Transforming cultural competence into cross-cultural efficacy in women's health education.

To prepare students to be effective practitioners in an increasingly diverse United States, medical educators must design cross-cultural curricula, including curricula in women's health. One goal of such education is cultural competence, defined as a set of skills that allow individuals to increase their understanding of cultural differences and similarities within, among, and between groups. In the context of addressing health care needs, including those of women, the author states that it is valid to define cultural groups as those whose members receive different and usually inadequate health care compared with that received by members of the majority culture. The author proposes, however, that cross-cultural efficacy is preferable to cultural competency as a goal of cross-cultural education because it implies that the caregiver is effective in interactions that involve individuals of different cultures and that neither the caregiver's nor the patient's culture offers the preferred view. She then explains why cross-cultural education needs to expand the objectives of women's health education to go beyond the traditional ones, and emphasizes that learners should be trained in the real-world situations they will face when aiding a variety of women patients. There are several challenges involved in both cross-cultural education and women's health education (e.g., resistance to learning; fear of dealing openly with issues of discrimination; lack of teaching tools, knowledge, and time). There is also a need to assess the student's acquisition of cross-cultural efficacy at each milestone in medical education and women's health education. Components of such assessment (e.g., use of various evaluation strategies) and educational objectives and methods are outlined. The author closes with an overview of what must happen to effectively integrate cross-cultural efficacy teaching into the curriculum to produce physicians who can care effectively for all their patients, including their female patients.     

Medical education for a changing world: moving beyond cultural competence into transnational competence.

Given rapidly changing global demographic dynamics and the unimpressive evidence regarding health outcomes attributable to cultural competence (CC) education, it is time to consider a fresh and unencumbered approach to preparing physicians to reduce health disparities and care for ethnoculturally and socially diverse patients, including migrants. Transnational competence (TC) education offers a comprehensive set of core skills derived from international relations, cross-cultural psychology, and intercultural communication that are also applicable for medical education. The authors discuss five limitations (conceptual, vision, action, alliance, and pedagogical) of current CC approaches and explain how an educational model based on TC would address each problem area.The authors then identify and discuss the skill domains, core principles, and reinforcing pedagogy of TC education. The five skill domains of TC are analytic, emotional, creative, communicative, and functional; core principles include a comprehensive and consistent framework, patient-centered learning, and competency assessment. A central component of TC pedagogy is having students prepare a "miniethnography" for each patient that addresses not only issues related to physical and mental health, but also experiences related to dislocation and adaptation to unfamiliar settings. The TC approach promotes advances in preparing medical students to reduce health disparities among patients with multiple and diverse backgrounds, health conditions, and health care beliefs and practices. Perhaps most important, TC consistently directs attention to the policy and social factors, as well as the individual considerations, that can alleviate suffering and enhance health and well-being in a globalizing world.     

Losing culture on the way to competence: the use and misuse of culture in medical education.

Most cultural competence programs are based on traditional models of cross-cultural education that were motivated primarily by the desire to alleviate barriers to effective health care for immigrants, refugees, and others on the sociocultural margin. The main driver of renewed interest in cultural competence in the health professions has been the call to eliminate racial and ethnic disparities in the quality of health care. This mismatch between the motivation behind the design of cross-cultural education programs and the motivation behind their current application creates significant problems. First, in trying to define cultural boundaries or norms, programs may inadvertently reinforce racial and ethnic biases and stereotypes while doing little to clarify the actual complex sociocultural contexts in which patients live. Second, in attempting to address racial and ethnic disparities through cultural competence training, educators too often conflate these distinct concepts. To make this argument, the authors first discuss the relevance of culture to health and health care generally, and to disparities in particular. They then examine the concept of culture, paying particular attention to how it has been used (and misused) in cultural competence training. Finally, they discuss the implications of these ideas for health professions education.     

The ethics of cultural competence.

Cultural competence curricula have proliferated throughout medical education. Awareness of the moral underpinnings of this movement can clarify the purpose of such curricula for educators and trainees and serve as a way to evaluate the relationship between the ethics of cultural competence and normative Western medical ethics. Though rarely stated explicitly, the essential principles of cultural competence are (1) acknowledgement of the importance of culture in people's lives, (2) respect for cultural differences, and (3) minimization of any negative consequences of cultural differences. Culturally competent clinicians promote these principles by learning about culture, embracing pluralism, and proactive accommodation. Generally, culturally competent care will advance patient autonomy and justice. In this sense, cultural competence and Western medical ethics are mutually supportive movements. However, Western bioethics and the personal ethical commitments of many medical trainees will place limits on the extent to which they will endorse pluralism and accommodation. Specifically, if the values of cultural competence are thought to embrace ethical relativity, inexorable conflicts will be created. The author presents his view of the ethics of cultural competence and places the concepts of cultural competence in the context of Western moral theory. Clarity about the ethics of cultural competence can help educators promote and evaluate trainees' integration of their own moral intuitions, Western medical ethics, and the ethics of cultural competence.     

