An exciting course that challenges you to explore how culture and language impact the effectiveness of clinical encounters.

Come learn from distinguished clinicians and researchers about the role of race and culture in caring for patients. The speakers will present insights, findings, and programs targeting culturally diverse patients.

Cross-cultural medicine is a rapidly growing area, and an area that can enrich your own personal perspective on the delicate interplay that race and ethnicity have on health care. This course will examine and promote culturally competent health care.

This course is designed to provide information that will help health care professionals provide culturally competent patient care.

As the ultimate goal, “cultural competence” may be viewed as that combination of awareness, knowledge, skills, attitudes and behaviors, which, when applied in the health care setting, results in a maximally beneficial outcome for both the patient and the provider. A general framework for cultural competence follows:

As a largely didactic course, Ethnicity and Medicine will focus mainly on the “knowledge” branch of the cultural competency formula (however, discussion section will focus on skill-building, and lecturers will address clinical skills when appropriate). The following graphic illustrates the teaching framework used in Ethnicity and Medicine:

Ethnicity and Medicine will build a knowledge base in the context of the five major dimensions of how culture impacts patient care. These five dimensions are outlined in the Course Curriculum below, along with specific examples of material presented in this course. Finally, as depicted in the graphic, Ethnicity and Medicine will begin to make connections between cultural competency at the individual practitioner level and how that can translate to the American health care delivery system in general.

A second major goal for this course is to stimulate interest in, encourage, and promote continued interest in cross-cultural medicine among students. It is our hope that this course will help launch career interests in the rapidly emerging field of cross-cultural medicine. Through this course, you will be exposed to new ideas, you will be introduced to some of the leaders in the field, and you will begin to become familiarized with the resources available here at Stanford. The field of cross-cultural medicine is wide open, and we hope that with the help of this course, students will be stimulated to seek out pre-clinical, clinical, public service, and research opportunities in related areas. Today’s students are on the cutting edge of cross-cultural health science research, and with Stanford’s impressive research infrastructure, it is our goal to promote student involvement in the expansion of knowledge which is so critically needed in this area.

Each section of the syllabus contains a short introduction which includes prompts to help students conceptualize the material in terms of the following five course objectives. Throughout the course, students should constantly evaluate and conceptualize the information they receive in terms of these five dimensions:

1. Awareness/Sensitivity. Obviously, the lectures, readings and discussions should serve to heighten one’s awareness of how cultural variables may influence health, illness, and the giving and receiving of health care interventions.

2. Knowledge of Self. In the study of cross-cultural medicine we will examine the various values, beliefs, customs, patterns of thought and behavior, and other variables which may distinguish one group of people from another, and which may impact health, illness, and the giving and receiving of health care. To understand these factors as they play in the lives of other people, we must first have a solid understanding of how they influence us in our own lives. A knowledge of self is critical to the understanding of others. Without a knowledge of self, one has nothing against which to compare the characteristics of others.

As issues come up for various ethnic groups throughout this course, students are encouraged to constantly relate these issues back to their own experience, comparing and contrasting, and working to truly identify the nature of differences which may exist between oneself and the ethnic/cultural group being studied.

3. Knowledge of Others. Developing a knowledge-base about the intersection of ethnicity and medicine is clearly a main objective of this course. Within each unit of this course, students should attempt to outline the issues most relevant to the ethnic group(s) being studied, and to develop a base of knowledge regarding each group. As noted in 2 above, this information should be constantly compared and contrasted to one’s knowledge base regarding self. Cautionary Note: it is important to remember that in developing a “knowledge base” about a particular ethnic group, one is engaging in the act of stereotyping. The information in such a knowledge base will not necessarily apply to all members of the group in question, and relying too heavily on such a knowledge base can lead to a ”cookbook” approach to clinical medicine, with a basis on stereotypes which may or may not hold for individual patients or colleagues (see “Thinking About Ethnicity with Respect to Medicine” below for further discussion).

4. Skill-building. Within each unit in this course, students are encouraged to actively search for clinical applications to the issues raised. Practical skills form the functional interface between ethnicity and medicine. Without the proper skills, awareness and knowledge base become largely academic and are virtually useless to us as clinicians. In the context of cross-cultural medicine, “skills” refers largely to one’s ability to communicate effectively. The ability to elicit information, listen, understand, explain, recognize differences, and negotiate treatment intervention competently and sensitively, reflects learned skills. Like all skills, these abilities require first an understanding of their application, and secondly they require practice. Fortunately, the skills of cultural competence can indeed be learned by everyone if given the desire. As a mainly didactic course, Ethnicity and Medicine will serve mostly to help students identify and understand the application of the various skills of communication employed in cross-cultural medicine. The discussion section will provide greater opportunity for students to practice communication skills in the context of cross-cultural medicine through case studies, role-plays, and other experiential activities.

