1 Review article

2 A brief review on cultural competency in medical education

3 Abstract

4 Cultural competency is a wide notion with a variety of academic bases and differing

5 perspectives on how it should be implemented. While it is widely acknowledged that cultural

6 competency should be an element of general practise, there is a paucity of literature in this

7 area. It has been commonly claimed that cultural competency is a fundamental prerequisite

8 for working well with persons from different cultural backgrounds. Medical students must

9 learn how to connect successfully with patients from all walks of life, regardless of culture,

10 gender, or financial background. Hence, National Medical Council (NMC) has included

11 cultural competence as a course subject in the curriculum of medical education. The

12 opportunities and concept of Competency Based Medical Education, the inclusion of cultural

13 competency in medical course by NMC, various models and practice skill of cultural

14 competence in medical education are discussed in this paper. This study will be useful to

15 researchers who are looking at cultural competency as a research variable that influences

16 study result.

17 Keywords: Competency Based Medical Education, Culture awareness, Cultural competence,

18 Healthcare quality, Medical education, National Medical Council.

19

20

21

22

23

24
25

26 Introduction of cultural competence, differences its concepts and characteristics

27 Cultural competence refers to a combination of knowledge, behaviours, policies, and attitudes

28 that operate together in a system, organisation, or among specialists to allow successful cross-

29 cultural work. "Culture" describes to integrated patterns of human behaviour that encompass

30 ethnic, social, racial, and religious groups' language, ideas, acts, conventions, beliefs, and

31 organizations. "Competence" means to an individual's or an organization's ability to operate

32 successfully in the context of patients' and their communities' customs, cultural beliefs, and

33 demands [1].Some of the research examined cultural variations as disparities in health

34 understandings across various population groups, such as Indigenous people's holistic health

35 understandings and how they vary from mainstream approaches to health [2]. Other research

36 looked at communication challenges such as cultural differences and linguistic discordance,

37 and how these effect clinical interactions, especially among Hispanic populations in the US

38 [3].

39 Culture competency concept

40 Cultural competency is a wide notion with many different perspectives on what it is and how

41 it should be manifested [4]. It's usually characterised as "a collection of consistent

42 behaviours, attitudes, and rules that allow a system, agency, or person to successfully

43 function within a cross cultural environment or circumstance" [5]. The scope, duration,

44 content, and manner of delivery of cultural competence curricular frameworks and models

45 differ significantly [6]. Furthermore, a broad range of methods for assessing cultural

46 competence have been created, each with its individual theories about what constitutes

47 cultural competence [7].

48 Bean R [8],Gopalkrishnan N.[9], Graf A.[10] explained component of behavioural, or the

49 skills essential to collaborate across cultures, may vary from individual skills, which is verbal
50 and nonverbal, and skills in dealing with interpreters, to wider community development

51 skills, or even policy creation skills. They explained the emotive component, which includes

52 attitudes like respect, sensitivity, and openness to diversity, helps in the growth of the healthy

53 cross-cultural relationships. They also elaborated the cognitive element which means

54 previous awareness of cultural differences aids in the development of better connections and

55 the avoidance of cross-cultural misunderstanding.

56

57 Competency based medical education (CBME)

58 CBME is the inclusion of cultural competency in medical course by NMC. CBME, which is

59 an outcomes-based approach to the implementation, design, evaluation, and assessment of

60 doctors and physician training programmes, has sparked a lot of controversy and discussion

61 [11]. The opportunities and constraints of CBME are discussed in thought papers, conceptual

62 frameworks, implementation documents, consensus statements, and institution-specific

63 descriptions [12]. With the growing implementation of CBME, medical education is

64 experiencing a transition. It is education is dependent on the outcomes method for creating,

65 executing, measuring, and evaluating medical education programmes that uses competences

66 as an organisational framework. Program delivery is directed by competences that are clearly

67 described, sequenced progressively, and gained in workplace-based learning contexts, which

68 are the practical day-to-day differences for both clinical instructors and learners [13].

69

70 Inclusion of cultural competency in medical education by CBME

71 Over the last 20 years, a recent educational paradigm known as competency-based medical

72 education has arisen, and many healthcare training programmes throughout the globe have

73 embraced it. CBME's mission is to create "a health professional who can practise medicine at

74 a set degree of skill, in accordance with local circumstances, and to address local
75 requirements". Van Melle et al. [14] utilised a 2-step strategy to determine the important and

76 necessary parts of CBME. To ensure CBME authenticity, they recognised 5 critical

77 components that must be involved in the implementation process. The degree of exactness

78 with which anything is replicated or reproduced is characterised as fidelity, and it is regarded

79 essential for the success of competency based medical education implementation.

80 Health professionals that are skilled in taking care of patients and demographic groups that

81 vary in age, gender, socioeconomic level, migratory status, and ethnicity are required in a

82 health system that serves diverse communities. Cultural competence (CC) amongst healthcare

83 professionals is seen as one technique for ensuring equitable access to healthcare for people

84 of all races and ethnicities, as well as ensuring that patients get treatment tailored to their

85 specific requirements.NMC established a one-month foundation course for MBBS students in

86 2019. The goal of this course was to assist organizations and teachers in preparing new

87 medical students with the necessary knowledge and abilities for human exposure interactions

88 and interpersonal connections in a variety of contexts, such as hospitals, communities, and

89 clinics.

90

91 How is cultural competency established?

92 In General Practice, there are many different strategies to acquire cultural competency, and

93 rigorous assessment [15]. In general practise, formal cultural competency training tends to be

94 undeveloped and uneven, and most parts of cultural competence are acquired via, experiential

95 and informal learning, and in-practice exposure [16-18]. Cross-cultural consultations were

96 shown to be extra stressful for general practice registrars owing to their reported lack of

97 knowledge, confidence, and abilities in this field [19]. Cultural diversity has been found to

98 help in the development of cultural competence via experience and training over time, which

99 is particularly important in general practice training [20, 21]. Exposure to diversity may
100 motivate for learning and operate as a trigger and developing cultural competency of the

101 practise as well as the system or individual may be a synergistic process. Through modelling

102 cultural knowledge, incompetent attitudes, and abilities of further clinical supervisors or staff,

103 there is also the potential of perpetuating existing obstacles in the treatment of patient [22].

104 Stronger role models and exposure to a more diversified case of cross-cultural mix during

105 training appear to enhance general practice registrars' readiness and ability to give cross-

106 cultural care [23].

