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Mixed Messages: Residents’ Experiences Learning Cross-Cultural Care

Park, Elyse R. PhD; Betancourt, Joseph R. MD, MPH; Kim, Minah K. PhD; Maina, Angela W. BS; Blumenthal, David MD, MPP; Weissman, Joel S. PhD

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Purpose An Institute of Medicine report issued in 2002 cited cross-cultural training as a mechanism to address racial and ethnic disparities in health care, but little is known about residents’ training and capabilities to provide quality care to diverse populations. This article explores a select group of residents’ perceptions of their preparedness to deliver quality care to diverse populations.

Method Seven focus groups and ten individual interviews were conducted with 68 residents in locations nationwide. Qualitative analysis of focus-group and individual interview transcripts was performed to assess residents’ perceptions of (1) preparedness to deliver care to diverse patients; (2) educational climate; and (3) training experiences.

Results Most residents in this study noted the importance of cross-cultural care yet reported little formal training in this area. Residents wanted more formal training yet expressed concern that culture-specific training could lead to stereotyping. Most residents had developed ad hoc, informal skills to care for diverse patients. Although residents perceived institutional endorsement, they sensed it was a low priority due to lack of time and resources.

Conclusions Residents in this study reported receiving mixed messages about cross-cultural care. They were told it is important, yet they received little formal training and did not have time to treat diverse patients in a culturally sensitive manner. As a result, many developed coping behaviors rather than skills based on formally taught best practices. Training environments need to increase training to enhance residents’ preparedness to deliver high-quality cross-cultural care if the medical profession is to achieve the goals set by the Institute of Medicine.

Dr. Park is senior scientist in health policy, Institute for Health Policy, and clinical assistant in psychology, Massachusetts General Hospital; and instructor in psychiatry, Harvard Medical School, Boston, Massachusetts.

Dr. Betancourt is senior scientist, Institute for Health Policy, Massachusetts General Hospital; and assistant professor, Department of Medicine, Harvard Medical School, Boston, Massachusetts.

Dr. Kim is assistant professor, Ewha Womans University, Seoul, Korea.

Ms. Maina is a research assistant, Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Blumenthal is director, Institute for Health Policy, Massachusetts General Hospital; and professor, Departments of Medicine and Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Dr. Weissman is senior scientist, Institute for Health Policy, Massachusetts General Hospital; and associate professor of medicine and lecturer in the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Correspondence should be addressed to Dr. Park, Massachusetts General Hospital / Harvard Medical School, 50 Staniford Street, 9th floor, Boston, MA 02114; telephone: (617) 724-6836; fax: (617) 724-4738; e-mail: 〈epark@partners.org〉.

Growing attention is being given to racial and ethnic disparities in health care1 and the influence that race, ethnicity, and other sociocultural factors have on care and outcomes.2 A study sponsored by the Commonwealth Fund explored some of these issues and found, for example, that African Americans, Hispanics, and Asian Americans were more likely than whites to report that their doctors did not listen carefully to their questions and that they did not fully understand their doctors.3 Sociocultural differences between patient and provider influence communication and clinical decision making, and evidence suggests that provider–patient communication is directly linked to patient satisfaction, adherence, and, subsequently, health outcomes.4–6

Perhaps now more than ever before, physicians face the challenge of being able to provide quality care to patients of diverse sociocultural backgrounds. The Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care cited cross-cultural training as a mechanism to address this issue and help to eliminate racial and ethnic disparities in health care.1 There is a growing literature about cross-cultural training curricula,7–11 but little is known about whether residents receive formal cross-cultural training and feel prepared to deliver high-quality cross-cultural care. Do residents have the necessary knowledge, attitudes, and skills to deliver the best care possible to a diverse patient population? From a medical education perspective, preparedness requires specific training to gain knowledge, develop professional attitudes, and acquire useful skills.12,13 There is growing interest in assessing the quality of graduate medical education, in particular because of its impact on the preparedness of residents to function in both the present and future health care system. Applied to cross-cultural care, this training should provide knowledge about the impact of sociocultural factors on health and health care, and introduce caregivers to communication skills and other techniques that allow them to explore and negotiate these factors in the clinical encounter in an effective and efficient manner.1,14

