S P E C I A L T H E M E R E S E A R C H R E P O R T

Cross-cultural Education in U.S. Medical Schools:

Development of an Assessment Tool
Eduardo Peña Dolhun, MD, Claudia Muñoz, MPH, and Kevin Grumbach, MD

ABSTRACT

Purpose. Medical education is responding to an
increasingly diverse population and to regulatory and
quality-of-care requirements by developing cross-cultural
curricula in health care. This undertaking has proved
problematic because there is no consensus on what ele-
ments of cross-cultural medicine should be taught. Fur-
ther, less is known about what is being taught. This study
hypothesized that a tool could be developed to assess
common themes, concepts, learning objectives, and
methods in cross-cultural education.
Method. In 2001, 31 U.S. medical schools were invited
to provide the researchers all written and/or Web-based
materials related to implementing cross-cultural compe-
tency in their curricula. A tool was developed to measure
teaching methods, skill sets, and eight content areas in
cross-cultural education.
Results. A total of 19 medical schools supplied their
curricular materials. There was considerable variation in
approaches to teaching and in the content of cross-
cultural education across the schools. Most emphasized
teaching general themes, such as the doctor–patient
relationship, socioeconomic status, and racism. Most also
focused on specific cultural information about the ethnic
communities they served. Few schools extensively
addressed health care access and language issues.
Conclusions. This assessment tool is an important step
toward developing a standard nomenclature for measur-
ing the success of cross-cultural education curricula. On
the national level, the tool can be used to compare pro-
gram components and encourage the exchange of ef-
fective teaching tools by promoting a common language,
which will be essential for developing and implementing
curricula, for comparing programs, and evaluating their
effects on quality of care.
Acad. Med. 2003;78:615–622.

Demographic changes and regulatory
and quality-of-care requirements are
creating a growing need for health care
professionals to learn and develop skills
Dr. Peña Dolhun is assistant professor, Department
of Family and Community Medicine, Ms. Muñoz is
research associate, Center for California Health
Workforce Studies, and Dr. Grumbach is director,
Center for California Health Workforce Studies, and
professor, Department of Family and Community
Medicine; all are at the University of California, San
Francisco.
Correspondence and requests for reprints should be
addressed to Dr. Peña Dolhun, 500 Parnassus
Ave, MU3-E, Box 0900, UCSF, Department of
Family Medicine, San Francisco, CA 94143-0900;
telephone: (415) 314-7641; e-mail: hpenae@fcm.
ucsf.edui.
to effectively care for the United States’
diverse population. Medical education is
responding to this need by developing
cross-cultural curricula in health care. A
growing body of literature has described
the challenges of implementing these
types of curricula at all levels of medical
education.1–8 The Liaison Committee
for Medical Education (LCME), the As-
sociation of American Medical Colleges
(AAMC), the Accreditation Council
on Graduate Medical Education
(ACGME), the American Medical As-
sociation (AMA), the Institute of Med-
icine (IOM), and several national
conferences8 have either focused en-
tirely or placed strong emphasis on
curricular development in cross-cultural
medicine.
Integrating cross-cultural education
into medical school curricula has
proved problematic, as there is no
consensus on what elements of cross-
cultural medicine should be taught.
Further, less is known about what is
being taught. Consequently, medical
educators do not benefit from an
agreed-upon typology that defines key
thematic areas, teaching methods, and
skill sets.1
Given the lack of standardized
approaches, we were interested in
measuring the degree of variation of
content, skills, and methods in cross-

ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003 615

cultural curricula taught in U.S. med-
ical schools. The goal of this project
was to develop a standard nomencla-
ture for describing and assessing cross-
cultural curricula in medical training.
We hypothesized that a tool could be
developed to assess common themes,
concepts, learning objectives, and
methods. By validating a tool to better
classify themes, content, and language,
we seek to further the development of
standards for cross-cultural education.
M ETHOD
Program Selection
In the summer of 2001, we selected for
study 31 U.S. medical schools that are
nationally recognized for their efforts to
integrate cross-cultural competence in-
to medical school curricula. Most of
the schools that we invited to partici-
pate in our study have received funding
from initiatives promoting the integra-
tion of cross-cultural competence in
medical education.