107 Medical colleges attempt to educate doctors who can treat patients from a variety of

108 socioeconomic and cultural backgrounds. Medical students must learn how to connect

109 successfully with patients from all ages of life, regardless of gender, culture, or financial

110 background. Communication skills are related with clinical competency and the skill to elicit,

111 analyse, and interact appropriate clinical details to patients in relation to being essential to

112 physician-patient interactions in terms of patient satisfaction and involvement during the

113 physician encounter [24]. During medical school, physicians' subjective judgments of

114 medical students' clinical knowledge, interpersonal and communication skills and patient

115 engagement are used to evaluate their clinical performance [25]. Assessment of knowledge,

116 attitudes, and skills is challenging due to the complexity of conceptualising cultural

117 competency. Cultural competency instruments and tests often contain reflect biases or

118 assumptions. Cultural competence assessment among general practice registrars, on the other

119 hand, might motivate them to learn and reflect a supportive training environment. The

120 majority of educational intervention assessment research were process-oriented, even though

121 complex behaviour evaluations must be multi-faceted [26]. Multiple confounders, like as

122 other environmental and social determinants of health access, and other systemic obstacles

123 outside the individual control clinician contacts, are often present and must be taken into
124 consideration, making assessment even more challenging. This information has been included

125 into a suggested strategy for evaluating educational interventions on patient outcomes.

126

127

128 Importance of cultural competence in medical education

129 We are surrounded by people of different ethnic or racial origins, migrants, immigrants, and

130 refugees. Cultural competency is critical since it is hard to form such connections without it.

131 We'll instead co-exist with individuals we don't understand, improving the likelihood of

132 damaged emotions, misunderstandings, and bias—all of which can be avoided. Beyond the

133 obvious instructional messages, the most essential socialisation mechanisms in medical

134 education exist. The official curriculum, the informal curriculum, and the Hidden Curriculum

135 are three possible sources of influence in medical school, according to Hafferty [27]. The

136 Hidden Curriculum's norms are largely communicated via structural and cultural variables

137 such as institutional regulations, "slang" or colloquialisms, assessment systems, and resource

138 allocation. The Hidden Curriculum's messaging may contribute to a loss of idealism and a

139 loss of ideals, which can lead to a lack of concern about unconscious prejudice [28]. The

140 structural norms of an organisation may be significant guides for conduct, but they are

141 typically unarticulated until they are challenged.Efforts to teach doctors to deliver high-

142 quality, culturally aware treatment have steadily increased in medical education. Many

143 countries are growing more diverse, cultural competency training has pushed to the forefront

144 of medical education. Ethnic minorities today make up roughly demographic trends and 30%

145 of the population, indicate that by 2050, they will be the majority [29]. Furthermore, there is a

146 clearer understanding of the role of culture on health care and health inequalities [30].

147 Cultural norms influence health-seeking behaviour [31]. Some patients may put off seeking

148 treatment because of a sense of cultural insensitivity, apprehension that they will get worse
149 care, or the belief that they have been handled unjustly because of their ethnic or race origin

150 [32]. Furthermore, inequities in health care have long been noted, with racial discrepancies in

151 treatment remaining even after accounting for income level, health condition, and insurance

152 status [33, 34]. The most popular paradigm in medical education for addressing culture and

153 race as social determinants of health is cultural competence. By training medical students and

154 professionals to better understand their patients' culture and ethnicity, cultural competence

155 attempts to enhance patient–provider communication. To assist alleviate the stigma of a

156 mental health diagnosis for a patient in an Asian immigrant household, students may be

157 trained to utilise sensitive terminology or work with cultural liaisons [35-37].

158 Bourgois et al [38] have released a systematic evaluation tool to help health care

159 practitioners, address socioeconomic factors of health in their clinical practises. A practical

160 guide for medical educators based on this paradigm might help with attempts to enhance race

161 and culture education in medical school curriculum, as well as culture and race representation

162 in national examinations, question banks, board preparation courses, and virtual-case-based

163 learning modules."A collection of congruent behaviours, attitudes, and policies that come

164 together in a system, agency, or among professionals that allow that system, agency, or

165 professions to perform successfully in cross-cultural contexts," according to Cross et al [39].

166 This term encompasses a variety of intervention strategies aimed at improving healthcare

167 systems' cultural competency.When it comes to getting health care, health professionals have

168 a critical role in influencing the patient experiences and type of interactions.

169 Miscommunication [40], as well as service user distrust [41], disempowerment and poor

170 satisfaction may emerge from cultural and language disparities between health service

171 consumers and healthcare practitioners [42]. The majority of workforce interventions cultural

172 competence have centred on training and educating health care professionals in the essential
173 and significant educating attitudes, skills & knowledge to appropriately react to socio-cultural

174 barriers that emerge in clinical encounters [43].

175

176

177

178 WHO facilitation in the cultural competency development

179 Interventional majority of trials evaluated workshops of standalone delivered by certified

180 medical educators [44]. Educators believed that training and experience in cultural

181 competency teaching was essential due to the subject's complexity. Cultural competence

182 training is regarded to have the potential to perpetuate existing myths, prejudices, and

183 stereotypes in society [45], especially if it is completed without the supervision of the cultural

184 group and direct involvement in question. Patients, educators, and students recognise the

185 benefit of cultural mentors in several research [46]. Cultural mentors are recognised as

186 community advocates who may share their knowledge while encouraging connections

187 between communities and health care professionals. Community ownership of cultural

188 knowledge is also respected by other community members and ensuring cultural mentors play

189 a prominent role in training. Pessimistic attitudes of learners, competing community and

190 family responsibilities, and an expertise in training and lack of confidence are all barriers to

191 community people participating in GP registrar training. However, there is a need among

192 culturally diverse groups to train with general practice registrars, which should be encouraged

193 [46].

194 The researchers went on to say that cultural competence refers to "the integrated pattern of

195 human behaviour that includes thoughts, communications, actions, customs, beliefs, values,

196 and institutions of a racial, ethnic, religious, or social group," as well as "having the capacity

197 to function effectively" among people with "the integrated pattern of human behaviour that
198 includes thoughts, communications, actions, customs, beliefs, values, and institutions of a

199 racial, ethnic, religious, or social group."Leininger (1991) defined the term as "the application

200 of culturally based care knowledge in facilitative, assistive, creative, sensitive, safe, and

201 meaningful ways to individuals or groups for beneficial and satisfying health and well-being

202 or in the face of death, disabilities, or difficult human life conditions" [47, 48].

