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Cross-cultural Education in U.S. Medical Schools: Development of an Assessment Tool

Peña Dolhun, Eduardo MD; Muñoz, Claudia MPH; Grumbach, Kevin MD

Special Theme: Cultural Competence: SPECIAL THEME RESEARCH REPORTS

Purpose Medical education is responding to an increasingly diverse population and to regulatory and quality-of-care requirements by developing cross-cultural curricula in health care. This undertaking has proved problematic because there is no consensus on what elements of cross-cultural medicine should be taught. Further, less is known about what is being taught. This study hypothesized that a tool could be developed to assess common themes, concepts, learning objectives, and methods in cross-cultural education.

Method In 2001, 31 U.S. medical schools were invited to provide the researchers all written and/or Web-based materials related to implementing cross-cultural competency in their curricula. A tool was developed to measure teaching methods, skill sets, and eight content areas in cross-cultural education.

Results A total of 19 medical schools supplied their curricular materials. There was considerable variation in approaches to teaching and in the content of cross-cultural education across the schools. Most emphasized teaching general themes, such as the doctor–patient relationship, socioeconomic status, and racism. Most also focused on specific cultural information about the ethnic communities they served. Few schools extensively addressed health care access and language issues.

Conclusions This assessment tool is an important step toward developing a standard nomenclature for measuring the success of cross-cultural education curricula. On the national level, the tool can be used to compare program components and encourage the exchange of effective teaching tools by promoting a common language, which will be essential for developing and implementing curricula, for comparing programs, and evaluating their effects on quality of care.

Dr. Peña Dolhun is assistant professor, Department of Family and Community Medicine, Ms. Muñoz is research associate, Center for California Health Workforce Studies, and Dr. Grumbach is director, Center for California Health Workforce Studies, and professor, Department of Family and Community Medicine; all are at the University of California, San Francisco.

Correspondence and requests for reprints should be addressed to Dr. Peña Dolhun, 500 Parnassus Ave, MU3-E, Box 0900, UCSF, Department of Family Medicine, San Francisco, CA 94143-0900; telephone: (415) 314-7641; e-mail: 〈penae@fcm.ucsf.edu〉.

The authors thank Robert Like, MD, MS, and Joseph Betancourt, MD, MPH, for reviewing a draft of this manuscript, and Christopher Hartung for graphics support. This work was supported by The California Endowment (Grant no. 200022145) and the Bureau of Health Professions, U.S. Health Resources and Services Administration (contract no. 230-00-0109).

Demographic changes and regulatory and quality-of-care requirements are creating a growing need for health care professionals to learn and develop skills to effectively care for the United States' diverse population. Medical education is responding to this need by developing cross-cultural curricula in health care. A growing body of literature has described the challenges of implementing these types of curricula at all levels of medical education.1,2,3,4,5,6,7,8 The Liaison Committee for Medical Education (LCME), the Association of American Medical Colleges (AAMC), the Accreditation Council on Graduate Medical Education (ACGME), the American Medical Association (AMA), the Institute of Medicine (IOM), and several national conferences8 have either focused entirely or placed strong emphasis on curricular development in cross-cultural medicine.

Integrating cross-cultural education into medical school curricula has proved problematic, as there is no consensus on what elements of cross-cultural medicine should be taught. Further, less is known about what is being taught. Consequently, medical educators do not benefit from an agreed-upon typology that defines key thematic areas, teaching methods, and skill sets.1

Given the lack of standardized approaches, we were interested in measuring the degree of variation of content, skills, and methods in cross-cultural curricula taught in U.S. medical schools. The goal of this project was to develop a standard nomenclature for describing and assessing cross-cultural curricula in medical training. We hypothesized that a tool could be developed to assess common themes, concepts, learning objectives, and methods. By validating a tool to better classify themes, content, and language, we seek to further the development of standards for cross-cultural education.

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METHOD

Program Selection

In the summer of 2001, we selected for study 31 U.S. medical schools that are nationally recognized for their efforts to integrate cross-cultural competence into medical school curricula. Most of the schools that we invited to participate in our study have received funding from initiatives promoting the integration of cross-cultural competence in medical education.

