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Manish C. Champaneria; Sara Axtell, PhD
University of Minnesota Medical School–Minneapolis

JAMA. 2004;291:2142.

Cultural perceptions of illness have been reported to influence health-seeking behaviors, patient-physician communication, and health outcomes.^1-2 Recent changes in US demographics have underscored the demand for cultural awareness in clinical settings, as the current minority population in the United States is projected to exceed 50% by 2056. The percentage of minority physicians and medical students, however, has not been increasing proportionately.³

Medical schools have responded in part with 2 broad strategies: cultural immersion programs and cultural competence curricula. The former typically include either a clinical rotation in another country or a more local experience with native communities. In 2002, 38% of US medical students participated in international electives, compared with 6% in 1982.⁴ By contrast, cultural competence curricula use case-based, small-group formats to explore the core cultural issues and health beliefs of various ethnic groups, complementary and alternative medicine, language barriers, substance abuse, racism, and cross-cultural interviewing skills.^5-7 Such curricula also include role play, panel discussions with patient advocates and interpreters, and simulated encounters.⁶ As of 2000, 87% of US medical schools addressed cultural competence in 3 or fewer lectures during the preclinical years,⁷ and 8% of schools offered separate courses on the topic. This compares with only 13% that included any such material in 1991.⁸

Students who participated in cross-cultural exchanges, particularly international rotations, reported that they had gained improved cultural sensitivity, communication skills, appreciation for public health, and respect for cultural differences.^{4, 9} Preclinical medical students in a 2001 program that fused domestic and international immersion experiences, including domestic community service, didactic seminars on cultural issues, a 6-week foreign language program abroad, and interaction with local minority families reported increased knowledge of local cultures and greater ease with patients of other cultures.¹⁰ Because these findings are based on self-reported data, however, it is not clear whether they accurately reflect students' actual knowledge and abilities. No studies have reported lack of impact or negative effects of immersion programs, although negative findings may be subject to publication bias.

Reports documenting the outcomes of intramural cultural competence training are scarce and inconsistent. We searched MEDLINE and PubMed databases for articles reporting outcome data for cultural competence training using key words such as cross-cultural education, cultural competence, medical education, multicultural curriculum development, and outcomes. This yielded 2 articles, neither of which used objective measures of learning or behavior. Crandall et al¹¹ described the outcomes of a year-long, 20-session course for second-year medical students to promote knowledge of culture and diversity. Postcourse surveys showed increases in students' estimates of their proficiency in cross-cultural skills. For instance, participants reported a greater awareness of patients' cultural sensibilities, alternative therapies, and cultural cues during interviews and physical examinations as well as increased skill in interacting with interpreters. The study's limitations, such as the small number of students participating in the course, possible selection bias in the volunteer group, and potential biases inherent in self-reported data, again require cautious interpretation of the results.

Beagan¹² reported a lack of impact on first- and second-year medical students following a 2-year course that focused on cultural and social issues such as medical ethics, health policy, and population health. In this case, student questionnaire responses indicated a failure to recognize the impact of these issues and the effects of race, class, sex, culture, and sexual orientation on health care. Similar to the previous study, the limitations of this study include a cross-sectional design that did not guarantee comparable cohorts of students before the course began, self-reported data that may have been skewed or inaccurate, and course content that did not foster specific cross-cultural skills but that was rather an amalgam of preexisting courses displaced by curricular change.¹²

Acknowledgment: We thank Debra Wong for her editorial assistance.

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