As the United States population grows increasingly diverse, the delivery of quality health care to all patients, regardless of race, ethnicity, culture, and language proficiency, is becoming more of a challenge. Two reports from the Institute of Medicine (IOM)—Crossing the Quality Chasm and Unequal Treatment—cited persistent racial/ethnic disparities in health care, and both reports highlighted the importance of patient-centered care and cross-cultural training as a means of improving quality across the board. These recommendations were based on the premise that health care professionals need to have the knowledge and skills to provide culturally competent care to a variety of populations. In particular, improvement of provider–patient communication is essential to addressing the quality-of-care differences associated with race, ethnicity, or culture.
In 2003, a national survey of resident physicians in their last year of training was conducted to determine whether the nation's future physician workforce felt sufficiently prepared to deliver quality care to diverse populations. The objectives of this survey were to assess the resident physicians' self-perceived levels of preparedness, assess the educational climate for cross-cultural training, and determine whether respondents received formal training and evaluation in cross-cultural care during their residency. Results of this study were published in the Journal of the American Medical Association in 2005. The present report reviews the major findings of that work and identifies their implications for clinical care and medical-education policy.
The national survey had 2,047 respondents, out of 3,435 eligibles, representing internal medicine, surgery, pediatrics, obstetrics/gynecology, emergency medicine, psychiatry, and family medicine. Men and women were almost equal in number, while respondents' racial/ethnic groups were non-Hispanic white (57.1%), Black non-Hispanic (6.2%), Hispanic (5.0%), Asian/Pacific Islander (22.7%), and other (4.2%). Overall, 25.6 percent were international medical graduates.
Attitudes, Preparedness, and Skills
Nearly all residents thought it was important to consider the patient's culture when providing care (26% said "moderately important" and 70% "very important"). Residents in emergency medicine and surgery were significantly less likely to respond "very important" (43% and 47%, respectively) compared with other specialties, among whom 67 percent to 94 percent (p<.001) answered "very important." Many residents felt that cross-cultural issues "often" resulted in negative consequences for clinical care, including longer office visits (43%), patient noncompliance (21%), delays obtaining consent (19%), unnecessary tests (9%), and lower quality of care (7%).
Although less than half of the residents felt "well prepared" or "very well prepared" to treat patients from diverse cultures or racial and ethnic minorities, few thought they were "very unprepared" or "somewhat unprepared" when asked in a general sense. However, many more residents felt unprepared to deliver care to patients with specific characteristics likely to arise in cross-cultural situations. For example, more than one out of five residents felt unprepared to treat patients with mistrust (28%), cultural issues at odds with Western medicine (25%), or religious beliefs that affect care (20 percent). Similarly, some residents felt unprepared to treat users of complementary medicine (26%), new immigrants (25%), or patients with limited English proficiency (22%). By comparison, when it came to managing common clinical problems and delivering services that each resident expected to perform during his or her medical careers, the percentage citing lack of preparedness was quite low.
Training, Evaluation, and Educational Climate
Most resident physicians—particularly those in emergency medicine, general surgery, and ob/gyn—reported receiving little or no instruction in cross-cultural skills beyond what is learned in medical school. Approximately half reported receiving minimal training in understanding how to address patients from different cultures (50%) or in identifying patient mistrust (56%), relevant religious beliefs (50%), relevant cultural customs (48%), and decision-making structure (52%). Whereas family-medicine residents received more instruction than did those in any of the other six specialties, residents in general surgery and emergency medicine reported having very little instruction in cross-cultural skills.
About 10 percent of all residents reported never being formally evaluated on doctor–patient communication, and an additional 21 percent said they were "rarely" evaluated in that area. Adding the responses of those who were never evaluated on doctor–patient communication in general to the responses of all residents who said that very little or no attention was paid to cross-cultural issues (56%) yields a total of 66 percent of residents who received little or no evaluation on cross-cultural aspects of doctor–patient communication.
Over half of respondents (58%) said that lack of time presented a moderate or major problem for them in delivering cross-cultural care. Other frequently mentioned problems included lack of language-appropriate written materials (62%), poor access to interpreters (53%), and lack of experience (22%). Although dismissive attitudes of attending physicians or of resident colleagues have been suggested in previous focus groups, only 18 percent and 15 percent of respondents, respectively, mentioned such problems in the survey. About 30 percent cited the lack of good role models as a problem, and 31 percent stated (in response to a separate question) that they had no role models or mentors during their residencies who were good at providing cross-cultural care.
