Fellow Bio:

My Recommendations Regarding a Process for the Integration of Cultural Humility Into the Medical School Curriculum

The UW School of Medicine and Public Healtha's need for a cultural humility curriculum is not new. Within the past few years this need has been highlighted in the LCME's accreditation report on the current medical school curriculum, thus adding more official urgency to the fulfillment of the curricular void. Different efforts have been made to integrate cultural humility into the curriculum, but the ultimate goal of a longitudinal integration has not yet been accomplished. I believe that one reason for this is that any type of curricular change is one that takes time, especially if it is to have widespread effects and be integrated longitudinally. Moreover, cultural humility is something that is not easily learned or taught, thus it requires careful planning. Instructors of the different disciplines need to receive appropriate training in order to teach cultural humility, especially if their knowledge in this area is limited or non-existent. The end result of a longitudinal integration of cultural humility into the medical school curriculum would provide this topic with the necessary importance at both the administrative and student level. Cultural humility training is not something that should be regarded as supplementary or of secondary importance. Rather, it should be regarded as a necessary component to the training of future physicians. My experience with the development of the medical school elective course, Health Care in Diverse Communities in the Spring 2004 is one that provided me with insights on curriculum development, from which I would like to suggest recommendations regarding how the process of integrating cultural humility into the medical school curriculum might proceed. I offer you my humble opinion as a former elementary school teacher, former student coordinator for Health Care in Diverse Communities, current medical school student, future physician, and life-long advocate for the integration of cultural humility into the medical school curriculum. I thank you in advance for your time and consideration.

PLEASE NOTE: In this report I have chosen to use the term cultural humility rather than cultural competency and my reasons for this choice are many. First, competency is a concept associated with mastery and I believe that mastery in the sense of cultural competency is rarely achieved. I believe that one can never know everything related to culture as defined below. Competency in the cultural sense, if ever achieved, is a life-long process. Second, "humility" is a term that I associate with respect, and when working with people of different cultures, it is necessary to approach interactions with respect. Furthermore, my preference for cultural humility is one that highlights the magnitude of the task and training process. Perhaps first and foremost, I have been inspired by the ideas expressed in the article, "Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education" by Melanie Tervalon and Jann Murray-Garcia (J Health Care for the Poor and Underserved, 9(2): 1998).

DEFINITIONS:

Culture: (according to Britannica.com) is a "behaviour peculiar to Homo sapiens, together with material objects used as an integral part of this behavior. Thus, culture includes language, ideas, beliefs, customs, codes, institutions, tools, techniques, works of art, rituals and ceremonies, among other elements."

TIMING:

I acknowledge the complexity of a longitudinal integration of cultural humility into the medical school curriculum. At the same time, I also acknowledge the current state of health disparities, the demographics provided by the most recent U.S. Census, and the urgent need for future health care professionals to be appropriately trained to serve a growingly diverse world. To reconcile the logistics of a longitudinal integration with the changes taking place in society, I propose gradual but prompt changes in the curriculum with the long term goal being longitudinal integration of cultural humility into the core medical school curriculum.

Two of my colleagues (Li Cowell and Elizabeth Felton) and I, along with the guidance of Sharon Younkin, Ph.D and Patricia Tellez-Giron M.D., developed the medical school elective course titled, Health Care in Diverse Communities which was first offered in Spring 2004. Although this course exists, it does not do justice to cultural humility; rather it serves only as a beginning. Learning about these issues should not be an option but instead should be a requirement. This process can begin with an administrative endorsement of the teaching and learning of issues pertaining to cultural humility and the need for all future physicians to initiate and/or continue the process of becoming culturally humble doctors. In my experience as a medical student, I have noticed that knowledge of the basic sciences is considered at times to be more important than other aspects of our training. Although it is necessary to perform well in basic science courses and to pass Step 1 of the Medical Board Examinations, adding emphasis to cultural humility need not dilute the heavily scientific curriculum. Instead, the addition of cultural humility curriculum can only enrich our preparation.

