Educating Medical Students for Work in Culturally Diverse Societies FREE

Centuries of migration have made society in the United Kingdom multiracial, multiethnic, and multicultural.¹ However, it was not until 1991 that the United Kingdom decennial national census inquired about an individual's race or ethnicity.² Minority groups were defined as black Caribbean, black African, black other, Indian, Pakistani, Bangladeshi, Chinese, other Asian, or other nonwhite. Based on the census classifications, 3 million of a population of 55 million were defined as members of a minority racial or ethnic group, with wide regional variation. For example, almost 60% of those from minority groups reside within the West Midlands or greater London areas.³

Medical students studying and working at health service institutions within these areas undoubtedly meet and work with diverse groups.⁴

The UK National Health Service recently has been described as "a long-established, white-dominated organisation [which] is liable to have procedures, practices and a culture that tend to exclude or to disadvantage non-white people."⁵ This comment resulted from a police investigation into the unprovoked racist murder of a black teenager.⁶ This acknowledgment of institutional racism signals the need for medical education and the National Health Service to examine their policies and practices to ensure that they reflect cultural sensitivity and competence. Recommendations and materials are available both in the United States and United Kingdom for medical educators who wish to develop such programs.^7- 11 Despite these resources, little attention has been paid in UK medical curricula to how physicians will be effectively prepared to meet the needs of a diverse local population.¹²

To our knowledge, this article presents the first published literature review to identify and comprehensively describe the individual programs that have been conducted in undergraduate medical courses that provide teaching and learning of cultural diversity, in particular, racial and ethnic diversity. The findings of this literature review are part of the first stage in a project to implement teaching of cultural diversity in a UK undergraduate medical course.

A systematic search was performed using Medical Subject Headings and text words, in English, of the following 5 databases: (1) MEDLINE, (2) Bath International Data Service (BIDS) Institute for Scientific Information (ISI) science and (3) social science citation indexes, (4) BIDS International Bibliography for the Social Sciences, and (5) Educational Resources Information Centre (ERIC). Searches were conducted from 1963 to August 1998 for the MEDLINE database and from 1981 to August 1998 for BIDS and ERIC.

Search terms included medical education, education-medical, educational measurement, teaching, curriculum, higher education, medical schools, medicine, medical students, minority groups, ethnic groups, culture, sociology, ethnic minority, ethnicity, diversity, diversity (faculty), diversity (institutional), diversity (student), inequalities, racism, race relations, prejudice, and socioeconomic factors.¹³

In addition, a search of the following Web sites and online data sets was undertaken: Kings Fund¹⁴; Centre for Ethnic Relations, University of Warwick¹⁵; Health Education Authority¹⁶; European Research Centre on Migration and Ethnic Relations, University of Utrecht, the Netherlands¹⁷; International Centre for Intercultural Studies, Institute of Education, University of London¹⁸; and the Refugee Studies Program, University of Oxford.¹⁹

These searches were supplemented by a citation search using the BIDS ISI science and social science databases. All references appended to each index article also were reviewed. We manually searched articles published in Medical Education and Academic Medicine (1994-1998) and conferred with key medical educators within the British system.

Included in the analyses were articles that described, in English, programs specifically for medical students related to teaching and learning about cultural diversity, in particular, racial and ethnic diversity.

All abstracts were reviewed by 2 authors (R.F.L. and P.M.A.) independently. Disputed abstracts were referred (to P.S.G.) for a decision.

Information about the programs that had been conducted was extracted and tabulated, including year of publication, setting, year of students who participated, whether a program was required or optional, teaching staff, involvement of minority racial and ethnic communities, program length, content and teaching methods used, nature of any student assessment, and type of evaluation of the educational intervention. We developed a narrative classification of the published data.

We identified 1456 articles, from which 17 programs that had been presented between 1967 and 1997 met the inclusion criteria and were analyzed (Table 1).

All programs were set in the United States, Canada, Australia, or the United Kingdom, with the majority (n=13) in North America. The sessions were almost exclusively developed under the auspices of departments of family medicine, community medicine, preventive medicine, behavioral science, psychiatry, or educational development. However, members of departments of pharmacology and anthropology were involved in 2 initiatives.^20- 21 One program arose in response to students witnessing insensitive and inappropriate behaviors by faculty.²² Students then acted as sole facilitators for the session that was developed.

Nearly all the programs described were for medical students in years 1 or 2 of their training. Exceptions were the University of Pittsburgh (Pittsburgh, Pa) program²³ (second- and fourth-year students); the program described by Kaufert et al²¹ (first- and fourth-year students); and the program at the University of Queensland, Brisbane, Australia (fourth-year students).²⁴

One of the documented motivations for developing a program to enhance cultural competence was a perception of negative discrimination. The program at the University of Southern California School of Medicine (Los Angeles), was based on the results of a student-conducted survey that demonstrated that 17% of first-year medical students at this institution were from minority groups (defined as blacks, Asians, and Hispanics), in contrast to the 86% of patients at the teaching hospital. The University of Pennsylvania (Philadelphia) program²⁵ was initiated after students expressed concern to faculty staff about insensitive behavior by their teachers.

Six programs involved members of minority ethnic communities who volunteered to be interview subjects or simulated patients for the students. The students conducted interviews individually or in pairs^{21,23- 24,26,28} or questioned volunteers as part of a small group discussion (Table 1).²⁰

In 3 programs, members of minority nonmedical community groups were key organizers of the teaching program and served as resources.^26,29- 30

One group convened a panel of experts, consisting of 2 Native Canadian interpreters, 2 patient advocates, and a physician, who participated in discussions of video vignettes with students.²¹

Two interventions reported the use of video recordings of simulated consultations that had been developed in cooperation with local communities.^22,29 Chugh and coworkers³¹ developed simulated consultations based on information gained from semistructured interviews with 21 migrants to Alberta, Canada.