203

204 Self-awareness and health professionals

205 Health practitioners are influenced by culture in an unconscious way. Self-awareness and

206 comprehension foster strong professional perspectives, allowing health-care workers to

207 connect with others while maintaining personal integrity and respecting the individuality and

208 diversity of each client. Self-awareness, also known as self-exploration, is the first step in the

209 process of professional growth and diversity competency. Self-examination or knowledge of

210 personal biases and prejudices, according to many theorists and diversity trainers, is a key

211 stage in the cognitive process of gaining cultural competence [49-51]. However, considering

212 the possible effect of emotions and conscious sensations on behavioural outcomes,

213 considerations of emotional responses evoked by this cognitive awareness are rather

214 restricted.

215

216 Cultural competence models

217  Sunrise model for cultural competence

218 The growth of cultural competency models in nursing has been attributed to a number of

219 methods, as stated below:

220 Theoretical frameworks from nursing and a few other disciplines, mostly sociology and

221 anthropology, were used by early researchers. Orque (1983) [52] designed the
222 Cultural/Ethnic System Framework based on sociological concept, while Leininger

223 developed the care component based on nursing theory and the culture component based on

224 anthropological theory.

225 According to Leininger (2002a) [53], the Sunrise Model with the cultural care theory was

226 created using anthropological insights, as well as her wide and varied life experiences,

227 nursing experiences, creative thinking, and values.The Sunrise Model was created to portray

228 the concept of cultural care universality and diversity, according to Leininger (2002c) [54]:

229 The Model displays several variables or components that need to be thoroughly examined

230 using the theory. It offers as a cognitive guide for deciphering cultural care phenomena from

231 a holistic viewpoint of numerous aspects that may impact care and people's well-being."The

232 Sunrise Model has served as the template for the creation of various culture-specific models

233 and tools," Giger and Davidhizar (1998) [55] wrote. Indeed, both Giger and Davidhizar

234 (2002) [56] and Campinha-Bacote (2002b) [57] credited Leininger's transcultural nursing

235 theory and foundational work with helping them construct their models.Furthermore, Schim

236 and Doorenbos (2010) [58], Jeffreys (2010a) [59], Andrews and Boyle (2008) [60], and

237 Pacquiao (2012) [61] all cite Leininger's transcultural nursing idea and theory as a key

238 influence. Finally, various researchers [62-64] have found that concept analysis over

239 literature review is a useful technique for developing theoretical models that derive their

240 composite domains directly from the definition, or attributes, of cultural competence. There is

241 minimum 5 domains (constructs, or phenomena) in general across the methodological

242 models, including biological variability, social structure, communication, health beliefs and

243 religion and practises. These 5 categories also correspond to the spirituality, body, and mind,

244 components of Spector's (2004a) paradigm [65].

245  Purnell model for cultural competence

246 Some models are built using ideas from a variety of areas. For example, the Purnell model

247 was based on ideas from anthropology, biology, geography, sociology, economics, political

248 science, pharmacology, and nutrition, as well as communication, family development, and

249 social support theories.

250 The Purnell Model for Cultural Competence, as well as the model's organisational structure

251 and assumptions. Additionally, non–native American health-care professionals will benefit

252 from an understanding of American cultural values, traditions, and beliefs. The American

253 references are designed to depict actions and practises rather than dictate or forecast them.

254 When investigating complex phenomena like culture and ethnicity, Western academic and

255 health-care institutions emphasise structure, systematisation, and formalisation. The Purnell

256 Model for Cultural Competence presents a methodical, comprehensive, and simple

257 framework for learning and comprehending culture, given the complexity of humans. The

258 model's empirical framework can help managers, administrators, and health-care providers,

259 across all culturally competent therapeutic interventions, health disciplines provide holistic,

260 as well as illness and health promotion, disease, wellness, and injury prevention, health

261 restoration and maintenance, and health teaching in educational and practise settings [66].

262 The following are the goals of this model:

263  Create a framework for all health-care practitioners to learn about cultural ideas and

264 traits.

265  In the framework of historical viewpoints, define the conditions that influence a person's

266 cultural worldview.

267  Create a model that connects the most important cultural linkages.

268  Connect cultural features to create congruence and make it easier to provide competent

269 health care and deliberately attentive.

270  Create a framework that considers human traits like intentionality, motivation, and

271 meaning.

272  Establish a framework for assessing cultural data.

273  Consider the person, family, or community in the context of their ethnocultural

274 surroundings.

275 The features of the other component of cultural competence remain abstract in both kinds of

276 models since they focus on only single component of cultural competence and describe its

277 domains openly. The areas of cultural skills, cultural sensitivity, and cultural knowledge are

278 shared by most theoretical cultural competency models in Tables 1 for example, yet the

279 definition of culture is anything from apparent.

