By 2050, it is projected that fewer than

Cultural Competence Teaching in U.S. Pediatric Clerkships in 2006 Angela P. Mihalic, MD, Alison E. Dobbie, MD, and Scott Kinkade, MD Abstract Purpose Cultural sensitivity may be especially important in the care of children, and national pediatric associations have issued policy statements promoting cultural competence in medical education. The authors conducted a national survey to investigate the current state of cultural competence teaching and learning within U.S. pediatric clerkships. Method The authors surveyed 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural curricula, content, teaching methods, and evaluation. Question types were multiple-choice single/best answer, checklists, five-point Likert-type scales, and free-text responses. Results Of 100 respondents (80% response rate), most agreed or strongly agreed that teaching culturally competent care is important (91%), enhances the physician/ patient/family relationship (99%), and improves patient outcomes (90%). Twenty four of 98 respondents (25%) reported cultural competence teaching. The most common teaching methods were lectures (63%), experiential learning through community activities (58%), and smallgroup discussions (54%). Only 14 respondents reported any curricular evaluation, the commonest methods being student surveys, clinical case presentations, and standardized patient experiences. Top factors facilitating curriculum development were culturally diverse populations of patients, students, faculty, and hospital staff, and faculty interest and expertise. Top challenges included lack of protected time for program development, funding, and faculty expertise. Conclusions Few U.S. pediatric clerkships currently provide cultural competence curricula. The authors suggestions to promote cultural competence teaching include providing faculty development opportunities and developing and disseminating teaching materials and evaluation tools. Such dissemination is important to graduate physicians, who can provide culturally sensitive pediatric care to the changing U.S. population. Acad Med. 2007; 82:558 562. By 2050, it is projected that fewer than 50% of the persons living in the United States will identify themselves as non- Hispanic white. Additional estimates predict that by 2050, 24% of the population will be ethnically Hispanic, and 15% will be black. 1 Between 1990 and 2000, the number of Americans with Dr. Mihalic is assistant professor of pediatrics and director of the pediatric clerkship, University of Texas Southwestern Medical School, Dallas, Texas, and a participant in the PAS Educational Scholars Program of the Pediatric Academic Societies/Ambulatory Pediatric Association, The Woodlands, Texas and McLean, Virginia. Dr. Dobbie is professor and chair of family and community medicine, University of Texas Southwestern Medical School, Dallas, Texas, and serves as Dr. Mihalic s project mentor for her work in the PAS Educational Scholars Program of the Pediatric Academic Societies/Ambulatory Pediatric Association, The Woodlands, Texas and McLean, Virginia. Dr. Kinkade is assistant professor of family and community medicine and director of predoctoral education, University of Texas Southwestern Medical School, Dallas, Texas. Correspondence should be addressed to Dr. Mihalic, Department of Pediatrics, University of Texas Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063; e-mail: (angela.mihalic@utsouthwestern.edu). a first language other than English grew by 47%, and the population with limited English proficiency increased by 53%. 2 Yet, only 15.2% of current medical students identify themselves as members of minority groups that are underrepresented in medicine (i.e., black, Hispanic, and American Indian). 3 Therefore, future generations of minority children born in our rapidly diversifying population may receive health care from physicians whose ethnic, linguistic, and/ or cultural backgrounds often differ from their own. These cultural differences may adversely affect physicians understanding of their minority patients needs. In turn, this misunderstanding may reduce quality of care, jeopardize patient safety, and contribute to health care disparities. 4 Health care beliefs, expectations of the physician patient relationship, and acceptance of Western medicine vary widely across cultures. Culturally competent health care fosters respect for the patient s health beliefs, enhances the physician patient relationship, and encourages collaborative management of the patient s illness. 5,6 In addition, culturally effective care can increase compliance and improve patient safety and clinical outcomes. 7 Cultural sensitivity may be especially important in the care of children. 4 Acknowledging this importance, several national pediatric associations have issued policy statements regarding cultural competence in medical education. In 1999, the American Academy of Pediatrics (AAP) published a policy statement defining culturally effective health care and describing its importance in pediatrics. 8 In 2002, in their General Pediatric Clerkship Curriculum and Resource Manual, the Council on Medical Student Education in Pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA) cited cultural sensitivity and tolerance as essential medical student characteristics. 9 In 2004, the AAP published a second policy statement promoting the development of curricula across the spectrum of medical education to provide the knowledge and skills for culturally effective pediatric care. 10 In its 2005 report, Cultural Competence Education for Medical Students, the 558