One such initiative is PRIME (Pro-
moting, Reinforcing and Improving
Medical Education), a four-year project
sponsored by the U.S. Public Health
Service, Bureau of Health Professions,
Division of Medicine. PRIME is de-
signed to encourage and support
primary care students by developing
specialized curricula that emphasize the
practical knowledge and skills neces-
sary to meet the unique needs of
underserved populations. Ten medical
schools were in the PRIME program at
the time of our study.
Undergraduate Medical Education
for the Twenty-first Century (UME-
21) is another national initiative that
was begun in 1998 to promote the
integration of innovative curricula in
U.S. medical schools. Eighteen medical
schools were chosen by the U.S.
Health Resources and Services Admin-
istration to participate in the project.
Of these medical schools, eight were
selected as UME-21 partners to imple-
616 ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
ment the full array of their proposed
curricular innovations and ten were
chosen as UME-21 Associate Partners
to implement a distinct curriculum in-
novation project.
We invited five other medical
schools, in addition to those sponsored
by the PRIME or UME-21 programs,
to participate, based on their national
reputations for academic excellence
and/or their innovative curricula.
Two of the schools we invited to
participate were each both a PRIME
and a UME-21 school. We counted
each of these schools once.
Data Sources and Extraction
We contacted all 31 schools by mail, e-
mail, and/or telephone. Contact indi-
viduals for each school were asked to
provide us with all written and/or Web-
based materials related to implement-
ing cross-cultural competency in their
curricula. The materials ranged from
syllabi to class outlines to recommen-
ded readings. In one case, an in-depth
interview with the course director
served for data collection.
We classified and scored the mate-
rials using a tool we developed.
Creating the Assessment Tool
We created a tool to measure the
degrees to which cross-cultural educa-
tion themes were included in medical
school curricula. The themes were
selected and defined a priori based on
standard areas of teaching. A literature
review of relevant articles was con-
ducted using the Medline key terms
‘‘cross cultural competency,’’ ‘‘cross
cultural education,’’ and ‘‘cross cultural
curricula.’’ A Web-based search of
published curricula was undertaken.
We also consulted expert opinions
regarding content and skill areas that
were contemporary and relevant.
The items extracted were then synthe-
sized to form distinct, relevant catego-
ries.
We defined eight content areas with
component items that are unique
subjects taught within a commonly
accepted rubric of cross-cultural edu-
cation curricula:
n General concepts of culture (culture,
individual culture, group culture)
n Racism (racism and stereotyping)
n Doctor–patient interactions (trust
and relationship)
n Language (meaning of words, non-
verbal communication, use of in-
terpreters, coping with language
barriers)
n Specific cultural content (epidemiol-
ogy, patient expectations and prefer-
ences, traditions and beliefs, family
role, spirituality and religion)
n Access issues (transportation, insur-
ance status, immigration/migration)
n Socioeconomic status (SES)
n Gender roles and sexuality
The Appendix contains a detailed de-
scription of each content area and
component items and criteria for
scoring each item.
In addition to these content areas,
we also categorized teaching methods
and skills. Skill sets are advanced
in concert with knowledge acquisi-
tion. Categories of teaching methods
included case study, didactic, partici-
patory, mentoring, small-group, large-
group, internships, site visits, and
projects. Skill categories included in-
trospection, history taking, negotiation,
and soliciting explanatory models (see
Appendix).
We used a four-point Likert-type
scale to score content areas: 1 ¼ not
addressed/not able to verify, 2 ¼ men-
tioned, 3 ¼ significantly addressed, and
4 ¼ extensive, in-depth treatment.
Teaching methods and teaching of
skills were rated as present or not pre-
sent. It is important to note that scoring
assessed only the degrees to which cur-
ricula included different content areas,
teaching methods, and skill teaching.