One such initiative is PRIME (Promoting, Reinforcing and Improving Medical Education), a four-year project sponsored by the U.S. Public Health Service, Bureau of Health Professions, Division of Medicine. PRIME is designed to encourage and support primary care students by developing specialized curricula that emphasize the practical knowledge and skills necessary to meet the unique needs of underserved populations. Ten medical schools were in the PRIME program at the time of our study.

Undergraduate Medical Education for the Twenty-first Century (UME-21) is another national initiative that was begun in 1998 to promote the integration of innovative curricula in U.S. medical schools. Eighteen medical schools were chosen by the U.S. Health Resources and Services Administration to participate in the project. Of these medical schools, eight were selected as UME-21 partners to implement the full array of their proposed curricular innovations and ten were chosen as UME-21 Associate Partners to implement a distinct curriculum innovation project.

We invited five other medical schools, in addition to those sponsored by the PRIME or UME-21 programs, to participate, based on their national reputations for academic excellence and/or their innovative curricula.

Two of the schools we invited to participate were each both a PRIME and a UME-21 school. We counted each of these schools once.

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Data Sources and Extraction

We contacted all 31 schools by mail, e-mail, and/or telephone. Contact individuals for each school were asked to provide us with all written and/or Web-based materials related to implementing cross-cultural competency in their curricula. The materials ranged from syllabi to class outlines to recommended readings. In one case, an in-depth interview with the course director served for data collection.

We classified and scored the materials using a tool we developed.

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Creating the Assessment Tool

We created a tool to measure the degrees to which cross-cultural education themes were included in medical school curricula. The themes were selected and defined a priori based on standard areas of teaching. A literature review of relevant articles was conducted using the Medline key terms “cross cultural competency,” “cross cultural education,” and “cross cultural curricula.” A Web-based search of published curricula was undertaken. We also consulted expert opinions regarding content and skill areas that were contemporary and relevant. The items extracted were then synthesized to form distinct, relevant categories.

We defined eight content areas with component items that are unique subjects taught within a commonly accepted rubric of cross-cultural education curricula:

  • ▪ General concepts of culture (culture, individual culture, group culture)
  • ▪ Racism (racism and stereotyping)
  • ▪ Doctor–patient interactions (trust and relationship)
  • ▪ Language (meaning of words, nonverbal communication, use of interpreters, coping with language barriers)
  • ▪ Specific cultural content (epidemiology, patient expectations and preferences, traditions and beliefs, family role, spirituality and religion)
  • ▪ Access issues (transportation, insurance status, immigration/migration)
  • ▪ Socioeconomic status (SES)
  • ▪ Gender roles and sexuality

The Appendix contains a detailed description of each content area and component items and criteria for scoring each item.

In addition to these content areas, we also categorized teaching methods and skills. Skill sets are advanced in concert with knowledge acquisition. Categories of teaching methods included case study, didactic, participatory, mentoring, small-group, large-group, internships, site visits, and projects. Skill categories included introspection, history taking, negotiation, and soliciting explanatory models (see Appendix).

We used a four-point Likert-type scale to score content areas: 1 = not addressed/not able to verify, 2 = mentioned, 3 = significantly addressed, and 4 = extensive, in-depth treatment. Teaching methods and teaching of skills were rated as present or not present. It is important to note that scoring assessed only the degrees to which curricula included different content areas, teaching methods, and skill teaching. We made no attempt to evaluate the quality of the material in the curriculum. The study was designed to systematically categorize and descriptively analyze curricula, not to evaluate quality or effectiveness of curricula.

Two of us (EPD and CM) independently rated the collected materials from each of the schools. Scores were then compared. Agreement was greater than 90%, on average. EPD and CM reviewed disputed scores jointly. Any unresolved scores were given the lower rating. Preliminary scores were sent to contact individuals with a request for review and feedback. Opportunities to amend preliminary scores occurred over a one-month period. Score changes were justified either by providing written documentation or by a direct telephone interview. Three schools modified at least one of their preliminary scores, with 12 items revised to higher scores and three to lower scores.

Scores for every school were entered into a standard statistical software program. To validate the content of each category, intraclass reliability was computed using Cronbach's alpha statistic. Based on the results, we made several modifications. Table 1 shows the final categories and the Cronbach's alpha value for each category with multiple component items.