Association of American Medical Colleges (AAMC) introduced the Tool for Assessing Cultural Competence Training. This tool provides a mechanism for medical schools to map and track cultural competence teaching content across all four years of their curricula. 11 Despite these national policy statements and interventions, a 2006 PubMed search revealed no manuscripts describing the teaching and learning of culturally competent pediatric care within U.S. pediatric clerkships. Most reported cultural competence curricula do not address pediatric issues, 12,13 and most occur in the first two years of medical school rather than within the clinical clerkships. 14,15 As part of the educational scholars program of the Pediatric Academic Societies (PAS)/APA, we conducted a national survey of pediatric clerkship directors to investigate the current state of cultural teaching in U.S. pediatric clerkships. (The PAS Educational Scholars Program is a threeyear faculty development program that includes didactic sessions, workshop participation and review, and a longitudinal, mentored, educational research project.) In this article, we report the survey s findings and provide recommendations to promote the teaching of culturally competent pediatric care. Method In April 2006, we surveyed all 125 U.S. pediatric clerkship directors concerning the teaching of culturally competent/ culturally effective pediatric care within their clerkships and elsewhere in the medical school curriculum. Questionnaire design. We designed an online questionnaire using content from a literature search that we carried out, the 1999 and 2004 AAP policy statements, 8,10 the AAMC cultural competence education report, 11 the family medicine cultural competency curricular guidelines, 16 and the report Child Health in the Multicultural Environment. 17 A multidisciplinary panel of 12 clinician educators at our institution pilot tested the questionnaire for content, clarity, usability, and length. The PAS educational scholars program faculty also provided valuable input. The COMSEP executive committee approved the questionnaire and distributed it electronically via their listserve. Our institutional review board awarded the study exempt status. Questionnaire content and delivery. In our questionnaire, we inquired about the presence or absence of cultural competence teaching in U.S. pediatric clerkships. Where curricula existed, we asked about curricular content, teaching and learning methods, and evaluation strategies. We also solicited clerkship directors attitudes regarding the importance of cultural competence teaching, and we asked about local factors that facilitated or hindered them in developing cultural competence curricula. Finally, we inquired whether cultural issues related to children were taught elsewhere in the medical school curriculum. Question types were multiple choice/single best answer, checklists, fivepoint Likert-type scales, and free-text responses. We used simple, descriptive analyses to report the responses. We distributed the questionnaire electronically via Survey Monkey though the COMSEP listserve. We attached a PDF version for respondents who preferred a paper version. We sent the questionnaire a second time after one week. After two weeks, we sent personal electronic reminders to nonresponders. Results Respondent demographics. One hundred U.S. pediatric clerkship directors responded to our survey, a response rate of 80%. The response rate was consistent across all AAMC regions; central, 22 schools (71%); northeastern, 27 schools (77%); western, 14 schools (82%); and southern, 36 schools (86%). Fifty-nine (60%) of respondents taught at public medical schools, and 39 (40%) taught at private schools. Eighty-eight respondents (88%) had six- or eightweek clerkships. Clerkship group sizes ranged from fewer than 10 students (18%), 10 20 students (39%), 20 30 students (32%), to over 30 students (11%). There was no association between size or length of clerkship and provision of cultural teaching. Of the 98 respondents who reported the presence or absence of a cultural competence curriculum, 24 (24.5%) offered such a curriculum, and 74 (75.5%) did not. Two respondents failed to answer the question on presence or absence of a cultural curriculum. Attitudes toward teaching culturally competent care of children. On a fivepoint Likert scale from strongly disagree to strongly agree, most respondents agreed or strongly agreed that teaching culturally competent care is important (91%), that such care enhances the physician/patient/family relationship (99%), and that culturally competent care improves patient outcomes (90%). Ninety-three (93%) clerkship directors agreed or strongly agreed that their students saw culturally diverse patients. However, only 72 (72%) agreed or strongly agreed that their faculty had the skills to teach culturally competent care, and 82 (82%) agreed or strongly agreed that their faculty role-modeled such care. Cultural curricular content. The content of the 24 reported curricula is summarized in Table 1. The five most commonly taught cultural knowledge topics were health beliefs, health care disparities and access to care, legal and ethical cultural issues, influence of