We made no attempt to evaluate the
Table 1 contact individuals with a request for
review and feedback. Opportunities to
Intraclass Reliabilities for Eight Content amend preliminary scores occurred
Areas of Cross-cultural Education, 19 U.S. over a one-month period. Score
Medical Schools, 2001 changes were justified either by provid-
ing written documentation or by a
Intraclass direct telephone interview. Three
Content Area Reliability* schools modified at least one of their
General concepts of culture .89 preliminary scores, with 12 items re-
Culture vised to higher scores and three to
Individual culture lower scores.
Group culture
Scores for every school were entered
Racism .88 into a standard statistical software
Racism program. To validate the content of
Stereotyping
each category, intraclass reliability was
Doctor–patient interactions .90 computed using Cronbach’s alpha sta-
Trust tistic. Based on the results, we made
Relationship several modifications. Table 1 shows
Language .83 the final categories and the Cronbach’s
Meaning of words alpha value for each category with
Nonverbal communication multiple component items.
Use of interpreters
A mean score was computed for the
Coping with language
barriers
six major content area categories made
up of more than one item: general
Specific cultural content .82 concepts of culture, racism, doctor–
Epidemiology
patient interactions, language, specific
Patient expectations and
preferences cultural content, and access issues.
Traditions and beliefs Descriptive analysis of content categ-
Role of family ories consisted of display of medians,
Spirituality/religion interquartile ranges, and highest and
Access issues .89 lowest scores.
Transportation
Insurance status R ESULTS
Immigration/Migration
Socioeconomic status NA Nineteen of the 31 schools we invited
(61%) participated in the study: Uni-
Gender roles/sexuality NA
versity of Iowa Roy J. and Lucille A.
*Measured as Cronbach’s alpha. Carver College of Medicine, University
of Kentucky College of Medicine,
quality of the material in the curricu- Wake Forest University Health Scien-
lum. The study was designed to sys- ces (School of Medicine), Kansas
tematically categorize and descriptively University Medical Center, Medical
analyze curricula, not to evaluate qua- University of South Carolina College
lity or effectiveness of curricula. of Medicine, University of Minnesota
Two of us (EPD and CM) indepen- School of Medicine–Twin Cities, Uni-
dently rated the collected materials versity of New Mexico School of
from each of the schools. Scores were Medicine, Dartmouth Medical School,
then compared. Agreement was greater University of California San Francisco
than 90%, on average. EPD and CM School of Medicine, University of
reviewed disputed scores jointly. Any Miami School of Medicine, University
unresolved scores were given the lower of Nebraska College of Medicine,
rating. Preliminary scores were sent to University of Pennsylvania School of
ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
Medicine, University of Pittsburgh
School of Medicine, Cornell University
Joan and Sanford I. Weill Medical
College and Graduate School of Med-
ical Sciences, Harvard Medical School,
University of California Los Angeles
David Geffen School of Medicine,
Stanford University School of Medi-
cine, University of Washington School
of Medicine, and Wayne State Univer-
sity School of Medicine. Five medical
schools were private and 14 were
publicly funded. Six U.S. geographic
areas were represented: West, North-
west, Northeast, Southeast, Southwest,
and Midwest.
The responding schools formally in-
tegrated cultural competence into their
curricula to varying degrees. Six schools
(32%) had developed separate courses
that addressed cultural competence.
Two of these courses were electives
dedicated exclusively to cross-cultural
issues in medicine. The remaining 13
schools integrated cultural competence
throughout their medical training cur-
ricula in courses and lectures where the
topic would be relevant. The extents to
which cultural competence was inte-
grated in this manner varied greatly
from school to school.
Some schools indicated that they
encouraged faculty to address cross-
cultural issues informally. However, it
was impossible to measure the extent
of this informal integration. When
asked to indicate whether cultural-
competence training was mandatory,
16 (84%) schools stated that all
students did receive mandatory in-
struction.
Figure 1 is a box plot illustrating the
central tendency of scores for each
content category. Each box extends
from the twenty-fifth percentile to the
seventy-fifth percentile, with the dark
black line depicting the median score
(the fiftieth percentile). The thin black
horizontal lines show the lowest and
highest scores. In some categories, the
top quartile cut point was the maxi-
mum score.
617
 taught negotiation as a specific skill,
and a third of the schools offered soli-
citing explanatory models as a tool to
be used in cross-cultural encounters.