Table 1

Table 1

A mean score was computed for the six major content area categories made up of more than one item: general concepts of culture, racism, doctor–patient interactions, language, specific cultural content, and access issues. Descriptive analysis of content categories consisted of display of medians, interquartile ranges, and highest and lowest scores.

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RESULTS

Nineteen of the 31 schools we invited (61%) participated in the study: University of Iowa Roy J. and Lucille A. Carver College of Medicine, University of Kentucky College of Medicine, Wake Forest University Health Sciences (School of Medicine), Kansas University Medical Center, Medical University of South Carolina College of Medicine, University of Minnesota School of Medicine–Twin Cities, University of New Mexico School of Medicine, Dartmouth Medical School, University of California San Francisco School of Medicine, University of Miami School of Medicine, University of Nebraska College of Medicine, University of Pennsylvania School of Medicine, University of Pittsburgh School of Medicine, Cornell University Joan and Sanford I. Weill Medical College and Graduate School of Medical Sciences, Harvard Medical School, University of California Los Angeles David Geffen School of Medicine, Stanford University School of Medicine, University of Washington School of Medicine, and Wayne State University School of Medicine. Five medical schools were private and 14 were publicly funded. Six U.S. geographic areas were represented: West, Northwest, Northeast, Southeast, Southwest, and Midwest.

The responding schools formally integrated cultural competence into their curricula to varying degrees. Six schools (32%) had developed separate courses that addressed cultural competence. Two of these courses were electives dedicated exclusively to cross-cultural issues in medicine. The remaining 13 schools integrated cultural competence throughout their medical training curricula in courses and lectures where the topic would be relevant. The extents to which cultural competence was integrated in this manner varied greatly from school to school.

Some schools indicated that they encouraged faculty to address cross-cultural issues informally. However, it was impossible to measure the extent of this informal integration. When asked to indicate whether cultural-competence training was mandatory, 16 (84%) schools stated that all students did receive mandatory instruction.

Figure 1 is a box plot illustrating the central tendency of scores for each content category. Each box extends from the twenty-fifth percentile to the seventy-fifth percentile, with the dark black line depicting the median score (the fiftieth percentile). The thin black horizontal lines show the lowest and highest scores. In some categories, the top quartile cut point was the maximum score.

Figure 1

Figure 1

As Figure 1 demonstrates, there was considerable variation across schools in the degrees to which different content areas were included in their curricula. Half of the schools had scores of 3 or greater (denoting significant or extensive treatment of the subject) for six of the eight categories: conceptual cultural themes, racism, doctor–patient interactions, specific cultural content, SES, and gender roles/sexuality. However, many of the schools had scores falling in the lower range for these categories, with a fourth of the schools having scores of 2 or lower (denoting limited or no coverage) for the content areas of racism, doctor–patient interactions, and gender roles/sexuality. Four schools made no specific mention of teaching about doctor–patient interactions as part of their cross-cultural curriculum.

Scores tended to be lowest in the content categories of language and access. Fifty percent of the schools scored between 1.5 and 2.5 in the language category, with only two schools showing significant or extensive treatment of the subject. A fourth of the schools did not specifically cover access-to-care issues in their cross-cultural curricula.

In addition to the substantial variation across schools in the coverages of different content areas, there was also considerable variation within schools in the degrees to which they included different content areas. That is, most schools did not receive uniformly high or low scores in all content categories, but tended to emphasize certain areas more than others.

The methods used by the schools we studied were very consistent. All schools offered a didactic component and encouraged active student participation through case studies and small- and large-group discussion groups. Ten schools (53%) required student projects. Nearly half (42%) had a mentoring system explicitly created to encourage cross-cultural awareness. A fourth implemented site visits and internships specifically designed to address cross-cultural medicine themes. All schools incorporated the skill of history taking into their curricula, with a majority (74%) encouraging time for introspection. Half of the schools taught negotiation as a specific skill, and a third of the schools offered soliciting explanatory models as a tool to be used in cross-cultural encounters. All but one school (95%) offered mandatory courses beginning in the first year, though there was wide variation thereafter. Five schools (26%) offered cross-cultural education in year one only, and nearly a third offered it in both the first and the second years. Four schools (21%) offered some form of cross-cultural education throughout all four years. One school offered it in years one through three. Only two schools offered cross-cultural education as an elective.

