Curriculum

Harvard Medical School (HMS) established the Culturally Competent Care Education Committee (CCCEC) to develop a strategic plan to assure that all students obtain the necessary skills, knowledge and attitudes to practice culturally competent medicine.

Recently, Culturally Competent Care was included as one of Dean Joseph Martin's "Five Great Challenges" of medical education in his presentation at the March 2004 medical education reform retreat.

<back to top>

The Association of American Medical Colleges (AAMC) identifies four essential components in culturally competent care: 1) awareness of self and one's value system; 2) an understanding of the concept of culture and its role as a factor in health and healthcare; 3) a sensitivity to cultural issues for each patient; and 4) an understanding and ability to use specific methods to deal effectively with cultural issues in interacting with individual patients, their families, members of the healthcare team, and the wider community. This has been codified by the Liaison Council on Medical Education (LCME), which now has standards that require cross-cultural curricula as part of undergraduate medical education (Liaison Committee on Medical Education, 2001):

ED21: The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

All instruction should stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. To demonstrate compliance with this standard, schools should be able to document objectives relating to the development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are achieved.

ED22: Medical students must learn to recognize and appropriately address gender and cultural bias in themselves and others, and in the process of healthcare delivery.

The objectives for clinical instruction should include student understanding of demographic influences on healthcare quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. The objectives should also address the need for self-awareness among students regarding any personal biases in their approach to healthcare delivery.

<back to top>

The committee's educational goals are aligned with those of the Association of American Medical Colleges and enhance the school's goal to graduate competent physicians. They include the following learning objectives:

• To explore the epidemiology of the health of different populations.
• To define cultural competence, culture, race and ethnicity.
• To increase awareness of racial/ethnic disparities in healthcare.
• To provide information on non-medical factors (race/ethnicity, culture, class and language proficiency) that influence clinical decisionmaking, including the exploration of bias, stereotyping, discrimination and racism.
• To become familiar with prevailing cultural practices, and establish the importance of sociocultural factors and their impact on health beliefs, behaviors, and medical care.
• To learn a set of key concepts and skills that enhance the ability to communicate with, diagnose, and treat patients whose sociocultural backgrounds differ from their own (including identifying core cross-cultural issues, eliciting the explanatory model, determining the social context, using an interpreter, and provider-patient negotiation).
• To learn practical application of these concepts and skills in the clinical setting.

<back to top>

The following is a list of points across the HMS curriculum wherein issues of culture and diversity, and cultural competence training, have been integrated:

Emerging a Culturally Competent Physician: Self-Awareness
and Cultural Identity
This course will explore and reflect on the culture of western medicine into which students are being socialized. Students will explore the values they bring into the profession and how these values influence their personal and professional lives, including responses to diverse patient cultures. The course will be taught in both large and small group sessions. In addition to interactive large group sessions, there will be small group exercises designed to illustrate our underlying assumptions about ourselves and others upon which relationships are based. These experiences will not offer formulaic approaches to different identified groups, but will help students approach and successfully interact with any person, regardless of differences. As this learning is a life-long process, the course will model a commitment to self-awareness and introspection, fundamental to the process of developing healing partnerships with patients and colleagues alike. This is an elective course designed to directly address LCME educational objective 22.

Patient-Doctor I (PDI)
The course coordinator identified several sessions of PDI that integrate issues of culture; "The Explanatory Model: Eliciting a History of Complementary and Alternative Medicine Use," "Past Medical History: Occupational History," "Obtaining the History of Present Illness, Past Medical History," "Obtaining Family Genealogy," "Skills Session," and Videotaped Interview." Several additional sessions are also relevant to culturally competent care— "Introduction to Medical Interview," "Shadowing the Clinician," and "Learning to Measure Vital Signs."

Patient-Doctor II (PDII)
The course coordinator has identified one session that directly integrates issues of CCC: "When the Provider and Patient come from Different Cultures." Additionally, students learn to conduct the physical exam in culturally appropriate manner with diverse populations, and student rotations and clinical experiences in cross-cultural care will be developed.

Patient-Doctor III (PDIII)
Four tutorials address diversity directly. They are, "Alternative Medicine", "Practicing Medicine in a Diverse World", "Caring for Gay and Lesbian Patients", and "Spirituality and Patient Care". Dr. Joseph Betancourt is developing three additional integration points for PDIII; 1) a plenary session on cross-cultural issues early in PDIII for faculty and students, 2) curriculum modifications that encourage students to identify clinical situations where cross-cultural issues have arisen for discussion in tutorials PDIII, and 3) the identification by PDIII tutors of cases that can be disseminated more broadly (i.e. case conferences, etc).

Clinical Epidemiology
In 2004, cultural issues were integrated into this required course. A case study of an older African-American male who is being treated for both hypertension and chronic kidney disease is now a part of the formal curriculum. Students are also asked to discuss possible barriers including patient level barriers, physician level barriers and system level barriers that prevent equal access to medicine.

Physician in Community Service Learning: Putting Theory into Practice
This is a year long elective course that offers a systematic and intellectually rigorous framework in service learning that provides a forum for reflection, while developing a knowledge base in theoretical concepts in community health and practical skills necessary for physicians working in diverse communities.

Physician in Community: A Service Learning Course in Community Medicine and International Health
This spring/fall course is designed to provide first and second year students with a theoretical and practical background for community work, both domestic and international.

The Health Care of Women and Children: Social, Economic and Policy Issues Affecting Clinical Care" clerkship
Opportunities for introducing issues of cultural competence are being sought in the women's and children's health clerkship. In addition to sessions addressing gender and socioeconomic issues, a hour session by Lee Patcher, M.D. from the University of Connecticut entitled, "Culture and Clinical Care: Working with Ethnomedical Beliefs and Practices", is held. The talk addresses issues in delivering care for asthmatic children in the Hispanic community and how the cultural context alters management.

Introduction to Psychiatry
A three-hour session addressing Minority Mental Health has been integrated into this required course.

Medicine, Human Rights, and the Physician
A session on racial/ethnic disparities and cross-cultural care was taught as part of the "Medicine, Human Rights, and the Physician" elective course to second year students in the fall of 2002. Approximately 30 first year HMS students attended. The goal of the committee is to integrate a section of culturally competent care on a yearly basis.

<back to top>