Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Chapter 5: Curriculum Content

According to the Liaison Committee on Medical Education an accreditation standard for medical schools is that “faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments,” and that “medical students should learn to recognize and appropriately address gender and cultural biases in health care delivery, while considering first the health of the patient.” Medicine, however, is only one of the many health care fields that now require cultural and linguistic competency training for its professionals (see Chapter 10, Resources, Section I, for statements from several health care fields regarding this requirement).

This chapter provides guidance and recommendations to COEs on content areas that should be considered for inclusion in a cultural and linguistic competency curriculum in any health care profession. This chapter begins with a discussion about the theory of learning objectives and core topics and ends with practical examples from organizations that have put these theories into practice. The topics covered in this chapter include: learning objectives, recommended core competencies, recommended core curriculum topics, and examples of curriculum models. The last section includes three models that are used in curriculum development.

As stated in the Executive Summary, this curriculum guidance is provided to COE grantees as a generic model for use in planning and developing cultural and linguistic competence educational activities with faculty and students. Naturally, practitioners and educators in COEs focused on different areas of health care will need to concentrate on different core competencies and content topics, identify appropriate and discipline-based learning objectives, use various teaching methods and tools, and employ appropriate assessment and evaluation strategies. The curriculum can build on work many COEs are already doing and is not mandatory or intended to replace existing or planned cultural and linguistic competency activities.

COEs are strongly encouraged to use these recommendations to develop collaborative partnerships with communities and other university departments and to share experiences in using these recommendations with other COEs. Of course, each COE following these suggestions will need to tailor them to meet its individual needs.

I. Learning Objectives

COEs developing content for a curriculum on cultural and linguistic competence will want to meet objectives in three areas:

A. Awareness/attitudinal
B. Skills
C. Knowledge

A. Awareness or attitudinal objectives

Awareness or attitudinal objectives include self-awareness and awareness of the dangers of bias, stereotyping and overgeneralization. These objectives also include awareness about the following variations in patient populations, among others:

• Immigrants, refugees, and other stigmatized groups
  
• Those who live in poverty and other class-based differences
  
• Those who have limited English proficiency; believe in complementary, alternative, and integrative medicine and other healing traditions; and who believe in traditional, alternative, and folk healers

B. The skills objectives

The skills objectives naturally involve communication, such as interacting with and interviewing patients, and include other communication skills related to:

• Forming a therapeutic alliance and achieving common ground
  
• Greeting and closing behaviors in clinical settings
  
• Negotiating and problem solving
  
• Communicating appropriately with culturally diverse patients and families
  
• Working effectively with interpreters using different modalities, such as those who are on-site and over-the-phone; having a pre-session with an interpreter, and working to ensure the patient’s understanding through an interpreter
  
• Eliciting a patient’s history or use of traditional/alternative/folk remedies; recognizing symptoms or signs related to the use of traditional/alternative/folk remedies; and collaborating with traditional/alternative/folk healers
  
• Negotiating cross-cultural conflicts relating to diagnosis, treatment, and compliance with treatment and prescription plans
  
• Apologizing for cross-cultural errors and seeking clarification from patients on these issues.

In interacting with diverse patients along the lines outlined above, it is critically important for health care providers to understand that communication patterns, perception of provider and patient/family interactive roles, and interpretation of diagnoses and treatment information may be very different from what they are accustomed to if they are unaccustomed to working with patients from different cultures. Additionally, since cultures tend to differ along these communication dimensions, having a facility for working with one cultural group does not always carry over when working with another group.

Communication skills also involve having the ability to develop a culturally and linguistically appropriate diagnostic, treatment, and care plan with patients and their families (see Appendix A, The Toolbox, for samples and Chapter 10, Resources, for other resources in patient assessment) and for having a format to use when assessing a patient’s family and community support.

C. The knowledge objectives

The knowledge objectives involve having an understanding of a wide variety of historic, demographic, health, and other factors within the general and local populations and within the health and mental health professional workforce. For example, health care practitioners will need a thorough understanding of the historic and contemporary effect of racism, bias, discrimination, prejudice, and other forms of oppression various population groups have experienced in accessing and using the health care system.

These practitioners also may need to understand the cultural issues relating to spirituality, health, and illness and the different healing traditions, such as Ayurvedic and Traditional Chinese Medicine, among others. They will certainly need to understand the concept of culture-driven behavior as it may affect the onset, distribution, course, treatment, and outcome of disease processes. They will need to know the difference between interpretation and translation and how to use each of these professional resources when working with patients with limited English proficiency.