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DISCUSSION

The quest for a standard pedagogy by which to teach cross-cultural issues in U.S. medical schools continues. Much of the difficulty in this quest lies in a critical paradox: Excellent work has been done over the years to create model programs and curricula, but models often are not shared and there are no uniform criteria or standards by which to evaluate the content and quality of one program relative to another.

Our tool furthers the goal of developing standard criteria. The items in the tool are generalizable enough to be applied to all U.S. medical schools.

We found considerable variation in approaches to teaching cross-cultural medicine across medical schools that are leaders in curricular development in this area, although common pedagogic techniques such as small-group discussion and case studies were widely used. Most schools emphasized teaching general themes in culture, the doctor–patient relationship, SES, and racism. The schools, for the most part, also focused on specific cultural information pertaining to the ethnic communities they served. There was wide variation in scores across all items, indicating that some schools focused extensively on certain areas, whereas others neglected them.

Few schools extensively addressed two general content categories: language and access issues. Recent attention has been paid to the importance of language differences as independently predicting health care satisfaction.9 In light of the importance of language differences, it was surprising that schools were not demonstrating more attention to this area. Notable was the relative lack of focus on using an interpreter. This inattention to language issues may be explained by the lack of local expertise and relevance to the school (some schools did not have populations with low English proficiency). Language issues may be addressed outside the context of cross-cultural education, assuming that students will learn the language skills elsewhere.

Because access issues play an important role in acquiring health care, especially for those with limited English proficiency and low SES, it was also surprising to find only a modest treatment of this subject in most schools. Access to health care, as well, may be addressed outside the context of cross-cultural education.

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Limitations

Our study had certain limitations. The schools selected were not a random sample. We purposefully selected schools that were likely to be leaders in establishing cross-cultural education curricula and were, therefore, not representative of all medical schools. This limits the generalizability of our results to the greater medical school population. The small size of the sample makes statistical comparisons between subgroups of schools unreliable. Thus, we could not compare scores for schools with separate cultural competence courses versus schools that integrated the topic into the overall curriculum.

We and the school contacts were potentially biased. Bias was reduced by cross-referencing our scores and by requiring schools to provide written materials or substantial justification of any score modification. Finally, subject matter that was not clearly stated, documented, or published could not be scored, making it more difficult to rate schools with curricula that diffused cross-cultural education throughout many courses rather than in concentrated, easily identifiable and assessable courses.

Some content areas may also have been taught outside the rubric of cross-cultural medicine and therefore were not reported by schools as part of their cross-cultural curricula. For example, it was difficult to assess the treatment of spirituality/religion and gender roles/sexuality within the context of culture. Most of the programs that dealt with spirituality and/or sexuality did so separately from cultural competence. Only in a small number of cases were these topics discussed specifically within the context of culture. Finally, as noted above, our study was not designed to evaluate the quality of curricula. The scores should not be interpreted as directly measuring the quality of the curricula, although failure to include important content areas may obviously have quality implications.

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CONCLUSION

U.S. medical schools are developing cross-cultural curricula to meet the challenge of educating tomorrow's physicians for a increasingly diverse patient population. Our assessment tool can be used as a guide in the development of cross-cultural curricula in health care.

Individual institutions will be able to tailor how each concept and skill is illustrated and taught. Institutions undergoing curricular changes may be able to use this tool as a framework for understanding the range of content areas that may be covered in their curricula. Mature programs can use the tool as part of ongoing development and evaluation.

On a national level, our tool can be used to compare program components and encourage the exchange of effective teaching tools by promoting a universal language. It is an important step toward developing a standard nomenclature that will further efforts to measure the success of cross-cultural education curricula. Leaders in the field of cross-cultural curricula emphasize broad-based, integrative curricula that encompass the range of content areas addressed in our study. In preparing medical students for careers in an ever-changing United States, the challenge for each school will be to balance local realities—demographics, resources, expertise, and traditions—with the broader, and often disparate, needs of the nation.