All but one school (95%) offered man-
datory courses beginning in the first
year, though there was wide variation
thereafter. Five schools (26%) offered
cross-cultural education in year one
only, and nearly a third offered it in
both the first and the second years.
Four schools (21%) offered some form
of cross-cultural education throughout
all four years. One school offered it in
years one through three. Only two
Figure 1. Central tendency scores of 19 U.S. medical schools in eight content areas of cross-cultural schools offered cross-cultural education
education, 2001. A four-point Likert scale was used to score content areas: 1 ¼ category not addressed/ as an elective.
not able to verify, 2 ¼ category mentioned, 3 ¼ category significantly addressed, and 4 ¼ category
received extensive, in-depth treatment . Each box in the figure extends from the twenty-fifth percentile to
the seventy-fifth percentile, with the dark black horizontal lines depicting the median score (fiftieth D ISCUSSION
percentile). The thin black horizontal lines show the lowest and highest scores. In some categories, the
top quartile cut point was the maximum score. The quest for a standard pedagogy by
which to teach cross-cultural issues in
U.S. medical schools continues. Much
As Figure 1 demonstrates, there was access-to-care issues in their cross- of the difficulty in this quest lies in
considerable variation across schools in cultural curricula. a critical paradox: Excellent work has
the degrees to which different content In addition to the substantial varia- been done over the years to create
areas were included in their curricula. tion across schools in the coverages of model programs and curricula, but
Half of the schools had scores of 3 or different content areas, there was also models often are not shared and there
greater (denoting significant or exten- considerable variation within schools are no uniform criteria or standards by
sive treatment of the subject) for six of in the degrees to which they included which to evaluate the content and
the eight categories: conceptual cultural different content areas. That is, most quality of one program relative to
themes, racism, doctor–patient interac- schools did not receive uniformly high another.
tions, specific cultural content, SES, or low scores in all content categories, Our tool furthers the goal of de-
and gender roles/sexuality. However, but tended to emphasize certain areas veloping standard criteria. The items in
many of the schools had scores falling in more than others. the tool are generalizable enough to be
the lower range for these categories, The methods used by the schools applied to all U.S. medical schools.
with a fourth of the schools having we studied were very consistent. All We found considerable variation in
scores of 2 or lower (denoting limited or schools offered a didactic component approaches to teaching cross-cultural
no coverage) for the content areas of and encouraged active student partic- medicine across medical schools that
racism, doctor–patient interactions, ipation through case studies and small- are leaders in curricular development
and gender roles/sexuality. Four schools and large-group discussion groups. Ten in this area, although common peda-
made no specific mention of teaching schools (53%) required student pro- gogic techniques such as small-group
about doctor–patient interactions as jects. Nearly half (42%) had a men- discussion and case studies were widely
part of their cross-cultural curriculum. toring system explicitly created to used. Most schools emphasized teach-
Scores tended to be lowest in the encourage cross-cultural awareness. A ing general themes in culture, the
content categories of language and fourth implemented site visits and doctor–patient relationship, SES, and
access. Fifty percent of the schools internships specifically designed to ad- racism. The schools, for the most part,
scored between 1.5 and 2.5 in the dress cross-cultural medicine themes. also focused on specific cultural in-
language category, with only two All schools incorporated the skill of formation pertaining to the ethnic
schools showing significant or exten- history taking into their curricula, with communities they served. There was
sive treatment of the subject. A fourth a majority (74%) encouraging time for wide variation in scores across all
of the schools did not specifically cover introspection. Half of the schools items, indicating that some schools

618 ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003

focused extensively on certain areas,
whereas others neglected them.
Few schools extensively addressed
two general content categories: lan-
guage and access issues. Recent atten-
tion has been paid to the importance of
language differences as independently
predicting health care satisfaction.9 In
light of the importance of language dif-
ferences, it was surprising that schools
were not demonstrating more attention
to this area. Notable was the relative
lack of focus on using an interpreter.
This inattention to language issues may
be explained by the lack of local ex-
pertise and relevance to the school
(some schools did not have populations
with low English proficiency). Lan-
guage issues may be addressed outside
the context of cross-cultural education,
assuming that students will learn the
language skills elsewhere.