One way to ascertain the preparedness of future physicians is to better understand their perspectives regarding this issue. The aims of our study were to explore a group of residents’ perceptions of (1) their preparedness (knowledge, attitudes, and skills) to deliver cross-cultural care; (2) the educational climate in which this training occurred; and (3) the quantity and quality of training received. The goal of our qualitative research was to understand and present these residents’ personal training experiences and their thoughts and actions about providing care to diverse patient populations.15,16

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Method

We chose focus-group interviews and individual, in-depth interviews, both of which formats allowed respondents to identify and describe in their own words areas of cross-cultural care they deemed important. Focus groups encouraged interaction between residents, thus broadening the range of ideas and opinions generated; individual interviews captured residents’ opinions that might not have been expressed in a group format. We developed the focus-group design and facilitation procedures based on recommended focus-group guidelines.17,18

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Participants and recruitment

We conducted seven focus-group and ten individual interviews with residents from February 2003 to June 2003. We recruited residents through general listings sent by program directors and used purposive sampling to assure that participants from seven specialties (internal medicine, family practice, pediatrics, obstetrics–gynecology, psychiatry, emergency medicine, and general surgery) were represented. We selected participants from accredited residency programs around the country that were affiliated with an academic health center. For the focus groups, we selected four program sites based in large cities with diverse patient populations (Boston, Massachusetts; New York, New York; and Los Angeles and San Diego, California), and added two sites in centers that served rural populations at the request of a funder (Davis and Fresno, California). We conducted individual interviews with residents from hospitals in Houston, Texas; Jackson, Mississippi; the Bronx, New York; and Chicago, Illinois.

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Data collection

The focus-group interviews lasted for approximately 90 minutes and individual interviews approximately 25 minutes; all interviews were audiotaped. Residents completed a brief demographic survey prior to beginning the interview, signed written consent forms, and were given remuneration for their time and participation. All procedures and data collection forms were approved by the Massachusetts General Hospital Institutional Review Board.

We developed a semistructured interview guide using information from a review of the literature and from a cross-cultural needs assessment that had been conducted among residents at Massachusetts General Hospital.19 The guide was piloted on a group of residents at a Boston-based hospital to assess content, length, and understandability, and then finalized and used for all group and individual interviews. The guide contained questions about residents’ perceived preparedness to deliver cross-cultural care (with prompts for knowledge, attitudes, and skills), the educational and institutional climate in which this care was delivered, the amount of cross-cultural training they had received, and recommendations for curricular improvement. We instructed residents to think about cross-cultural care as providing care to patients with social, economic, or cultural backgrounds that differed from their own. During the pilot, it was apparent that residents were initially very focused on language differences, separate from other cultural issues. Accordingly, during the group and individual interviews we encouraged residents to think about cross-cultural issues other than language.

Group interviews were co-facilitated by two study investigators: a research psychologist (EP), health services researcher (JW), or internist (JB). The individual interviews were each conducted by one of these three investigators. We asked residents to be frank and assured them that the purpose was not to achieve consensus but rather to gather data that illustrated all of their impressions. Facilitators asked specific questions to assure comprehensive collection and to clarify responses.

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Data analysis

We transcribed all session tapes. Thematic content analysis was conducted by three research assistants, under the supervision of a qualitative researcher (EP). These three coders separately reviewed transcripts and entered data into a standard database. We applied inductive concepts of the grounded theory20 to arrive at the thematic analysis framework. Once thematic saturation (the point at which no new themes emerged) was reached, we identified categories within each theme. We observed no systematic differences between the urban and rural sites or group and individual interview formats, and so we combined the responses of these groups. The reviewers developed a list of themes, refined the content and parameters of the codes, then coded responses for frequency, intensity, and extensiveness.17 At each analysis phase, the three coders compared their results and resolved discrepancies. Statements characteristic of the sentiment of the group were highlighted by the coders and selected by the facilitators. An expert review of the data was conducted (JB). The hallmark of qualitative research is that it goes beyond how much of something there is to tell us about essential qualities; quantities are described when reporting results.21 Thus, in reporting our findings we used descriptive words such as “some” to indicate that a sentiment was repeatedly brought up, and “many” to indicate that an idea was often endorsed.

We took many steps to maximize reliability and validity. The facilitators discussed their impressions and debriefed following each session, and co-facilitators took notes at each session to record interactions, nonverbal language, and environmental factors. One of the group facilitators (EP) oversaw data analyses. A facilitator reviewed every transcript to assure that the interview content was complete and accurate. The three coders carefully reviewed, separately and then together, all of the transcribed data. Coders carefully examined data that seemed discrepant, unexpected, or unclear and compared all coded data to the transcript text.

