INTRODUCTION

Research has shown that perceived sociocultural differences can affect communication and decision making and are directly linked to patient satisfaction, treatment plan adherence, and overall care quality.1,2,3,4 “Cultural competency” and “cultural humility” have emerged as approaches to addressing these differences in the healthcare system. Cultural competency has been defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable… (providers) to work effectively in cross-cultural situations.”5,6 Some argue that cultural competency is an unfeasible goal and that it is unrealistic to set this as a standard for health professionals. Others propose that providers should strive for cultural humility, a set of skills focused on continuous learning and self-reflection on one’s interactions with individuals from cultures different from their own.7 As cultural competency is an older term and appears more frequently in the literature, the authors use this going forward, acknowledging that many institutions have embraced the term cultural humility.

Healthcare training institutions have the responsibility to cultivate the compassion and humanism needed to produce well-rounded providers. The Liaison Committee on Medical Education (LCME) suggests that the medical curriculum should include teaching on the importance of developing strategies for addressing healthcare disparities, the principles of culturally competent care, and the ways in which culture affects a patient’s experience of symptoms, disease, and treatment.8 Most accreditation bodies do not provide guidelines on how to accomplish this task, and as such, medical schools have implemented a myriad of teaching and assessment methods related to cultural competency and humility.8,9

Prior systematic reviews have examined curricula for healthcare professionals to analyze the impact of cultural competence training. Multiple studies have shown that cultural competency curricula positively changed provider skills, knowledge, and attitudes. Beach et al.10 found that there was good evidence that cultural competency interventions improved patient satisfaction, but limited evidence that these interventions led to improvement in health outcomes. The current authors set out to review the cultural competency literature and noticed a lack of studies outlining what topics medical schools were focusing on in their cultural competency interventions. Additionally, there was no standardized conceptual framework to categorize published interventions by length, teaching approaches, or whether the intervention was required for graduation.

The authors’ goal for this work was to review the field of cultural competency curriculum for medical students and to categorize current published practices. The authors hope to identify gaps in the current literature such that medical educators are better equipped to develop deliberate curriculum focused on caring for diverse populations.

METHODS

A scoping review was completed by searching the databases PubMed, Scopus, MedEdPORTAL, and MEDLINE. The terms used in PubMed were “medical education” AND (“cultural competency” OR “cultural competence”), which yielded 490 articles. Scopus was searched using the terms “medical education” AND (“cultural competency” OR “cultural competence”), yielding 798 articles. MEDLINE was searched using the following: (“Education, Medical”[Mesh] OR “Education, Medical, Undergraduate”[Mesh]) AND “Cultural Competency”[Mesh], for a result of 358 articles. As the term cultural humility is newer, it did not have its own MESH term and it was not included. Finally, MedEdPORTAL was searched using the term cultural competency which yielded 155 articles. This search resulted in 1801 total articles.

The resultant articles were considered eligible if they met the following criteria: (i) written in or translated into English; (ii) published on or prior to December 31, 2017; (iii) had full text accessible online for review; and (iv) described a specific cultural competency intervention targeted to medical students. To reduce selection bias, two reviewers independently reviewed the results from each database to determine the articles that met the inclusion and exclusion criteria (J.R.D. and F.F.). Any discrepancy was discussed with at least one other reviewer and resolved by majority opinion. Reviewers used the inclusion and exclusion criteria to review abstracts, by which 1476 articles were discarded. The remaining 325 articles were reviewed in their entirety. One hundred and seventy-one articles were excluded for not fulfilling the inclusion criteria, and of which, 29 articles were excluded since they did not have full text accessible for review. This resulted in 154 articles fulfilling criteria with full text available, which were included in the analysis of this literature review (Fig. 1).