Because access issues play an impor-
tant role in acquiring health care,
especially for those with limited English
proficiency and low SES, it was also
surprising to find only a modest treat-
ment of this subject in most schools.
Access to health care, as well, may be
addressed outside the context of cross-
cultural education.
Limitations
Our study had certain limitations. The
schools selected were not a random
sample. We purposefully selected
schools that were likely to be leaders in
establishing cross-cultural education
curricula and were, therefore, not re-
presentative of all medical schools. This
limits the generalizability of our results
to the greater medical school popula-
tion. The small size of the sample makes
statistical comparisons between sub-
groups of schools unreliable. Thus, we
could not compare scores for schools
with separate cultural competence
courses versus schools that integrated
the topic into the overall curriculum.
We and the school contacts were
potentially biased. Bias was reduced by
ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
cross-referencing our scores and by
requiring schools to provide written
materials or substantial justification of
any score modification. Finally, subject
matter that was not clearly stated,
documented, or published could not
be scored, making it more difficult to
rate schools with curricula that diffused
cross-cultural education throughout
many courses rather than in concen-
trated, easily identifiable and assessable
courses.
Some content areas may also have
been taught outside the rubric of cross-
cultural medicine and therefore were
not reported by schools as part of their
cross-cultural curricula. For example, it
was difficult to assess the treatment of
spirituality/religion and gender roles/
sexuality within the context of culture.
Most of the programs that dealt with
spirituality and/or sexuality did so
separately from cultural competence.
Only in a small number of cases were
these topics discussed specifically with-
in the context of culture. Finally, as
noted above, our study was not de-
signed to evaluate the quality of cur-
ricula. The scores should not be
interpreted as directly measuring the
quality of the curricula, although
failure to include important content
areas may obviously have quality im-
plications.
C ONCLUSION
U.S. medical schools are developing
cross-cultural curricula to meet the
challenge of educating tomorrow’s phy-
sicians for a increasingly diverse patient
population. Our assessment tool can be
used as a guide in the development of
cross-cultural curricula in health care.
Individual institutions will be able to
tailor how each concept and skill is
illustrated and taught. Institutions un-
dergoing curricular changes may be
able to use this tool as a framework
for understanding the range of content
areas that may be covered in their
curricula. Mature programs can use the
tool as part of ongoing development
and evaluation.
On a national level, our tool can be
used to compare program components
and encourage the exchange of effec-
tive teaching tools by promoting a uni-
versal language. It is an important step
toward developing a standard nomen-
clature that will further efforts to
measure the success of cross-cultural
education curricula. Leaders in the
field of cross-cultural curricula empha-
size broad-based, integrative curricula
that encompass the range of content
areas addressed in our study. In pre-
paring medical students for careers in
an ever-changing United States, the
challenge for each school will be to
balance local realities—demographics,
resources, expertise, and traditions—
with the broader, and often disparate,
needs of the nation.
The ability to set national standards
hinges on developing a common lan-
guage with which to develop and
implement curricula, compare pro-
grams, quality of care, and their effects
on health outcomes. Further research
will be needed to move from descrip-
tive studies toward rigorous evaluation
of the effects of cross-cultural educa-
tion on clinician behavior and patient
care outcomes.
The authors thank Robert Like, MD, MS, and
Joseph Betancourt, MD, MPH, for reviewing
a draft of this manuscript, and Christopher
Hartung for graphics support. This work was
supported by The California Endowment (Grant
no. 200022145) and the Bureau of Health
Professions, U.S. Health Resources and Services
Administration (contract no. 230-00-0109).
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Description of Content Areas and Their Component Items and of Criteria Used to Assess
Cross-cultural Education in U.S. Medical Schools
Content Areas and Component Items
General Concepts of Culture
Culture. Culture is a common set of
shared values, beliefs, and customs. Signif-
icant treatment of culture would pro-
vide a forum to explore ideas of culture in
depth, such as addressing ethnocentrism
and cultural relativism. Extensive treat-
ment would include discussion of culture as
an evolving process and distinguish it from
other related concepts such as ethnicity and
nationality.