They will also need to know the:

• Health risks and illnesses experienced by individuals who are homosexual, bisexual, and/or transgender
  
• Health risks and illnesses and wellness, health promotion, and utilization of preventive services experienced by African American, Hispanic American, Asian American/Pacific Islander American, American Indian/Native American, European American populations, and multi-racial/ethnic populations
  
• Potential benefits and side effects of various complementary and alternative medicine (C/AM) treatment modalities and potential drug interactions between C/AM treatment modalities and allopathic medications

II. Recommended Core Competencies

The recommended core competencies in this section were developed by the University of Medicine & Dentistry of New Jersey–New Jersey Medical School in collaboration with Dr. Maria L. Soto-Greene, chief of staff and vice president, director of the Hispanic Center of Excellence. A fundamental part of the development of the core competencies was the IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002), the findings of which are discussed at the end of this section.

Among the specific areas related to cultural competency that a COE should require of its students and faculty are knowledge and skills in the following:

• The effect that race, ethnicity, gender, age, language, country of origin, sexual orientation, religion/spirituality, socioeconomic class, political orientation, educational/intellectual levels, and physical/mental ability have on creating and contributing to health disparities
  
• The demographic influences on health care quality and effectiveness in the diagnosis and treatment of disease at an individual and community level
  
• The total health needs of their patients and the effects that social and cultural circumstances have on their health and their community
  
• The effect of provider bias on the practitioner-patient relationship and health outcomes.

Students and faculty also should be able to:

• Define the terms frequently used in cultural/linguistic competency development
  
• Identify ways to eliminate provider bias in the practitioner-patient interaction and the health care system
  
• Recognize the influence gender, sexual orientation, race/ethnicity, religious, socio-economic status (SES), and cultural biases have on care

Among the skills students and faculty should have are the ability to recognize and appropriately address:

• Gender, sexual orientation, race/ethnicity, religious, SES, and cultural biases in patients
  
• Gender, sexual orientation, race/ethnicity, religious, SES, and cultural biases in health care delivery.

Students and faculty also should be able to:

• Work effectively with limited English speaking patients
  
• Demonstrate the ability to perform a clinical assessment including a diagnostic and treatment plan that accommodates the belief system, gender, language, and cultural and socioeconomic context of the patient
  
• Negotiate with the patient or family a treatment plan that is medically appropriate and compatible with the patient’s beliefs, needs, and desires
  
• Apply knowledge of the patient’s gender, sexual orientation, race/ethnicity, religious, socioeconomic status (SES), and culture to provide culturally competent care
  
• Identify suspected gender, sexual orientation, race/ethnicity, religious, SES, and cultural biases in another health care professional and respond appropriately

The IOM report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002) makes clear the problem of bias, stereotyping, and prejudice in health care settings. The report found that while it is reasonable to assume that most health care providers find prejudice morally abhorrent and at odds with their professional values, these providers are like other members of society who may not recognize manifestations of prejudice in their own behavior.

The report’s executive summary explains the problem of bias in health care settings:

“While there is no direct evidence that provider biases affect the quality of care for minority patients, research suggests that health care providers’ diagnostic and treatment decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity. Schulman et al (1999), for example, found that physicians referred White male, Black male, and White female hypothetical “patients” (actually videotaped actors who displayed the same symptoms of cardiac disease) for cardiac catheterization at the same rates (approximately 90 percent for each group), but were significantly less likely to recommend catheterization procedures for Black female patients exhibiting the same symptoms. Weisse et al. (2001), using a similar methodology as that of Schulman, found that male physicians prescribed twice the level of analgesic medication for White “patients” than for Black “patients.” Female physicians, in contrast, prescribed higher doses of analgesics for Black than for White “patients,” suggesting that male and female physicians may respond differently to gender or racial cues.

“In another experimental design, Abreu (1999) found that mental health professionals subliminally “primed” with African American stereotype-laden words were more likely to evaluate the same hypothetical patient (whose race was not identified) more negatively than when primed with neutral words. And in a study based on actual clinical encounters, van Ryn and Burke (2000) found that doctors rated Black patients as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, more likely to lack social support, and less likely to participate in cardiac rehabilitation than White patients, even after patients’ income, education, and personality characteristics were taken into account. These findings suggest that while the relationship between race or ethnicity and treatment decisions is complex and may also be influenced by gender, providers’ perceptions and attitudes toward patients are influenced by patient race or ethnicity, often in subtle ways.”