280

281  Different models of culture competence

Related
Cultural competence Methodolog
Model title assessment Context Reference
elements y
tools
Cultural knowledge,
A model for
Awareness, Healthcare Burchum (2002)
cultural - Literature
Sensitivity, (nursing) [67]
competence Review
interaction, and skill
Culturally
CCS
Competenc Cultural Caring, Kim-Godwin et
(Cultural Healthcare Literature
e Sensitivity, al. (2001)
Competence (nursing) Review
Community Knowledge, and skill [68]
scale)
Care
Cultural
Competence
Culturally
Assessment Desire, Awareness/
Competenc Balcazar et al.
Instrument- Knowledge, Skill, Healthcare Literature
e (2009)
University of Organisational (nursing) review
Conceptual [69]
Illinois at Support
Model
Chicago
(CCAI-UIC
The Process
of Cultural
Cultural Desire,
Competenc Campinha-
IAPCC-SV Encounter, Healthcare Literature
e in Bacote (2002)
and IAPCC-R Awareness, Skill and (nursing) review
Healthcare [70]
Knowledge
Service
Delivery
Cultural CCA Cultural Diversity, Healthcare Literature Doorenbos and
 (Cultural
Competenc Sensitivity and (hospice, Schim (2004)
Competence review
e Model Awareness nursing) [71]
Assessment)
Model for
CCA Tool
Cultural
(Cultural Cultural Awareness, Papadopoulos et
Competenc Healthcare Literature
Competence Knowledge and al. (2004)
e (nursing) review
Assessment Sensitivity [72]
Developme
Tool)
nt
Cultural (Lucas et al.
Competenc 2008
Healthcare
e developed) Attitude/ Awareness, Literature Sue (2001)
(counselling
Multidimen Cultural Skill, Knowledge review [73]
)
sional Competency
Model Measure
Communication
Communic
Skills, Situational and Teal and Street
ation of Healthcare Literature
- self-awareness, (2009)
Culturally (physicians review
Adaptability and [74]
Competent
Knowledge
Global Attitude,
Inter- Empathy, Motivation,
cultural (Adjusting Involvement,
Qualitative Arasaratnam
Communic other measures Experience, Business
study (2006)
ation developed) Communication (university)
(Interview) [75]
Competenc ICC measure Competence,
e Model Intercultural
Interaction
Cultural competence
elements:
Environmental
Domain: [Encounter]
Cognitive Domain:
The Model [Knowledge,
of Cultural Awareness], Healthcare Literature Suh (2004)
-
Competenc Cultural competence (nursing) review [76]
e attributes: openness,
flexibility and ability,
Affective Domain:
[Sensitivity]
Behavioural Domain:
[Skills]
Army
Leaders
Abbe et al.
Cross- Affect/ Motivation, Business Literature
- (2007)
cultural Knowledge, Skill (army) review
[77]
Competenc
e
Intercultur
al Comprehension, Skill Business Deardorff
Competenc - and Knowledge, (university Delphi study (2006)
e Process Motivation/Attitude education) [78]
Model
Model for - Environmental, Business Literature Overall (2009)
Informatio Interpersonal, (information review [79]
n and Cognitive science &
Library of library)
Science
Professiona
 ls Cultural
Competenc
e
In
internation
(Internationa
al business, Cultural Knowledge
l Johnson et al.
a Model of Personal Skills, Literature
- management (2006)
Cross- Attributes review
) [80]
Cultural
Business
Competenc
e
(Ang et al.
(Internationa
2004 Motivational,
Facets of l
developed) Behavioural Literature Earley (2002)
Cultural management
Cultural Cognitive/Meta review [81]
Intelligence )
Intelligence Cognitive,
Business
Scale (CQS)
Culturally Intelligent
Domain of Behaviour Thomas et al.
Literature
Cultural - Cultural Skill, Business (2008)
review
Intelligence Knowledge, Meta- [82]
Cognition,
Intercultur
al AIC
Knowledge,
Component (Assessment of Literature Fantini (2006)
Awareness, Attitude, Business
s and Intercultural review [83]
Skill
Competenc Competence)
y
Cultural Distance,
The Knowledge,
Rainbow Motivation, Skills,
model of Effectiveness, Self-
ICCI
ICC Awareness,
(Intercultural Kupka and
(Intercultur Appropriateness, Literature
Communication Business Everett (2007)
al Contextual review
Competence [84]
Communic Interactions, Foreign
Inventory)
ation Language
Competenc Competence,
e) Intercultural Affinity

282

283

284

285

286

287

288 Prescription for success in Cultural Competence Medical Education

289  Utilize interactive educational methods, like self-reflective journal assignments,

290 standardized patient encounters, and role-play

291 It is critical to adopt interactive teaching approaches that align with adult learning

292 principles to successfully teach useful skills. Standardized patient interactions using

293 patient actors may help residents and medical students practise new skills of interaction

294 while receiving immediate comment from the trained actor [85]. Role-playing exercises

295 do the same thing [86]. The ability to offer response to a colleague during role-playing

296 might provide medical students with better insight into their personal behaviours. Lastly,

297 narrative writing invites them to freely reflect on their personal faiths, and values [87,

298 88], as well as their own experiences with discrimination, prejudice, difficult patient

299 contacts, and earlier errors [89].

300

301  Teach practical skills

302 Traditionally, cultural competency programmes have taken a knowledge-based approach

303 [90]. Lists of recommended phrases, pictures, or ways for handling minority groups are

304 often included in such courses, depicting for every single group as having distinct beliefs,

305 values, and behaviours depend on culture. This simplistic approach ignores variation

306 within groups while emphasising contrasts between them, thereby perpetuating

307 stereotyping [91]. Cultural competency programmes, on the other hand, should recognise

308 variation in social groups and educate medical students how to use socio-cultural

309 information at the personal level. Clinicians observe various behavioural patterns and

310 health beliefs even within a family unit, depending on individual preferences,

311 experiences, and acculturation degree [92, 93]. The capacity to extract an individual's

312 impressions of sickness and health, also their treatment preferences and explanatory

313 model, and skills that are transferable across cultures and patients.

314  Cultural competence as part of clinical education, rather than single seminars
315 Learning to be culturally competent is a lengthy and difficult procedure. Most cultural

316 competency instruction for medical students, on the other hand, lasts shorter than a week

317 [94], which is improbable to result in long-term behaviour change. Cultural competency

318 training should be included into students' clinical education to enhance culturally

319 appropriate knowledge and abilities. There are several chances for our students to address

320 cultural concerns. Whether take care of a patient from a different culture or just one who

321 does not share the Western biological concept of illness, the conversation during medical

322 rounds should be wide and incorporate cultural background of patients, as well as

323 educating about pathophysiology and treatment.

324

325  Observe and get direct feedback from faculty

326 Input from faculty members and direct observation of cultural competency training, in

327 addition to feedback from standardised peers and patients, may create a memorable and

328 helpful experience. Numerous factors influence an individual's culture, including religion,

329 economic position, education, age, immigrant history, and vacation destinations. As a

330 result, there may be a teaching opportunity in cultural competency in almost every

331 physician-patient contact. A clinic preceptor, for example, might offer comment on the

332 student's ability to do one of the skills, like eliciting the patient's grasp of the disease

333 aetiology [95, 96].

334

335  At all levels, support cultural diversity including medical students and medical

336 school faculty

337 Patient satisfaction is also linked to racial disharmony between the physician and the

338 patient, as well as less participative clinical encounters [97]. Diverse health-care

339 practitioners should be promoted from the start and at various levels. Physicians may help
340 by acting as role models for minority students considering a career in medicine, and

341 medical schools must continue to attract a diverse student body. Minority pupils'

342 education must be improved at all levels of schooling, which will need societal initiatives.

343 Although minority doctors give disproportionately more treatment to marginalised groups

344 [98, 99].

345

346  Get buy-in from the top

347 Medical school "teachers and students must exhibit a grasp of the way in which

348 individuals of many cultures and belief systems perceive health and sickness and react to

349 varied symptoms, illnesses, and treatments," according to the “Liason Committee on

350 Medical Education”. On these reasons, obtaining the backing of medical school deans as

351 well as an assurance from curriculum directors to formal cultural competence training

352 would help to ensure that cultural competence training is fully integrated into medical

353 education. Some institutions have developed such a collaboration. The Dean of Medical

354 Education at wake forest school of medicine, i.e., established a CCTT (Cultural

355 Competency Theme Team), which is made up of people who supervise curricular

356 components. Throughout the four years of medical school, the CCTT is in responsible of

357 integrating culturally appropriate activities. Some top-level educators and administrators,

358 especially those who attended medical school in a less varied culture, may benefit from

359 fundamental cultural competency training in order to function as successful advocates and

360 partners. Their personal involvement will also send a message about the importance of

361 cultural competency education. Cultural training for administrators and health care

362 practitioners at all levels is supported by the American College of Physicians [100]. If

363 medical schools are to mould future doctors' practises in the context of cultural
364 competency, it is critical that the medical profession reconsiders long-held attitudes,

365 beliefs, and prejudices that may not be in line with present societal diversity.