faith or religion on health care, and the social and historic contexts of communities. The most commonly taught skills were linguistic differences (use of medical translators), culturally effective medical interviewing and communication, and recognizing, eliciting, and negotiating different core cultural issues. The top five attitudinal areas taught were appreciation for diverse health beliefs; socioeconomic factors and health; impact of race on health care delivery; self-reflection to understand one s personal culture, biases, and tendency to stereotype; and impact of gender on health care delivery. Only four respondents (16%) taught the culture of American medicine, and only two respondents (8%) covered ethnopharmacology (the study of differences in response to drugs by varied racial and ethnic groups) or cultural issues of refugees/foreign-born adoptees. Cultural teaching and learning methods. Of the 24 schools with a cultural curriculum, the most common teaching and learning methods were didactic lectures (63%), experiential learning through community activities (58%), and small-group discussions (54%). Other reported methods included Web-based learning (29%), standardized patients (21%), videos (21%), and 559

Table 1 Content of Cultural Competence Curricula in Pediatric Clerkships at 24 U.S. Medical Schools, 2006 * Schools teaching Content area the area: No. (%) Cultural knowledge Health beliefs 18 (75) Health care disparities access to care 17 (71) Legal and ethical cultural issues 13 (54) Influence of faith or religion on health care 12 (50) Social and historic context of your community 11 (46) Folk illnesses and healing practices 10 (42) Disease incidence, prevalence, and outcomes among distinct populations 10 (42) Relationship of culture to growth and development 9 (38) Refugees/foreign-born adoptees 2 (8) Ethnopharmacology 2 (8) Other 7 (29) Cultural skills Linguistic differences, use of medical translators 20 (83) Culturally effective medical interviewing and communication 16 (67) Recognizing, eliciting, and negotiating different core cultural issues 14 (58) Eliciting patients explanatory models and agendas 8 (33) Other 3 (13) Cultural attitudes Appreciation for diverse health beliefs 20 (83) Socioeconomic factors and health 18 (75) Impact of race on health care delivery 16 (67) Self-reflection to understand one s personal culture, biases, and tendency to stereotype 13 (54) Impact of gender on health care delivery 9 (38) Culture of American medicine 4 (17) Other 1 (4) * The authors sent a questionnaire to all 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural competence curricula and, when present, its content, teaching methods, and evaluation. A total of 100 directors responded, and 24 of reported that their schools offered cultural competence teaching; this table presents highlights of their responses. specially designed clinical experiences (21%). Three schools used directed readings (13%), and two reported problem-based learning (8%). Evaluation methods for assessing cultural competence. Of the 24 programs teaching cultural competence curricula, only 14 (58%) reported any evaluation methods (described in Table 2). The most common evaluation methods were student surveys, clinical case presentations, and standardized patient experiences. Other reported evaluation methods included written and online case exercises, videotaped and audiotaped clinical encounters, reflective journals and portfolios, and an objective structured clinical exam. Facilitating factors and challenges in developing curricula. Twenty-four respondents reported factors that facilitated cultural curricular development, and 95 reported challenges and barriers to curriculum development. These factors are summarized in Figure 1. The 24 respondents with a curriculum reported that the top factors that facilitated its development were a culturally diverse patient population, faculty interest, faculty expertise, culturally diverse clinic/hospital staff, culturally diverse student group, and culturally diverse faculty. The top three challenges that hindered or prevented curricular development were lack of protected time for program development, lack of grant support/funding, and lack of faculty expertise. Cultural competence teaching outside the pediatric clerkship. Many of the 100 respondents reported that, in their institutions, students learn cultural aspects of child health in courses other than the pediatric clerkship. The most common settings were the preclinical clinical medicine course (60%), a preclinical human behavior course (56%), or other clinical clerkships (34%). Respondents from only 10 institutions reported a preclinical course specifically addressing culturally competent care, and only nine reported having a fourth-year elective devoted to culturally competent care. Discussion Our survey demonstrates that despite the AAP policy statements on culturally effective pediatric care, and despite widespread agreement about the importance of teaching such care within the pediatric clerkship, only 25% of U.S. programs currently offer such teaching. Clerkship directors believed that some cultural competence teaching happened through the informal curriculum during inpatient and outpatient clinical experiences and by role modeling by residents and faculty. Unfortunately, the literature suggests that this may not be the case. Few faculty and residents have received faculty development in culturally sensitive care, and they may not have the knowledge, skills, and attitudes to role model effectively. 