5. Integration. The ultimate goal for the study of ethnicity and medicine is to develop awareness, knowledge, skills, attitudes, and behaviors in parallel, such that one begins to develop an integrated approach to the practice of medicine. As we move through the course, you are encouraged to actively try to make cognitive and behavioral connections between the awareness, knowledge, skills, attitudes, and behaviors which will develop along the way.

Several key concepts which should always be kept in mind when studying aspects of cross-cultural medicine are outlined below. They may help serve as “guideposts” in your study of ethnicity and medicine, in this course and beyond.

Broadly Defining “Culture.”

“Culture,” it turns out, is a fairly difficult term to define. In fact, there are probably as many definitions of “culture” as there are people who have tried to define it. In the context of medicine, it is useful to define “culture” very broadly, as consisting of the assumptions, beliefs, and expectations that influence behaviors and decision-making. Thus, we might include such typical variables as race, ethnicity, country of origin, and so on, in our definition. But we might also include such things as socio-economic status, sexual orientation, gender, age, ability (the other way of looking at “disability”), degree of acculturation, and religious conviction. Note that each of these latter variables cuts across all racial/ethnic lines. This course, Ethnicity and Medicine, focuses somewhat more narrowly on ethnicity and the closely related but distinct issue of race. This is by necessity, given only nine class meetings. Thus, one of the major dilemmas of this course is how to cover the wide range of elements contained in the broader conceptualization of culture, while focusing primarily on ethnicity, and given the existing time constraints. As a partial solution, we encourage breadth of thinking as you complete the readings, listen to lectures, and participate in discussions.

This course may be viewed as a “sampling” of ethnicity and medicine, which is, in turn, a sampling of the broader topic of culture and medicine. The sampling which this course provides is a very valuable one, and this is particularly true when one considers the study of cross-cultural medicine as a lifelong endeavor, one which will require continual sampling of the myriad topics out there.

Intra-cultural Variation

In the study of cross-cultural medicine it is easy to make generalizations about particular cultural groups (without such generalizations there would be no point in studying cross-cultural medicine). However, one VERY important point is often overlooked, or becomes lost along the way, and that is this: Often THERE IS GREATER VARIATION WITHIN ANY GIVEN CULTURAL GROUP (e.g., African-Americans, East Europeans, female or male homosexuals, the poor, etc.) THAN THERE IS AMONG CULTURAL GROUPS, especially within similar socioeconomic levels. Thus, for example, if we had a group of 10 “White” subjects and a group of 10 “Hispanic” subjects, we would likely find that while the individuals in each group differ greatly, if we could somehow average the individuals in each group, the “White” group would not be that different from the “Hispanic” group. Geneticists describe this as the fact that there is often more intra-racial genetic diversity than inter-racial genetic diversity. This simple concept is commonly overlooked or ignored in practice. Indeed, if we could all always remember this simple fact, there would be little or no need for so-called “sensitivity training,” because we would automatically treat each person as a highly unique individual (regardless of skin color, style of dress, pattern of speech, etc.) first and foremost, and only later would we pay any attention to possible generalizations regarding groups to which she or he may belong.

Stereotypes May Result from the Study of Culture/Ethnicity in Medicine

An important corollary to the above notion of intra-ethnic diversity is the fact that in studying culture/ethnicity in medicine, we do make generalizations about specific groups of people. For example, we may say (or hear) that Native American Indians are at much greater risk of experiencing alcoholism than the population as a whole. This is a statistical reality. However, if as a clinician we see a Native American Indian in our practice and presume for some reason that she suffers from alcoholism, we are stereotyping, and this not only has broad societal ramifications, but it may also negatively impact the clinical encounter, reducing the satisfaction of both the patient and the clinician. On the other hand, if this same woman comes into our practice and we work her up, conscious of the fact that alcohol may be an issue, but not necessarily expecting it to be so, we are “hypothesis testing,” rather than stereotyping, and we are practicing good medicine and doing our patient a service. The distinction between stereotyping and hypothesis testing is fairly subtle, but very important, and hinges mainly on how we use the information we have about particular groups of people.