Another necessary ingredient to this proposed gradual process of curricular integration is time. With the current integration of several basic science courses (e.g. Anatomy and Histology), more time has become available for additions to be made. By integrating cultural humility into our required academic schedule, it will be possible to emphasize its importance and role in our training. Ideally, the incorporation of cultural humility is something that would begin in the first year curriculum. This would create a foundation upon which students would naturally continue to build on cultural knowledge and experience throughout their four years of undergraduate medical education.

STRUCTURE:

Part of the integration of cultural humility into the medical school curriculum includes using what is already in place. One of my recommendations is to increase the recruitment of diverse patients to become part of the standardized patient population and this can be accomplished by tapping into local community organizations. These types of relationships would build greater trust with the Madison community and allow a wider variety of patients to participate in the education of their future physicians. Furthermore, through a more diverse standardized patient population we could learn more about issues such as folk illnesses and remedies. It would also be beneficial if we could learn how to use interpreters, even if the skills taught remained at the basic, even logistical, level (e.g. physician facing the patient rather than the interpreter; seating of interpreter relative to the patient). I believe that the UW Hospital's Interpreter Services could serve as an excellent resource for this purpose. Moreover, it would also be helpful to be exposed to different types of interpreters (e.g. spoken language vs. sign language).

One important lesson that I learned early on in my experience with Health Care in Diverse Communities is that of the importance of having a course that uses different modalities of learning, especially the modalities of discussion and reflection (i.e. active dialogue between and among the students and instructors, coupled with guidance promoting individual and group reflection). Cultural humility curricula does not purely consist of facts; rather, it involves a thought-provoking learning process, which lends itself to challenging and engaging discussion. I also believe that we would benefit more from small group discussions than from whole-group discussions. In order to have each of us reflect and feel comfortable sharing our thoughts on an issue, it important for us to be in a group in whom we trust. This trust could be built over an extended period of time and I believe that it would be beneficial for a student to remain in the same small group for as long as possible.

This small group could provide a non-judgemental environment for all participants (key component to self-reflection and sharing). Universal norms and guidelines could be established so as to create consistency in small group discussion. Given that becoming a culturally humble physician requires time, the experience would be greatly enhanced by the fact that we would be learning alongside our small group leader. Together, we could understand "personal biases and one's own culture, examining how these affect delivery of care" (Overall Objective 1b. from Health Care in Diverse Communities). The use of journals is another activity that would enhance the learning process. The small groups could begin as the discussion groups that follow the summer reading requirement (see below).

As mentioned above, the use of different modalities is ideal so as to provide different approaches to the material. Those other modalities include: lectures, panels and community involvement projects. Some topics are best taught in a lecture format. Using the Health Care in Diverse Communities syllabus as an example, these topics include: introduction to terminology (cultural competency vs. cultural sensitivity vs. cultural humility), health disparities, and errors due to poor translation. Through panels of patients and health care professionals students could learn about a variety of perspectives at one time and have opportunities to ask questions. As a student I have always appreciated hearing and learning from patients. Since our medical school environment exposes students to a limited subgroup of the Madison community, participating in community projects would allow us to truly explore the diverse communities in the area. This type of community involvement project was and continues to be a required activity for students taking the medical school elective Health Care in Diverse Communities. At the same time, it would be necessary to accommodate our busy schedules by requiring only one activity per semester. Furthermore, we could fulfill this requirement by using our current activities (e.g. MEDIC, Special Olympics, etc.) while making sure to submit a written reflection of their experience. Increasing the visibility of students as representatives of the UW School of Medicine and Public Health can strengthen ties with the Madison community.

TRAINING OF INSTRUCTORS

If the ultimate goal is to have a longitudinal integration of cultural humility into the medical school curriculum, all instructors must be ready to facilitate these educational experiences. I realize that instructors also have busy schedules and obligations outside of their teaching duties, so I propose that training take place during the summer (in the form of an intense training session) and regular follow-up meetings during the year. During this training, instructors can receive guidance on how to modify their course modules and cases used in the case-based learning sessions. All instructors should be trained and encouraged to teach about the appropriate use of genetic information (e.g. high incidence of sickle cell disease in the African American community or high incidence of Tay-Sachs disease in the Ashkenazi Jewish community) without stereotyping or over-generalizing. I have experienced that certain instructors have provided us with information about a certain ethnic community without including an explanation on the proper use of this information.