Figure 1
figure 1

Flow diagram and results of literature review. Using PubMed, MedEdPORTAL, Scopus, and MEDLINE databases, 1801 articles were identified. During screening of titles and abstracts, 1476 were removed based on inclusion and exclusion criteria. One hundred and seventy-one articles were then excluded after full-text review because they did not meet criteria or the full text was not available. One hundred and fifty-four articles were included in final synthesis.

A modified narrative synthesis format for discussing results was chosen for the conceptual framework as the articles varied in terms of research designs and data outcomes.11,12 The stages of the narrative synthesis included the following: (1) developing the preliminary synthesis, (2) comparing themes within and between studies, and (3) thematic classification. The preliminary synthesis included extracting the following data: length of intervention, teaching methods, country of origin, outcome measure, voluntariness of the intervention, type of intervention employed, and summary of main study findings. Interventions were placed into five categories by length: 1–3 h, half day to 1 day, 1 day to 1 week, longer than 1 week, and longitudinal throughout a year or entire curriculum. Interventions that did not have lengths mentioned were classified as undetermined. Two independent reviewers thematically categorized each study by area of focus (J.R.D. and F.F.). Finally, the authors resolved uncertainties in classification through discussion with multiple reviewers (K.E.J., F.F., J.R.D., J.T.). Studies that were particularly innovative or broadly reflective of the category were highlighted. As many of the selected articles had disparate outcome measures, such as standardized patients’ feedback, pre- and post-surveys, and focus groups, the efficacy of interventions was not compared.

RESULTS

Interventions Identified

One hundred fifty-four unique articles fulfilled all inclusion criteria (Fig. 1). These were subsequently categorized by teaching methods, length of intervention, topics covered, outcome measure, and voluntariness of participation (Table 1). Topics identified were placed into two major categories, “General” and “Specific Population.” Those in the “Specific Population” category were further classified into categories including race/ethnicity, global health, rurality, socioeconomic status, language, refugee/asylum seekers, disability identities/deaf culture, religion/spirituality at the end of life, and Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ). Most interventions utilized lectures to teach students (83/154). Discussion groups were another popular teaching format (56/154). Most interventions (64/154) were 1-h to 3-h events, and 45/154 of interventions were longitudinal. Most of the studies evaluated the intervention (139/154) with many using surveys (100/154) and knowledge-based tests (23/154).

Table 1 Intervention Classification

Specific findings for each category are described in the following subsections. Interventions with interesting approaches in their teaching methods, evaluation, or content are also included.

General

Fifty-six articles were classified as general, which included programs that provided frameworks for communicating with patients of diverse backgrounds, emphasized identifying one’s own bias, and/or focused on general principles for addressing sociocultural determinants of health.7,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66 Of the 56 articles, 20 were 1–3-h experiences, six were half day, three were between a day and a week, three were greater than 1 week, 23 were longitudinal activities, and one article did not discuss program length. The most common teaching method was lecture (31/56), followed by discussion (26/56). Other popular teaching methods included written reflections (14/56), role-play (11/56), standardized patient encounters (10/56), and online modules (8/56). Of the general interventions, 34 were required. Forty-four of the 56 interventions were evaluated: surveys were the most popular form of analysis (34/56), knowledge-based tests (5/56), standardized patient encounters (4/56), focus groups (2/56), and interviews (2/56).

In Betancourt and Cervantes, students learned to approach patients by assessing core cross-cultural issues, exploring the meaning of illness, determining social context, and engaging in negotiation. The authors stressed the importance of combining the knowledge of specific cultures with general communication skills that are applicable for diverse patient populations.17

Similarly, Dao et al.16 sought to avoid the propagation of stereotypes by providing students with a general approach to patients of diverse backgrounds. Students were introduced to fundamental sociomedical themes to help them understand the impact of these factors on patient care. Themes included socioeconomic class, race, gender, LGBTQ issues, “compliance,” the medical gaze, faith, and advocacy.16

Specific Populations

Ninety-eight articles were identified that described programs focused on a single population and the sociocultural factors that affect its members’ health. These interventions were further subdivided into the following categories: race/ethnicity, global health, socioeconomic status, language, refugee/asylum seekers, disability identities and deaf culture, spirituality at the end of life, rurality, and LGBTQ.

