One challenging domain to address is ‘self-reflection and culture of medicine ’, described in the Association of American Medical College’s revised Tool for Assessing Cultural Competency Training^8,9. Students’ unconscious or unexplored assumptions about patients from diverse backgrounds may affect the therapeutic relationship^10,11; and assumptions about the patient’s health literacy and beliefs are a potential source of health disparities¹². Student learning may be influenced by the ‘hidden curriculum’ of corridor conversations and behaviors (as opposed to verbal injunctions) of role models^10,13 rather than formal instruction. This learning is not easily captured by traditional evaluations. Focus groups^13,14 and other qualitative methods provide an additional lens to examine these influences. Reflective practice (RP), variously defined, is at once a method of self-reflection for practitioners, a teaching strategy for engaging learners and a means of assessing teaching and practice^15–17.

Written Assignment (Fig. 1) Students were required to write about experiences from two different models of healthcare during the clerkship. Experiences were chosen from the following: a) Outpatient clinic; b) Visit to botanicas; c) Home visits; d) The group medical visit. They were asked to reflect on how cultural differences could enhance or complicate the encounter, lessons learned about practicing across cultures, and physician role-models treating diverse patients (Questions 1 to 6). Descriptive responses were expected. In project year 2, two questions (7 and 8) were added asking students to self-rate learning about complementary and alternative medicine (CAM) and cross-cultural medicine (Fig. 1) with Likert scale responses of 1=not, 2=somewhat, 3=moderately and 4=definitely enhanced.

Discussion sessions Since students did not read each others assignments, the discussion session provided the only formal opportunity to compare and contrast students’ views. The facilitators elucidated and guided exploration of such similarities and differences. For example, a session might begin with the faculty probing the students’ understanding of ‘culture’ by stating: ‘Some of you wrote about culture as characterized by race and ethnicity. Others wrote about the culture of medicine. How might these differ?’ Or “Some of you want patients to take responsibility for their health; others emphasize the effect of culture on how patients construe illness and health. What are the benefits and pitfalls of each position?” Facilitators ensured that discussions did not merely reiterate assignments, but deepened and extended them. Group discussions emphasized exploring different ways of addressing cross-cultural encounters that students perceived to be frustrating and resulting in barriers to optimal healthcare (language differences, time constraints, stereotyping by faculty or residents).

The faculty facilitators did not receive any special training for conducting the sessions. Their preparation consisted of a careful reading of students’ essays. Facilitators followed a question route based on the main topics of the essays, specifically employing the following questions: a) What do we mean by culture? (probe: Is Medicine a culture?) b) What are examples of ways working across culture enhanced your patient encounters? (probe: patient as physician’s teacher) c) What were some of the difficulties you encountered working across culture? How did you ameliorate them? d) There is a lot of agreement about examples of negative role-modeling. What do you think are some of the factors that influence physicians to behave in these ways? What will prevent you from behaving in these ways? e) What is the most important lesson about working across cultures that you learned on this clerkship?

We also conducted qualitative thematic analyses of the written assignment and discussion sessions¹⁸. Two levels of analysis occurred for the written assignment (Fig. ​(Fig.2).2). First, one faculty (JS) reviewed all assignments and compiled verbatim summaries (i.e., using exact student language) from each group’s assignments, eliminating only redundancies, repetitions, and extensive examples. Second, these summaries were reviewed by three faculty (JS, FC, DL) who independently extracted themes. Extracted themes were collated and then compared for agreement and disagreement. Through group discussion, consensus was achieved on major recurring themes across all 23 rotations¹⁹.

For the discussion sessions, JS, WN and FC independently summarized their impressions of sessions in writing, and common themes were extracted by consensus.

In year 2 of the program, we administered five cultural knowledge questions to evaluate students’ knowledge of their Latino patients’ health belief and practices. Responses were analyzed based on the number of correct answers given pre- and post-participation in the clerkship.

Results All students participated and completed assignments. Most students reported spending about 30 minutes on the written assignment. Overall student ratings (response rate 156/188=83%) of sessions showed predominantly positive responses. A rating of 1 or 2 (outstanding or excellent) was given by 80.5% of students for “value for reflecting on CAM and culturally-relevant experiences”; 70.5% for “value to prepare for medical practice in a diverse environment”; 84.9% for “importance of cultural competency training during medical school”; and 87.6% for “teaching skills of facilitators”. In particular, students explicitly expressed appreciation in their written comments for faculty summaries of their written assignments. In year 2, student mean rating of self-confidence in addressing CAM was 2.75±SD 0.68 (n=83/90): confidence for addressing cultural issues was greater at 3.17±SD 0.57 (n=83/90) out of 4 for questions 7 and 8 (Fig. 1)