366

367  Make a cadre of enthusiastic faculty

368 Training an extra set of academics in CC will start to develop an "early majority" of

369 backers to supplement the efforts of the medical champion(s). Beyond the early adopters,

370 this group is crucial for the expand of new programmes. As previously said, cultural

371 competency education should not be limited to seminars, and it should not be taught just

372 by one or two physician advocates. Furthermore, teaching opportunities surrounding

373 culture will be addressed more often as a result of training an early majority of dedicated

374 staff doctors with the abilities required to consistently talk about diverse topics as part of

375 patient care. The "hidden curriculum," the informal element of medical education

376 supplied via role modelling and other often subconscious activities, will be influenced by

377 the frequent discussion of cultural concerns during rounds [101].

378

379  Make it a “Real Science”

380 “Cross-cultural communication” education might be considered a “soft science”, with

381 talks of empathy and explanatory models in contrast to the fact-based bulk of medical

382 education. Courses should stress the amount of study on health inequalities, the relevance

383 of culture in patient care, and the established usefulness the education of cultural

384 competency to meet medical trainees' desire for scientific proof. Beach et al. [102] found

385 in a recent comprehensive study that cultural competency education enhances health

386 workers' knowledge, attitudes, and abilities, also the patient satisfaction.

387

388
Table 2 - Studies about culture competence by authors
Referenc
Author Study
e
Reviewed there was strong evidence of enhanced
practitioner knowledge and skills, as well as substantial data
of better practitioner abilities and attitudes. However, there
is less proof for the effects of training interventions and
cultural competence education on patient health and
Beach et al.
healthcare outcomes, which is important for determining [103]
(2005)
overall intervention effectiveness. The benefits of cultural
competency education interventions on patient satisfaction
have also been studied. However, there was little indication
of patient compliance, and no outcomes of health were
recorded.
Analysed cultural competence workforce strategies that
incorporated health outcomes measurements Despite the
Lie et al. fact that seven studies were discovered, their
[104]
(2011) methodological quality was poor to moderate, and there was
no evidence of a favourable association between better
health outcomes and cultural competence training efforts.
Studied when healthcare workers demonstrate a grasp of the
May and
relevance of cultural diversity and create relationships with
Potia et al. [105]
culturally different clients from them, they are culturally
(2013)
competent.
Stated that according to Kohlberg's theory of moral
reasoning, an individual's personal beliefs and values play a
McLeod- significant influence in their decision-making, implying that
Sordjan et al. physical maturity does not always imply a high degree of [106]
(2014) moral reasoning. Given this context, it may be reasonable to
conclude that moral reasoning is not an exact idea but rather
situational.
Betancourt Proposed that the training of cultural competence made a [107]
and Green et key element of the curriculum and officially evaluated in
 al. (2010) health education.
Described that though cultural competency is the most
popular approach to diversity, it has significant conceptual
flaws. Culture is portrayed as permanent, homogeneous,
and too determinant of others' lives, whereas it is
underemphasized in professionals' lives. Professionals with
cultural competency are assumed to be members of
dominant groups, making racialized and ethnic minority
professionals invisible. It is seen as a goal that may be
Beagan et al.
achieved, thereby individualising failure to do so. This is a [108]
(2018)
misinterpretation of structural power relations that cannot
be changed individually. Worse, competency is judged in
terms of learner confidence and/or comfort, which may
have nothing to do with productively collaborating across
differences. Cultural humility with critical reflexivity, on
the other hand, is an ethical posture that requires accepting
responsibility for one's privilege and reflecting on one's
own actions in respect to power systems.
389

390

391

392

393

394

395

396

397

398

399

400
401

402 Conclusion

403 Cultural competency has arisen as a critical counterweight to the evidence-based mental

404 health care movement, which often results in a "one-size-fits-all" approach. Efforts within

405 health-care systems to build cultural competency or other modalities of responding to

406 diversity may act as a counterweight to the homogenising processes of assimilation and

407 marginalisation of minority groups. Current methods to cultural competency, on the other

408 hand, have been chastised for essentializing, commodifying, and appropriating culture, which

409 has resulted in stereotyping and additional disempowerment of patients. Researchers came up

410 with the term "cultural competence" & developed conceptual models to define the features of

411 culturally competent persons in response to this demand. The purpose of this study was to

412 identify the most recent cultural competency frameworks and to explain in what way this

413 notion has been operationalized in distinct models. It also showed in what manner these

414 models have been utilised in empirical investigations of cultural competency in practise.

415

416

417

418

419

420

421

422

423

424

425
426

427 References

428 1. Cross TL. Towards a culturally competent system of care: A monograph on effective

429 services for minority children who are severely emotionally disturbed.

430 2. Dingwall KM, Puszka S, Sweet M, Mills PP, Nagel T. Evaluation of a culturally

431 adapted training course in Indigenous e-mental health. Australasian Psychiatry. 2015

432 Dec;23(6):630-5.

433 3. McGuire AA, Garcés-Palacio IC, Scarinci IC. A successful guide in understanding

434 Latino immigrant patients: an aid for health care professionals. Family & community

435 health. 2012 Jan;35(1):76.

436 4. Chun MB, Takanishi Jr DM. The need for a standardized evaluation method to assess

437 efficacy of cultural competence initiatives in medical education and residency

438 programs. Hawaii medical journal. 2009 Jan 1;68(1).

439 5. National Health and Medical Research Council (Australia). Cultural competency in

440 health: a guide for policy, partnerships and participation. National Health and

441 Medical Research Council; 2006.

442 6. Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH. Does cultural

443 competency training of health professionals improve patient outcomes? A systematic

444 review and proposed algorithm for future research. Journal of general internal

445 medicine. 2011 Mar;26(3):317-25.

446 7. Chipps JA, Simpson B, Brysiewicz P. The effectiveness of cultural‐competence

447 training for health professionals in community‐based rehabilitation: A systematic

448 review of literature. Worldviews on Evidence‐Based Nursing. 2008 Jun;5(2):85-94.

449 8. Bean R. The effectiveness of cross-cultural training in the Australian context.

450 Canberra: Department of Immigration and Multicultural Affairs; 2006 Nov.

451 9. Gopalkrishnan N. Rethinking child protection: Issues of cultural competence.