As a result of the problems of bias, stereotyping, and prejudice in health care settings, it is clear that education designed to meet the standards of multicultural evidence-based clinical care should cover a wide variety of topics, including the human genome project, population genetics, and ethnopharmacology. Such care for different populations should also involve tailoring clinical practice and preventive service guidelines for health and mental health conditions, and should recognize the role of complementary, alternative, and integrative medicine; of various healing modalities; and of traditional healers. By taking these steps, health care practitioners will improve the quality of care they deliver while also improving patient safety by helping to manage risks more effectively and reduce the rate of medical errors.

Health care providers need to strike a balance between understanding existing statistics about patients who represent various populations and not allowing these statistics to unduly influence their decision making. The process of addressing a patient should be guided by a thorough understanding of health statistics but not determined by it. For example, when a provider examines a Black male in his 50s, the practitioner understands that many Black males in this age group are prone to conditions of the prostate, and so the practitioner would need to examine the patient’s prostate. But not all Black males in this age group have such problems. In other words, clinicians need to balance data while avoiding using data to reinforce stereotypes.

III. Recommended Core Curriculum Topics

Given the disparities cited in the IOM and other reports, the recommended core curriculum topics should include eliminating health and health care disparities in a variety of forms. These include historic and contemporary experiences of diverse population groups with the health care system, such as racism and other forms of discrimination and prejudice and barriers to care. The core curriculum also should address health and health care disparities that are related to access, service utilization, quality, and outcomes. In an effort to eliminate disparities, faculty should encourage collaboration with communities, and should comply with legislative and institutional guidelines, such as those put forth by the LCME.

A core curriculum also should address the effect of stereotyping in clinical decision-making. Course work on this topic should include a history of stereotyping to show how it can limit access to health care and to education, and a thorough discussion of bias, discrimination, racism, and privilege. These courses also should address the effects of stereotyping on outcomes.

In many health care settings, practitioners may fail to recognize the role of culture and language in health and illness behavior, and in health care delivery. Many Americans believe strongly in self-care and alternative healers, for example, or their culture may have healing traditions of which those who were trained in traditional medicine are unaware. Religion and spirituality also play a significant role in how a patient will respond to a prescribed treatment plan. The professional cultures of medicine, dentistry, pharmacy, psychology, and other health care disciplines may not address the cultural issues involved in delivering care. In some cultures, for example, it is not appropriate to look directly into a person’s eyes, and a physician or nurse trained in the American health care system may do so out of habit as result of his or her training. In many cultures, patients will be reluctant to speak directly about some topics, meaning health care practitioners will need to make a professional judgment based on what can be implied from a patient’s words.

For these reasons, health care providers should never make assumptions based on the color of a patient’s skin, may need to be exposed repeatedly to patients from a variety of cultural settings, and may need to rely on a variety of experts to help them understand the needs of their patients.

COEs seeking to address the challenges of cross-cultural or intercultural communication will want to describe the cultural and linguistic components involved in physician-patient communication, identify the cultural differences that may affect patient—clinician communication, and solutions to bridging linguistic and cultural differences. They will also want to teach students how to work with interpreters and translators. Doing so will involve developing a thorough understanding of the CLAS Standards and the guidance on working with those who have limited English proficiency (LEP) issued by the Federal Department of Health and Human Services Office for Civil Rights (OCR). The OCR issued revised Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. More information on the OCR’s LEP guidance is available online at (http://www.hhs.gov/ocr/lep/).

An area of health care that is related to cross-cultural or intercultural communication involves health literacy. Nearly half of all American adults—some 90 million people—have difficulty understanding and using health information. There is a higher rate of hospitalization and use of emergency services among patients with limited health literacy, according to a report in 2004 from the Institute of Medicine, Health Literacy: A Prescription to End Confusion (http://www.iom.edu/report.asp?id=19723). Health literacy involves reading skills as well as writing, listening, speaking, knowledge of health concepts and arithmetic, and is defined as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health, the report says.

Public health agencies, health care systems, the health care education system, the individual health care practitioner, the media, and health care consumers need to work together to improve the Nation’s health literacy, the IOM report explains. Limited health literacy affects more than just the uneducated and poor. Even well educated people with strong reading and writing skills may have trouble comprehending a medical form or doctor’s instructions regarding a drug or procedure, the report noted. More than 300 studies show that most of the people for whom health-related materials are intended cannot understand the materials.