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Results

Sociodemographic characteristics of residents are presented in Table 1. Of 68 respondents, 40 (59%) were women. Residents’ specialties were internal medicine, family practice, pediatrics, obstetrics–gynecology, psychiatry, emergency medicine, and general surgery. Thirty-three (49%) were white, 6 (8%) identified as Hispanic, 7 (10%) as African American, and 14 (21%) as Asian. Sixty-three (93%) residents had completed medical school training in the United States.

Table 1

Table 1

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Preparedness to deliver cross-cultural care

Residents identified components of preparedness (knowledge, attitudes, and skills) that they felt were needed in an effective cross-cultural encounter. Most residents felt their preparedness had increased as a result of their on-the-job clinical experiences; as they continued in their clinical training, they realized how much more they needed to learn about different patients’ cultures and backgrounds.

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Knowledge

When we asked residents to identify what was important to know about a patient in a cross-cultural encounter, their responses showed no clear consensus about what information was necessary. Many residents emphasized understanding a given patient’s family structure (e.g., who makes decisions in the family) and present living situation, while many others underscored the importance of understanding the role of religion for patients and families in making medical decisions. Some residents mentioned that thresholds of acceptable behavior varied by culture and therefore sought to understand patients’ cultural mores on issues such as child discipline and domestic violence. For some residents, it was important to find out about patients’ alternative medicine practices and past medical experiences, and yet others sought information about patients’ views on end-of-life care and preventive health. In the words of one resident:

Well, in certain cultures there is sort of a hierarchy of responsibility. Some cultures you know for an ill patient there is usually a family member who is sort of head of the group that you speak to, or [in others] you speak to the whole family as a whole about their condition and not so much the patient.

Another resident said:

[We had a case in which] the baby was probably brain dead and was not going to do well, so we spent a while trying to talk to the family about the option of withdrawing support and just trying to explain what the prognosis was for the baby....We spoke almost exclusively with the father and he actually had to call the Middle East and speak to his temple elder to get permission, which took about four or five days, and it was really [the temple elder’s] decision whether or not to withdraw support.

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Attitudes

The value of cross-cultural care.

Most residents felt that effective cross-cultural care was needed to provide high-quality care to diverse patients; this perception was strongest within psychiatry and family medicine. However, these feelings were strongly tempered by concerns about the practicality of providing such care in resource-strained clinical environments. Some participants, particularly emergency medicine and surgery residents, felt strongly that providing culturally sensitive care was unrealistic for them due to their time constraints. Many residents expressed self-doubt over how to handle situations when they elicited culturally relevant information that would take additional time to address. For instance, one resident commented:

You can’t really spend a lot of time thinking about the person or that cultural background....I almost ask none of those questions because it almost doesn’t matter for my interaction as a doctor with that patient. I have no opportunity to ... in terms of opening up or asking those questions, there are no resources that I have. Well, you don’t have time for the answers. You don’t even want to hear the answers.

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Concern about stereotyping.

Although most residents endorsed the value of learning about different cultures, they struggled to accept that it was not possible to learn about every culture they might encounter. They were also very aware of the possibility that learning about the beliefs and practices of specific cultures could lead to stereotyping their patients. As a result, most residents claimed that they did not alter their practices solely due to a patient’s cultural background; rather they strove to treat all patients similarly. While residents repeatedly expressed the importance of treating each patient as an individual and being cognizant of both intracultural and intercultural differences, they also expressed difficulties in separating the tendency to stereotype from the goal of respecting individual cultures. As one resident explained:

No matter how much you can learn about one culture, you can’t generalize to every individual in that culture because it’s quite different. You still have to be open-minded...because it varies tremendously even within a small cultural group.

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Awareness of beliefs.

Many residents felt that they needed to be aware of their own social and medical beliefs and practices, particularly their expectations about medical treatment. Many tried to remind themselves that their own beliefs might differ from their patients’ beliefs, even if they came from similar backgrounds. Thus, these residents emphasized that it was important to be open-minded about patients’ beliefs and treatment expectations; they believed that difficulties arose when patients sensed that the residents were not being open-minded and cognizant of cultural differences. Some voiced frustration with the difficulty of knowing what to do when patients’ beliefs contrasted sharply with their own. Three residents expressed this difficulty as follows:

Now what happens if you understand the patient’s beliefs and cultural background but then that goes really against what you believe?