Implications for Clinical Care
Residents felt that poor handling of patients' cross-cultural issues often had negative consequences for clinical care, including longer office visits, patient noncompliance, delays obtaining informed consent, ordering of unnecessary tests, and lower overall quality of care. This is especially troubling, given that residents reported they were unprepared to handle several key cross-cultural issues in the clinical encounter, as noted above. And it is important to note that a broad array of patients—not just racial or ethnic minorities, new immigrants, or patients with limited-English proficiency—may share a mistrust of the health system, or hold a health belief or religious value that can affect care. Crossing the Quality Chasm argues that the quality of our health care system needs to be improved, especially in making it more patient-centered and equitable; yet, the reported deficiencies in providing care across a diversity of cultures threaten the realization of such improvement.
Implications for Medical Education Policy
Several key findings from the research should influence graduate medical education. In particular, they lead to recommendations for improving the training of resident physicians so that they are prepared to provide quality care to diverse populations.
- Cross-cultural issues matter in the care of patients and are central to quality, yet fewer than half of the resident physicians surveyed feel well prepared to deal with them.
Recommendation: Cross-cultural curricula should be integrated into all graduate medical education (GME).
- Our research corroborates the IOM's recommendations in Unequal Treatment and Crossing the Quality Chasm and its calls for greater patient-centeredness and cross-cultural skills as a means of improving quality of care and eliminating disparities.
- Fewer than half of the resident physicians surveyed had any cross-cultural training outside of what they received in medical school.
Recommendation: Cross-cultural curricula in GME should build on what is learned in medical school, focus on practical tools and skills, and be based on a set of standard principles that are useful across clinical disciplines.
- Standard principles of cross-cultural education in residency training should be based on those highlighted in Unequal Treatment. They include providing physicians with an overview of health care disparities and their root causes; methods for understanding the clinical decision-making process (including strategies to avoid stereotyping); a framework for communicating across cultures (including assessment of core cross-cultural issues, exploration of the meaning of the illness, determination of the social context, and negotiation techniques); instruction on how to use an interpreter; and skills for better understanding the community receiving care.
- Cross-cultural education should be integrated into mainstream educational activities—including lectures, morning reports, case reviews, and work and grand rounds—both on a formal and informal basis.
- The cross-cultural communication skills taught to resident physicians should be readily usable in the clinical encounter, especially given the competing responsibilities and time constraints they face.
- System supports (such as interpreters, the assistance of multidisciplinary teams, and printed educational information in multiple languages and aimed at people with low levels of health literacy) should be developed in tandem with cross-cultural curricular efforts.
- Cross-cultural education should span all disciplines—and it is especially critical in emergency medicine and surgery, in which diagnostic accuracy and the obtaining of informed consent are paramount. Yet research highlights serious self-reported deficiencies among residents in both disciplines.
- One-third of the surveyed resident physicians stated they did not have role models or mentors who could demonstrate effective cross-cultural care.
Recommendation: Faculty development (including for attending physicians and fellows) in cross-cultural education is essential to the training and mentoring of residents in cross-cultural care.
- Given the importance of good role models and mentors in medical education, faculty should be trained in the same standard principles of cross-cultural care, and they should be provided with (or develop) discipline-specific clinical cases as a means of providing cross-cultural instruction to resident physicians.
- Two-thirds of the surveyed resident physicians stated they were not evaluated in cross-cultural aspects of doctor–patient communication.
Recommendation: Evaluation of resident physicians' general and cross-cultural communication skills is essential and should be mandatory and formalized.
- Given the important message that simply evaluating a particular competency has on resident physicians' perceived value of that competency, it is necessary that evaluation in the area of general and cross-cultural communication be mandatory and formalized.
Creating assessment tools is an important step toward developing a standard nomenclature for measuring the success of cross-cultural education curricula. Once these tools have been created, they can be used to compare program components and in turn contribute to the development and implementation of consistent curricula across graduate medical education.