Individual culture. Each person has
a culture. Significant treatment of individ-
ual culture would include a discussion of
how an individual’s culture is dynamic and
may evolve over time. Extensive treatment
would further explore the participants’ own
cultural backgrounds, allowing for reflec-
tion, discussion, and sharing of experiences
and ideas.
Group culture. This item is a more
specific culture, such as the acquired
culture of medicine. Significant discussion
of group culture would acknowledge that
culture may be something an individual is
born into or adopts later in life. Extensive
discussion might include examining how an
individual’s own culture affects how he or
she experiences and interprets the world.
Every interaction between two individuals
is a cultural exchange that flows bi-direc-
tionally and is, as such, a dialectic and
mainly an unconscious process.
Racism
Racism. Light treatment of racism might
include brief mention of the role of race
620 ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
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APPENDIX
and/or racism in society. Significant discus-
sion would examine race and racism in
greater depth, such as having a small-group
discussion of racism or having the partic-
ipants write about their own experiences
and feelings. Extensive treatment would
include the aforementioned plus requiring
a project, reading, or having an expert or
panel to discuss racism.
Stereotyping/racial profiling. Brief dis-
cussion of the topic would mention stereo-
typing and that many groups in the U.S.
commonly experience racial profiling. Sig-
nificant discussion might emphasize that
the patient is not a mere reflection of some
‘‘other’’ culture. Extensive treatment might
include discussions about how with any
given individual, personal qualities and
experiences may play a much more mean-
ingful role in how he or she interacts with
the health care system and caregivers. A
program may also address using a patient’s
perceived race to modify differential di-
agnoses and/or tailor therapeutic interven-
tions. Other extensive treatments might
include examining national legal cases of
racial profiling, discussing the role of race in
clinical presentation, addressing ethnophar-
macology, encouraging a reflective project
on the learner’s own stereotypes, and/or
talking about how stereotypes differ from
generalizations.
Doctor–Patient Interactions
Trust. Significant treatment of the doc-
tor–patient relationship would explore the
idea of trust and would mention and/or
8. Symposium sponsored by the California En-
dowment on Setting Standards in Cul-
tural Competence Training for Healthcare
Professionals, Glendale, CA, April 12–13,
2002.
9. Carrasquillo O, Orav J, Brennan T, Burstin
HR. Impact of language barriers on patient
satisfaction in an emergency department.
J Gen Intern Med. 1999;14:82–7.
define trust as a key element in establishing
and maintaining a good rapport with pa-
tients. Extensive treatment would specifi-
cally focus on trust, either through in-depth
discussion or some other meaningful
method.
Relationship. The doctor–patient rela-
tionship is a unique relationship in society.
This item explores this unique relationship
in-depth. Significant and extensive discus-
sion would focus on the historical, socio-
logical, psychological, and anthropological
aspects of this relationship.
Language
The meaning of words. This item
provides a forum for discussing language
and its importance in transferring informa-
tion. In-depth discussion might address the
idea that words have unique historical
contexts and, thus, the same word may
convey similar or disparate meanings for two
individuals.
Nonverbal communication. This item
specifically highlights the importance of
paying attention to nonverbal communica-
tion (gesture, body position, eye contact,
etc.) and how this nonverbal communica-
tion may vary from culture to culture.
Attention may be paid to touch, for
example, examining its meaning, impor-
tance, and use, and how these may vary
from culture to culture. Significant discus-
sion would be in-depth. Extensive treat-
ment would include role-playing or
discussion around a video vignette, for
example.
 Use of interpreters. This item addresses
the role of interpreters. Significant discus-
sion might include using professional versus
nonprofessional interpreters. Extensive dis-
cussion might address the skills involved in
effectively using an interpreter, such as
positioning and directing the conversa-
tion to the patient, not to the interpreter.
(Note: The use of interpreters may be
considered a skill set topic. We placed it
under the category of language because of
its a priori relevance within the category
and its relationship with the category’s
component items.