Each individual is going to have their own perspectives and beliefs and you have to figure out some way to communicate with them despite your beliefs being totally different or the same.

To you pain is not good, or in the situation it’s hard to see someone suffer, and to her it is normal to get permission from her husband for anything and it’s normal for him to deny her pain relief. And it’s normal for her to accept that. And we find that outrageous and yet we shut all that down and are supposed to look at the world through their eyes.

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Skills

Almost all respondents reported that they had developed some cross-cultural skills, although they had done so primarily as a result of their personal or clinical experiences rather than from formal training. With the exception of residents from psychiatry and family medicine, most residents did not learn these skills through formal training. Residents described several skills that they perceived to be important and for which they desired more training, which are described below.

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Skills needed to overcome literacy and language barriers.

It was clear that residents had difficulty treating patients with low literacy levels or limited English proficiency. To help overcome literacy and language barriers, some residents try to assess comprehension by using the “teach back” technique and try to improve communication through visual cues (e.g., pictures) or gesticulations. These two residents’ comments are illustrative:

Be careful with your interpretation of what you think they’re telling you. And with how well you think that they’re understanding your point....So make sure that you have the patients actually say it back to you.

I started walking into a room and if I’m not sure [if a patient speaks English] I say, “Do you speak English?” and everyone is offended....So I don’t know.

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Skills needed to overcome cultural barriers.

Residents often had difficulty with patients with whom there was no apparent language barrier but with whom a cultural barrier existed. One resident dealt with this by simply acknowledging to patients unfamiliarity with their culture and asking what culturally specific information patients would like him to know:

I think the biggest one is to not be afraid of the fact that you’re going to hurt their feelings by asking them, “What cultural things do you think I should know about you to help me care for you better?”

Some residents tried to improve communication by asking a patient’s perceptions about the cause of her or his illness, while others relied on using culturally specific idioms.

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Skills needed to build trust.

Residents felt strongly that they needed to build trust in order to be effective, and yet they found this to be particularly difficult. Some residents tried to build trust by demonstrating empathy and concern through emotional expressions in the form of speech, eye contact, or touch. A few residents acknowledged that spending more time with a patient was helpful in building trust, albeit inconvenient.

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Skills needed to negotiate treatment plans.

One of the most prominent areas of residents’ self-perceived skill improvement was in negotiating a treatment plan with patients and family members and learning how to compromise. However, many struggled to learn how and when to accept failed negotiations. In the words of two residents:

I have a patient who is Hispanic who really doesn’t want to come to terms with his diagnosis of diabetes. He’s a young guy and he’s trying all kinds of herbs, and I had to put aside my scientific thinking to come to an agreement with him that he could do that as long as he also monitored his blood sugar.

You have to kind of balance and choose between respecting their background and you know, like [accepting the thinking that], vapor rub, Vicks Vapor Rub cures everything and it doesn’t do any harm....I try to validate as much as I can that I know is not harmful.

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Educational climate

Institutional priority.

Overall, residents felt that cross-cultural care was a low priority at their respective institutions. Although some residents felt there was a relatively strong sense of endorsement in terms of supporting diversity among the staff (e.g., institutions that attempted to get a diverse pool of residents), they perceived much less of an institutional commitment to support cultural issues in education or clinical practice. The sense was that it would be unrealistic to expect this to be a greater institutional priority. One resident’s words are illustrative:

In our department, we have residents from all over the world. So I think that there’s an appreciation for diversity [among staff and patients], because we’re always going to end up in the hospital with patients from different backgrounds. So I think that there’s an appreciation for it, but...I don’t know that there’s much beyond that.

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Mentors and evaluation.

Although residents identified a few selectively dedicated mentors, attendings were not perceived as particularly supportive or knowledgeable in terms of teaching cross-cultural care. For example, a few residents commented that cultural factors were addressed by attendings only if a resident brought them up. Very few residents recalled being evaluated on cross-cultural care; almost all relied on self-evaluation based on perceived patient satisfaction. For instance, one resident explained that:

Even in clinic when you’re talking to attending surgeons or attending doctors, it’s very rare that somebody would say, “You know what, this patient he’s not doing this or he’s doing [that]—there is this problem because of his culture.” Very rare; very, very rare. [Instead, the attitude is] “he’s got this diagnosis and let’s treat him.”

