How should ethnic diversity be represented in medical curricula? A plea for systematic training in cultural competence

Ethnic diversity has become a common reality in European societies, including those of Germany and the Netherlands. Given that ethnic minority groups and immigrants are known to be especially vulnerable to inequalities in health, access to services and quality of care, the need for cultural competency training in medical education is widely acknowledged. This paper presents four key issues in providing medical students and physicians with the knowledge, attitudes and skills to adapt medical care to ethnically diverse populations. It then describes two educational programmes delivered by the University of Amsterdam (UvA Academic Medical Centre, the Netherlands) and Giessen University Medical School (Germany), respectively, to illustrate that translating theoretical educational objectives into educational practice can lead to different teaching programmes depending on specific local conditions. In the conclusions, emphasis is placed on the need for systematic approaches that do not limit their focus to patients and groups of specific ethnic or migration backgrounds. Issues of culture, communication and research in relation to ethnically diverse populations are magnifications of general problems in medicine and healthcare. Explicit attention to ethnic diversity thus offers a view through a ‘magnifying glass’ of subjects of much broader importance and can be a means for improving health care in general

‘A role model is like a mosaic’: reimagining URiM students’ role models in medical school

Background: Role modelling is a widely acknowledged element of medical education and it is associated with a range of beneficial outcomes for medical students, such as contributing to professional identity development and a sense of belonging. However, for students who are racially and ethnically underrepresented in medicine (URiM), identification with clinical role models may not be self-evident, as they have no shared ethnic background as a basis for social comparison. This study aims to learn more about the role models of URiM students during medical school and about the added value of representative role models. Methods: In this qualitative study we used a concept-guided approach to explore URiM alumni’s experiences with role models during medical school. We conducted semi-structured interviews with ten URiM alumni about their perception of role models, who their own role models were during medical school and why they considered these figures as role models. Sensitizing concepts guided the topic list, interview questions and finally served as deductive codes in the first round of coding. Results: The participants needed time to think about what a role model is and who their own role models are. Having role models was not self-evident as they had never thought about it before, and participants appeared hesitant and uncomfortable discussing representative role models. Eventually, all participants identified not one, but multiple people as their role model. These role models served different functions: role models from outside medical school, such as parents, motivated them to work hard. Clinical role models were fewer and functioned primarily as examples of professional behaviour. The participants experienced a lack of representation rather than a lack of role models. Conclusions: This study presents us with three ways to reimagine role models in medical education. First, as culturally embedded: having a role model is not as self-evident as it appears in existing role model literature, which is largely based on research conducted in the U.S. Second, as cognitive constructs: the participants engaged in selective imitation, where they did not have one archetypical clinical role model, but rather approach role models as a mosaic of elements from different people. Third, role models carry not only a behavioural but also a symbolical value, the latter of which is particularly important for URiM students because it relies heavier on social comparison

How should health service organizations respond to diversity? A content analysis of six approaches

Background Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches? Methods We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches. Results We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender. Conclusions Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes

Shared decision-making in an intercultural context. Barriers in the interaction between physicians and immigrant patients

OBJECTIVE: The objective of this exploratory paper is to describe several barriers in shared decision-making in an intercultural context. METHODS: Based on the prevailing literature on intercultural communication in medical settings, four conceptual barriers were described. When the conceptual barriers were described, they were compared with the results from semi-structured interviews with purposively selected physicians (n = 18) and immigrant patients (n = 13). Physicians differed in medical discipline (GPs, company doctors, an internist, a cardiologist, a gynaecologist, and an intern) and patients had different ethnic and immigration backgrounds. RESULTS: The following barriers were found: (1) physician and patient may not share the same linguistic background; (2) physician and patient may not share similar values about health and illness; (3) physician and patient may not have similar role expectations; and (4) physician and patient may have prejudices and do not speak to each other in an unbiased manner. CONCLUSION: We conclude that due to these barriers, the transfer of information, the formulation of the diagnosis, and the discussion of treatment options are at stake and the shared decision-making process is impeded. PRACTICE IMPLICATIONS: Improving physician's skills to recognize the communication limitations during shared decision-making as well as improving the skills to deal with the barriers may help to ameliorate shared decision-making in an intercultural settin

Cultural competence: a conceptual framework for teaching and learning

The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework. The framework illustrates the following cultural competencies: knowledge of epidemiology and the differential effects of treatment in various ethnic groups; awareness of how culture shapes individual behaviour and thinking; awareness of the social context in which specific ethnic groups live; awareness of one's own prejudices and tendency to stereotype; ability to transfer information in a way the patient can understand and to use external help (e.g. interpreters) when needed, and ability to adapt to new situations flexibly and creatively. The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra importance when dealing with patients from different ethnic groups. We hope our framework contributes to the further development of cultural competency in medical curricul