Recognizing that low literacy may negatively affect health and well-being, the Federal Agency for Health care Research and Quality (AHRQ) Rockville, MD, commissioned an evidence report from the RTI International-University of North Carolina Evidence-based Practice Center (RTI-UNC EPC) on the topic. In the report, the researchers consolidate and analyze the body of literature that has been produced to date regarding the relationship between literacy and health outcomes and the evidence about interventions intended to improve the health of people with low literacy. The report, Literacy and Health Outcomes, Summary, Evidence Report/Technology Assessment No. 87, by Berkman, N.D., DeWalt, D.A., Pignone, M.P., Sheridan, S.I., Lohr, K.N., Lux, L., Sutton, S.F., Swinson, T., Bonito, A.J., is AHRQ Publication No. 04-E007-1.: Agency for Health care Research and Quality, January 2004. (http://www.ahrq.gov/clinic/epcsums/litsum.htm).

Recognizing these problems, health care professionals can be taught to assess their patients’ health care literacy and devise strategies to work effectively with low literacy patients. Students and faculty can identify patients with limited or low health literacy skills by using the following tools (see Appendix A, The Toolbox, for more information):

• Ask Me 3™ (Partnership for Clear Health Communication; http://www.askme3.org)
  
• Rapid Estimate of Adult Literacy in Medicine (REALM) – English and Spanish language versions
  
• Test of Functional Health Literacy in Adults (TOFHLA)

A number of useful overall curriculum guides are available to COEs developing curriculum content in cultural and linguistic competence.

In 1996, the Society of Teachers of Family Medicine’s Task Force on Cross-Cultural Experiences published (Like, Steiner, & Rubel, 1996) an extensive set of guidelines on necessary curriculum elements for the cultural competency education of family practice residents. The curriculum brought together the thinking of family practice clinicians and medical anthropologists and is an excellent and comprehensive model, based on a framework of clinically appropriate attitudes, knowledge, and skills. While created for family practice graduate students, the elements in the curriculum will serve as a useful guide for persons designing curricula for any health professionals directly involved in patient care (see Appendix A). The framework does not suggest any particular order in which the elements are to be taught, but the framers envisioned a three-year developmental course of study that included applying the information in the context of patient care and community contact. The authors suggest a variety of techniques for delivering the curriculum: hospital rounding, including grand rounds, lectures, clinical case conferences, small group seminars, Balint groups, precepting, video viewing, journal club, home visits, and community fieldwork experiences.

Additionally, in 2002, a National group of physicians, nurses, health educators, medical anthropologists, and health administrators gathered under the sponsorship of The California Endowment to define a cultural competence curriculum appropriate to health providers, also used the attitudes, knowledge, and skills framework. That curriculum, referenced in Chapter 10, can be found in the publications section at the website of The California Endowment, www.calendow.org. The materials also contain information on delivery strategies, evaluation issues, and appropriate trainers.

Finally, the American Association of Medical Colleges plans to publish guidance in 2005 for creating and evaluating cultural and linguistic competency in medical colleges. Called the Tool for Development of Cultural Competence Training (TAACT), the guidance will outline necessary content for a comprehensive cultural and linguistic competency curriculum in medicine. All of these curriculum guides are referenced in the resources chapter.

IV. Examples of Curriculum Models

The examples of curriculum models that follow could be used or adapted for use in a program on cultural and linguistic competence. Each one offers a highly useful example of how the teaching of cultural and linguistic competence has been developed for different settings: a medical school, a primary care physician’s office practice, and for psychiatrists. These models are applicable to a wide variety of health care practitioners seeking a systematic review of an individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician.

The three examples are:

A. A Cross-Cultural Care Primer from the Harvard Medical School
B. A Family Physician’s Practical Guide to Culturally Competent Care, an online course from the Federal Office of Minority Health’s Cultural Competency Curriculum Modules (CCCMs)
C. The Outline for Cultural Formulation in The Diagnostic and Statistical Manual-IV (DSM-IV TR), published by American Psychiatric Association – NAAPIMHA Curriculum on AAPI Mental Health

A. Cross-Cultural Care Primer—Harvard Medical School

The Cross-Cultural Care Primer was developed under the direction of Joseph R. Betancourt, MD, MPH, and the Culturally Competent Care Education Committee (CCCEC) at the Harvard Medical School (HMS). Based on the work of Betancourt; J. Emilio Carrillo, MD, MPH; and Alexander R. Green, MD, the primer was developed to provide a patient-centered care framework that could be used for teaching medical students and for caring for patients in cross-cultural situations. In 2003, the primer was distributed to all second-year students at the Harvard Medical School and to all Patient-Doctor II course directors and preceptors. Students used the primer to prepare for the Observed Structured Clinical Exam II (OSCE II), which includes a section on cross-cultural care. The primer has also been distributed throughout the school and its affiliated hospitals. Dr. Augustus A. White, III, chair of the CCCEC, is recommending that students use the primer with at least one patient.