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Resources.

Residents felt that there was a dearth of resources available to help them with language barriers and other cultural issues. Most residents claimed that there were not enough interpreters at their hospitals, and because they were unable to obtain adequate assistance, they were concerned that language barriers and cultural differences undermined their abilities to make a medical diagnosis or explain a complex medical concept. In addition, residents expressed discontent with the time needed to involve an interpreter, as obtaining an interpreter could delay treatment and lengthen visits. One resident recalled:

I remember waiting for a good two days for somebody to be able to translate a particular dialect of Arabic for a patient for a consent.

Residents often resorted to using a patient’s family member or other unofficial interpreters and thus had concerns about privacy issues. Many residents said that having hospital staff from similar cultures as their patients was an invaluable resource for them and, although this could also lead to privacy concerns when staff members were called upon to help communicate, it helped bridge cultural barriers between themselves and their patients. Within each hospital we studied there were some resources available to assist with cross-cultural care (e.g., ethics counsel, chaplain), but resources greatly varied by specialty (e.g., some psychiatry programs had cultural consults).

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Cross-cultural training

Formal.

Residents reported having received little formal (didactic) cross-cultural care training. Some residents reported that ad hoc learning occurred through lectures given by representatives from a specific culture. Some residents had been to lectures by medical interpreters, but many residents had not received hands-on training on how to work with an interpreter to overcome language and cultural barriers. Some residents had had opportunities to learn through culturally specific case presentations or workshops, and other residents had taken medical language classes.

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Informal.

The most common mechanisms residents cited for learning effective cross-cultural care were through experiences with treating diverse patients and learning through interacting with other residents and interpreters. A few residents mentioned that they learned through observing attending doctors interact with patients, however, most residents said that their learning had occurred through their personal experiences. Many residents expressed that their cultural awareness developed through traveling, through working abroad, and from their own racial/ethnic backgrounds, not through formal training opportunities.

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Residents’ recommendations for training and resources

At the end of each focus-group and individual interview, we asked the residents to make recommendations for improving medical education for effective cross-cultural care.

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Formal.

Many residents suggested additional formal training in cross-cultural care but cautioned that culture-specific training could lead to stereotyping. Formal training recommendations for residents and attendings alike included cross-cultural communication lectures, language and idiom training, and medical language classes. Another suggestion was to have interpreters educate residents about cultural issues, and they emphasized the need for lectures given by individuals from cultures representative of patients they commonly treat. Some residents recommended that training programs include panel discussions on cross-cultural issues and were especially supportive of case-based discussions that integrated ethnic and racial issues. Also, a few residents suggested journal clubs that included evidence-based research on health disparities.

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Informal.

Many residents felt that training programs should provide more hands-on experience working with different cultures (e.g., community medicine rotations that provide opportunities to treat diverse patients and see these patients for follow-up). They also wanted to interact with interpreters. A frequent suggestion was that residents have opportunities to interact with community members. A few residents also recommended peer resident training and individualized cultural training.

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Systems changes.

Almost all residents strongly recommended increasing the number and availability of interpreters. They also emphasized that an interdisciplinary format was needed to assure quality cross-cultural care; for example, a clinical team composed of social workers and auxiliary staff. Also, some residents recommended additional mechanisms for working in community-based settings and developing continuity of care opportunities that would provide in-depth experiences with patients. Although there was disagreement about whether or not faculty members should represent minority groups or just be more culturally aware, residents recommended increasing the diversity among faculty.

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Discussion

With an increasingly diverse U.S. population, it is critical that residents receive training that prepares them to care for patients from different cultural backgrounds. Our study suggests that the future physician workforce may not be optimally prepared to meet this challenge, given the conflicting messages they receive from the institutions at which they train. The interviews we conducted suggest that residents appreciate the importance of cross-cultural education, yet they seem to lack clear notions of what it is they are supposed to achieve and how this should be done.