Toward cultural competence in cancer genetic counseling and genetics education: lessons learned from Chinese-Australians.

PURPOSE: In societies such as Australia with a strong multicultural makeup, culturally determined attitudes to genetics, testing, and counseling may be incompatible with current genetics service provision. METHODS: An ethnographic investigation using purposive sampling to increase subject diversity was used to explore the range of beliefs about kinship and inheritance using Chinese-Australians as a case. Participants comprised a sample of 15 Chinese-Australians who had been recruited through several community-based organizations. RESULTS: The level of acculturation does not correlate with holding beliefs about inheritance, kinship, and causes of hereditary cancer that are based on "Western" biomedical or traditional concepts. Mismatch between beliefs may exist within families that can impact participation in cancer genetic testing. Family history taking that underpins the surveillance, management, and referral to genetic counseling where there is a strong family history of breast, ovarian, or colorectal cancer can also be impacted unless recognition is made of the patrilineal concept of kinship prevalent in this Chinese-Australian community. CONCLUSION: This community-based study confirmed and validated views and beliefs on inheritance and kinship and inherited cancer attributed to senior family members by Chinese-Australians who attended cancer genetic counseling. Barriers to communication can occur where there may be incompatibility within the family between "Western" and traditional beliefs. The findings were used to develop strategies for culturally competent cancer genetic counseling with Australian-Chinese patients. These include nonjudgmental incorporation of their belief systems into the genetic counseling process and avoidance of stereotyping. They have also influenced the development of genetics education materials to optimize family history taking.     

Measures of cultural competence: examining hidden assumptions.

PURPOSE: The authors critically examined the quantitative measures of cultural competence most commonly used in medicine and in the health professions, to identify underlying assumptions about what constitutes competent practice across social and cultural diversity. METHOD: A systematic review of approximately 20 years of literature listed in PubMed, the Cumulative Index of Nursing and Allied Health Literature, Social Services Abstracts, and the Educational Resources Information Center identified the most frequently used cultural competence measures, which were then thematically analyzed following a structured analytic guide. RESULTS: Fifty-four instruments were identified; the 10 most widely used were analyzed closely, identifying six prominent assumptions embedded in the measures. In general, these instruments equate culture with ethnicity and race and conceptualize culture as an attribute possessed by the ethnic or racialized Other. Cultural incompetence is presumed to arise from a lack of exposure to and knowledge of the Other, and also from individual biases, prejudices, and acts of discrimination. Many instruments assume that practitioners are white and Western and that greater confidence and comfort among practitioners signify increased cultural competence. CONCLUSIONS: Existing measures embed highly problematic assumptions about what constitutes cultural competence. They ignore the power relations of social inequality and assume that individual knowledge and self-confidence are sufficient for change. Developing measures that assess cultural humility and/or assess actual practice are needed if educators in the health professions and health professionals are to move forward in efforts to understand, teach, practice, and evaluate cultural competence.     

Viewpoint: physician, know thyself: the professional culture of medicine as a framework for teaching cultural competence.

The need for physicians who are well equipped to treat patients of diverse social and cultural backgrounds is evident. To this end, cultural competence education programs in medical schools have proliferated. Although these programs differ in duration, setting, and content, their intentions are the same: to bolster knowledge, promote positive attitudes, and teach appropriate skills in cultural competence. However, to advance the current state of cultural competence curricula, a number of challenges have to be addressed. One challenge is overcoming learner resistance, a problem that is encountered when attempting to convey the importance of cultural competence to students who view it as a "soft science." There is also the challenge of avoiding the perpetuation of stereotypes and labeling groups as "others" in the process of teaching cultural competence. An additional challenge is that few cultural competence curricula are specifically designed to foster an awareness of the student's own cultural background. The authors propose the professional culture of medicine as a framework to cultural competence education that may help mitigate these challenges. Rather than focusing on patients as the "other" group, this framework explores the customs, languages, and beliefs systems that are shared by physicians, thus defining medicine as a culture. Focusing on the physician's culture may help to broaden students' concept of culture and may sensitize them to the importance of cultural competence. The authors conclude with suggestions on how students can explore the professional culture of medicine through the exploration of films, role-playing, and the use of written narratives.     

