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Despite growing recognition of the need to increase cultural diversity undergraduate education in the UK, the US and Canada, there is a lack of cohesion in the development and delivery of cultural diversity teaching in medical schools in these three countries. This article highlights 12 tips for developing cultural diversity education in undergraduate medical programmes by integrating it in institutional policies, curriculum content, faculty development and assessment. These tips can be used to help ensure that students gain needed knowledge, skills and attitudes consistent with a view of patients as complex individuals with unique needs.
Medical schools have over the last two decades attempted to increase cultural diversity undergraduate education in order to address three main objectives: (1) enhancing cross-cultural patient–doctor encounters, (2) eliminating health inequities and (3) improving health outcomes of the marginalized and underserved. Across many Western countries, there have been several drivers pushing this change from legislation to changing population demographics (General Medical Council 1993; Migrant-Friendly Hospital Project Group 2005; Liaison Committee on Medical Education 2007). The World Health Organization called for all medical schools to become more socially accountable by ‘direct[ing] their education, research, and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve’ (Boelen & Heck 1995, p. 3).
The attempts to respond to these drivers resulted in disparate outcomes in how cultural diversity medical education is developed and delivered. Dogra and Williams (2006) concluded that there are gaps at each of three levels of policy (i.e. governance, strategic and operational) which have lead to lack of coherence in the development and delivery of cultural diversity teaching in medical schools in the UK. The US and Canada struggle with the same conceptual, curricular and logistics issues.
As governing and licensing bodies which require diversity to be addressed by medical schools do not provide leadership in conceptualizing and framing cultural diversity, cultural diversity education remains mostly unsystematic, non-uniform and fragmented. Medical schools are left free to determine their own policies, pedagogical approaches, methods, formats and structure for cultural diversity education. Comprehensive evaluation of the effectiveness of existing programmes is very sparse and limited’ however, some good quality published literature on developing and delivering cultural diversity education exists (Lock 1993; Dogra 2001; Green et al. 2002; Betancourt 2003; Crandall et al. 2003; Frank & MacLeod 2005; Kumaş-Tan et al. 2007).
In this article, we present 12 tips to help guide medical schools, educators and healthcare institutions in developing comprehensive cultural diversity educational programmes with respect to institutional policies, curriculum content, faculty development and assessment. These tips can be used to help ensure that students gain needed knowledge, skills and attitudes consistent with a view of patients as complex individuals with unique needs. These tips are accompanied by examples of good practice that we have identified.
Developing a diversity and human rights education policy is a first step towards institutional ownership of cultural diversity education. Organizations need to provide sufficient resources to integrate cultural diversity in strategic plans across entire academic programmes including important areas, such as research, practice and policies. Institutional policies also need to address areas, such as admission, employment and promotion equality. Learning and teaching documents should outline aims and learning outcomes with respect to diversity education,
For instance, St. George’s Medical School in London is in the process of implementing a policy which states that diversity and human rights values and objectives must be included in terms of reference and the decision-making process for all university committees. The Learning and Teaching committee has agreed that diversity and human rights issues should be embedded into teaching practice, teaching plans, assessments, placements, practical sessions, as well as monitoring and evaluation of student activities and learning programmes (personal communication).
Tutors often say that they were not taught about diversity issues during medical school and because there is so much cultural diversity amongst the student body, they are afraid to raise issues in case they are perceived to be wrong. Develop a language and give both students and academics a forum to discuss a range of issues that have often been (or still are) seen as taboo. This will provide the environment in which students feel safe to express and examine critically presented views and opinions.
For instance, the University of Massachusetts Medical School developed best practice recommendations to address the needs of gay, lesbian, bisexual and transgendered students and patients (Ferrara 2007).
Clarify your perspectives of cultural diversity, as this influences the type of teaching developed. Challenge the dominant trend of cultural diversity education which assumes that doctors need only understand how a specific minority group differs from the majority population, for example knowing about different cultures, customs and protocols (Dogra 2005). Be clear about what is expected. The following learning outcomes could be suggested as a minimum requirement:
Do not reduce cultural diversity education simply to the awareness of ethnic, racial or religious differences with respect to health outcomes, health beliefs and coping skills of specific cultural groups but include the diversity of human experience. Cultural diversity education needs to be considered in the context of human rights, structural inequalities and social injustice.
For instance, a newly developed Alan Klass Memorial Program at University of Manitoba in Canada exemplifies an approach which encourages students to learn about cultural diversity beyond the boundaries of race and ethnicity as a category deeply connected to a wide range of social determinants of health (Durcan 2007). Students examine and reflect on how unequal distribution of power and resources, social injustice and discrimination are relevant to disparities in health and healthcare delivery within disadvantaged populations.
Before students can acquire the understanding of multiple and complex intersectionalities of culture and health, as well as developing effective cross-cultural communication skills they need to be aware of their own biases and prejudices. They also need to acquire understanding regarding how open they are to different perspectives and views. Give students the opportunity to critically examine their own identity and appraise how this identity locates them in relation to their peers, their supervisors and their patients (Beagan 2000).
For instance, the University of Alberta’s medical school created a Theatre Forum for their first-year undergraduate students where they engaged in an interactive drama consisting of a series of scenarios between an Aboriginal elder, her granddaughter, her doctor and a medical student. This programme helped students to reflect on their own attitudes toward Aboriginal people (Crowshoe et al. 2005).
