The Teaching of Cultural Issues in U.S. and Canadian Medical Schools

Abstract

Despite the importance of culture in health care and the rapid growth of ethnic diversity in the United States and Canada, little is known about the teaching of cultural issues in medical schools. The study goals, therefore, were to determine the number of U.S. and Canadian medical schools that have courses on cultural issues, and to examine the format, content, and timing of those courses.
The authors contacted the deans of students and/ or directors of courses on cultural issues at all 126 U.S. and all 16 Canadian medical schools. Using a cross-sectional telephone survey, they asked whether each school had a course on cultural sensitivity or multicultural issues and, if so, whether it was separate or contained within a larger course, when in the curriculum the course was taught, and which ethnic groups the course addressed.
The response rates were 94% for both U.S. (118) and Canadian (15) schools. Very few schools (U.S. = 8%; and Canada = 0%) had separate courses specifically addressing cultural issues. Schools in both countries usually addressed cultural issues in one to three lectures as part of larger, mostly preclinical courses. Significantly more Canadian than U.S. schools provided no instruction on cultural issues (27% versus 8%; p = .04). Few schools taught about the specific cultural issues of the largest minority groups in their geographic areas: only 28% and 26% of U.S. schools taught about African American and Latino issues, respectively, and only two thirds of Canadian schools taught about either Asian or Native Canadian issues. Only 35% of U.S. schools addressed the cultural issues of the largest minority groups in their particular states.
Most U.S. and Canadian medical schools provide inadequate instruction about cultural issues, especially the specific cultural aspects of large minority groups.

Full text

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E
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ESEARCH
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EPORT
The Teaching of Cultural Issues in U.S. and Canadian
Medical Schools
Glenn Flores, MD, Denise Gee, and Beth Kastner, MPH
A
BSTRACT
Purpose. Despite the importance of culture in health care
and the rapid growth of ethnic diversity in the United
States and Canada, little is known about the teaching of
cultural issues in medical schools. The study goals, therefore,
were to determine the number of U.S. and Canadian med-
ical schools that have courses on cultural issues, and to ex-
amine the format, content, and timing of those courses.
Method. The authors contacted the deans of students and/
or directors of courses on cultural issues at all 126 U.S. and
all 16 Canadian medical schools. Using a cross-sectional
telephone survey, they asked whether each school had a
course on cultural sensitivity or multicultural issues and, if
so, whether it was separate or contained within a larger
course, when in the curriculum the course was taught, and
which ethnic groups the course addressed.
Results. The response rates were 94% for both U.S. (118)
and Canadian (15) schools. Very few schools (U.S. = 8%;
and Canada = 0%) had separate courses specifically ad-
dressing cultural issues. Schools in both countries usually
addressed cultural issues in one to three lectures as part of
larger, mostly preclinical courses. Significantly more Ca-
nadian than U.S. schools provided no instruction on cul-
tural issues (27% versus 8%; p= .04). Few schools taught
about the specific cultural issues of the largest minority
groups in their geographic areas: only 28% and 26% of
U.S. schools taught about African American and Latino
issues, respectively, and only two thirds of Canadian
schools taught about either Asian or Native Canadian is-
sues. Only 35% of U.S. schools addressed the cultural is-
sues of the largest minority groups in their particular states.
Conclusions. Most U.S. and Canadian medical schools
provide inadequate instruction about cultural issues, espe-
cially the specific cultural aspects of large minority groups.
Acad. Med. 2000;75:451–455.
Dr. Flores is assistant professor of pediatrics and
public health, Boston University Schools of Medicine
and Public Health; founder and co-director, Pediatric
Latino Clinic, Boston Medical Center; consultant,
Center for MassHealth Evaluation and Research,
University of Massachusetts School of Medicine,
Worcester; and Robert Wood Johnson Minority Med-
ical Faculty Development Scholar. Ms. Gee is a med-
ical student, Boston University School of Medicine.
Ms. Kastner is research coordinator, Division of
Pediatric Emergency Medicine, Boston Medical
Center.
Presented in part at the annual meetings of the As-
sociation for American Medical Colleges, Washing-
ton, DC, November 3, 1996, and the Pediatric Ac-
ademic Societies, Washington, DC, May 4, 1997.
Correspondence and requests for reprints should be
addressed to Dr. Flores, Division of General Pediat-
rics, Boston Medical Center, 91 East Concord Street,
Maternity 419, Boston, MA 02118; e-mail: 具glenn.
flores@bmc.org典.
The United States and Canada rapidly
are becoming more diverse. Racial and
ethnic minorities comprise 28% of the
U.S. population
1
and 15% of the Ca-
nadian population.
2
It is estimated that
by 2000, minorities will outnumber
whites in at least three states and
the District of Columbia.
3
In eight of
the ten largest American cities, ethnic
minority groups already outnumber
whites.
4
In addition, more than 31 mil-
lion Americans are unable to speak the
same language as their health care pro-
viders.
5
Numerous studies have documented
that culture (including language) can
profoundly influence health care. Cul-
ture has been shown to affect access, ad-
herence, health status, continuity of
care, preventive screening, doctor – pa-
tient communication, analgesia ade-
quacy, use of harmful remedies, im-
munization rates, and prescription
practices.
6
Despite the importance of culture in
health care and the growing diversity of
the United States and Canada, little is
known about the teaching of cultural is-
sues in medical schools. Only one pub-
lished study has examined this topic.
Lum and Korenman
7
found that in
1991–92, most U.S. medical schools did
not have courses on cultural sensitivity.
Their study, however, had a 78% re-
sponse rate, and they did not survey Ca-
nadian medical schools or examine in