The ability to set national standards hinges on developing a common language with which to develop and implement curricula, compare programs, quality of care, and their effects on health outcomes. Further research will be needed to move from descriptive studies toward rigorous evaluation of the effects of cross-cultural education on clinician behavior and patient care outcomes.

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REFERENCES

1. Green AR, Betancourt JR, Carrillo JE. Integrating social factors into cross-cultural medical education. Acad Med. 2002;77:193–7.
2. Robins LS, Fantone JC, Hermann J, Alexander GL, Zweifler AJ. Culture, communication, and the informal curriculum: improving cultural awareness and sensitivity training in medical school. Acad Med. 1998;73 (10 suppl):S31–S34.
3. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 199; 130:829–34.
4. Wells S, Black R. Cultural Competence Training for Healthcare Professionals. Bethesda, MD: American Occupational Therapy Association, 2000.
5. Like RC, Steiner RP, Rubel AJ. STFM care curriculum guidelines. Recommended core curriculum guidelines on culturally sensitive and competent health care. Fam Med. 1996;28:291–7.
6. Culhane-Pera KA, Reif C, Egli E, Baker NJ, Kassert R. A curriculum for multicultural education in family practice. Fam Med. 1997;29:719–23.
7. Chrisman NJ. Faculty infrastructure for cultural competence education. J Nurs Educ. 1998;37:45–7.
8. Symposium sponsored by the California Endowment on Setting Standards in Cultural Competence Training for Healthcare Professionals, Glendale, CA, April 12–13, 2002.
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APPENDIX Description of Content Areas and Their Component Items and of Criteria Used to Assess Cross-cultural Education in U.S. Medical Schools

Content Areas and Component Items

General Concepts of Culture

Culture. Culture is a common set of shared values, beliefs, and customs. Significant treatment of culture would provide a forum to explore ideas of culture in depth, such as addressing ethnocentrism and cultural relativism. Extensive treatment would include discussion of culture as an evolving process and distinguish it from other related concepts such as ethnicity and nationality.

Individual culture. Each person has a culture. Significant treatment of individual culture would include a discussion of how an individual's culture is dynamic and may evolve over time. Extensive treatment would further explore the participants' own cultural backgrounds, allowing for reflection, discussion, and sharing of experiences and ideas.

Group culture. This item is a more specific culture, such as the acquired culture of medicine. Significant discussion of group culture would acknowledge that culture may be something an individual is born into or adopts later in life. Extensive discussion might include examining how an individual's own culture affects how he or she experiences and interprets the world. Every interaction between two individuals is a cultural exchange that flows bi-directionally and is, as such, a dialectic and mainly an unconscious process.

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Racism

Racism. Light treatment of racism might include brief mention of the role of race and/or racism in society. Significant discussion would examine race and racism in greater depth, such as having a small-group discussion of racism or having the participants write about their own experiences and feelings. Extensive treatment would include the aforementioned plus requiring a project, reading, or having an expert or panel to discuss racism.

Stereotyping/racial profiling. Brief discussion of the topic would mention stereotyping and that many groups in the U.S. commonly experience racial profiling. Significant discussion might emphasize that the patient is not a mere reflection of some “other” culture. Extensive treatment might include discussions about how with any given individual, personal qualities and experiences may play a much more meaningful role in how he or she interacts with the health care system and caregivers. A program may also address using a patient's perceived race to modify differential diagnoses and/or tailor therapeutic interventions. Other extensive treatments might include examining national legal cases of racial profiling, discussing the role of race in clinical presentation, addressing ethnopharmacology, encouraging a reflective project on the learner's own stereotypes, and/or talking about how stereotypes differ from generalizations.

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Doctor–Patient Interactions

Trust. Significant treatment of the doctor–patient relationship would explore the idea of trust and would mention and/or define trust as a key element in establishing and maintaining a good rapport with patients. Extensive treatment would specifically focus on trust, either through in-depth discussion or some other meaningful method.

Relationship. The doctor–patient relationship is a unique relationship in society. This item explores this unique relationship in-depth. Significant and extensive discussion would focus on the historical, sociological, psychological, and anthropological aspects of this relationship.

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Language

The meaning of words. This item provides a forum for discussing language and its importance in transferring information. In-depth discussion might address the idea that words have unique historical contexts and, thus, the same word may convey similar or disparate meanings for two individuals.