Using the tool for assessing cultural competence training (TACCT) to measure faculty and medical student perceptions of cultural competence instruction in the first three years of the curriculum.

PURPOSE: To compare faculty and student perceptions of cultural competence instruction as measured by the AAMC's Tool for Assessing Cultural Competence Training (TACCT) as part of a comprehensive curricular needs assessment. METHOD: In 2005, 25 basic science and clinical course directors and 92 third-year medical students at the University of California, Irvine, School of Medicine were asked to indicate which of 67 separate items listed on the TACCT describing knowledge, skill, and attitude about cultural competence were covered during the first three years of the curriculum. The mean percentage of "yes" responses to each item was computed and compared for both faculty and students. RESULTS: Response rates were 100% (25/25) for course directors and 75% (69/92) for students. Students systematically perceived that cultural competence instruction occurred more often in the curriculum (range of 28% to 93% "yes" responses) compared to the faculty (range of 8% to 64%). However, faculty and students demonstrated a high level of concordance (intraclass correlation coefficient = 0.89 across all items) in their perceptions about instruction, as measured by their relative rank orderings of the 67 TACCT items. Students and faculty identified clusters of TACCT items pertaining to health disparities, community partnerships, and bias/stereotyping as least likely to be presented. CONCLUSIONS: Faculty and third-year students at one medical school responded congruently about the relative degree to which cultural competence instruction occurred. The TACCT can be used to identify significant gaps in cultural competence training and inform curricular revision. Further studies involving other schools are warranted.     

Eradicating essentialism from cultural competency education.

An increasingly diverse society requires physicians to be able to competently treat those with whom they do not share ancestry and/or culture. Therefore, medical school educators need to train physicians who are capable of interacting appropriately and effectively with individuals from a broad array of populations and cultures. Such education cannot be simply a list of traits about other groups, as this may merely reinforce stereotypes. Instead, this education must expose and eradicate the existing essentialist biases in medicine. Essentialism, by focusing on differences, artificially simplifies individual and group identities and interactions. The essentialist viewpoint needs to be replaced with an ethnogenetic one, which recognizes that groups, cultures, and the individuals within them are fluid and complex in their identities and relationships. The ethnogenetic perspective must be fully integrated into medical education if medical schools are to produce physicians who will be truly qualified to give competent patient care in our increasingly complex societies.     

Knowledge of cultural competence among third-year medical students

An increasingly diverse population and ongoing health disparities have brought national attention to cultural competence training in medical schools. However, few data exist on medical students' knowledge in cultural competence. The purpose of this study is to assess medical students' knowledge in cultural competence to identify training areas for curriculum development. All third-year medical students at a single institution during the period of November 2001 to February 2004 completed a questionnaire to assess their knowledge of cultural competence during their medicine clerkship. The 40-item questionnaire measured several domains of cultural competence: health disparities, stereotyping, exploring culture, perceptions of health and illness, and communication/language. The mean knowledge score was 55%, and no student scored >80%. Race and prior cultural training were not predictors of overall performance.     

Cross cultural issues in patient education

This paper discusses the role of patient education within the context of cultural diversity and adult learning theory. Cultural variations in health care beliefs are illustrated with examples from multiple ethnic groups. Strategies for developing effective cross cultural educational programs are presented.     

Lessons in cultural competence: Adapting research methodology for Latino participants

Recent publications have suggested that research with diverse ethnic groups requires a reexamination of the methods and measures that have been developed on European‐American samples. This is a methodological paper, sharing the lessons learned in the field by one research team. It reports on a study of persons with type 2 diabetes and their partners that included both Latino and European‐American participants. Involvement of a multiethnic research team, the willingness to be flexible, and a healthy skepticism about our current methods are among the suggestions that emerge. More specifically, the article addresses such topics as the establishment of trust in the participants, language and meaning, the practical implications of cultural values, and the impact of social class on procedures. © 2002 Wiley Periodicals, Inc.     

Medical students' self-evaluations of their patient-centered cultural sensitivity: implications for cultural sensitivity/competence training

The goals of this study were to (1) empirically assess the need for training in patient-centered culturally sensitive health care among medical students and (2) determine if training in such care needs to be customized to some degree based on individual or subgroup differences. Two hundred seventeen advanced (third- and fourth-year) medical students from 4 medical schools participated. Participants self-reported their current levels of engagement in patient-centered culturally sensitive health care using an online version of the Tucker-Culturally Sensitive Health Care Inventory Provider Form. Results indicated that participating advanced medical students gave self-ratings of engagement in patient-centered culturally sensitive health care that indicate high engagement in some but not all of the behaviors and attitudes that indicate this care. Additionally, their self-ratings differed in association with their gender, race/ethnicity, being fluent in a language other than English, and prior experience providing health care to racial/ethnic minority patients. Conclusions include that some medical students need training in patient-centered culturally sensitive health care, and this training ideally should be assessment-based and customized to address areas where there are low self-ratings of engagement in patient-centered culturally sensitive health care.     