452 InNational Conference on Multicultural Families: Investing in the Nation’s Future,

453 Maroochydore 2006.

454 10. Graf A. Assessing intercultural training designs. Journal of European Industrial

455 Training. 2004 Feb 1.

456 11. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, Harris P,

457 Glasgow NJ, Campbell C, Dath D, Harden RM. Competency-based medical

458 education: theory to practice. Medical teacher. 2010 Aug 1;32(8):638-45.

459 12. Ellaway R. CanMEDS is a theory. Advances in Health Sciences Education. 2016

460 Dec;21(5):915-7.

461 13. Norman G, Norcini J, Bordage G. Competency-based education: milestones or

462 millstones?. Journal of graduate medical education. 2014 Mar;6(1):1-6.

463 14. Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J,

464 International Competency-based Medical Education Collaborators. A core

465 components framework for evaluating implementation of competency-based medical

466 education programs. Academic Medicine. 2019 Jul 1;94(7):1002-9.

467 15. Matthew SM, Bok HG, Chaney KP, Read EK, Hodgson JL, Rush BR, May SA,

468 Salisbury SK, Ilkiw JE, Frost JS, Molgaard LK. Collaborative development of a

469 shared framework for competency-based veterinary education. Journal of veterinary

470 medical education. 2020 Nov;47(5):578-93.

471 16. Kerdijk W, Snoek JW, van Hell EA, Cohen-Schotanus J. The effect of implementing

472 undergraduate competency-based medical education on students’ knowledge

473 acquisition, clinical performance and perceived preparedness for practice: a

474 comparative study. BMC medical education. 2013 Dec;13(1):1-9.

475 17. Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J,

476 International Competency-based Medical Education Collaborators. A core

477 components framework for evaluating implementation of competency-based medical

478 education programs. Academic Medicine. 2019 Jul 1;94(7):1002-9.

479 18. Shah N, Desai C, Jorwekar G, Badyal D, Singh T. Competency-based medical

480 education: An overview and application in pharmacology. Indian journal of

481 pharmacology. 2016 Oct;48(Suppl 1):S5.

482 19. Renzaho AM, Romios P, Crock C, Sønderlund AL. The effectiveness of cultural

483 competence programs in ethnic minority patient-centered health care—a systematic

484 review of the literature. International Journal for Quality in Health Care. 2013 Jul

485 1;25(3):261-9.

486 20. Park ER, Betancourt JR, Kim MK, Maina AW, Blumenthal D, Weissman JS. Mixed

487 messages: residents’ experiences learning cross-cultural care. Academic Medicine.

488 2005 Sep 1;80(9):874-80.

489 21. Pieper HO, MacFarlane AE. I'm worried about what I missed”: GP registrars’ views

490 on learning needs to deliver effective healthcare to ethnically and culturally diverse

491 patient populations.

492 22. Weissman JS, Betancourt J, Campbell EG, Park ER, Kim M, Clarridge B,

493 Blumenthal D, Lee KC, Maina AW. Resident physicians’ preparedness to provide

494 cross-cultural care. Jama. 2005 Sep 7;294(9):1058-67.

495 23. Begg H, Gill P. Views of general practitioners towards refugees and asylum seekers:

496 an interview study. Diversity in Health and Social Care. 2005;2(4):299-305.

497 24. Colliver JA, Swartz MH, Robbs RS, et al. Relationship between clinical competence

498 and interpersonal and communication skills in standardizedpatient assessment. Acad

499 Med. 1999;74:271-274.

500 25. Laidlaw TS, Kaufman DM, MacLeod H, et al. Relationship of resident

501 characteristics, attitudes, prior training and clinical knowledge to communication

502 skills performance. Med Educ. 2006;40:18-25.

503 26. Saha S, Perrin N, Gerrity M, Gatchell M. Measuring physician cultural competence:

504 results from a national survey. J Gen Intern Med. 2010 Jun 1;25:329-9.

505 27. Chudley S, Skelton J, Wall D, Jones E. Teaching cross-cultural consultation skills: a

506 course for UK and internationally trained general practice registrars. Education for

507 Primary Care. 2007 Jan 1;18(5):602-15.

508 28. Fredericks B. The need to extend beyond the knowledge gained in cross-cultural

509 awareness training. The Australian Journal of Indigenous Education. 2008;37(S1):81-

510 9.

511 29. Greer JA, Park ER, Green AR, Betancourt JR, Weissman JS. Primary care resident

512 perceived preparedness to deliver cross-cultural care: an examination of training and

513 specialty differences. Journal of general internal medicine. 2007 Aug;22(8):1107-13.

514 30. Betancourt JR. Cross-cultural medical education: conceptual approaches and

515 frameworks for evaluation. Academic Medicine. 2003 Jun 1;78(6):560-9.

516 31. Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum.

517 Academic medicine: journal of the Association of American Medical Colleges. 1998

518 Apr 1;73(4):403-7.

519 32. Campbell A, Sullivan M, Sherman R, Magee WP. The medical mission and modern

520 cultural competency training. Journal of the American College of Surgeons. 2011 Jan

521 1;212(1):124-9.

522 33. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their

523 implications for health care delivery. Jama. 1994 Mar 2;271(9):690-4.
524 34. Flores G, Gee D, Kastner B. The teaching of cultural issues in US and Canadian

525 medical schools. Academic Medicine. 2000 May 1;75(5):451-5.

526 35. Carrese JA, Rhodes LA. Bridging cultural differences in medical practice. Journal of

527 General Internal Medicine. 2000 Feb;15(2):92-6.

528 36. Canto JG, Allison JJ, Kiefe CI, Fincher C, Farmer R, Sekar P, Person S, Weissman

529 NW. Relation of race and sex to the use of reperfusion therapy in Medicare

530 beneficiaries with acute myocardial infarction. New England Journal of Medicine.

531 2000 Apr 13;342(15):1094-100.

532 37. Ayanian JZ, Cleary PD, Weissman JS, Epstein AM. The effect of patients'

533 preferences on racial differences in access to renal transplantation. New England

534 Journal of Medicine. 1999 Nov 25;341(22):1661-9.

535 38. Duncan GF, Gilbey D. Cultural and communication awareness for general practice

536 registrars who are international medical graduates: a project of CoastCityCountry

537 Training. Australian Journal of Rural Health. 2007 Feb;15(1):52-8.

538 39. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement

539 with stigma and inequality. Social science & medicine. 2014 Feb 1;103:126-33.

540 40. Cross TL. Towards a culturally competent system of care: A monograph on effective

541 services for minority children who are severely emotionally disturbed.

