This study suggests that although residents did not receive much training in cross-cultural care, there was a genuine interest in obtaining skills in this area; these findings are similar to a recent national resident study.16,17
Most residents endorsed its importance and genuinely enjoyed working with a diverse group of patients. Furthermore, residents acknowledged that the physician-patient relationship could be negatively impacted and less than optimal care could result from difficulties with cross-cultural care.
It is encouraging that since 2002 curricular changes have been made to promote cultural competence in medical education18
and, similarly, that residency programs now have cultural competence guidelines, put forth by the Accreditation Council on Graduate Medical Education,19
to follow. Although it is promising that the number of residency programs providing cultural competence training has increased20
and is anticipated to continue to do so, there is a need for development and assessment of quality, effective curricula.
Several cross-cultural training guidelines have been recommended,21–23
but there is great variability in the quality of training programs as well as a need for a unified conceptual teaching framework.24
The Cultural Competence Research Agenda project, sponsored by U.S. Department of Health and Human Services and the Agency for Healthcare Research and Quality, identified unanswered questions that need to be examined in the realm of cross-cultural teaching including the content
of training (e.g., what competencies and basic skills produce behavioral changes by trainees and improvement in health and health care delivery outcomes) and the form
of training (e.g., which educational delivery techniques are most effective at conveying key knowledge and skills and changing trainee behavior).25
Residents in our study recommended increasing community-based opportunities, involving patients in the teaching process, training staff and attendings, and integrating cross-cultural care into their existing training (e.g., journal clubs, case presentations). Key academic informants who were interviewed about their impressions on cultural competence24
also noted that education of faculty was crucial given their impact as clinical role models. Thus, both residents and field experts emphasize that faculty need to be trained as well. This is likely out of concern that a system be created in which expectations about the residents' cultural competencies are higher than that of their supervisors.
This study also highlighted residents' perceived barriers in delivering cross-cultural care. Residents in this study expressed some similar barriers that have emerged from previous research. Shapiro et al.26
reported that residents perceived 3 major barriers to cultural competence: time constraints, language and interpreter limitations, and patient shortcomings. Therefore, skill-based training must include ways to problem-solve communication difficulties when confronting language barriers and diverse health beliefs; hospitals must strive to address issues regarding lack of interpreters and time.
When developing cross-cultural curricula, the challenges of conducting this training, at the residency level, must also be acknowledged. This study revealed how, at the residency level compared with the medical school curriculum, one faces the reality of time limitations and fixed ideas about what cross-cultural skills mean. Of concern was that some residents felt that cultural competence was something inherent that could not be taught, which was similar to Shapiro's findings about residents' skepticism about the value of cross-cultural curricula. Another concern raised in our study was that some residents were overwhelmed by their own expectations that they would need to know about every patient culture. Similar to a study conducted by Lingard et al.,27
some residents believed that communication difficulties could be resolved by attainment of cultural-specific knowledge. Therefore, cross-cultural training must emphasize the time efficiency of this practice and teach the difference between cultural-specific and cross-cultural approaches. Bearing this in mind, in implementing a cross-cultural curriculum, we need to clarify that cross-cultural education is a set of skills that can be broadly applied rather than a required insurmountable knowledge-base.
There are several limitations to this study. First, although our response rate was quite high and we interviewed almost all of the graduating medical residents at Massachusetts General Hospital, this was a small 1-hospital sample. Therefore, these results are reflective of residents' impressions within an academic medical center setting, which may not be generalizable to all internal medicine residency programs or to trainees in other specialties. As this is a qualitative study, which by definition is exploratory in nature, our findings do not provide data on causation, but instead provide direction and insights about themes, which should be assessed in future research. Finally, we acknowledge that although we focused on the perceptions of preparedness of individual practitioners, the cultural practices of institutions and the health system may also be quite important in reducing disparities in health care.
This study greatly informed our cross-cultural curriculum development. Applying what we learned from this research endeavor through the lens of a residency program director, we felt that learning about residents' needs, what they valued about their training, and specific challenges they were confronting at our institution, helped us to create a cross-cultural curriculum that was appealing and relevant. We incorporated their concerns (e.g., fear of stereotyping) and addressed skepticisms (this is something that cannot be taught) and erroneous beliefs (that they would be expected to know a lot about many cultures) upfront. Furthermore, we learned about the importance of making the curriculum relevant to the patient population that they were treating.
In conclusion, we found that, despite limited formal training, residents seemed to genuinely value and have an interest in cross-cultural care. In developing quality cross-cultural curricula, we must build on residents' training recommendations such as making changes to the educational climate, involving patients in the teaching process, and providing a format for residents to discuss challenging cases. Furthermore, if this training is to be successful, it must be focused on overcoming barriers that the residents illustrated: at the patient, physician, and systems levels.