The goals of the primer are to:

• Establish the importance of socio-cultural factors and their effect on health beliefs, behaviors, and medical care
  
• Learn a set of key concepts and skills that enhance the ability to communicate with, diagnose, and treat patients from diverse socio-cultural backgrounds (including identifying core cross-cultural issues, eliciting the explanatory model, determining the social context, using an interpreter, and provider-patient negotiation)
  
• Learn the practical application of these concepts and skills in the clinical setting

The primer says clinicians should follow four steps when caring for all patients, but in particular those patients who are from a social or cultural background different from that of the care provider. Clinicians should think of these four steps as a “review of systems” focused on issues that, if not addressed, may lead to poor health outcomes. The four steps are:

1. Identify the core cross-cultural issues
2. Explore the meaning of the illness
3. Determine the social context
4. Negotiate

Step 1—Identify the Core Cross-Cultural Issues. When a clinician sees a patient from a different or unfamiliar socio-cultural background, he or she should consider a broad set of core cross-cultural issues that may be important for that individual. The clinician should try to place the individual patient on a continuum as it relates to issues that are important to all cultures by considering the following:

• Styles of communication: How does the patient communicate? Communication includes issues relating to: eye contact, physical contact, and personal space; and issues about how the patient may prefer to hear “bad news.” For example, is the patient deferential or confrontational? Does the patient display stoicism or express symptoms willingly?
  
• Mistrust and prejudice: Does the patient mistrust the health care system? If so, clinicians should recognize prejudice and its effects and attempt to build trust by reassuring the patient of one’s intentions. Keep in perspective “what’s at stake” for the patient, and show respect for the patient’s concerns.
  
• Autonomy, authority, and family dynamics: How does the patient make decisions? What is the role of the family versus the individual in decision making? What support does the patient have from his or her family of origin, partner, and friends? What is the role of the authority figure within the family or social group? What role does community or spiritual leaders play in important decisions?
  
• The role of the practitioner and biomedicine: What does the patient expect of clinicians and what is the clinician’s role? What are the patients’ expectations for the practitioner and biomedicine? What perspectives does the patient have about the practitioner? Does the patient consider the clinician to be a service provider or gatekeeper, for example? What are the patient’s views on alternative medicine versus biomedicine?
  
• Traditions, customs and spirituality: How do these factors influence the patient? These attitudes include issues regarding medical procedures, such as drawing blood, and rituals pertinent to the medical encounter. What culturally specific “alternative” therapies does the patient consider, including culturally specific diet and preferences?
  
• Sexual and gender issues: How central are these issues to the patient’s life? Is there gender concordance or discordance? What attitudes does the patient have toward the physical exam and the gender of the practitioner? Clinicians should use the preferred pronoun for patients who are transgender or transsexual and consider the issue of shame or embarrassment when discussing sexual issues. Consider also the differences in sexual behavior, orientation, and identity.

Step 2—Explore the Meaning of the Illness. Each patient will have a different understanding about disease and treatment. These perspectives will shape the patient’s behavior. It may be particularly helpful to assess the patient’s concept of illness, or “explanatory model,” when the practitioner does not feel he or she understands the patient’s behavior, when there is non-adherence to a treatment plan, or when there is some sort of conflict.

Clinicians can make such determinations by asking the patient the following questions:

• What do you think has caused your problem? How?
  
• Why do you think it started when it did?
  
• How does it affect you?
  
• What worries you most: the severity of the condition, or duration of the illness, or both?
  
• What kind of treatment do you think you should receive? What expectations do you have?

Step 3—Determine the Social Context. The “social context” is of equal importance as an area of exploration, given how social and cultural factors are intertwined. Certain key areas should be considered when identifying the patient’s social context:

• Tension (social stress and support systems): Does the patient have social support, or is he or she isolated?
  
• Environment change (degree and reason for change, expectations, and acculturation): What was the patient’s previous health care experience, and how does that experience shape his or her interaction with the health care system now?
  
• Life control (including social status, poverty, and education): What resources does the patient have? Can he or she afford medications?
  
• Literacy and language: Does the patient have limited English proficiency or literacy, and how does such a limit affect his or her health care?

Step 4—Negotiate. Once the above information is obtained, the clinician should engage in negotiation with the patient to try to achieve the best possible outcome. Sometimes what is acceptable is better than what is optimal, if the risk of trying to secure the optimal would involve losing the patient’s trust. Such negotiation requires exploring the meaning of the illness for the patient and formulating a mutually acceptable plan.