542 41. Cass A, Lowell A, Christie M, Snelling PL, Flack M, Marrnganyin B, Brown I.

543 Sharing the true stories: improving communication between Aboriginal patients and

544 healthcare workers. Medical Journal of Australia. 2002 May;176(10):466-70.

545 42. Shahid S, Finn LD, Thompson SC. Barriers to participation of Aboriginal people in

546 cancer care: communication in the hospital setting. Medical Journal of Australia.

547 2009 May;190(10):574-9.

548 43. Roe, Y.L., Zeitz, C.J. and Fredericks, B., 2012. Study protocol: establishing good

549 relationships between patients and health care providers while providing cardiac care.

550 Exploring how patient-clinician engagement contributes to health disparities between

551 indigenous and non-indigenous Australians in South Australia. BMC health services

552 research, 12(1), pp.1-10.

553 44. Betancourt JR, Green AR, Carrillo JE, Owusu Ananeh-Firempong II. Defining

554 cultural competence: a practical framework for addressing racial/ethnic disparities in

555 health and health care. Public health reports. 2016 Nov 15.

556 45. Wear D, Zarconi J, Aultman JM, Chyatte MR, Kumagai AK. Remembering Freddie

557 Gray: medical education for social justice. Academic Medicine. 2017 Mar

558 1;92(3):312-7.

559 46. Acquaviva KD, Mintz M. Perspective: are we teaching racial profiling? The dangers

560 of subjective determinations of race and ethnicity in case presentations. Academic

561 Medicine. 2010 Apr 1;85(4):702-5.

562 47. Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerability: operationalizing

563 the concept to address health disparities in clinical care. Academic medicine: journal

564 of the Association of American Medical Colleges. 2017 Mar;92(3):299.

565 48. Downing R, Kowal E. A postcolonial analysis of Indigenous cultural awareness

566 training for health workers. Health Sociology Review. 2011 Mar 1;20(1):5-15.

567 49. Weissman JS, Betancourt J, Campbell EG, Park ER, Kim M, Clarridge B,

568 Blumenthal D, Lee KC, Maina AW. Resident physicians’ preparedness to provide

569 cross-cultural care. Jama. 2005 Sep 7;294(9):1058-67.

570 50. Anderson-Wurf J. SUPERVISION OF INTERNATIONAL MEDICAL

571 GRADUATE (Doctoral dissertation, The University of New South Wales).

572 51. Leininger MM. What is transcultural nursing and culturally competent care. Journal

573 of transcultural nursing. 1999 Jan 1;10:9-.

574 52. Orque MS, Bloch B. Ethnic nursing care: A multicultural approach. Mosby; 1983.

575 53. Leininger M. Culture care theory: A major contribution to advance transcultural

576 nursing knowledge and practices. Journal of transcultural nursing. 2002

577 Jul;13(3):189-92.

578 54. Leininger M. Part I. The theory of culture care and the ethnonursing research method.

579 Transcultural nursing: Concepts, theories, research and practice. 2002 Mar 4:71-98.

580 55. Davidhizar R, Bechtel G, Giger JN. A model to enhance culturally competent care.

581 Hospital Topics. 1998 Jan 1;76(2):22-6.

582 56. Giger JN, Davidhizar R. The Giger and Davidhizar transcultural assessment model.

583 Journal of Transcultural Nursing. 2002 Jul;13(3):185-8.

584 57. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare

585 services: A model of care. Journal of transcultural nursing. 2002 Jul;13(3):181-4.

586 58. Schim SM, Doorenbos AZ. A three-dimensional model of cultural congruence:

587 Framework for intervention. Journal of social work in end-of-life & palliative care.

588 2010 Nov 29;6(3-4):256-70.

589 59. Jeffreys MR. A model to guide cultural competence education. Teaching cultural

590 competence in nursing and health care: Inquiry, action, and innovation. 2010 Jun

591 21;2:45-59.

592 60. Andrews MM. Andrews/Boyle transcultural nursing assessment guide for individuals

593 and families. Transcultural concepts in nursing care. 2008:453-7.

594 61. Andrews MM. Culturally competent nursing care. In. MM Andrews & JS Boyle.

595 Transcultural Concepts in Nursing Care. 2012:17-37.

596 62. Burchum JL. Cultural competence: An evolutionary perspective. InNursing forum

597 2002 Oct 1 (Vol. 37, No. 4, p. 5). Blackwell Publishing Ltd..

598 63. Jirwe M, Gerrish K, Keeney S, Emami A. Identifying the core components of

599 cultural competence: findings from a Delphi study. Journal of clinical nursing. 2009

600 Sep;18(18):2622-34.

601 64. Kim‐Godwin YS, Clarke PN, Barton L. A model for the delivery of culturally

602 competent community care. Journal of advanced nursing. 2001 Sep 4;35(6):918-25.

603 65. Spector R. Cultural Diversity in Health and Illness (6th edn) Brunner.

604 66. Purnell L, Paulanka BJ. The Purnell model for cultural competence. Transcultural

605 health care: A culturally competent approach. 2008;3:19-56.

606 67. Burchum JL. Cultural competence: An evolutionary perspective. InNursing forum

607 2002 Oct 1 (Vol. 37, No. 4, p. 5). Blackwell Publishing Ltd..

608 68. Kim‐Godwin YS, Clarke PN, Barton L. A model for the delivery of culturally

609 competent community care. Journal of advanced nursing. 2001 Sep 4;35(6):918-25.

610 69. Balcazar FE, Suarez-Balcazar Y, Taylor-Ritzler T. Cultural competence:

611 Development of a conceptual framework. Disability and rehabilitation. 2009 Jan

612 1;31(14):1153-60.

613 70. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare

614 services: A model of care. Journal of transcultural nursing. 2002 Jul;13(3):181-4.

615 71. Doorenbos AZ, Schim SM. Cultural competence in hospice. American Journal of

616 Hospice and Palliative Medicine®. 2004 Jan;21(1):28-32.

617 72. Papadopoulos I, Tilki M, Lees S. Promoting cultural competence in health care

618 through a research based intervention in the UK. Diversity in Health and Social Care.

619 2004 Nov 1;1(2):107-15.

620 73. Sue DW. Multidimensional facets of cultural competence. The counseling

621 psychologist. 2001 Nov;29(6):790-821.

622 74. Teal CR, Street RL. Critical elements of culturally competent communication in the

623 medical encounter: a review and model. Social science & medicine. 2009 Feb

624 1;68(3):533-43.