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detail the format, content, and timing of
courses. The objectives of our study,
therefore, were to (1) determine the
number of U.S. and Canadian medical
schools that have separate courses on
cultural issues; (2) examine the format,
content, and timing of courses; and (3)
investigate whether the cultural issues of
major ethnic groups are taught in these
courses.
M
ETHOD
Subjects
For 1996 to 1998, we attempted to con-
tact by telephone the deans or assistant
deans of students and/or the directors of
courses on cultural issues at all 126 U.S.
(excluding Puerto Rico) and all 16 Ca-
nadian medical schools. When tele-
phone contact failed, we also e-mailed
and faxed the deans and course direc-
tors. Up to eight calls per school were
made for initial non-responders to in-
crease the likelihood of a response.
Study Design and Survey
The study design was a cross-sectional
telephone survey. The survey instrument
consisted of the following questions and
requests: (1) Does your school offer a
course on cultural sensitivity or multi-
cultural issues? (2) If so, is the course
incorporated into the curriculum as a
separate required course or elective, or as
part of a larger course? (3) Please briefly
describe your course. (4) In which
year(s) of medical school is the course
taught? (5) How many years has the
course been in existence? (6) Which
ethnic groups are addressed in the
course?
The survey took five to ten minutes
to complete. We also requested supple-
mental course materials (syllabi or hand-
outs).
Definition
A course was considered to meet the
qualifications of teaching about cultural
issues if it had one or more of the fol-
lowing topics as a central focus: culture,
cultural differences, ethnicity, race, or
language and its relation to health care.
Analysis
Data were entered and bivariate analy-
ses performed using Epi Info 6.03.
8
Ma-
jor ethnic/racial groups in a U.S. med-
ical school’s region were identified using
data from the Statistical Abstract.
4
Multiple logistic regressions were done
in a stepwise fashion using True Epi-
stat
9
; two dependent variables were ex-
amined: course of any kind offered on
cultural issues; and separate course of-
fered on cultural issues. Independent
variables examined in multivariate
analyses included: medical school own-
ership (public versus private); age of
school in years, endowment in dollars,
percentage of women students, percent-
age of minority students, class size, and
preference given to applicants from the
inner city.
R
ESULTS
Response Rates
All medical schools that were success-
fully contacted agreed to participate in
the study. Only eight U.S. schools and
one Canadian school did not respond to
repeated contacts, for a response rate of
94% for each country (118/126, and 15/
16, respectively). We were unable to
determine why the nine schools chose
not to participate in the study.
Course Format, Duration,
and Timing
Only 8% of U.S. and no Canadian
medical schools taught cultural issues to
medical students in separate courses
(Table 1). Most schools (U.S., 87%;
Canadian, 67%) presented cultural is-
sues as a few lectures incorporated into
larger courses or electives; the numbers
of such lectures ranged from one to
three. Cultural issues were taught in
electives by 16% of U.S. but no Cana-
dian schools. Canadian schools were
significantly more likely than were U.S.
schools to offer no instruction on cul-
tural issues (27% versus 8%, respec-
tively; p= .04).
Most courses (both separate and in-
tegrated) in U.S. and Canadian medical
schools had been taught for less than six
years (Table 1). A surprisingly large pro-
portion of schools reported teaching
courses for more than 15 years. Several
schools in each nation stated that they
were uncertain how long the courses
had been taught.
The most common format for teach-
ing cultural issues in both countries was
case-based instruction (Table 1). Didac-
tic and group-learning formats were
used more often in U.S. schools,
whereas problem-based learning was
more common in Canadian schools.
Cultural issues were taught as part of
clinical clerkships in 6% of U.S.
schools, but in no Canadian school.
Most courses on cultural issues were
taught in the first two years of medical
school in both countries (Table 1). Ca-
nadian schools reported substantially
more often that they taught about cul-
tural issues in the third and fourth years
of medical school. For example, about
three fourths of Canadian schools said
that they taught about culture in the
third year, compared with about one
fourth of U.S. schools. About two thirds
of U.S. schools taught about culture for
only one to two years, whereas almost
three fourths of Canadian schools
taught about culture for three to four
years. Cultural issues were taught only
in the first two years by 61% of U.S.
and 27% of Canadian schools. Of note,
20% of U.S. and 36% of Canadian
schools reported teaching about culture
in all four years of medical school.
Course Coverage of Specific
Ethnic/Racial Groups
Most U.S. and Canadian medical
schools did not address the specific cul-