Nonverbal communication. This item specifically highlights the importance of paying attention to nonverbal communication (gesture, body position, eye contact, etc.) and how this nonverbal communication may vary from culture to culture. Attention may be paid to touch, for example, examining its meaning, importance, and use, and how these may vary from culture to culture. Significant discussion would be in-depth. Extensive treatment would include role-playing or discussion around a video vignette, for example.

Use of interpreters. This item addresses the role of interpreters. Significant discussion might include using professional versus nonprofessional interpreters. Extensive discussion might address the skills involved in effectively using an interpreter, such as positioning and directing the conversation to the patient, not to the interpreter. (Note: The use of interpreters may be considered a skill set topic. We placed it under the category of language because of its a priori relevance within the category and its relationship with the category's component items.

Coping with barriers. This item specifically addresses the difficulties of cross-cultural or cross-linguistic exchange and provides a forum to discuss the unique difficulties that health care providers face in serving a patient or populations linguistically distinct from their own. Significant treatment would provide the learner with strategies and techniques on how to approach a patient who speaks a language foreign to that of the providers. More in-depth exploration would provide an arena in which to explore the psychological or experiential consequences of a “difficult” cultural/linguistic exchange.

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Specific Cultural Content

Epidemiology. This item highlights background information on the health status of populations of interest, disparities in health, and specific diseases or illnesses associated with unique groups of individuals and disease prevalence. Epidemiology may also include treatment subjects ranging from genetics to metabolism. Significant and extensive treatments of the subject might include projects, site visits, and/or interviews of clinicians, public health experts, patient advocates, or patients.

Patient expectations and preferences. This item addresses the role of patient expectations and preferences and how they influence the patient–doctor relationship and clinical outcomes. Significant or extensive treatment would include in-depth discussion and/or role-playing, for example.

Traditions, customs, values, and health beliefs. This specific section illustrates useful information about one or more specific cultures. Significant and extensive treatment might provide learners with a multimedia demonstration of customs, hands-on experiences, and a special guest lecture. This section would also include the idea that groups of individuals, because of their particular histories and or geographic locations, have developed unique, shared ideas on how an individual relates to the body, disease, or a caregiver, for example. This section moves from general discussions on culture to specific and concrete examples of cultural groups, such as Russian immigrants or Chinese Americans. Complementary and alternative medicine (CAM) also comes under this item because CAM is a product of an individual or common health belief system, as is, importantly, the predominant or allopathic form of health care in the United States.

Role of the family. This item addresses the role of the family in patient care. Significant exploration of the subject would seek to demonstrate or illustrate how distinct cultures have unique ways of relating to the health care giver, employing group decision-making or nondisclosure of life-threatening illness to an elderly parent, for example. This item may include a discussion on paternalism, autonomy, and other styles of medical care. Extensive treatment would include role-playing or an interview of a family or an individual in a family, for example.

Spirituality/religion. This item highlights the role of spirituality and/or religion in health, illness, and the treatment of diseases. Categories of spirituality and religion may range from general cultural beliefs to particular acts of spirituality, such as rituals involved in death and dying. Significant treatment of the subject would provide a case study that includes spirituality or a video vignette, for example. Extensive treatment might include a role-play, panel discussion, or a patient interview, for example. (Note: Although there is an important conceptual distinction between what is generally referred to as “spirituality in medicine” and religious culture per se, there is enough practical overlap to allow for a combined category.)

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Access Issues

Transportation. In general, this item provides a forum to increase awareness that transportation plays a significant role in access to health care. Although socioeconomic status (SES) plays a major role in access to transportation, significant language barriers may not be obvious to health care providers. This item may provide information on how patient populations travel to the clinic, such as by using public versus private transportation and how culture and language may affect access to the different modes of transportation. The transportation item highlights how SES and language differences may limit an individual's ability to simply “find” proper and efficient modes of transportation. Significant treatment would explicitly mention specific transportation issues relevant to particular patient populations' access to health care services. Extensive treatment would provide a breakdown of the various modes of transportation used by the patients to go to the school's clinics and hospitals. Another form of extensive treatment may be providing an in-depth case study of a patient whose health care access was compromised by inability to access proper transportation.