All People Possess Preconceptions, Misconceptions and Biases Regarding Others

For some people this is hard to believe. Regardless of our good intentions, WE ALL REGULARLY STEREOTYPE OTHERS. This doesn’t make us bad people, it simply makes us human. Think about a group with which you have had little or no experience. Now, consider what you know about members of that group, regardless of how little it may be. There, you’ve just stereotyped a member of a particular group. See how easy it is? We all do it. And we do it all the time. Recognizing this tendency, what can be done? As physicians we are devoting ourselves to taking care of others. Indeed, we are pledging to provide the best care possible, often to complete strangers. Providing optimal care necessitates that we do everything possible to ensure sensitive and competent treatment. Ultimately, this requires that we learn to recognize our own preconceptions about others, and then learn to work around these preconceptions. It is probably not realistic to presume that one can stop having preconceptions about others. However, it is realistic to learn about our biases and how they can lead to poor patient outcomes. By learning to hypothesis test rather than stereotype, we may be empowered to apply our knowledge of cross-cultural issues without damaging the patient-provider relationship in the process.

Understanding Self is Key to Understanding Others

A central principle in the study of cross-cultural medicine is that the study of others begins with the study of self. In order to sensitively and effectively approach individuals from cultural backgrounds other than our own in a medical setting, we must first have an understanding of the factors which makes us, as individuals, culturally unique. What values, beliefs, customs, characteristics, social norms and mores make you an unique individual? These culturally-related factors will undoubtedly differ from person to person. Furthermore, these factors may have profound influences on how an individual approaches their own health, illness, and health care. Thus, as clinicians, we will commonly be faced with situations in which our own values, beliefs, customs, characteristics, and social norms and mores will differ significantly from those of our patients. One useful paradigm for approaching the cross-cultural clinical encounter is to a) have a prior understanding of one’s own values, beliefs, etc., b) elicit the medically relevant values, beliefs, etc. of one’s patients, c) recognize the important differences in value, belief, etc. systems between patient and provider, and d) negotiate an acceptable treatment plan for the patient (see Berlin and Fowkes 1993, in Unit 1 of your syllabus for further elaboration.)

Systematic and conscious examination of one’s own values, beliefs, etc., is not commonly done by individuals in our society, unless given a structured forum in which to do so. Thus, a prime objective of any educational experience regarding culture and medicine should be to create an environment in which individuals can and do systematically and objectively examine their own culturally-related values, beliefs, customs, characteristics, and social norms and mores - the “self” which they bring to the clinical encounter. In fact, it has been suggested that teachers of cross-cultural medicine should direct the “knowledge” arm of the teaching paradigm mainly at “knowledge of self.” Ethnicity and Medicine, however, given its lecture format, will focus primarily on developing knowledge in the realm of the “other” rather than the “self.” The discussion section following lecture will provide greater opportunity, for those who enroll in it, to more closely examine “self,” and will thus provide a more holistic experience for those students.

The role of self in cross-cultural medical education cannot be overemphasized. As we hear and read about various ethnic groups and associated health issues in this course, all students are highly encouraged to continually relate, compare, and contrast the knowledge they receive about others directly to oneself.

The Study of Ethnicity/Culture in Medicine is Vital to All Health Care Providers

In the past it has been suggested that the study of cross-cultural aspects of health care is mostly only a concern to primary care specialists. The rapidly emerging reality, however, is that anyone who treats patients (even the most highly specialized of physicians) must be versed in the knowledge and skills of cross-cultural medicine if they are to be a truly competent and confident practitioner. Indeed, even health science researchers who never encounter individual patients need to understand the issues inherent in cross-cultural medicine. Without an understanding of these issues, one cannot fully digest, interpret, and apply the existing literature (particularly when stratified by ethnicity or other “cultural” variables) to a clinical problem. Even worse, without an understanding of the intersection of culture, health, and medicine, a researcher may be unable to properly formulate hypotheses from the outset. If medicine is to embrace the notion of treating the “person” rather than the disease, then everyone from primary care physicians to specialists to researchers must develop the knowledge and practice the skills of cross-cultural medicine.