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Table 1
Selected Characteristics of Courses on Cultural Issues Taught in 118 U.S. and 15 Canadian
Medical Schools*
Characteristic
% of Medical Schools
U.S. Canadian
Course type†
Separate course 8 0
One to three lectures as part of larger course 87 73
Elective 16 0
None offered 8 27
Number of years course taught‡
0–5 41 50
6–10 15 13
11–15 12 0
>15 15 25
Unknown 15 13
Course format§
Case-based 59 63
Didactic 57 38
Group learning 31 13
Problem-based learning 10 38
Clerkships 6 0
Year of medical school in which course taughtن
First 84 91
Second 72 91
Third 28 73
Fourth 26 36
Unknown 7 0
Number of years during which course taught‡
11918
2489
3636
42036
Unknown 7 0
Ethnic group taught about**
African Americans/Africans 28 7
Latinos 26 7
Asians/Pacific Islanders 17 27
Native North Americans 17 27
Other 14 —
None 7 27
Unknown 15 7
*Survey responses received from 94% (118/126) of U.S. and 94% (15/16) of Canadian medical schools.
†Column total for U.S. schools exceeds 100% because some schools offered more than one course type (for
example, four schools offered a separate course, an elective,
and
instruction as part of a larger course).
‡May not sum to 100% because of rounding.
§Column totals exceed 100% because courses can consist of more than one format.
نDoes not sum to 100% because course can be given in more than one year.
**Column totals exceed 100% because schools may teach about more than one ethnic group.
tural issues of the largest non-white eth-
nic groups (Table 1). More than two
thirds of U.S. schools did not teach
about African American cultural issues,
and close to three fourths failed to
teach about Latino cultural issues. More
than 80% of U.S. schools did not pro-
vide instruction about cultural issues
of either Asians/Pacific Islanders or Na-
tive Americans. The specific cultural is-
sues of the largest non-white ethnic
group in a given medical school’s
state were taught by only 35% of U.S.
schools.
More than two thirds of Canadian
schools did not teach about cultural is-
sues of either of the nation’s two largest
non-white ethnic groups, Native Ca-
nadians and Asians/Pacific Islanders
(Table 1). Significantly more Canadian
than U.S. schools (27% versus 7%, p=
.03) provided no instruction about the
specific cultural issues of any non-white
ethnic group.
Multivariate Analysis
Multiple logistic regression analyses
revealed that none of the seven inde-
pendent variables (medical school
ownership, age of school, endowment,
percentage of women students, percent-
age of minority students, class size, and
preference given to those from the
inner city) was significantly associated
with either of the two outcome varia-
bles (having any instruction about cul-
tural issues and having a separate course
on cultural issues).
C
ONCLUSION
It is surprising that most U.S. and Ca-
nadian medical schools do not teach
about specific cultural issues of the larg-
est minority groups. In the United
States, there are 33 million African
Americans, 31 million Latinos, almost
ten million Asians/Pacific Islanders, and
two million Native Americans,
1
but
cultural issues of these groups are taught
by only 17% to 28% of U.S. medical

