This survey of a national probability sample of resident physicians in their final year of training describes their self-perceived preparedness to care for culturally diverse populations in 2004. Our study has two major findings. First, resident physicians who received training in the area of cross-cultural care felt more prepared to care for diverse patient populations. Previous work has demonstrated that few residents report receiving cross-cultural care training in residency5
. The second major finding is that selected resident physicians’ characteristics, including personal and cultural backgrounds, linguistic abilities, and a sense of importance to practice in settings with diverse racial and ethnic patient mixes, were strongly associated with their sense of preparedness to provide cross-cultural care. However, at the same time, no single trait was exclusively predictive of preparedness across all patient types. These findings underscore the multidimensional nature of culture and how different personal characteristics inform self-perceptions of preparedness and skill in cross-cultural care. This warns against simplistic and generalized approaches to cross-cultural training.
The racial/ethnic background of a resident physician influenced their preparedness to deal with patients from similar backgrounds. This finding aligns with research that shows that interpersonal communication is sensitive to race concordance from the patient’s perspective as well13–16
. For instance, in a study of directly observed medical communication in the primary care setting, race concordance had an independent effect on patients’ judgment of the visit regardless of the verbal nature of the medical dialogue13
. Race concordant visits were longer and had higher ratings of patient positive affect compared with race-discordant visits. In addition, patients reported greater ease in discussing problems and making decisions perhaps reflecting mutual liking and respect, a sense of social or racial group affiliation and enhanced trustworthiness or positive expectations.
In the current study, African American resident physicians felt best prepared to deal with patients who had distrust in the healthcare system and more skillful in both knowing how a patient wants to be addressed and in negotiating a treatment plan with patients. These findings also align with what we know about the importance of trust17–19
, the persistent mistrust by African Americans of the health care system20
, higher rates of reported communication difficulties in racial and ethnic minorities21–22
, and reports by many African Americans that they would receive better care if they were of a different race or ethnicity21–22
International medical graduates (IMGs), many of whom are recent immigrants to the United States, are confronted by many cross-cultural challenges as they complete their residency training. These challenges include differences in language, lifestyles, sex-role differences, discrimination, changes in status and feelings of inadequacy23–25
. These reported challenges correlate with our findings that IMGs felt less prepared to deal with racial and ethnic minorities and those who used alternative or complementary medicine. While at the same time they report perceiving themselves as being more prepared to deal with new immigrants like themselves. These findings add to our understanding of the complexities of integrating IMGs into US training environments and suggest ways to tailor formal and informal residency orientation programs to the unique educational needs of IMGs26
Our findings are consistent with other studies of minority physicians who are more likely than white physicians to care for patients of similar racial and ethnic backgrounds, to practice in underserved areas and to care for poor, underinsured or uninsured persons and those on Medicaid27–28
. They are also more likely to conduct research that is inclusive of minority patients and concerns, and educate students in cultural competence29–31
. In addition to the data on race-concordance, improved communication and trust presented above, this research has led to a broad, nationwide call to continue efforts to diversify the health professions workforce32
Our study had a number of limitations. As with any survey, the 60% response rate could introduce bias if those responding were differentially prepared compared with nonrespondents. This rate compares favorably with other surveys of residents12–14
. Self-perceived preparedness may not predict future abilities, actual provision of care, or the quality of care provided33–34
. Also, there is no criterion standard to assess preparedness. However, accurate self-assessments are acknowledged as an important component of adult and lifelong learning34–35
and have been used in previous studies of educational quality 6–7,36
and shown to be valid predictors of examination scores37
, and faculty evaluations38–40
Two reports by the Institute of Medicine—“Unequal Treatment” and “In the Nation’s Compelling Interest”—unequivocally recommend both cross-cultural training and diversifying the health care workforce as a means to improve quality and eliminate racial and ethnic disparities1,2
. Our research supports this two-pronged approach8
. Key recommendations for how to advance this area of graduate medical education are described in detail elsewhere41
. It is essential that health care providers represent the diversity of our nation and have the training necessary to provide quality care to any patient they see, regardless of their race, ethnicity, culture, or language proficiency. Not only is this a key component of physician professionalism, but it will also help us bridge the quality chasm, which is much broader for patients who are at a greater cultural distance from Western medicine.