READINGS

Several undergraduate institutions and medical schools have required reading(s) prior to the start of the academic year. I would like to reiterate a recommendation that was proposed by one of my student predecessors (Evelyn Hsu, Class of 2003) and that would be to require the reading of The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. This book is one that has received much recognition and would be an appropriate way to prepare incoming students to learn about some of the issues pertaining to cultural humility. As mentioned above, the small groups set up to discuss the book could become the discussion groups for the remainder of a student's training.

LESSONS LEARNED FROM HCDC

I am including some of the general lessons I learned that could possibly be applied to the integration of cultural humility into the medical school curriculum.

• One of the goals of the medical school elective, Health Care in Diverse Communities, was to provide a multidisciplinary approach to cultural humility so as to acknowledge the teamwork required to ensure quality healthcare for all. By the time the elective ended in April 2004, we discovered several resources available at other heath professional schools and programs on campus. Moreover, now that the UW School of Medicine and Public Health shares a building with several of these programs, it would be beneficial to include this multidisciplinary perspective when making changes in the curriculum so as to encourage collaboration.
• At the beginning of the course, the students and faculty advisors reiterated that Health Care in Diverse Communities was to serve only as an introduction to cultural humility. Participants were informed that the learning process would continue throughout their training and clinical practice similar to the continuing education process that occurs in medicine. In both situations, we need to know where to look for more information. In the case of cultural humility, for example, there are several examples of resources that exist at the Ebling Library. One is a collection of books on diverse communities that used to have its special section at the Pharmacy Library. Also, Gerri Wanserski is one of the librarians at Ebling that is very knowledgeable in this area. As issues of cultural humility become incorporated into the curriculum, it will be important to draw attention to the many resources available to students such as those listed above.
• In designing the curriculum for the medical school elective Health Care in Diverse Communities we included several groups that call Wisconsin home. This was beneficial for everyone as we learned a little more about communities with whom we will work as we continue our training. I believe that whatever change is made to the curriculum regarding cultural humility, the content should begin by reflecting the needs of the communities of the state and must reiterate the impact of demographics on Wisconsin.
• Throughout the planning and my participation in the course, I became more aware of sensitive communication whether it is spoken, written, signed or otherwise. As professionals we must be aware of language and literacy barriers and must know how to listen to and hear issues that our diverse patients communicate. This increased awareness of sensitive communication needs to be included in cultural humility curriculum.
• Although Health Care in Diverse Communities included a session on health care disparities, it also included one on cultural resiliency. In part this was done to challenge the tendency to focus on the inequalities of health care. As a result of these and other sessions, I learned the value of including a balance of perspectives and to acknowledge both the inequalities and the rewards faced by members of diverse communities. I believe that this balance should be maintained as cultural humility is integrated into the curriculum.

In this report I have provided my ideas on how to longitudinally integrate cultural humility into the medical school curriculum. I have learned that change takes time so I have kept this in mind in my recommendations. I hope that you consider my thoughts and I hope to help in the process. Please feel free to contact me via email at: cmdelgadillo@wisc.edu or via phone at (608) 358-4572.

Last update:

April 28, 2005

A indicates the item has been completed.

Completed	When	What	On-line
	Year 1: Beginning of Semester 2	New Project Report	Submit Report
	Year 2: Beginning of Semester 1	Project Update	Submit Update
	Year 2: Beginning of Semester 2	Project Update	Submit Update
	Year 3: Beginning of third year	Project Update	Submit Update
	Year 4: August of fourth year	2-3 page final summary of project that includes a reflective evaluation of the project process	N/A
	Ongoing	Participate in program evaluation (written and/or focus group)	View Options
	By the end of fourth year	Select poster, presentation, paper, creative option or your own idea	View Options

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