18,19 Few clerkship directors reported teaching about working with interpreters. Because of the rapidly increasing numbers of Americans with limited English proficiency, and the tendency to inappropriately use children as interpreters, working well with interpreters is vital to promote effective patient physician communication and to reduce medical error. 4 Few clerkships included studies on the U.S. culture of medicine that might prompt students to examine U.S. medical norms and expectations. Without such self-reflection regarding their own cultural values, biases, and assumptions, it may be more challenging for students to appreciate patients cultural positions and effectively negotiate the therapeutic relationship. Almost no clerkship directors taught issues related to refugee medicine. This is surprising, considering the increasing 560

Table 2 Evaluation Methods for Cultural Competence Curricula in Pediatric Clerkships at 14 U.S. Medical Schools, 2006 * Evaluation method Schools using the method: No. (%) Student satisfaction (14 schools) Surveys 13 (93) Focus groups 2 (14) Structured interviews 0 Changes in knowledge (10 schools) Standardized patients 5 (50) Written case exercise 3 (30) Online case exercise 3 (30) Objective structured clinical exams 1 (10)... Pretest posttests (multiple choice, true false, etc.) 1 (10) Changes in skills (10 schools) Clinical case presentations 8 (80) Standardized patients 6 (60) Objective structured clinical exams 1 (10) Videotaped/audio taped clinical encounter 1 (10) Changes in attitudes (10 schools) Clinical case presentations 7 (70) Surveys/questionnaires 6 (60) Reflective journals/portfolios 3 (30) Structured interviews 1 (10) ideotaped/audiotaped clinical encounter 1 (10) Changes in patient outcomes (9 schools) Other 7 (78) Standard surveys 1 (11)... Structured interviews 2 (22) * The authors sent a questionnaire to all 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural competence curricula and, when present, its content, teaching methods, and evaluation. A total of 100 directors responded; 24 reported that their schools offered cultural competence teaching, and 14 reported using evaluation methods, as summarized above. influx of refugees into the United States, the high percentage of children among those refugees, and the multiple medical and psychological problems typically experienced by this population. 17 Most reported teaching and learning methods were traditional lectures and case-based discussions. Relatively few clerkships used Web-based learning methods or standardized patients to convey content. A few clerkships reported experiential learning activities within communities to enhance students cultural learning. 20,21 This type of learning activity was also reported in 2005 by Sidelinger et al, 21 who described a community academic partnership aimed at teaching culturally effective pediatric care in pediatric residency training programs in New York and California. These programs included cultural immersion experiences using local community leaders as teachers. Fewer that half of the clerkship directors who teach culturally competent care reported that they evaluate their programs, and none have reported outcome measures in the peer-reviewed literature. This lack of reported outcomes inhibits dissemination and sharing of effective curricular materials. Also, reported evaluation methods addressed only low-level outcomes measures, such as students satisfaction with the curriculum and attitudes towards cultural competency. No survey respondent described evaluation methods that demonstrated changes in learners behavior in the clinical setting with families from different cultures. The main reported challenges to developing a cultural competence curriculum are common across other content areas and include lack of time, money, and expertise. Responding directors expressed concern over lack of time in the clerkship to teach cultural competence as well as lack of available curricular materials. Surprisingly, almost all respondents reported that students learn cultural aspects of child health in courses other than the pediatric clerkship. This contradicts our experience, and our findings from the literature, that preclinical cultural curricula typically focus on adult topics. Therefore, we question the extent to which the preclinical curricula in those other courses really covered cultural topics specific to children. Our study yielded an excellent response rate of 80%. Although 70% is generally considered an acceptable response rate for generalization, we postulate that our nonresponders are more likely than our responders to not have a cultural competence curriculum. Therefore, our study results may overestimate the amount of cultural competence teaching that is occurring in U.S. pediatric clerkships. Conclusions U.S. pediatric clerkship directors generally agree with the national pediatrics associations that it is important to teach about culturally competent care, but few deliver such teaching, and almost none evaluate it. Common barriers include lack of time, money, faculty expertise, and easy access to validated teaching materials. We present the following recommendations to promote the teaching of culturally competent pediatric care within U.S. clerkships. First, medical educators should provide interested faculty with opportunities to gain content, teaching, and evaluation skills in cultural competency. Suggested strategies for faculty development include workshops at national meetings on pediatric cultural competence and culturally sensitive pediatric care. Second, faculty need protected time to develop, implement, evaluate, and disseminate curricular materials and evaluation tools. In the absence of major external funding sources such as 561