Incorporate cultural diversity education throughout the entire curriculum including pre-clinical and clinical years. Moreover, the content cannot be formatted into a 2 h lecture on dietary requirements of practicing Hindus or Muslims, a half-day workshop on health needs of people with different sexual orientation or a 1 day field trip to Aboriginal community. It must reflect the issues raised in previous tips across all disciplines taught in medical schools. Curriculum committees need to ensure that there is consistency without repetition and that the outcomes are meaningfully implemented.
Patient choice has been a recurrent theme in national government policy under different administrations. Patient-centred care must respect and reflect individual patient preferences, needs and values and ensure that patient values guide all clinical decisions. In order to achieve this objective, students must avoid making assumptions about how patients see themselves. A patient-centred approach is only possible if the understanding of culture, race and alike are challenged and explored. If clinicians believe that culture is an externally subscribed characteristic, the notion of the patient being able to define themselves is less important (Dogra 2003). Dogra (2003) argued that both the patient and health care provider’s meaning of culture and self is crucial and it is the interaction between these two perspectives that helps or hinders effective collaboration to ensure that culturally appropriate care is delivered.
Wynia and Matiasek (2006) provided examples of promising practices for patient-centred communication with vulnerable populations in several hospitals across the US. These practices included (but were not limited) to passionate advocating for communication programmes; collecting information on patient needs; engaging patients and communities; developing a diversified skilled workforce and providing effective assistance reflecting patients’ needs, such as low language and health literacy.
Provide students with learning opportunities that take place in an authentic context outside of medical schools and hospitals (i.e. community settings, such as community access centres or inner city clinics). Through the extended engagement with culturally diverse populations, students will have an opportunity to acquire a deeper insight of living experiences of the communities they serve, factors which determine their health needs and outcomes, as well as enhance their cross-cultural communication skills.
For example, at the Northern Ontario School of Medicine in Canada, 40% of learning occurs in community-based learning sites and community placements across the Northern Ontario. Students are provided with many theoretical and practical opportunities to learn from the expertise of Aboriginal, Francophone and rural communities about their history, traditions, needs and priorities and also advocate for them.
Cultural diversity education should be taught by teams of trained and experienced educators and professionals coming from various interdisciplinary backgrounds, such as various medical specialties, public health, medical ethics, medical anthropology, nursing and social work – to name just a few. Include in these teams front-line workers from community based agencies which serve marginalized and underserved populations. It is important that senior doctors are also visible in this aspect of teaching as they are the role models for training doctors as we discuss below.
The organization can have numerous policies that show very good intentions but these will stay on paper unless a compulsory training programme is put in place. People are often scared off by the idea of implementing a compulsory training programme, but there is a real danger that if it is not compulsory then it will turn into a support group for the already converted. While support is very important, we also need to reach those academics that still see diversity and equality teaching as a politically correct irrelevance that is simply common sense. Training and evaluation of faculty and clinicians on cultural diversity issues are very important since they serve as role models and their poor modelling may detract from work done in earlier years at medical school (Hasman et al. 2006).
It is unlikely that a single assessment method will be suitable for all policy, delivery and learned outcomes of cultural diversity education (Dogra & Wass 2006). Develop diverse and comprehensive tools for assessing the effectiveness of all components of cultural diversity education including institutional policies, curriculum content and learned outcomes. These assessment tools should not focus solely on student or faculty satisfaction and performance, but should also include evaluation of patient satisfaction.
For instance, the Association of American Medical Colleges (2008) recently published a document from the 2007 Diversity Research Forum in which a detailed framework for evaluating diversity, cultural climate and student support programmes at medical institutions is provided.
To have a more integrated approach, become committed to regular mapping of cultural diversity education on a local scale and beyond so that everyone knows what is going on, and what and where issues are being taught. Invite others to showcase work and exchange ideas at conferences, forums, workshops, fairs, panels or tutorials.
We have offered 12 tips for developing cultural diversity education in undergraduate medical programme by integrating it in institutional policies, curriculum content, faculty development and assessment. These tips may be useful to health professionals to overcome uncertainty that cultural diversity often creates. We believe that the integration of cultural diversity education in undergraduate medical programmes will improve the development of needed physician skills, such as critical thinking and critical self-reflection, ability to give and receive feedback, flexibility, humility, open-mindedness and curiosity, ability to work in a team with awareness and good communication skills, appropriate skills and attitudes to life long learning, effective study skills and independent learning. Application of these tips should enable the development of cultural diversity education to be more systematic than it has been to date and enable evaluation of its impact on patient experience and health outcomes.
Drs Carter-Pokras and Dogra gratefully acknowledge funding from the National Heart Lung and Blood Institute (NHLBI K07HL079255). This article stems from an earlier workshop: ‘International Perspectives on Cultural Competence Training: Assessment and Evaluation of Cultural competence Education in the UK, US and Canada: Discussion of Theory and Practice’ held at the 12th International Ottawa Conference on Clinical Competence in New York City on May 23, 2006. Nisha Dogra also acknowledges the initial input to the article by Margot Turner at St. Georges Medical School.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributorsNISHA DOGRA BM, DCH, FRPSych, MA, PhD is a Senior Lecturer in Child and Adolescent Psychiatry, Greenwood Institute of Child Health, University of Leicester.
SYLVIA REITMANOVA MD, MSC is a PhD candidate in Community Health in the Division of Community Health and Humanities, Memorial University of Newfoundland.
OLIVIA CARTER-POKRAS BS, MHS, PhD is an Associate Professor, Department of Epidemiology and Biostatistics, University of Maryland School of Public Health.