AMA Journal of Ethics^®

Godkin MA, Savageau JA. The effect of a global multiculturalism track on cultural competence of preclinical medical students. Fam Med. 2001;33(3):178-186.

Godkin MA, Savageau JA. The effect of medical students’ international experiences on attitudes toward serving underserved multicultural populations. Fam Med. 2003;35(4):273-278.

Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program. Am J Trop Med Hyg. 1999;61(6):1019-1023.

Immigration and globalization have linked world populations geographically, economically and socially, creating multicultural communities at local and global levels. Physicians must therefore be prepared to serve patients who differ from them in ethnicity, language, education, socioeconomic status and cultural beliefs and norms. Sensitivity to cultural differences helps physicians communicate more effectively with patients from diverse backgrounds and, thus, provide better care for them.

International experiences, especially in developing countries where differences between patients and physicians are quite extreme, are certain to pose communication problems that force physicians to learn to adapt. Hence these experiences, while challenging, are optimal for teaching future physicians to communicate successfully with and care for underserved multicultural populations.

According to articles by Michael Godkin and Judith Savageau [1,2] and an article by Anu R. Gupta et al. [3], international experiences promote pre-existing cultural competence among medical students and physicians and raise it to new levels. Although there is no single, agreed-upon definition, cultural competence is generally considered to mean possession of—or the effort to gain—the skills that enable a medical professional to work effectively within a patient’s or community’s cultural context [4]. Models of cultural competence propose multiple components, including awareness of others’ and one’s own social context, cultural knowledge, multicultural practice and desire to pursue the former three components [1,2,5]. Authors of all three articles concluded that international experiences cultivated acquisition of these skills among students and residents. Godkin and Savageau found specifically that international experiences developed higher levels of both personal awareness and professional knowledge of cultural differences. The work of Gupta et al. revealed that international experiences nurtured residents’ personal desire to care for underserved multicultural populations, a desire that the residents followed through on by having more patients in their practices from cultures or demographic categories different from their own.

Details of the Studies

Godkin and Savageau examined the 2001 curriculum of the Global Multiculturalism Track for preclinical medical students at the University of Massachusetts [1]. The track consisted of six weeks of language immersion abroad plus three domestic components: time with a local immigrant family, a community service project and a seminar series. The authors found that participants not only had a higher level of cultural competence overall compared to nonparticipants both before and after the course, but that they also developed significantly greater competence in the specific area of knowledge about other cultures.

In a follow-up study in 2003, the same authors examined the various international electives taken by preclinical and clinical medical students at the University of Massachusetts [2]. Preclinical electives offered language training, and clinical electives provided clinical training, but all involved cultural immersion. Preclinical participants had higher levels of cultural understanding overall compared to nonparticipants both before and after the international experience. Both preclinical and clinical participant groups reached higher levels of cultural competence through international experiences, and both reported significantly increased awareness of the “need to understand cultural differences.”

Clinical participants also said they became more self-aware and, as a consequence, grew more idealistic about their role as physicians. Preclinical participants did not become more idealistic, but neither did their idealism decline, as that of nonparticipants did. The desire of preclinical participants to work with underserved multicultural populations was stronger after the international electives than before.

Gupta et al. examined the International Health Program for internal medicine residents at Yale University in which residents spend four to eight weeks of vacation and elective time participating in clinical electives abroad [3]. Physicians who had participated in the international program were more likely to be working in public health and less likely to be in private practice. They were also more likely to consider undertaking international work in the future. Although members and nonmembers of the participant group agreed that “physicians have an obligation to the medically underserved,” international program participants were more likely to draw at least 20 percent of their patients from one or more of the following categories: immigrant, on public assistance, HIV-positive or substance abuser. These authors concluded, as did Godkin and Savageau, that international experiences enhanced pre-existing cultural sensitivity. More specifically, Gupta and colleagues found that the experiences cultivated personal desire to work abroad and reinforced the residents’ dedication to working with underserved patient populations in their practices.

Study Limitations

The three studies above share several limitations. There were no true nonparticipant “control” groups properly matched with the study group on other variables, and selection bias can be seen in the differences in baseline cultural awareness and sensitivity between the groups that participated in the training or elective and the groups of students and physicians used as “controls.” The study surveys were not previously validated, with the exception of a component of the survey used by Godkin and Savageau in 2001. Finally, the surveys were self-administered; none of the studies examined how well other physicians or patients thought participants applied cultural sensitivity to clinical encounters—physicians’ assessments of their own cultural competence cannot be assumed to be valid. For example, a recent study comparing physician-reported versus patient-reported “provider cultural competence” found no association between the two [6]. Future research on international experiences should address students’ and residents’ practical application of culture-related skills as assessed by other clinicians and patients.

Cultural sensitivity put into practice is considered a key to effective communication with and, by extension, compassionate care for diverse patient populations. It is therefore an important suite of traits to foster among medical students and residents. Indeed, the Liaison Committee on Medical Education (LCME) has included it in the accreditation standards:

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. … Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery [7].

Although international experiences provide excellent settings for acquiring cultural sensitivity, it is impractical as well as unreasonable to require such experiences of all medical students and residents. Medical schools therefore incorporate the topic into their general curricula in other ways, for example through lectures, discussions, activities with local multicultural communities or combinations thereof [8]. Teaching through domestic multicultural encounters is effective according to Godkin and Savageau, who credited the domestic components of the Global Multiculturalism Track with developing significantly higher levels of cultural knowledge among participants [2]. Moreover, a 2004 study by Reimann et al. found that a “diverse educational setting” was the single most influential background factor in their model of cultural competence, predicting both cultural awareness and knowledge which in turn predict “culturally competent actions” [9].

Extending Sensitivity to One’s Own Culture

An important element of translating cultural sensitivity into practical skills is personalizing the knowledge and awareness with individual patients. Physicians should avoid stereotyping patients by recognizing that ethnic, linguistic, educational, socioeconomic and cultural groups have intragroup variation [9]. Furthermore, physicians should not assume that interactions with patients who seem like them—who are on the far other end of the spectrum relative to underserved multicultural populations abroad—are free of communication problems that can negatively affect care. Although not often described as such, cultural competence is in many ways “interpersonal competence” [6]. The idea of striving to appreciate, learn about and effectively work within another person’s context should be applied to every patient interaction. Giving medical students and residents access to cultural competence through international experiences prepares them personally and professionally for the important task of successfully communicating with and caring for multicultural communities. Extending this concept to interpersonal competence would prepare them to successfully communicate with and care for all of their patients.

Question for Discussion

1. If, after an educational experience like one of those discussed in these three articles, you were asked whether the experience had improved your ability to understand and communicate with others, how accurate and dependable do you think your self-evaluation would be?
2. In general, to what extent do you think a person’s self assessments agree with others’ assessments of that person on a specific trait, competency or behavior?