Race/Ethnicity

Twenty articles identified interventions that addressed specific racial/ethnic populations without involving travel abroad.67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86 Seventeen of the 20 interventions were developed at US medical schools, while the remainder were from New Zealand, Canada, Australia, Romania, Germany, and Russia. Nine articles focused on populations that were indigenous to the study’s country of origin. Seven of the interventions were 1–3 h, one was half day, three were less than 1 week, four were integrated into clerkships, and five were longitudinal experiences. A multitude of teaching methods were employed including lecture (9/20), cultural immersion component (7/20), online modules (6/20), and videos (4/20). Nineteen of the articles evaluated their programs with the majority using surveys. All programs reported positive outcomes including improvement in students’ attitudes and acquisition of skills to provide population-specific care.

One Canadian study used videos about the care of Chinese patients and showed that 67.3% of students had learned useful strategies to better serve immigrant patients.73 An overwhelming 79.6% of respondents stated that online videos could be an effective method in cultural competency training. Another article compared two different types of online interventions: a module on interprofessional communication and a patient encounter between a student and a Salvadoran family.74 Students were evaluated through a standardized patient, and those who were exposed to the virtual patient module outperformed students who were not exposed to the module.

Global Health

Fifteen articles were identified that focused on cultural competency development through global health experiences.87,88,89,90,91,92,93,94,95,96,97,98,99,100,101 Fourteen of these described interventions with cultural immersion outside of one’s home country as the main teaching method, with nine of the 14 providing clinical experience. One intervention described a 3-h course preparing students to complete a global health program.101 Eleven of the interventions were 1 month to a semester long, three were longitudinal, and one was 3 h. Additional teaching methods included written reflections (4/15), lectures (6/15), discussions (4/15), online modules (1/15), and videos (1/15). None of the international interventions were required for medical students. Most of the articles used surveys to analyze outcomes, although three also used interviews with students and two used a focus group. In those interventions that addressed outcomes, the majority of students rated their program favorably.88,89,90,91,92,93,94,95,96,97,98,100

In the study of Nishigori et al.,96 students participating in an exchange program between the UK and Japan noted that they developed a deeper understanding of different healthcare systems. Mao et al.94 reported that students taking an acupuncture and traditional Chinese medicine elective “increased their understanding of the challenges faced by immigrants who try to negotiate the complex healthcare system.”

Of note, two of the articles evaluated the effects of their programs with long-term follow-up. Hutchins et al.97 showed long-lasting effects in former participants of a One Health trip to Ecuador, especially regarding the use of Spanish language and cross-cultural skills. Jacobs et al.98 reported a similar outcome with participants in an exchange program from Germany to Ethiopia after 8 years.

Socioeconomic Status

Six articles were identified specifically addressing issues affecting patients of low socioeconomic status (SES).102,103,104,105,106,107 Five of the interventions were extended clinical experiences, and one was 1–3 h. Four of the six used lectures as a teaching modality, and two used a small group. Standardized Patient (SP) sessions, online modules, and written reflections were also used.

Turner and Farquhar102 used an interprofessional curricular program to help students identify and understand the relationship between health conditions and poverty and work to promote the welfare of people who are economically disadvantaged. Students who completed the intervention performed better than students of the prior year on standardized patient encounters and the USMLE Step 2 Clinical Skills Exam.102

In the study of Sheu et al.,104 students volunteered at student-run clinics targeting low-income populations. Participating students reported improved understanding but did not score differently on validated surveys of sociocultural attitudes when compared to students who did not participate.104