Cultural Competency is a Lifelong Process

The term “cultural competency,” like other terms in cross-cultural medicine (e.g., “culture,” “ethnicity,” etc.), has many interpretations and definitions. For the purposes of this course we will define cultural competency as the clinician’s ability to work effectively with patients and colleagues from differing cultures.

It would be an impossible mission to know about the culturally sensitive and competent treatment of all patients. Thus, when one refers to the notion of becoming “culturally competent,” they are actually referring to the process of enhancing one’s knowledge base and clinical skills toward the goal of providing culturally competent care.

Ethnicity and Race

The terms “ethnicity” and “race” refer to closely related but distinct cultural variables. Again, both can be defined in many ways. “Ethnicity” generally refers to identification with a group based on such things as common ancestry, country of origin, religion, and race. “Race,” on the other hand, is a “pseudobiologic” construct used to identify groups based on perceived or presumed biological differences, and is often designated by skin color, rather than actual cultural differences. Thus, strictly speaking, the two terms are not interchangeable. However, in this course race and ethnicity can both be viewed as markers for hypotheses related to health factors.

No “Cookbook” Approach

In the study of cross-cultural medicine, it is important to keep in mind that there is no “cookbook” approach to patients from a particular cultural background. The intra-cultural variation within groups precludes a standard set of information which applies to all members of a given group of people. There is no set of “rules” for a given group which applies to all members of that group. Thus, simply memorizing a list of differences between one’s own cultural group(s) and another’s can lead to a collection of stereotypes which can cloud rather than clarify clinical encounters. As you gather information on various cultural groups throughout this course and in the future, be mindful that statements about a particular group are by definition stereotypes, and may not apply to individuals you come into contact with.

Multi-Group Identification

We have broadly defined “culture” to include such things as religion, sexual orientation, socioeconomic status, and others (see above). In cross-cultural medicine we often talk about membership in particular cultural groups (e.g., Hispanic, gay/lesbian, poor, refugee, Democrat, Hindu, etc.) in isolation, as if an individual belonged to just a single group at a given time. In reality, of course, every individual belongs to multiple “cultural” groups, and their identification, to varying degrees, with these groups may result in complex and unpredicted manifestations. For example, we may make certain predictions about an African-American patient, however, if we then learn that she is a practicing Buddhist, our expectations may change. Take a moment to list all of the groups with which you identify, then consider how your membership in each group influences you as an individual. Finally, now consider how these individual influences may interact with each other in complex ways.

Ethnic Categorization

What does it mean to say that someone is “Hispanic,” “African/African-American,” “White,” “Asian/Asian-American,” “Native American,” etc.? Each of these labels (and others not listed) identifies a broad and richly diverse group of peoples. For example, to identify someone simply as “Asian” ignores tremendous potential differences in language, customs, traditions, history, values, religion, family structure, diet, and other things which distinguish one “Asian” group from another. Thus, these broad terms actually convey very little meaning. Yet, these labels still persist in everything from U.S. Census data to lay conversation, and one must be mindful of what they really mean. The value of social or ethnic categorization is primarily as a marker for health status. Much more meaning, and potentially useful information can often be conveyed by using more specific identifying terms, such as “Korean-American,” or “Navajo,” rather than “Asian” or “Asian-American,” and “Native American” respectively.

Prejudice and Discrimination

Prejudice and discrimination still persist in the American health care system. Health care providers, in the business of taking care of people, are generally well intentioned, and are often unaware that certain actions or statements are racially, ethnically, or culturally offensive. Furthermore, a health care provider who has not directly experienced the effects of prejudice may find it difficult to understand the real impact that racially, ethnically, or culturally insensitive acts or words can have on an individual. Yet, for minority patients such actions or statements can be acutely felt, painful, and traumatic (Garcia and Wallace, “PAs and Cultural Diversity,” Physician Assistant: A Guide to Clinical Practice, Ballweg et al., ed., 1994). Indeed, as a result of a personal and collective history of prejudice and discrimination, racial, ethnic, or cultural minority patients may in fact be hypersensitive to such actions or words.

“Adult Learners”

In the study of cross-cultural aspects of medicine, “students” often play a key role as “teachers.” Each and every one of us represents a highly unique set of experiences, thoughts, and perspectives. Sharing one’s thoughts, experiences and perspectives with the larger class flavors our dialogue with the richness of diversity which we collectively represent. We encourage you to “teach” your classmates through sharing, both in and outside of class.

If you have any questions, please send e-mail to ron.garcia@stanford.edu

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