When the clinician is caring for a patient with limited or no English proficiency, securing a trained interpreter is critical. Once the clinician has secured an interpreter, he or she should follow these guidelines:

• Pre-interview: Prior to interviewing the patient, meet briefly with the interpreter to discuss logistics, known issues, and the goals for the encounter.
  
• Etiquette: When possible, try to arrange triangular positioning, in which the clinician faces the patient and the interpreter is on the side or behind the patient. Positioning should be done so as to encourage a therapeutic and supportive relationship and to ensure that all parties can hear during the session. But positioning should also take into account the interpreter’s safety. In general, first person is encouraged. In some instances, however, first person may not work because of the linguistic nuances, or when using the first person might cause confusion. Confusion is not uncommon with elderly patients, and when the conversation is over the phone where there are no verbal cues. Also, direct eye contact with the patient is recommended, but making eye contact—or not—is a cultural norm that should be respected. If the clinician has a question about the patient’s meaning or length of response, ask the patient and interpreter to clarify. Be aware that there are cultural variations regarding preferred etiquette, and having a team approach—involving the patient and provider in which the interpreter serves as a culture broker—may help address differences.
  
• The dialogue: Try to use single questions and short phrasing, attend to the interpreter’s need to interpret what the each party is saying, and break long statements and questions down to shorter segments.
  
• Debriefing: Give and get feedback from the interpreter and ask for questions.

In some instances, the clinician may not have a formal interpreter or telephone-based interpretation service available. In such cases, the clinician may need a casual or ad-hoc interpreter, which could be a co-worker or family member, but never a child. Be aware that when using ad hoc interpreters, there is a higher risk of error than when using trained interpreters. Ideally, an interpreter should be neutral, and qualified to transmit confidential and sensitive information. It is the clinician’s responsibility to ensure that the communication is effective, especially if the patient insists on using a family member or friend. Children who are minors should not be used as interpreters in any clinical situation unless it is an emergency. A professional interpreter should be obtained as soon as possible. What’s more, clinicians must be aware of state laws regarding the use of health care interpreters. In Massachusetts, for example, interpreters are required in emergency rooms and mental health settings.

In the unusual circumstance of having to use an ad hoc interpreter, the following can serve as a guide on how to proceed:

• Recognize the importance of the perspective of the family member or friend, get that perspective, and then emphasize the importance of getting as much information as possible directly from the patient
  
• Trust one’s senses: If the responses seem inadequately translated, or the history is confusing, insist on getting a trained interpreter
  
• Keep in mind that when using a family member or friend, there may be significant issues involving confidentiality and accuracy, which could embarrass the patient, and so using an ad hoc interpreter might be ill-advised. Additionally, when domestic violence is involved or suspected, do not use spouses or partners as interpreters. In such cases, what may seem routine may not be true, and so a neutral person would be most effective as an interpreter in such situations

For more information on using interpreters, see General Guidelines for Effective Use of Interpreters in a Medical Setting, by M. Jean Gilbert, Ph.D., in Appendix A, The Toolbox.

B. A Family Physician’s Practical Guide to Culturally Competent Care–An Example of an Online Training Course

A Family Physician’s Practical Guide to Culturally Competent Care is a free online self-directed training course for family physicians offered by the Federal Office of Minority Health’s Cultural Competency Curriculum Modules (CCCMs). The Website for A Family Physician’s Practical Guide to Culturally Competent Care offers continuing medical education (CME) credit and is designed to provide family physicians with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve. The CME activity is supported through funds from the Office of Minority Health (ORM) of the U.S. Department of Health and Human Services.

ORM recognizes that there is growing concern about racial and ethnic disparities in health, that the health care systems needs to accommodate increasingly diverse patient populations, and that cultural and linguistic competence has become a matter of National concern. To train family physicians to care for diverse populations, ORM commissioned the modules.

The CCCMs were developed because cultural and language differences may engender misunderstanding, lack of compliance, or other factors that negatively influence clinical situations. By becoming aware of their own attitudes, beliefs, biases, and behaviors that influence patient care, health care providers can help improve access and quality and enhance outcomes. Among the specific objectives of the CCCMs are to:

• Improve the health of racial and ethnic minority populations
  
• Close the gap between minority and non-minority populations
  
• Coordinate the development and implementation of policies and programs affecting these populations.