淋病奈瑟氏菌培养方法的比较

目的：比较两种培养基培养效果。方法：用华康科技有限公司生产的淋球菌培养基和法国进口梅里埃淋球菌培养基,分组对革兰氏染色为G^-的双球菌标本,在35℃、5％～10％CO2环境下培养。结果：用进口梅里埃培养基培养60例G^-的双球菌标本,阳性结果18例（阳性率30％）;用华康培养基培养78例G^-的双球菌标本,阳性结果26例（阳性率33．3％）。两种培养基培养效果无明显差别（Х^2=0．175,P〉0．05）。结论：国产华康淋球菌培养基可以代替进口梅里埃淋球菌培养基,其培养效果及质量等同于进口同类产品。     

Cultural competence springs up in the desert: the story of the center for cultural competence in health care at Weill Cornell Medical College in Qatar

The authors describe the factors that led Weill Cornell Medical College in Qatar (WCMC-Q) to establish the Center for Cultural Competence in Health Care from the ground up, and they explore challenges and successes in implementing cultural competence training.Qatar's capital, Doha, is an extremely high-density multicultural setting. When WCMC-Q's first class of medical students began their clinical clerkships at the affiliated teaching hospital Hamad Medical Corporation in 2006, the complicated nature of training in a multicultural and multilingual setting became apparent immediately. In response, initiatives to improve students' cultural competence were undertaken. Initiatives included launching a medical interpretation program in 2007; surveying the patients' spoken languages, examining the effect of an orientation program on interpretation requests, and surveying faculty using the Tool for Assessing Cultural Competence Training in 2008; implementing cultural competence training for students and securing research funding in 2009; and expanding awareness to the Qatar community in 2010. These types of initiatives, which are generally highly valued in U.S. and Canadian settings, are also apropos in the Arabian Gulf region.The authors report on their initial efforts, which can serve as a resource for other programs in the Arabian Gulf region.     

Components of culture in health for medical students' education.

Medical educators across the United States are addressing the topics of culture, race, language, behavior, and social status through the development of cross-cultural coursework. Dramatic demographic changes and nationwide attention to eliminating racial and ethnic health disparities make educating medical students about the importance of the effects of culture on health a 21st-century imperative. Despite the urgent need for including this topic material, few medical schools have achieved longitudinal integration of issues of culture into four-year curricula. The author makes the practical contribution of describing key themes and components of culture in health care for incorporation into undergraduate medical education. These include teaching the rationale for learning about culture in health care, "culture basics" (such as definitions, concepts, the basis of "culture" in the social sciences, relationship of culture to health and health care, and health systems as cultural systems), data on and concepts of health status (including demographics, epidemiology, health disparities, and the historical context), tools and skills for productive cross-cultural clinical encounters (such as interviewing skills and the use of interpreters); characteristics and origins of attitudes and behaviors of providers; community participation (including the use of expert teachers, community-school partnerships, and the community as a learning environment); and the nature of institutional culture and policies.     

Combating effects of racism through a cultural immersion medical education program.

The purpose of this paper is to provide a perspective from New Zealand on the role of medical education in addressing racism in medicine. There is increasing recognition of racism in health care and its adverse effects on the health status of minority populations in many Western countries. New Zealand nursing curricula have introduced the concept of cultural safety as a means of conveying the idea that cultural factors critically influence the relationship between carer and patient. Cultural safety aims to minimize any assault on the patient's cultural identity. However, despite the work of various researchers and educators, there is little to suggest that undergraduate medical curricula pay much attention yet to the impact of racism on medical education and medical practice. The authors describe a cultural immersion program for third-year medical students in New Zealand and discuss some of the strengths and weaknesses of such an approach. The program is believed to have great potential as a method of consciousness raising among medical students to counter the insidious effects of non-conscious inherited racism. Apart from the educational benefits, the program has fostered a strong working relationship between an indigenous health care organization and the medical school. In general, it is hoped that such programs will help medical educators to engage more actively with the issue of racism and be prepared to experiment with novel approaches to teaching and learning. More specifically, the principles of cultural immersion, informed by the concept of cultural safety, could be adapted to indigenous and minority groups in urban settings to provide medical students with the foundations for a lifelong commitment to practicing medicine in a culturally safe manner.