Insurance status. This item highlights the health insurance status of major subgroups and may include a section on how a particular language or cultural custom affects attitudes about insurance. As with transportation, major factors in this item are SES, level of education, and language barriers. The same criteria for significant and extensive treatment apply here as in the item above. A major factor is immigration/migration status and the level of cultural/societal assimilation of a particular ethnic group.

Immigration or migration. Immigration status, in and of itself, is a significant barrier to obtaining proper medical care because an individual needs to navigate a completely new and foreign environment. Significant treatment of this category might include large-group discussion or a didactic presentation that illustrates the role of immigration or migration in an individual's health.

Any of the above items that provide case samples, experts, historical vignettes, required readings, role-playing, and/or direct patient interviews, for example, would demonstrate extensive treatment of the subjects.

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Socioeconomic Status (SES)

Socioeconomic status is an important health-determining variable and has an important function in individual and group behavior. Significant treatment might include discussing SES as an important factor that behaves independently in determining health status. Mention of the association or nonassociation with race/ethnicity and how SES is often a confounding variable in medical research would qualify an extensive discussion of the issue.

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Gender Roles and Sexuality

This category may be quite broad. The role of gender or sexuality may be addressed through patient or family decision-making themes. Gender or sexuality may be the focus of discussions on explanatory models, compliance, etc. The role of gender might include discussions on transgender care, adolescent health, and homosexuality, for example. Significant treatment of the subject may provide a case study, special readings, or group discussion, for example. Extensive treatment of the subject may include role-playing, patient interview, or a project.

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Teaching Methods

Case study

Case studies are used for teaching.

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Didactic

Lectures are a component to teaching.

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Participatory

Active or interactive audience participation in which the audience members are required to openly discuss topic materials. This method may include discussing themes in small groups and role-playing. The participatory nature must be explicitly mentioned in the course description or syllabus.

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Mentoring

Mentors with experience in cross-cultural medicine are assigned to students to aid in the learning process.

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Small-group Instruction

Discussions and activities take place in groups generally of ten or fewer individuals.

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Large-group Instruction

Discussions and activities take place in large groups of 25 or more individuals, generally the entire class or a large portion of the class.

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Internships or Clerkships

This method uses guided practical experience to teach cross-cultural medicine.

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Site Visits

Visiting and observing health care settings with diverse patient populations enhance cross-cultural education.

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Projects

Individual or group projects are assigned that should illustrate concepts of cross-cultural medicine. Projects may include self-directed learning, experiential exercises (e.g., games/simulations), presentations, problem-based learning, simulated patients, objective structured clinical examinations (OSCEs), service learning, and studying websites.

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Cross-cultural Skills

Introspection. This skill trains students in self-assessment: how their own backgrounds affect attitudes and decision-making. Students learn to look at a series of interactions in a systematic way. Brief treatment might include a general large-group discussion, whereas significant and extensive treatment would provide a forum for introspection in small-group discussions, or writing projects, for example.

History taking. This skill addresses the art of taking a patient history with a cross-cultural emphasis. Significant and extensive treatment would provide an in-depth review of history taking that might include student observation by teachers or a role-play that illustrates several techniques useful in taking a history of a patient who is from a different culture, especially those foreign-born and who speak different languages.

Negotiation. This skill highlights the value of negotiation and teaches negotiation skills. Discussions would emphasize the importance of seeing and understanding the differing points of views between the health care provider and the patient and how to achieve an appropriate plan or therapy for the patient. This might include understanding and working in partnership with a patient's family or a CAM provider.

Soliciting explanatory models. This skill provides one or more explanatory models, such as the ETHNIC or LEARN model. Significant and extensive treatment would include an in-depth discussion of the value of using a model, the key element being the solicitation of the patient's health care values and ways of understanding his or her illness. Role-playing and implementing a model would constitute extensive treatment.

(Note: The elements in this Appendix may be particularly difficult to document as they are often incorporated into the curriculum in the form of clerkships and therefore are modeled by the staff. Programs that explicitly promote cultural competency, sensitivity, or humility, would qualify as providing extensive treatment of the above categories.)

9. Carrasquillo O, Orav J, Brennan T, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14:82–7.
© 2003 Association of American Medical Colleges