different cultures and creeds”; the story quoted students who cited behavioral changes resulting from their participation in the cultural competence training.10 As a result of CCCHC’s positive reputation, other local organizations (e.g., Sidra Research and Medical Center, Qatar University, and other entities within HMC) have sought our assistance in providing cultural competence training through lectures, workshops, and/or focus groups. CCCHC recently won the Unity in Diversity award in Qatar, given annually for exceptional efforts in cultural awareness training (Table 1).

Lessons learned through our efforts can aid others seeking to develop or expand cultural competence training programs in the Arabian Gulf region and beyond. Critical to this effort was an unswerving tenacity and passion for excellence in cultural competence training for medical students and professionals. Although we started simply with medical interpretation initiatives, we soon realized that a prerequisite to fully accepting these initiatives is a fundamental appreciation of the need for cultural competence. CCCHC has been bolstered by our consistent collection of data, evaluation of processes, and willingness to initiate next steps. Support from institutional leaders is vital. Simultaneously pursuing education, research, and outreach has provided the CCCHC with roots that strengthen its position in the institution.

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In Sum

To our knowledge, this is the first cultural competence training program designed for medical students in an extremely high-density multicultural setting in the Arabian Gulf. To maintain credibility in our institution and beyond, we believe that we must continue to pursue educational, clinical care, and research initiatives. Although CCCHC started as a just a trickle, the program has developed into “an oasis in the desert” for cultural competence training. We hope these initial efforts, including our challenges and successes, will serve as a resource for other health care programs in the region considering similar initiatives.

Acknowledgments: The authors thank Dr. Javaid Sheikh, dean of Weill Cornell Medical College–Qatar (WCMC-Q), and the faculty and staff of WCMC-Q for their continuous support. They also give special thanks to Dr. Nounou Taleghani for initially instituting the medical interpretation program; to Dr. Pablo Del Pozo, Dr. Bakr Nour, Dr. Ravinder Mamtani, Dr. Marcellina Mian, and Dr. Thurayya Arayssi for their continuous support; to Dr. Maya Hammoud for her encouragement to participate in research activities; to Dr. Amal Khidir for her help at the early preparation stage of the training and for her effort as a local co-primary investigator for the research project; to Dr. Subhi Al-Aref, then a fourth-year medical student, for helping with the educational DVD; to Hamad Medical Corporation management and staff for assistance with conducting the various surveys; and to Beth Ragle of the University of Michigan Department of Family Medicine and Cris Coren (freelance editor) for their assistance in preparing the manuscript.

Funding/Support: Dr. Fetters’ participation was made possible in part through support from the Jitsukōkai Medical Foundation.

Other disclosures: None.

Ethical approval: The Weill Cornell Medical College–Qatar Office of Research Compliance confirmed that the activities detailed in this article did not require ethical review or approval under Qatari or U.S. regulations for protection of human research subjects.

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References

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3. Office of Minority Health, U.S. Department of Health and Human Services. . National Standards on Culturally and Linguistically Appropriate Services (CLAS) http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Accessed February 8, 2012.

4. Liaison Committee on Medical Education. . LCME Accreditation Standards. http://www.lcme.org/functionslist.htm. Accessed February 28, 2012.

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8. Fiester A. What “patient-centered care” requires in serious cultural conflict. Acad Med. 2012;87:20–24

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10. Saulnier B. Border crossing: In a polyglot nation, WCMC-Q trains students to treat people of many cultures and creeds. Weill Cornell Medicine. Spring. 2010:22–23 http://www.weill.cornell.edu/news/publications/pdf/medicine2/2010-02.pdf. Accessed February 12, 2012.

11. Weill Cornell Medical College in Qatar. . Purpose and mission. August 2011 http://qatar-weill.cornell.edu/aboutUs/purposeMission.html. Accessed February 12, 2012.

12. Hamad Medical Corporation Web site. http://www.hmc.org.qa/hmcnewsite/default.aspx. Accessed February 12, 2012.

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14. Flores G, Laws MB, Mayo SJ, et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14

15. Cross Cultural Health Care Program Web site. http://www.xculture.org. Accessed February 12, 2012.

16. Permanent Population Committee. . Urban Growth and Internal Migration. http://www.ppc.gov.qa/english.htm. Accessed February 12, 2012.

17. Association of American Medical Colleges. . Tool for Assessing Cultural Competence Training (TACCT) https://www.aamc.org/initiatives/tacct. Accessed February 23, 2012.

18. Accreditation Council for Graduate Medical Education. . Advancing Education in Medical Professionalism. http://www.usahealthsystem.com/workfiles/com_docs/gme/2011%20Links/Professionalism%20-%20Faculty%20Dev..pdf. Accessed February 12, 2012.

19. Ring JM, Nyquist JG, Mitchell S Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competence Training. 2008 Oxford, UK Radcliffe Publishing Ltd

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21. Qatar National Research Fund. . National Priorities Research Program (NPRP) http://www.qnrf.org/funding_programs/nprp/index.php. Accessed February 23, 2012.

22. Fetters MD. Providing culturally appropriate health care services in Qatar: Development of a multilingual “patient cultural assessment quality” instrument. http://www.med.umich.edu/fammed/research/culture.htm. Accessed February 28, 2012.

23. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. . Consumer Assessment of Healthcare Providers and Systems (CAHPS) program. https://www.cahps.ahrq.gov/About-CAHPS/CAHPS-Program.aspx. Accessed April 1, 2012.

24. Weill Cornell Medical College in Qatar, Office of Public Affairs. . Liaison between medical and cultural teams at WCMC-Q leads to effective treatment and safe return of “missing” businessman. http://qatar-weill.cornell.edu/media/reports/2011/studentCCCHC.html. Accessed February 28, 2012.

© 2012 Association of American Medical Colleges

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