Other Grant support/funding Protected time for program development Chairman's/institutional support Student interest Culturally diverse faculty Culturally diverse students Culturally diverse clinic/hospital staff Facilitated by ' this factor s presence Faculty expertise Hindered by this factor s absence Faculty interest Culturally diverse patients 0 5 10 15 20 25 30 35 40 45 No. of clerkship directors who responded Significantly or A great deal Figure 1 Facilitating factors and challenges in developing cultural competence curricula at responding U.S. medical schools in 2006. The authors sent a questionnaire to all 125 U.S. pediatric clerkship directors concerning the presence or absence of cultural competence curricula and, when present, its content, teaching methods, and evaluation. A total of 100 directors responded; 24 reported factors that facilitated cultural curricular development, and 95 reported barriers and challenges to such development. the Health Resources and Services Administration Title VII funds, we recommend that U.S. medical schools promote and support the teaching of culturally competent care from internal resources. Third, skilled faculty should develop validated teaching materials and should disseminate them through national presentations, peer-reviewed publications, and online resources such as the AAMC MedEdPORTAL. 22 These materials should include more Webbased interactive cases, particularly cases concerning the use of interpreters and refugee medicine. Dissemination of these teaching materials will likely enhance the overall teaching of culturally sensitive health care of children in U.S. pediatric clerkships. In addition, we encourage the increased or expanded use of community partnerships to promote experiential learning that will augment traditional teaching methods. We currently lack outcomes data from most pediatric cultural curricula. Most reported evaluations have focused on the low-level outcomes of cultural attitudes and skills. No study has yet demonstrated that cultural teaching interventions influence students behavior in real patient settings or that they have improved patient care outcomes. Further studies should focus on these higher levels of evaluation. Teaching interventions that change behavior are vital if we are to graduate physicians who are competent to provide culturally sensitive pediatric care to the changing U.S. population. References 1 U.S. Census Bureau. Current population survey. Population by sex, age, Hispanic origin, and race. Available at: (http://www. census.gov/ipc/www/usinterimproj). Accessed August 24, 2006. 2 U.S. Census Bureau. Current population survey. Language use. Available at: (http:// www.census.gov/population/www/socdemo/ lang_use.html). Accessed August 24, 2006. 3 Association of American Medical Colleges. Minorities in Medical Education: Facts & Figures 2005. Washington, DC: Association of American Medical Colleges; 2005. 4 Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355:229 231. 5 Carrillo JE, Green AR, Betancourt JR. Crosscultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829 834. 6 Nunez AE. Transforming cultural competence into cross-cultural efficacy in women s health education. Acad Med. 2000; 75:1071 1075. 7 Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(suppl 1):181 217. 8 Committee on Pediatric Workforce, American Academy of Pediatrics. Culturally effective pediatric care: education and training issues. 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The development and evaluation of a programme to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232 241. 15 Crandall SJ, George G, Marion GS, Davis S. Applying theory to the design of cultural competency training for medical students: a case study. Acad Med. 2003;78:588 594. 16 Like RC, Steiner RP, Rubel AJ. STFM core curriculum guidelines. Recommended core curriculum guidelines on culturally sensitive and competent health care. Fam Med. 1996; 28:291 297. 17 Pachter LM, ed. Child Health in the Multicultural Environment, Report of the Thirty-First Ross Roundtable on Critical Approaches to Common Pediatric Problems. Columbus, Ohio: Ross Products Division, Abbott Laboratories; 2000. 18 Wright SM, Carrese JA. Serving as a physician role model for a diverse population of medical learners. Acad Med. 2003;78:623 628. 19 Park ER, Betancourt JR, Kim MK, Maina AW, Blumenthal D, Weissman JS. Mixed messages: residents experiences learning cross-cultural care. Acad Med. 2005;80:874 880. 20 Albritton TA, Wagner PJ. Linking cultural competency and community service: a partnership between students, faculty, and the community. Acad Med. 2002;77:738 739. 21 Sidelinger DE, Meyer D, Blaschke GS, et al. Community as teachers: learning to deliver culturally effective care in pediatrics. Pediatrics. 2005;115:1160 1164. 22 Association of American Medical Colleges. MedEdPORTAL. Available at: (www.aamc.org/mededportal). Accessed August 24, 2006. 562