625 75. Arasaratnam LA. Further testing of a new model of intercultural communication

626 competence. Communication Research Reports. 2006 Jul 1;23(2):93-9.

627 76. Suh EE. The model of cultural competence through an evolutionary concept analysis.

628 Journal of Transcultural Nursing. 2004 Apr;15(2):93-102.

629 77. Abbe A, Gulick LM, Herman JL. Cross-cultural competence in Army leaders: A

630 conceptual and empirical foundation. Arlington, VA: US Army Research Institute for

631 the Behavioral and Social Sciences; 2007 Oct 1.

632 78. Deardorff DK. Identification and assessment of intercultural competence as a student

633 outcome of internationalization. Journal of studies in international education. 2006

634 Sep;10(3):241-66.

635 79. Overall PM. Cultural competence: A conceptual framework for library and

636 information science professionals. The Library Quarterly. 2009 Apr;79(2):175-204.

637 80. Johnson JP, Lenartowicz T, Apud S. Cross-cultural competence in international

638 business: Toward a definition and a model. Journal of international business studies.

639 2006 Jul;37(4):525-43.

640 81. Earley PC. Redefining interactions across cultures and organizations: Moving

641 forward with cultural intelligence. Research in organizational behavior. 2002 Jan

642 1;24:271-99.

643 82. Thomas DC, Elron E, Stahl G, Ekelund BZ, Ravlin EC, Cerdin JL, Poelmans S,

644 Brislin R, Pekerti A, Aycan Z, Maznevski M. Cultural intelligence: Domain and

645 assessment. International Journal of Cross Cultural Management. 2008

646 Aug;8(2):123-43.

647 83. Fantini AE. Exploring and assessing intercultural competence.

648 84. Kupka B, Everett A, Wildermuth S. The rainbow model of intercultural

649 communication competence: A review and extension of existing research.

650 Intercultural Communication Studies. 2007;16(2):18.

651 85. Colliver JA, Swartz MH. Assessing clinical performance with standardized patients.

652 Jama. 1997 Sep 3;278(9):790-1.

653 86. Kripalani S, Bussey-Jones J, Katz MG, Genao I. A prescription for cultural

654 competence in medical education. Journal of general internal medicine. 2006

655 Oct;21(10):1116-20.

656 87. DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach

657 empathy. Academic Medicine. 2004 Apr 1;79(4):351-6.

658 88. Yamada S, Maskarinec GG, Greene GA, Bauman KA. Family narratives, culture,

659 and patient-centered medicine. FAMILY MEDICINE-KANSAS CITY-. 2003 Apr

660 1;35(4):279-83.

661 89. Erwin DO, Henry-Tillman RS, Thomas BR. A qualitative study of the experiences

662 of one group of African Americans in pursuit of a career in academic medicine.

663 Journal of the National Medical Association. 2002 Sep;94(9):802.

664 90. Betancourt JR. Cross-cultural medical education: conceptual approaches and

665 frameworks for evaluation. Academic Medicine. 2003 Jun 1;78(6):560-9.

666 91. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C,

667 Jenckes MW, Feuerstein C, Bass EB, Powe NR. Cultural competency: A systematic

668 review of health care provider educational interventions. Medical care. 2005

669 Apr;43(4):356.
670 92. Hunt LM, Schneider S, Comer B. Should “acculturation” be a variable in health

671 research? A critical review of research on US Hispanics. Social science & medicine.

672 2004 Sep 1;59(5):973-86.

673 93. Salant T, Lauderdale DS. Measuring culture: a critical review of acculturation and

674 health in Asian immigrant populations. Social science & medicine. 2003 Jul

675 1;57(1):71-90.

676 94. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C,

677 Jenckes MW, Feuerstein C, Bass EB, Powe NR. Cultural competency: A systematic

678 review of health care provider educational interventions. Medical care. 2005

679 Apr;43(4):356.

680 95. King DE, Blue A, Mallin R, Thiedke C. Implementation and assessment of a

681 spiritual history taking curriculum in the first year of medical school. Teaching and

682 Learning in Medicine. 2004 Jan 1;16(1):64-8.

683 96. Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond medical

684 “missions” to impact-driven short-term experiences in global health (STEGHs):

685 ethical principles to optimize community benefit and learner experience. Academic

686 Medicine. 2016 May 1;91(5):633-8.

687 97. Hoover E. An analysis of the association of American medical colleges' review of

688 minorities in medical education. Journal of the National Medical Association. 2005

689 Sep;97(9):1240.

690 98. Betancourt JR, Green AR, Carrillo JE, Owusu Ananeh-Firempong II. Defining

691 cultural competence: a practical framework for addressing racial/ethnic disparities in

692 health and health care. Public health reports. 2016 Nov 15.

693 99. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, Bindman

694 AB. The role of black and Hispanic physicians in providing health care for
695 underserved populations. New England Journal of Medicine. 1996 May

696 16;334(20):1305-10.

697 100. Groman R, Ginsburg J. Racial and ethnic disparities in health care: a position paper

698 of the American College of Physicians. Annals of Internal Medicine. 2004 Aug

699 3;141(3):226.

700 101. Turbes S, Krebs E, Axtell S. The hidden curriculum in multicultural medical

701 education: the role of case examples. Academic Medicine. 2002 Mar 1;77(3):209-

702 16.

703 102. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C,

704 Jenckes MW, Feuerstein C, Bass EB, Powe NR. Cultural competency: A systematic

705 review of health care provider educational interventions. Medical care. 2005

706 Apr;43(4):356.

707 103. Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, Palacio A, Smarth C,

708 Jenckes MW, Feuerstein C, Bass EB, Powe NR. Cultural competency: A systematic

709 review of health care provider educational interventions. Medical care. 2005

710 Apr;43(4):356.

711 104. Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH. Does cultural

712 competency training of health professionals improve patient outcomes? A systematic

713 review and proposed algorithm for future research. Journal of general internal

714 medicine. 2011 Mar;26(3):317-25.

715 105. May S, Potia TA. An evaluation of cultural competency training on perceived

716 patient adherence. The European Journal of Physiotherapy. 2013 Mar 1;15(1):2-10.

717 106. McLeod-Sordjan R. Evaluating moral reasoning in nursing education. Nursing

718 ethics. 2014 Jun;21(4):473-83.

719 107. Betancourt JR, Green AR. Commentary: linking cultural competence training to

720 improved health outcomes: perspectives from the field. Academic Medicine. 2010

721 Apr 1;85(4):583-5.

722 108. Beagan BL. A critique of cultural competence: Assumptions, limitations, and

723 alternatives. InCultural competence in applied psychology 2018 (pp. 123-138).

724 Springer, Cham.