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schools. In Canada, there are 1.2 mil-
lion Asians (of Chinese, Southeast
Asian, Japanese, or Korean descent)
and 1.1 million Native Canadians,
2
but
cultural issues of either group are taught
by only 27% of Canadian medical
schools. Greater cultural understanding
might help to eliminate the often dra-
matic ethnic disparities in health and
use of health services that exist in both
countries, such as significant racial dif-
ferences in cardiac procedures.
10,11
Al-
though cultural competency is a rela-
tively new field, medical school course
directors already have several available
resources for teaching about cultural is-
sues, including textbooks
12,13
and cul-
tural competency models.
6
Another im-
portant but underutilized educational
resource is citizens and faculty from ma-
jor ethnic groups residing in a medical
school’s surrounding communities. By
providing patients’ and clinicians’ per-
spectives on culture and health care,
these community members can have a
key impact on medical students.
Many studies
6
document that culture
can affect doctor – patient communica-
tion, access to health care, health
status, and the use of health services,
but very few U.S. and no Canadian
medical schools offer separate courses
about cultural issues. It is also concern-
ing that most schools teach about cul-
tural issues in only one to three lectures
in larger courses during the preclinical
years. Because culture can profoundly
influence clinical care and because the
ethnic diversity of patients will only in-
crease, we recommend that medical
schools consider teaching cultural issues
in a separate, devoted course. Part of
this course or the entire course might
be given during the medical students’
clinical years, so that students can di-
rectly and immediately apply the prin-
ciples. A comprehensive course on
cultural issues might consist of presen-
tation of a cultural competency model,
skills for using interpreters, folk ill-
nesses, sessions on cultural issues of ma-
jor ethnic groups, and analysis of cases.
We believe that adequate instruction
on these essential concepts can be ac-
complished only in a semester-long (or
longer), separate, required course.
Three potential limitations of this
study should be noted. It is possible that
the reported courses of some medical
schools participating in this study may
not have corresponded to the actual
courses taught. The study results, there-
fore, may overestimate the prevalence,
content, and ethnic coverage of courses
on cultural issues. Because the study
findings, however, already indicate that
the teaching of cultural issues in medi-
cal schools is not adequate, such over-
estimates would not alter the conclu-
sions. A second potential limitation is
that the people we interviewed may not
always have been aware of all courses in
which cultural issues were taught. It is
therefore possible that some courses
were overlooked in which a lecture or
component was devoted to cultural is-
sues. This might have led to an under-
estimation of the number of schools of-
fering any instruction on cultural issues,
but would not affect this study’s findings
regarding the limited number of schools
offering separate courses focusing on
cultural issues. A third limitation is
that, as with other surveys that do not
have a 100% response, non-response
bias may have distorted the findings.
Because response rates were high (94%
for both countries), however, the results
could change by no more than 6% with
full response by all schools, which still
would not substantially alter the con-
clusions.
It is not clear why most Canadian
medical schools have lagged behind
their American counterparts in teach-
ing cultural issues. Canadian schools
significantly more often offer no course
on cultural issues and no instruction
about the specific cultural issues of any
non-white ethnic group. These findings
are particularly surprising given the re-
cent creation of a new territory, Nuna-
vut, in which 85% of the residents are
Inuit.
14
These results are also of concern
in light of data that show the multilin-
gual nature of Canada is growing as a
result of increased immigration. In
1996, for example, 4.7 million Canadi-
ans, or 16% of the total population,
reported a mother tongue other than
English or French, a 15% increase
from 1991.
15
This increase was 2.5
times faster than the overall growth rate
of the Canadian population. The
greater recognition of diversity and the
growing multilingual population in
Canada suggest that a critical priority
for medical schools should be teaching
cultural issues to future Canadian phy-
sicians.
Fewer U.S. medical schools teach
cultural issues now compared with ear-
lier in the decade. A 1991 study
7
found
that 13% of U.S. schools had separate
cultural sensitivity courses, compared
with 8% in our study. It is disturbing
that the teaching of cultural issues in
U.S. and Canadian medical schools is
inadequate and may be getting worse,
particularly given the rapid growth of
diversity in both countries and mount-
ing evidence on the important effects of
culture in clinical care. Our findings
suggest that a required medical school
course on cultural issues would reverse
these disturbing trends, and ensure that
we train culturally competent physi-
cians able to provide quality care, with
improved communication and patient
satisfaction.
The authors thank Deborah Danoff, MD, for her
assistance during several phases of the study, and
Gregory Lawson, for providing information about
US medical schools for the multivariate analysis.
Supported by grants from the Robert Wood John-
son Minority Medical Faculty Development Pro-
gram (#030878) and an Institutional Research
Training Grant of the Health Resources Services
Administration (HRSA).
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