Language

Thirteen articles focused on the language barriers affecting clinical care.108,109,110,111,112,113,114,115,116,117,118,119,120 Five of the interventions were longitudinal, seven of these interventions were 1–3 h, and one was two and a half weeks. Eight out of the 13 interventions were mandatory. Almost all interventions included opportunities for students to practice their communication skills, whether through role-play, clinical experiences, online modules, or standardized patient encounters. Three interventions also consisted of a lecture on working with interpreters. Most of the articles described positive results and good student reviews. Nevertheless, one article found that almost 40% of students failed to use interpreters in an encounter with a patient of limited English proficiency.111

Zanetti et al.115 described a 4-year program that promotes cultural competency through civic engagement and second language fluency. Students who participated reported greater confidence in obtaining a medical history in a different language, advocating for the healthcare needs of underserved populations, and assessing the health beliefs and practice of patients from other cultures.115

Refugees or Asylum Seekers

Six articles which discussed interventions were aimed at populations of refugees or asylum seekers.121,122,123,124,125,126 One article described a 1–3-h intervention, one was a full day, three were longitudinal, and one did not specify time course. Most used lectures and clinical experiences as teaching methods. Evaluation methods included surveys and essays. Asgary et al.121 taught students about asylum law through a series of lectures, workshops, and clinical sessions. This intervention made use of hands-on work preparing medical affidavits to help patients receive governmental services of which 89% were accepted in court. The students improved their attitudes toward asylum seekers, knowledge of effects of torture, and efficacy in clinical evaluation.121

Disability Identities and Deaf Culture

Ten articles were identified that addressed interventions related to disabilities, a physical or mental impairment that limits the patient’s daily activities.127,128,129,130,131,132,133,134,135,136 Only one of the articles described a longitudinal intervention with three of the ten describing 1-h- to 3-h-long programs. The articles emphasized the importance of experience interacting with people with disabilities and developing a greater understanding of the problems they face when accessing healthcare. Nine of the interventions taught using lectures, two included standardized patient encounters, three used videos, one had an immersive experience, five used clinical experiences, and the last used role-play.

In the study of Thew et al.,133 medical students attended a lecture and then a role reversal scenario, in which students attempted to communicate without speaking to deaf volunteers acting as providers. Students rotated through a doctor’s office, a pharmacy, and an emergency department and then discussed their experiences in small groups. This intervention was evaluated with surveys and found improvement in the student’s comfort interacting with deaf patients.133

Hagood et al.131 describes an elective course focusing on the transition from pediatric- to adult-centered care and the impact of chronic illness on independent functioning. Students reported that they appreciated the opportunity to interview caregivers and patients with cystic fibrosis.131

Spirituality and End of Life

Seven articles were identified that focused on issues of cultural competency related to religion and spirituality in the palliative care setting.137,138,139,140,141,142,143 Six of the interventions were 1–3-h experiences, and the last was during a third-year clerkship. All the interventions were voluntary. For teaching methods, three interventions used lectures, two used online modules, and two used role-play. To evaluate program efficacy, two of the seven articles used reflective essays, and three used surveys. The remaining articles used SP exams and knowledge-based tests.

One interdisciplinary intervention employed an online module for students from schools of medicine, social work, nursing, and chaplaincy. Through qualitative analysis of survey responses, the study concluded that students benefited from the program, but that medical students were less comfortable addressing palliative care and religion than students from other programs. The authors propose that medical students might feel less confident because they have less experience with discussions about religion in their standard medical curriculum.142

Rurality

Three articles were identified that focused on rural populations, two from the USA and one from Australia.144,145,146 Two of the three interventions were longitudinal, and the last was a week long. All interventions used immersion as a teaching method and were evaluated, using surveys in two interventions and an interview in the other. Daly et al.144 placed students in a clinical setting in a rural area for 6 months. After this experience, the investigators conducted interviews with medical students, supervisors, and clinicians. Participants reported improved cultural awareness and personal/professional development and identified potential barriers to practicing in rural communities including academic isolation, geographical issues, and perceived education risk.144