Coping with barriers. This item specif-
ically addresses the difficulties of cross-
cultural or cross-linguistic exchange and
provides a forum to discuss the unique
difficulties that health care providers face in
serving a patient or populations linguisti-
cally distinct from their own. Significant
treatment would provide the learner with
strategies and techniques on how to
approach a patient who speaks a language
foreign to that of the providers. More in-
depth exploration would provide an arena
in which to explore the psychological or
experiential consequences of a ‘‘difficult’’
cultural/linguistic exchange.
Specific Cultural Content
Epidemiology. This item highlights
background information on the health
status of populations of interest, disparities
in health, and specific diseases or illnesses
associated with unique groups of individuals
and disease prevalence. Epidemiology may
also include treatment subjects ranging
from genetics to metabolism. Significant
and extensive treatments of the subject
might include projects, site visits, and/or
interviews of clinicians, public health ex-
perts, patient advocates, or patients.
Patient expectations and preferences.
This item addresses the role of patient
expectations and preferences and how they
influence the patient–doctor relationship
and clinical outcomes. Significant or ex-
tensive treatment would include in-depth
discussion and/or role-playing, for example.
Traditions, customs, values, and health
beliefs. This specific section illustrates
useful information about one or more
specific cultures. Significant and extensive
treatment might provide learners with
a multimedia demonstration of customs,
ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
hands-on experiences, and a special guest
lecture. This section would also include the
idea that groups of individuals, because of
their particular histories and or geographic
locations, have developed unique, shared
ideas on how an individual relates to the
body, disease, or a caregiver, for example.
This section moves from general discussions
on culture to specific and concrete exam-
ples of cultural groups, such as Russian
immigrants or Chinese Americans. Com-
plementary and alternative medicine (CAM)
also comes under this item because CAM
is a product of an individual or common
health belief system, as is, importantly, the
predominant or allopathic form of health
care in the United States.
Role of the family. This item addresses
the role of the family in patient care.
Significant exploration of the subject would
seek to demonstrate or illustrate how
distinct cultures have unique ways of
relating to the health care giver, employing
group decision-making or nondisclosure of
life-threatening illness to an elderly parent,
for example. This item may include a dis-
cussion on paternalism, autonomy, and
other styles of medical care. Extensive
treatment would include role-playing or an
interview of a family or an individual in
a family, for example.
Spirituality/religion. This item high-
lights the role of spirituality and/or religion
in health, illness, and the treatment of
diseases. Categories of spirituality and re-
ligion may range from general cultural
beliefs to particular acts of spirituality, such
as rituals involved in death and dying.
Significant treatment of the subject would
provide a case study that includes spiri-
tuality or a video vignette, for example.
Extensive treatment might include a role-
play, panel discussion, or a patient in-
terview, for example. (Note: Although
there is an important conceptual distinction
between what is generally referred to as
‘‘spirituality in medicine’’ and religious cul-
ture per se, there is enough practical overlap
to allow for a combined category.)
Access Issues
Transportation. In general, this item
provides a forum to increase awareness that
transportation plays a significant role in
access to health care. Although socioeco-
nomic status (SES) plays a major role in
access to transportation, significant lan-
guage barriers may not be obvious to health
care providers. This item may provide
information on how patient populations
travel to the clinic, such as by using public
versus private transportation and how
culture and language may affect access to
the different modes of transportation. The
transportation item highlights how SES and
language differences may limit an individ-
ual’s ability to simply ‘‘find’’ proper and
efficient modes of transportation. Signifi-
cant treatment would explicitly mention
specific transportation issues relevant to
particular patient populations’ access to
health care services. Extensive treatment
would provide a breakdown of the various
modes of transportation used by the
patients to go to the school’s clinics and
hospitals. Another form of extensive treat-
ment may be providing an in-depth case
study of a patient whose health care access
was compromised by inability to access
proper transportation.
Insurance status. This item highlights
the health insurance status of major sub-
groups and may include a section on how
a particular language or cultural custom
affects attitudes about insurance. As with
transportation, major factors in this item
are SES, level of education, and language
barriers. The same criteria for significant
and extensive treatment apply here as in
the item above. A major factor is immigra-
tion/migration status and the level of
cultural/societal assimilation of a particular
ethnic group.
