Medically Related Cultural Issues Can Be Learned Outside the Classroom

In reply: We appreciate Dr. Kwan's interest in our article. First, we need to correct an erroneous statement of Dr. Kwan's. He writes that “cultural issues are far more complicated than simply language and/or communication issues as the authors of this study have defined them.…” Nowhere in our paper did we provide such a definition of cultural issues. Indeed, in a recent paper,1 one of the authors (GF) presented a five-component model of cultural competency, consisting of (1) normative cultural values, (2) language problems, (3) folk illnesses, (4) patient's or parents' beliefs, and (5) providers', practices. These components involve both a knowledge base and practical skills (such as how to optimally use medical interpreters). Cultural issues can have a substantial impact on multiple aspects of health care, and we encourage readers to consult this article for in-depth detail. We believe that cultural issues unquestionably deserve to be taught as a separate course in medical schools because (1) the United States and Canada (and most countries in the world) are experiencing a tremendous growth in ethnic diversity, and (2) culture can have a profound influence on health care. As described in our report and elsewhere,1,2 the failure to consider a patient's cultural and linguistic issues can result in miscommunication, decreased access to care, impaired health status, suboptimal use of health services, adverse outcomes, decreased patient satisfaction, preventable morbidity, and even fatalities. In our report's conclusion, we recommend how and when medical students can be taught cultural issues. As with other crucial topics, we suggest that these issues be taught early (in the preclinical years) and often (with follow-up in the clinical years, and learning opportunities during residency and continuing medical education). We agree with Dr. Kwan that a solely didactic course is less likely to have a long-lasting impact on medical students education than is one that employs more active learning techniques. That is why we use many modalities when we teach cultural competency, including videotapes, case-based learning, analysis of published studies, and discussions. We encourage those who teach cultural issues in medical school to consider a similar variety of approaches. Dr. Kwan is correct that our study examined the number of medical schools who reported teaching cultural issues, and not medical students' knowledge of cultural issues. We believe that if cultural issues are not widely taught in medical schools, however, medical students will not have adequate opportunities to learn about them. It is fatally flawed reasoning to suggest that having a medical student simply spend several weeks practicing medicine in a culturally different setting is an adequate means of becoming culturally competent. To use Dr. Kwan's analogy, this would be equivalent to sending a U.S. medical student (who speaks only English) to Japan for a month, and expecting the student to be fluent in Japanese at the end of the month (despite having no Japanese language classes). Briefly providing health care to a certain population does not ensure that a medical student will learn about the normative cultural values, folk illnesses, and patients' beliefs that affect that population's clinical care; nor does it guarantee that the student will acquire adequate skills working with medical interpreters, or a familiarity with provider practices that may be responsible for ethnic disparities in health. Indeed, studies indicate that both students (at least in schools of nursing) and house officers do not believe that they have adequate awareness, comfort, and knowledge regarding culturally diverse patient populations.3–5 For example, a study of family practice residents and their patients at an institution serving a large Latino population found consistent disparities between residents' limited awareness of their patients' folk medicine beliefs and the high prevalence of such beliefs among patients.5 In most cases, 50% or more of the residents said they had never encountered the beliefs, but 20%-97% of the patients interviewed subscribed to them. As an example, 94% of the patients believed in the folk illness empacho, but 77% of the residents said they had never encountered it. Greater number of years in the residency program, Spanish fluency, and Latino ethnicity were not associated with greater awareness of patients' beliefs, which supports the contention that cultural exposure without instruction does not lead to cultural competency. It has been our experience that optimal learning comes from a combination of being taught fundamental principles and practical skills, followed by opportunities to apply the new knowledge and skills. Further, the notion that medical students will become culturally competent by some osmosis-like process from simple, uninformed contact with other cultures is potentially marginalizing and insulting to non-dominant ethnic and racial groups, and may be an important factor in the persistence of ethnic/racial disparities in health care. Teaching medical students, for example, about the culturally acceptable alternatives to folk remedies that can cause infant deaths from lead intoxication6 and liver failure7 not only saves lives, but also leads to better communication, patient satisfaction, and a higher quality of care. It is time for cultural competency to be taught as one of the “non-traditional” but vitally important topics, like medical ethics, that must be an essential component of medical education.

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