AMA Journal of Ethics^®

Diversity. A major buzz word here at the turn of the century. My parents grew up actively fighting racism; I still hear stories of the revolution that was the 60s and 70s. I sometimes wonder if my generation has that same fervor, the same desire to effect change in the world. One certainly cannot say that the battle against racism is over, but my time is one where fostering and accepting diversity has become the prominent social force. I like to think of it as a positive attack on the same problem, taking the offensive and being proactive.

As the nation comes to focus on diversity more and more, people are beginning to have a stronger appreciation for the things that make them unique. They are more resistant to being lumped into groups, and organizational structures have set a dynamic pace in trying to adapt to this increasingly heterogeneous melting pot. Look at education, marketing, and entertainment; evidence for changes in these sectors is readily apparent. Medical education and the practice of medicine have in no way been exempt; if anything, these may be some of the most affected arenas.

If medicine were simply the diagnosis of disease and prescription of pills or surgery, the repercussions of these social changes would be mild. Yet we know that so much of medicine is interpersonal relationships and delving into the very private world of our patients. We ask patients to share their daily existence; we ask them to alter their lives, be it diet, exercise, or new ways to reduce stress. Towards the end of life, we ask patients to examine their beliefs, ponder their meaning of life and death, and consider exactly what brings value to their existence. Medicine boils down to two fundamental but crucial topics: communication and decision making; culture plays an overwhelming role in both domains. As the population we care for changes, we must adapt and find ways to connect to those individual issues that will affect the manner in which we provide care for each of our patients.

I often reflect on my development as I complete my medical student training. I strive to be a superb physician, not only one who has expertise within his field, but one who has gained the respect and trust of his patients. Ideally, medical students and physicians would bond immediately with every one of their patients upon entering the room for the first time. There are some patients with whom you feel a kinship, even friendship, and some with whom a bond will never form, except for a mutual and distant respect. This becomes increasingly clear throughout my third year. I happen to be from the city in which I attend medical school, a fact that sometimes wins me a warmer welcoming from patients. Furthermore, several times a day, I come across a warm smile or an appreciative nod and hello from patients who are not even mine. More often than not, these are African Americans. That connection frequently comes into play when I see African American patients, especially when I am with residents or colleagues of another race. The discussion I have with black patients often has more candor and honesty.

I recall one particular case from my Pediatrics rotation. An 8-year-old African American boy had been in an accident at home and lacerated his right thigh. I entered the patient's room in the ED with my intern. Before introductions could even be made, the patient's mother immediately demanded to know if we were "real doctors" or just in training; she wanted no students "working on her son." I clarified our roles, specifically that I was a student and would simply observe, if that was acceptable (I entered the room with the goal of taking the history and physical, but it was clear that an adjustment was necessary). As the intern began to take the history, out of the corner of my eye, I saw the patient's mother begin to relax and look me over. She smiled and asked where I was from. I explained that I went to high school nearby and have family in the area; the smile widened. She began to ask the usual questions about college and medical school. Soon, I was able to obtain a detailed history from her, while the intern interviewed the child. By the time it came to treatment, the patient's mother wanted to give me, the student she was initially so strongly resistant to, the opportunity to sew her son's complicated laceration. Despite many friendly overtures and attempts to engage in conversation, the intern was never able to gain the same comfort, openness and trust from the patient's mother. Finally, the mother mentioned to me "how nice it is to see an African American face helping provide care for my son."

Do I believe that I, as an African American, will be better equipped to provide care to African Americans in the future? No. It is perfectly natural to be drawn to and comfortable with familiarity. Yet, as students and physicians who care for a broad population, it is our duty to move past those initial barriers to develop a strong patient-physician relationship, regardless of who the patient is. It is not easy, and it takes time.

If culture is a group's set of beliefs and practices, and fostering diversity is embracing the qualities that make each of us unique within those cultural groups, then being equipped to deal with an increasingly diverse environment is just one step beyond cultural competence. We must go forward from understanding the concept of culture to a more sophisticated attempt at comprehending how culture, along with age, sex, education, and a host of other factors come together to create and impact one person, our patient. How do you create culturally competent physicians? Should students arrive in medical school with this skill already? Was it their parents' responsibility? Should this be a concern of medical schools at all? Is it enough to have a "diverse" student body? Should this be a formal part of medical training? Clearly, these answers are in development, and these issues are being evaluated at medical schools across the country. Just as the goal of medical school is not to teach all of medicine in 4 years, but to provide a firm background and tools with which future physicians can continue to gain knowledge, no medical school should endeavor to create a culturally omnipotent physician either. The school's role is to teach students to respect their patients' individualism, to listen, to ask genuine questions, and to strive to provide equal care to all patients. A good start would be to encourage students to be truly interested in their individual patients and to remember that it is a privilege to be a physician.

"Carefully listening while providing comfort and companionship, sometimes referred to as the "sacrament of presence," is often the best medicine we have to offer, and it's exactly what our patients need".¹