Since 2002, encouraging curricular changes have been made to promote cultural competence education in medical school and residency. The Liaison Committee on Medical Education’s cultural competence accreditation standard22 requires that all medical schools integrate cultural competence training into their curricula. It appears that residency programs have responded to the Accreditation Council of Graduate Medical Education’s cultural competence standards.23 In 2000–2001, 35.7% of residency programs nationwide provided opportunities to develop cultural competence; in 2003–2004 this percentage rose to 50.7%.24 As this trend continues, educators might do well to conceive of cross-cultural education as occurring in two parts. First, residents are taught cross-cultural frameworks (e.g., knowledge and professional attitudes). Second, they are taught to apply specific skills and practices in a time-efficient, “culturally competent” manner. The residents we interviewed had a somewhat less than concrete understanding of the meaning of standards for cross-cultural care and, although they reported having some formal training mechanisms, they learned mainly through their own interactions with patients, other residents, and interpreters.

Nevertheless, most of the residents we interviewed were able to articulate at least some of what they thought that they should know about a patient in a cross-cultural encounter. Likewise, the residents with whom we spoke had developed ad-hoc strategies and skills as a means of coping in complex clinical environments, to help them diagnose patients, build trust, and negotiate treatment plans. Whether these views and skills are a reflection of what they were taught or whether they represent ideas and practices that they “picked up” along the way is difficult to tell, but it appeared that most residents in our study developed informal skills instead of learning from a formal curriculum and applying methods taught to them. If cross-cultural education is to achieve its goals, perhaps a more cohesive, evidence-based training approach is needed.

Despite having an overall sense of institutional endorsement for cross-cultural care, the residents we interviewed indicated they lacked the support needed to enable them to provide the best-quality care, and thus interpreted effective cross-cultural care as a lower priority. For example, cross-cultural aspects of cases were not usually included in core training mechanisms (e.g., case presentations), and residents did not believe their abilities in this area were evaluated. In addition, most residents felt that their institutions did not provide the needed time and resources to assist them with optimally treating diverse patients. So, although the residents in our study endorsed the importance of cross-cultural care, there was ambivalence about how realistic it was to be able to practice “good” cross-cultural care in today’s health care environment.

The residents we interviewed suggested a variety of systems changes and formal training mechanisms, as well as additional informal opportunities in which they could interact with patients and interpreters. They were quick to note that simply adding more lectures without attention to relevant content and integration with the rest of the curriculum would not be ideal. They were aware of the dangers of stereotyping and were concerned about the burden of being responsible for knowing culturally specific information about all patients. Furthermore, they did not want to be taught to be “culturally sensitive.” Instead, they desired an integration of culturally competent medicine in practice. The formal training mechanisms that they discussed appear to fail without the guidance or expectation of integration of these skills into practice. Therefore we suggest that programs will have to balance providing the culturally specific information that residents want and teaching clinical problem solving as opposed to cultural generalizations.

There are several limitations to our study. First, although residency directors posted general listings soliciting resident participation, the study participants were likely a self-selected group interested in the topic of cross-cultural care. However, if this is true, then our conclusions may be conservative in that the respondents may have presented an overly favorable view of their preparedness. On the other hand, it is possible that because cross-cultural care may have been especially important to the residents who chose to participate in this study, they were perhaps more self-critical of their preparedness on this issue. Second, residents were asked to self-assess their levels of preparedness to give effective cross-cultural care, and this self-assessment is likely to be an overestimation of ability.25 Third, due to the nature of qualitative data design and the high percentage of female participants (59%), these results may not be completely generalizable. Fourth, we focused on the perceptions of preparedness of individual practitioners, yet the cultural practices of specific institutions and the health care system in general may be more important in eventually reducing disparities in health care.

In conclusion, we found that the residents we interviewed were receiving mixed messages about cross-cultural care. They were told, and most believed, that such care was important to the delivery of high-quality care to diverse patient populations. Yet they received less than optimal education on this topic, perceived only a moderately supportive educational climate, and felt that even if they had been taught formally how to proceed, their clinic schedules provided little time to implement their training. Further study is needed to examine how to overcome these institutional and systematic barriers and meet the needs of residents in providing quality care to diverse patients.

The authors thank The Commonwealth Fund and The California Endowment for providing funding for this project. The funding provided by these two organizations supported the design and conduct of the study; data collection, management, analysis, and interpretation; and preparation and submission of the manuscript. The authors also acknowledge the work of Ms. Rachel Singer and Ms. Emelissa Tejada who served as two of the coders for the project.

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