The modules were developed with the intent that they would serve as a valued educational resource to equip family practitioners with specific cultural and linguistic competencies required to improve the quality of care for minority, immigrant, and ethnically diverse communities. Critical to their use, and hence to their effect on health care, is their widespread dissemination. Toward this end, the CCCMs were developed for CME credit. Participants are eligible for nine hours of CME credits. In addition, the modules were developed in several formats to increase usage by physicians and increase their dissemination in mainstream health care.

The modules are available as an interactive Website, on a DVD, and in a print version. Among the features of the Website are streaming video case studies, chat room functionality, instant scoring and CME certificate issuance, and links to additional resources. The site is designed to meet the needs of busy health care providers.

The Interactive Website

The Website for A Family Physician’s Practical Guide to Culturally Competent Care contains a variety of self-assessment tools, case studies, video vignettes, learning points, CME posttests, and the opportunity to submit and receive feedback regarding specific cases and content. The Website at http://cccm.thinkculturalhealth.org/ is free and serves not only as the portal to the CME program but also provides references on the latest issues in cultural and linguistic competency.

The CME program keeps track of which sections practitioners have completed, gives instant, on-line certifications for as many as nine hours of American Medical Association Category 1 CME credit and nine hours of American Academy of Family Physicians’ credit.

Once a practitioner registers on the Website to use the guide, he or she will be instructed to read the curriculum introduction and the overview of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (the CLAS standards). Practitioners also are instructed to read the themes and the background information about the cases, physicians, and patients introduced in the modules. Then the practitioner can begin to work through the contents of the modules and could start with any of three themes:

1. Culturally competent care
2. Language access services
3. Organizational supports.

Each theme includes three modules. The user must complete the modules in the theme in chronological order. Each module is organized in the following format:

The doctors’ week (case). This area introduces a case study in which a family physician must identify and meet the challenges of cultural or linguistic issues in clinical care. A supplementary video vignette is offered as well.

Self-exploration. This area includes questions designed to help clinicians understand their insights about and reactions to clinical situations. The user will be asked to answer, from different perspectives, questions about the case that follow the pattern of a modified BATHE (Background, Affect, Trouble, Handling, and Empathy) interviewing technique.

Learning points. This area informs course participants about the module topic.

Further exploration. The area asks the user to apply the module content to questions about the case and his or her medical practice.

Other perspectives. This section provides ideas from other curriculum participants about cultural and linguistic competency issues and their opinions about handling the cases.

Module posttest. The CME posttest includes 10 multiple-choice questions to test the participants’ knowledge of the module content. In order to receive CME credit, the user must achieve a score of 70 or higher.

Module components, learning objectives, and key points are provided in each module. Highlights throughout the text provide summaries of important concepts. Text boxes include facts about noteworthy aspects of culturally competent care.

Upon completion of this program, the user will be able to:

• Define issues related to cultural and linguistic competency in medical practice
  
• Identify strategies to promote self-awareness about attitudes, beliefs, biases, and behaviors that may influence the clinical care he or she provides
  
• Devise strategies to enhance skills used in the provision of care in a culturally competent clinical practice
  
• Demonstrate the advantages of the adoption of the CLAS standards as appropriate in a clinical practice

C. The DSM-IV TR Outline for Cultural Formulation When Assessing and Diagnosing Patients

Rendering psychological and psychiatric assistance to a diverse population carries with it some special issues as well as those more generally noted in other curricula. Consequently, faculty and clinicians in the mental health and behavioral health fields have been working to include diagnostic and clinical criteria that would assist practitioners in becoming more culturally and linguistically competent. One concise clinical tool to aid the clinician in this process is the Outline for Cultural Formulation (OCF) found in Appendix I of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (known as DSM-IV-TR) from American Psychiatric Association in Arlington, VA (www.appi.org).

Although intended for use with the DSM-IV TR in assessing mental disorders, the OCF is applicable to other clinical health care encounters. It provides a systematic review of the individual’s cultural background, the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that cultural differences may have on the relationship between the individual and the clinician. As a result of using the OCF, the clinician provides a narrative summary for each of the following categories:

1. Cultural identity of the individual
2. Cultural explanations of the individual’s illness
3. Cultural factors related to the psychosocial environment and levels of functioning
4. Cultural elements of the relationship between the individual and the clinician
5. Overall cultural assessment for diagnosis and care

1. Cultural identity of the individual. Note the individual’s ethnic or cultural reference groups. For immigrants and ethnic minorities, note separately the degree of involvement with both the culture of origin and the host culture, where applicable. Also note language abilities, use, and preference, including multilingualism.