Three programs seemed to rely exclusively on physicians or faculty^32- 34 who reported on their experience of cross-cultural medical care, with minimal evidence of patients being asked to describe their own personal experiences of health care services.

Two programs promoted the development of language skills to enable students to acquire sufficient skills to work effectively in Spanish as well as in English.^28,30 One of these provided classroom teaching and experiential learning with Latino physician preceptors²⁸; the other included conversation groups, as well as classroom teaching, visits to community projects, and a student-financed 8-day visit to Mexico.³⁰

Three programs reported the use of questionnaires^20,22,24 before and after teaching sessions. In most programs, this appeared to be part of an attempt to measure change in knowledge or attitudes. Two questionnaires were developed de novo.^20,24 Other projects used questionnaires only once (eg, Nora et al,³⁰ who used the misanthropy and ethnocentrism scale of Sullivan and Adelson³⁵). Lacey³² used questionnaires as an integral part of the teaching session and as a basis for discussion.³⁶

Other methods included review of case histories or transcripts in small groups,^20,32,37 role play,^22,25 panel³³ and case presentation, research projects,^23,38 and clinical clerkships.^23,28,38

Many courses addressed attitudes and health beliefs, alternative healing systems, demographics, complementary medicine, and language barriers. The student-initiated programs^22,25 took a broader view of cultural diversity and included sexual orientation and alcoholism as well as ethnicity. These sessions explicitly set out to discuss racism and prejudice and encourage participants to challenge offensive behaviors. Substance abuse and specific diseases were covered in research projects,^23,38 guest lectures, and workshops.²⁹

One program³³ took a theoretical approach and considered the anthropological and sociological theories of attitude development. In general, sessions had a practical focus.

One report mentioned conducting experiential seminars with faculty, using video and role play scenarios similar to those used with students.²⁵ Opportunities for reflection by teachers on their own attitudes and beliefs were not mentioned.

Ten of the 17 programs were either optional for students or there was no indication that they were a required course component. Only 1 of the 7 required programs was reported to have assessed students on their case presentations and contributions in tutorials.²⁴ Assessments in the optional courses included student self-assessment of competence,²⁶ tests in either written or oral proficiency in Spanish,^28,30 or written reports of research projects.²³ One group planned to develop 2 stations in an Objective Structured Clinical Examination.²⁰ One station was intended to assess and reinforce the students' skills in taking a patient's health beliefs history. The other would provide an opportunity to incorporate a patient's health beliefs into a negotiated treatment plan.

The majority of articles described 1 or, occasionally, 2 years of experience. An exception was Rogers and Coulehan,²³ who documented 16 years of an elective program run by the University of Pittsburgh in collaboration with Navajo people and the Indian Health Service in Arizona and New Mexico. Because of the program's short duration, evaluation methods relied heavily on assessment of student satisfaction immediately following a session.^{20,22,24,26,33} The University of Pittsburgh program²³ described the percentage of students who participated in the undergraduate program and then went on to work in the Indian Health Service, the health gains to the community members who participated in teaching and learning, and students' research publications.

Evaluations shed some light on the most appropriate time to teach cultural content. Kaufert et al²¹ reported a content analysis of the discussion that took place when their selection of vignettes was used with first- and fourth-year medical students. The first-year students lacked clinical knowledge and concentrated on the apparent sociocultural factors; fourth-year students focused on the clinical interaction they had witnessed. The wider sociopolitical and economic context and patient experiences of racism received little attention because students perceived this as being beyond their influence.

Few publications exist on a topic that is increasingly important in the United Kingdom and elsewhere.^8,39 The instructional initiatives are varied and the majority are directed at medical students early in their education. Since the majority of programs reported have been set in the United States, the teaching methods may not apply elsewhere. Few specialties other than family medicine, community medicine, and psychiatry have reported sponsoring such courses for medical students. Students who participate in an identical program at different stages in their education will have different priorities and learning objectives.²¹

Publication bias is the most important source of bias in systematic reviews.¹³ Although considerable effort was made to locate relevant studies, some may have been omitted from this review, since only English-language publications were searched. We did not search for the term cultural competence or for terms specifically relating to language, translation, or interpreting services. Relevant publications after August 1998 also have not been included. We deliberately narrowed the focus of this review by setting out to identify programs that specifically addressed ethnic and racial diversity. A broader view of culture and diversity could have been adopted that incorporated, for example, sex, age, disability, or sexual orientation. Data extraction was difficult, as the reporting of details and results was often incomplete or vague. We did not contact the authors for clarification. In addition, our medical education experts include representatives from outside the United Kingdom.

Despite these limitations, our review highlights the need for programs in multicultural education as part of the medical core curriculum, as well as training programs for medical educators. Because evaluations of the programs took place early in the students' education, it was not possible to chart improvements, or the lack thereof, in knowledge and attitudes toward cultural, racial, and ethnic diversity as students neared medical practice. Such information is important because the literature documents cases in which attitudes actually deteriorated as students progressed to the later years of their medical education.⁴⁰ If students respond less appropriately to diverse populations as they advance, then vertically integrated programs of teaching and learning that extend beyond year 2 are essential. Further research is needed into valid and appropriate methods of student assessment and program evaluation.