Our study helps answer the unexplored question about the long-term effectiveness of cultural competence training. Our results seem to support the commonly held hypothesis that the effectiveness of prior training diminishes with time but that the group with prior training retains more competence than the group without prior training. However, in our study, further examination of two fundamental domains of cultural competence showed varying patterns.
Regarding students’ ability to elicit patient perspectives, two components diminished in both the control and intervention groups. We found that students who received workshops a year before retained more ability to inquire about patient utilization of medication than the students who did not attend the workshops. However, both groups dropped significantly to the same low level in the ability to explore patient utilization of alternative medicine, regardless of the fact that the intervention group’s score was higher than the control group’s immediately after the workshop. This pattern implies that there is a need to strengthen medical education to prevent the loss of medical students’ consideration of alternative medicine as they become increasingly socialized in biomedicine-centered medical training.
In contrast, both the intervention and the control groups became better at eliciting patient concerns about prescribed medication. It is likely that both groups developed the skill through increased clinical experience. However, the significantly larger gain in the intervention group might be attributable to the prior training. The puzzling result—that the control group became better at inquiring about patients’ explanations of illness, whereas the intervention group got worse—needs explanation. We interviewed the few students in the control group whose increased scores in this item made the average OSCE2 score of the control group high. These students informed us that they had had clinical experiences in which their patients did not adhere to prescribed treatments. These students witnessed their medical teams exploring patients’ explanations of illness in depth. The implication for this finding is that we have to consider the powerful influence of the “informal curriculum” in shaping students’ cultural competence.
In terms of social factors, the general trend observed is that students’ ability decreased with time and that the intervention group scores higher than the control group. However, both groups dropped significantly to the same low level in the ability to explore patient literacy and access to clinic, regardless of the fact that the intervention group’s score was higher than the control group’s immediately after the workshop. This is likely attributable to the informal curriculum. Our students have frequently observed that attending physicians do not inquire about literacy and access to care; this is because Taiwan has a high literacy rate and easily accessible clinics. Nonetheless, we have to remind students not to neglect these factors.
An unusual pattern was observed in the consideration of social support. Both groups improved with time, but the intervention group scored significantly higher. This might be another example of the influence of the informal curriculum. In Chinese culture, families play a significant role in making decisions for and caring for sick family members. A significant proportion of the students in both groups had witnessed and experienced this phenomenon, which means that they would naturally be inclined to ask patients about their social support. We speculate in this way as a result of informal discussions with students and faculty members; our speculation could be the basis of interesting future research.
Our study has some limitations that should be noted. First, the OSCE tests occurred shortly after and then a year after the cultural competence workshops. Further studies are needed to answer what would happen if observations were made over longer periods and if further training were offered to the same type of participants as those in our study sample. Second, without an OSCE before the intervention, we cannot be certain that the two groups possessed similar cross-cultural communication skills before the workshops. However, the preintervention self-assessment of cross-cultural communication skills between control and intervention groups showed no difference. Future research designs could include a pre- and postintervention OSCE to address this issue. Third, we cannot be certain that the two groups had the same exposure to cross-cultural issues between the first and the second OSCEs. There was definitely no formal curriculum on these issues for either of the groups. In terms of the informal and hidden curriculum, we only know that the two groups rotated through the same clerkships. Future research designs could include a portfolio to trace long-term informal learning. In addition, faculty development would probably be helpful to improve students’ learning from both the formal and informal curricula.
In conclusion, our study adds to the knowledge base in cross-cultural medical education in several ways. First, it investigates the unexplored long-term effectiveness of cultural competence training. Second, the results illustrate the varying durability of different components of cultural competence and suggest which components need further strengthening. Finally, the study highlights the influence of the informal curriculum in shaping students’ cultural competence. This study can help in building a foundation for future studies evaluating the impact of both formal and informal curricula in cross-cultural medical education.