2. Cultural explanations of the individual’s illness. The following may be identified: the predominant idioms of distress through which symptoms or the need for social support are communicated (such as “nerves,” possessing spirits, somatic complaints, and inexplicable misfortune), the meaning and perceived severity of the individual’s symptoms in relation to norms of the cultural reference group, any local illness category that the individual’s family and community use to identify the condition (such as those explained in the DSM-IV TR’s “Glossary of Culture-Bound Syndromes”), the perceived causes or explanatory models that the individual and the reference group use to explain the illness, and current preferences for and past experiences with professional and popular sources of care.

3. Cultural factors related to the psychosocial environment and levels of functioning. Note culturally relevant interpretations of social stressors, available social supports, and levels of functioning and disability. These stressors would include those in the local social environment and the role of religion and kin networks in providing emotional, instrumental, and informational support.

4. Cultural elements of the relationship between the individual and the clinician. Indicate differences in culture and social status between the individual and the clinician and problems that these differences may cause in diagnosis and treatment, such as difficulty in communicating in the individual’s first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy, and in determining whether a behavior is normative or pathological.

5. Overall cultural assessment for diagnosis and care. The formulation concludes with a discussion of how cultural considerations specifically influence comprehensive diagnosis and care.

The clinician assesses the first four interrelated sections, which provide information that will have an effect (in the fifth section) on the differential diagnosis and the treatment plan. Clinicians must cultivate an attitude of “cultural humility” in knowing their limits of knowledge and skills in applying the OCF with accuracy rather than reinforcing potentially damaging stereotypes and over-generalizations.

Cultural identity involves a range of variables not only including ethnicity, acculturation and biculturality, and language, but also age, gender, socioeconomic status, sexual orientation, religious and spiritual beliefs, disabilities, political orientation, and health literacy, among other factors. In addition, assessment of cultural identity must move from merely the clinician’s perspective to include the patient’s self-construal of identity over time.

The second section asks the clinician to inquire about the patient’s idioms of distress, explanatory models, and treatment pathways (including complementary and alternative medicine and indigenous approaches) and to assess these pathways against the norms of the cultural reference group. The third section highlights the importance of the assessment of family and kin systems and religion and spirituality. The fourth section focuses on the complex nature of the interaction between the clinician and the individual including transference and counter-transference, which may either aid or interfere with the treatment relationship. In the final section, the clinician summarizes his or her understanding of the previous sections and can apply this understanding to a differential diagnosis and treatment plan.

NAAPIMHA Curriculum on AAPI Mental Health

The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) has found the DSM IV TR Outline for Cultural Formulation provides a rich theoretical framework in making culturally appropriate assessments, diagnosis, and treatment plans. Using the DSM IV TR, NAAPIMHA developed a curriculum and pre-service training program in 2002 that is designed to help reduce disparities in mental health care for diverse populations by building a workforce capacity. The aim of the curriculum was to address the mental health needs of Asian Americans and Pacific Islanders and was developed under a grant from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

The curriculum, called Growing Our Own, is for the disciplines of psychiatry, psychology, social work, and counseling. It draws upon years of experience, assessing what does and does not work in providing culturally competent mental health services to the AAPI communities. It is being implemented at the Asian Counseling and Referral Services in Seattle, Wash.; the Asian Pacific Development Center in Denver, CO; Hamilton Madison House in New York, NY; Hale Na’au Pono in Wai’anai, Hawaii; and at two sites in San Francisco, CA: RAMS, Inc. and The University of California, San Francisco (UCSF) at San Francisco General Hospital. The sites were chosen based on their history of providing culturally competent services and training and their diverse geographical representation.

The five modules of the Growing Our Own curriculum build on each other and are intended to help the intern or resident develop an approach that avoids simplistic cookbook conclusions. The five modules are as follows:

Module 1 – Self Assessment helps interns or residents to recognize the biases that influence what we see and how these biases affect decision-making.

Module 2 – Connecting With Your Client is designed to help trainees become familiar with AAPI in general and provide them with the requisite knowledge, skills, and attitudes to communicate effectively with consumers and work with interpreters.

Module 3 – Culturally Responsive Assessment and Diagnosis is designed to identify factors that lead to the development of a culturally competent assessment and diagnosis.

Module 4 – Culturally Responsive Intervention focuses on concepts and strategies the intern or resident should consider in formulating and implementing a culturally responsive intervention plan, regardless of the particular intervention model employed.

Module 5 – Culturally Responsive Systems identifies barriers that consumers and service providers face under the current mental health system, highlights the important role of mental health professionals as agents of institutional change, and offers recommendations to help guide culturally competent systems change.