Immigration or migration. Immigration
status, in and of itself, is a significant barrier
to obtaining proper medical care because an
individual needs to navigate a completely
new and foreign environment. Significant
treatment of this category might include
large-group discussion or a didactic presenta-
tion that illustrates the role of immigration
or migration in an individual’s health.
Any of the above items that provide case
samples, experts, historical vignettes, re-
quired readings, role-playing, and/or direct
patient interviews, for example, would
demonstrate extensive treatment of the
subjects.
Socioeconomic Status (SES)
Socioeconomic status is an important
health-determining variable and has an
621
important function in individual and group
behavior. Significant treatment might in-
clude discussing SES as an important factor
that behaves independently in determining
health status. Mention of the association or
nonassociation with race/ethnicity and how
SES is often a confounding variable in
medical research would qualify an extensive
discussion of the issue.
Gender Roles and Sexuality
This category may be quite broad. The role
of gender or sexuality may be addressed
through patient or family decision-making
themes. Gender or sexuality may be the
focus of discussions on explanatory models,
compliance, etc. The role of gender might
include discussions on transgender care,
adolescent health, and homosexuality, for
example. Significant treatment of the sub-
ject may provide a case study, special
readings, or group discussion, for example.
Extensive treatment of the subject may
include role-playing, patient interview, or
a project.
Teaching Methods
Case study
Case studies are used for teaching.
Didactic
Lectures are a component to teaching.
Participatory
Active or interactive audience participa-
tion in which the audience members are
required to openly discuss topic materials.
This method may include discussing themes
in small groups and role-playing. The
participatory nature must be explicitly
mentioned in the course description or
syllabus.
622 ACADEMIC MEDICINE, VOL. 78, NO. 6 / JUNE 2003
Mentoring
Mentors with experience in cross-cul-
tural medicine are assigned to students to
aid in the learning process.
Small-group Instruction
Discussions and activities take place in
groups generally of ten or fewer individuals.
Large-group Instruction
Discussions and activities take place in
large groups of 25 or more individuals,
generally the entire class or a large portion
of the class.
Internships or Clerkships
This method uses guided practical expe-
rience to teach cross-cultural medicine.
Site Visits
Visiting and observing health care set-
tings with diverse patient populations en-
hance cross-cultural education.
Projects
Individual or group projects are assigned
that should illustrate concepts of cross-
cultural medicine. Projects may include
self-directed learning, experiential exercises
(e.g., games/simulations), presentations,
problem-based learning, simulated patients,
objective structured clinical examinations
(OSCEs), service learning, and studying
websites.
Cross-cultural Skills
Introspection. This skill trains students
in self-assessment: how their own back-
grounds affect attitudes and decision-mak-
ing. Students learn to look at a series of
interactions in a systematic way. Brief
treatment might include a general large-
group discussion, whereas significant and
extensive treatment would provide a forum
for introspection in small-group discussions,
or writing projects, for example.
History taking. This skill addresses the
art of taking a patient history with a cross-
cultural emphasis. Significant and extensive
treatment would provide an in-depth review
of history taking that might include student
observation by teachers or a role-play that
illustrates several techniques useful in tak-
ing a history of a patient who is from
a different culture, especially those foreign-
born and who speak different languages.
Negotiation. This skill highlights the
value of negotiation and teaches negotia-
tion skills. Discussions would emphasize the
importance of seeing and understanding the
differing points of views between the health
care provider and the patient and how to
achieve an appropriate plan or therapy for
the patient. This might include understand-
ing and working in partnership with a
patient’s family or a CAM provider.
Soliciting explanatory models. This skill
provides one or more explanatory models,
such as the ETHNIC or LEARN model.
Significant and extensive treatment would
include an in-depth discussion of the value of
using a model, the key element being the
solicitation of the patient’s health care values
and ways of understanding his or her illness.
Role-playing and implementing a model
would constitute extensive treatment.
(Note: The elements in this Appendix
may be particularly difficult to document as
they are often incorporated into the
curriculum in the form of clerkships and
therefore are modeled by the staff. Pro-
grams that explicitly promote cultural
competency, sensitivity, or humility, would
qualify as providing extensive treatment of
the above categories.)