LGBTQ

Eighteen articles were identified as focusing on cultural competency training on gender and sexual minorities.147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163 Most of the interventions (16/18) were designed as 1–3-h sessions, used lectures as a teaching modality (8/18), and used surveys as an assessment tool (15/18). SP sessions were also commonly used to teach and assess students’ ability to take an inclusive sexual history. Vanderleest and Galper147 describe a mandatory lecture-based intervention that educated second-year students on terms including “transgender,” “transsexual,” and “transition.” The lecture also taught students about how discrimination and bias contribute to transgender health disparities.147 In another SP session, students took a social history and discovered that the patient was questioning their sexual orientation and dealing with family pressures. Eighty-seven percent of students rated the session as good or excellent.150

DISCUSSION

Prior reviews have not focused on cultural competency training for medical students specifically and included providers at different levels of training and from different professions.10,164,165 This review focuses on medical students and is unique in that it identifies the primary teaching methods, lengths of interventions, topics covered, and evaluation methods used in published cultural competency interventions. Most interventions (54%) used lectures as a teaching modality, and 64% of the interventions were about specific populations. Most used some form of evaluation, with almost 65% using surveys to evaluate student improvement. Of note, about half of the programs were voluntary which introduces selection bias and can affect the student’s self-perception of improvement.

As expected, lectures remain the predominant teaching modality in medical school.166 It has become increasingly common for medical schools to expand their teaching to include non-traditional modalities such as team-based learning, standardized patients, and simulated patient experiences.166,167,168 As the curricular interventions for cultural competency training develop, medical schools should continue to move beyond lectures to encompass other teaching methods.

The use of computer modules as a teaching modality was explored in several studies. Online modules and virtual patient interactions can be ideal methods to provide students an opportunity to trial different communication techniques in a low-risk environment. However, no studies directly compare the effectiveness of virtual patients to standardized patient encounters representing a gap in the current medical education literature.

A divide between the philosophies behind general versus specific population-focused interventions became apparent in reviewing the literature. Some authors argue that focusing on factual knowledge of a specific population increases the risk of promoting stereotypes and promotes the idea that one can gain complete understanding of another culture. These authors advocated for programs that focus on one’s own biases and learning general strategies for cross-cultural communication.16 The efficacy of interventions that focus on specific populations compared to those that employ a more general model should be evaluated through a randomized controlled trial.

In addition to formally comparing teaching styles, specific interventions should be assessed in a standardized way. The Tool for Assessing Cultural Competence Training (TACCT) was developed by the Association of American Medical Colleges (AAMC) to assess the entire curriculum of an institution. It does not, however, assess skills gained from individual interventions and their specific impact on a student’s knowledge and abilities.169 Furthermore, the TACCT was not designed to suggest teaching strategies. The development of a separate tool to examine educational goals and student outcomes from individual interventions would be a useful tool for more standardized evaluation of smaller components of curricula. Similarly, Gozu et al.164 found that most educators have limited access to objective and standardized evaluation tools for cultural competence training interventions.

Strengths of this study include the number of papers reviewed, the description and analysis of the components of the interventions, and the inclusion of papers from different countries. However, there are several limitations in the present review. First, this review is subject to publication bias, given that the authors are unable to speak to non-published interventions. Second, given the lack of direct comparisons between teaching methods and intervention types, the authors are unable to speak to relative effectiveness. Lastly, cultural competency as both a scholarly concept and search term presents a limitation. Cultural competency as a MESH term may not capture all dimensions of culture and diversity.

CONCLUSIONS

The available literature describes a myriad of educational interventions for medical students that address the unique obstacles they may face when caring for patients of different backgrounds. The authors advocate for further research into non-traditional modalities, such as low-cost and easily disseminated online modules. Further research should focus on developing standardized assessment tools for these interventions, as well as randomized controlled trials to compare the relative effectiveness of general and population-specific cultural competency interventions.