Thematic analysis of student assignments (Table 1) suggested 7 predominant themes: 1) Cross-cultural encounters provide mutual learning opportunities for physician and patient. Students shifted from describing the medical encounter as a top-down transmission from doctor to patient to a more horizontal, mutual process of learning about and appreciation for the other. 2) Medicine is a culture in and of itself. Students commented on particular ways of thinking (logico-deductive), evaluating evidence (EBM), speaking (“medicalese”), appearing (white coats), and behaving (professional objectivity) that defined Medicine as a culture with specific beliefs and assumptions. 3) Language barriers significantly complicate the doctor–patient relationship, and strategies for addressing them are essential. Students repeatedly expressed frustration at not sharing a common language with patients, and felt that this inhibited rapport. They recognized the important role of a well-trained interpreter; and also expressed the intention to learn Spanish and attend to nonverbal cues. 4) Cultural beliefs can negatively affect patient compliance, while expressing interest in the patient’s views builds trust. Students described penetrating “below the surface” of a patient’s noncompliance only to discover culturally-based misunderstandings, fears, or beliefs. They identified a direct link between understanding the patient’s perspective, developing trust, and formulating culturally appropriate and acceptable treatment plans. 5) The family-centric orientation of many cultures means that physicians should be prepared to acknowledge the role of the family in patient care. This theme included observations about involving family members in treatment plans; and identifying the “real” decision-maker in the family (not necessarily the patient). 6) A larger number of patients than expected are frequent users of CAM. Students were often surprised at the prevalence of CAM practices in the community, and at patients’ preference to use CAM over western medicine. Students wrote that unless they specifically inquired about CAM practices, patients would not necessarily disclose them. 7) Positive physician attitudes and behaviors in cross-cultural encounters are essential, and include listening, being open-minded and avoiding stereotyping. Students commented on both negative and positive physician role-models and highlighted the importance of positive interactions in a therapeutic relationship.

Analysis of the discussion sessions by 3 faculty suggested added value of these peer interactions. The written exercise allowed students to describe concerns in a secure and candid fashion. The discussion enhanced the written exercise by enabling students to recognize shared concerns, deepen understanding, and problem-solve with peers and faculty. Of note, students also reflected on parallel experiences about cross-cultural encounters from prior clerkships.

Based on our analysis of the data, we developed a three-tiered theoretical framework for our RP model. The first essential tier is direct participant observation or experience, which occurs through student exposure to cross-cultural settings. Teaching and learning occur, but are limited by student multi-tasking, inattention, and in clinics, variability of the physician role-model as a medical educator. The second tier is individual reflection accomplished through the written assignment. This allows the student to better organize and consolidate jumbled impressions. The final tier, facilitated group reflection, provides the opportunity to confront other perspectives, have assumptions and expectations challenged, and deepen and extend learning .

Our study has several strengths. Two consecutive years of data are presented for a significant number of students. Our educational intervention was distinct in its structure and format and instructions to students were clearly presented. The evaluation data was complete with a high student response rate. We evaluated outcomes using multiple methods including written essays, in-class discussions and a pre-post knowledge test. We used a ‘triangulation’ approach to analyze qualitative data, combining interpretation from four different faculty with diverse teaching experiences and from different disciplines to reduce bias.

Our study is limited by the specificity of the patient cultural group (Latinos with diabetes) within our practice setting, and we cannot be certain if findings generalize to other cultural groups. However, there is no reason to believe that the techniques that we shared with students would not be effective in other cross-cultural settings. We did not analyze thematic responses by student demographics because the number of themes identified and class size did not permit such analysis (50% female, ethnic mix approximately 43% white, 40% Asian, 10% Hispanic, 1% African American). There is literature that suggests that providers’ own background and their cultural experiences impact their cross-cultural communication skills and their perceptions of their patients^20–22. Our evaluation tool was not validated because no validated tools for this purpose were available. Lastly, in asking students to rate their self-reported knowledge change about CAM and culture (questions 7 and 8, Fig. 1), we did not explicitly define the difference between the two and our questions may not be sufficiently sensitive to differentiate knowledge gain in these two areas. However, the in-class discussions about CAM and culture suggested that most students were able to identify CAM as alternative approaches to Western medicine, while culture was consistently discussed in the context of differences in values, beliefs, practices and social norms among different groups.

Despite these study limitations, our findings reinforce existing literature about the power of the hidden curriculum^15–17,23. For example, although role-modeling was not identified as an explicit clerkship learning objective, it emerged as a powerful influence on learning, both negatively and positively. Similarly, the concept of the culture of medicine was not part of the clerkship’s formal objectives, yet it consistently appeared in students’ written and discussion comments. Without the addition of the RP components, these and other influential dimensions would have remained submerged.

We note that a few key ingredients are necessary to achieve desired goals. First, students benefit from having interdisciplinary faculty facilitate discussions. While physician faculty may add real-world credibility, “outsider” perspectives of faculty trained in the social sciences and philosophy expands their understanding of clinical issues. Second, the lack of evaluative function of participating faculty creates an environment of safety and openness. Third, we found an incremental approach of pedagogical value. Although our model runs the risk of being perceived as “repetitive” or “redundant”, circling back to clinical experiences through different modalities (written, oral) and in different settings (individual vs. facilitated group reflection) reduces the burden of multi-tasking, and encourages Socratic self-discovery. We believe that this approach is essential to stimulating critical thinking as opposed to rote regurgitation and adopting “politically correct” postures. This approach may allow students to develop practice styles that incorporate carefully considered ethical conclusions about interactions across cultures rather than simply imitating faculty or residents. We believe that this model of RP, woven into an existing curriculum, addresses the need for “critical consciousness”² in the continuum of cultural competency training toward the development of self-awareness. However, because faculty themselves do not consistently practice RP at our institution, we are not certain if adoption of RP as a habit by physicians might enhance the effectiveness of our curriculum. Finally, as noted in the Program Description, facilitator skills needed to conduct the reflective practice sessions are easy to acquire and maintain and no specific training is necessary.

In summary, integration of a brief RP curriculum occupying only 2 hours of a required clerkship was feasible and highly acceptable to students, and associated with more complex and nuanced understanding and useful problem-solving of challenges frequently arising in cross-cultural encounters.