Cultural Competency – The
Evolution of Early, Integrated
Education For Medical Students,
Residents and Faculty at One
Maria L. Soto-Greene, M.D.
Vice President, Hispanic Serving Health Professions
Schools, Inc.
Senior Associate Dean for Education
Director, Hispanic Center of Excellence
New Jersey Medical School
Newark, New Jersey
Developing, integrating, and evaluating a
cultural competency curriculum for:
 Medical students
 Medical residents
 Faculty
 Hospital interpreters
Overall Goal
Adapted from the Promoting, Reinforcing, and Improving
Medical Education (PRIME) project by the American
Medical Student Association (AMSA) and HRSA with
expectation that:
 Students will learn about culture and diversity’s role in
 Students will learn the importance of being culturally
 Students will develop cultural and linguistic competency
through participation in a variety of clinical experiences
while completing a community learning experience
Comprehensive Curriculum
1st year
Art of Medicine Course
History & Physical Exam Course
Administration of the Health BELIEF Attitude Survey
2nd year
Communications exercise during the Introduction to
Clinical Medicine course
 Teach students how to conduct a triadic interview
Comprehensive Curriculum
3rd year
Expansion of training into third year clerkships with
concomitant faculty training.
4th year
Graduation Objective Structured Clinical Examination
(OSCE) that assesses our graduate’s cultural and
linguistic competency skills.
Re-administering the Health BELIEF Attitude Survey.
“The Art of Medicine begins with the
communication between a physician and
the patient.”
Introduced new components to the history
Trained H & P faculty on these additional
Introduced the appropriate use of an interpreter
Integrated these components into the ambulatory
preceptorships in the community
Students’ Views
The Health BELIEF Attitude Survey is an
instrument used to assess how important
students consider obtaining a patients health
care view points.
 This survey was developed and piloted at
UTHSC at San Antonio by their HCOE, a
HSHPS member, and Society of Teachers of
Family Medicine Foundation.
ETHNIC: A Framework for Culturally
Competent Clinical Practice
E: Explanation
What do you think may be the reason you have these
What do friends, family, and others say about these
Do you know anyone else who has had or who has this kind of
Have you heard about/read/seen it on TV/radio/newspaper?
(If the patient cannot offer an explanation, ask what most
concerns them about their problems).
Developed by:
Steven J. Levin, M.D.
Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
ETHNIC: Cont’d
T: Treatment
H: Healers
Developed by:
What kinds of medicines, home remedies or other
treatments have you tried for this illness?
Is there anything you eat, drink or do (or avoid) on a
regular basis to stay healthy? Tell me about it.
What kind of treatment are you seeking from me?
Have you sought any advice from alternative/folk
healers, friends or other people (non-doctors) for help
with your problems? Tell me about it.
Steven J. Levin, M.D.
Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
ETHNIC: Cont’d
N: Negotiate
Negotiate options that will be mutually acceptable to you and
your patient and that do not contradict, but rather incorporate
your patient’s beliefs.
I: Intervention
Determine an intervention with your patient. May include
incorporation of alternative treatments, spirituality, and
healers as well as other cultural practices (e.g. food eaten or
avoided in general and when sick).
C: Collaboration Collaborate with the patient, family members, other
health care team members, healers and community
Developed by:
Steven J. Levin, M.D.
Robert C. Like, M.D., M.S., Jan E. Gottlieb, M.P.H.
Department of Family Medicine
UMDNJ-Robert Wood Johnson Medical School
Introduction of Culture
Glossary of Cultural Terms
 Case studies from the AMSA project
 Cultural and Spiritual Beliefs
 Complementary and Alternative Medicine
Definition of Culture
We adopted, with some modification, the broader definition
of cultural and linguistic competency recommended by
HRSA in its publication: “Cultural Competence Works 2001.
Cultural & Linguistic is: “…a set of congruent behaviors,
attitudes, policies and procedures that come together in a
system, agency or among professionals which enable they
system, agency, or those professionals to work effectively
and efficiently in cross-cultural and diverse linguistic
situations on a continuous basis.”
Prior to session, introductions take place. Interpreter introduces
her/himself to provider. Provider introduces interpreter to patient.
Interpreter tells provider if patient says she/he is a non-citizen or an
illegal immigrant.
The provider and interpreter should develop trust between themselves
and with the patient.
To achieve effectiveness, provider talks directly to patient in the first
person; speaks in small segment; and clarifies technical terms.
Interpreter is linguistically competent; speaks simply and clearly in the
first person; explains cultural and linguistic topics; interprets everything
said without adding or deleting; stops provider and patient if they are
speaking too long; and refrains from offering advice.
INTERPRET (cont’d)
The provider has the lead role. When working with an untrained
interpreter, the provider is also responsible for explaining the
interpreter’s roles and duties as outlined on this card to the interpreter.
Proper positioning is crucial. Provider faces patient. Interpreter sits
beside and slightly behind patient. Avoid triangular dynamics.
Useful resources include the following:
Diversity Rx
Bilingual Dictionaries
MA Medical Interpreter Assoc.
The provider and interpreter put ethics into practice. They exercise
confidentiality and a non-judgmental attitude.
A culturally competent triadic interview involves an ample timeframe.
Learn to work effectively and efficiently.
Third year medical students
Began by pilot testing a cross cultural
curriculum with 40 third year medical
students during their medicine clerkship.
Assessed level of competency at baseline
and after the curriculum using 2 modalities.
Medical Student Objective
Structured Clinical Examination
Students in the cross cultural curriculum had
higher exam scores and higher levels of
confidence and satisfaction. All 40 students had
the same level of interest in cross cultural issues.
Goal: to develop an integrated third year medical
student curriculum that emphasis sociocultural
issues throughout their rotations.
Graduation Objective Structured
Clinical Examination (OSCE)
At the core of this examination is the doctorpatient communication.
OSCE’s are used to assess the core skills,
knowledge and attitudes of tomorrow’s physicians
including more recently in licensure.
Specifically, our OSCE will test a student’s ability
to communicate using cross cultural principles.
Cultural Competency Training:
Medical Residents
Assess level of need and competency at baseline.
Assess effectiveness of curriculum with the goal
of implementing a formal cultural competency
residency training program.
A determinant of success is whether the medical
resident trained receives increased patient
satisfaction when working with diverse cultural
Medical Residents
Medical Interpreter Training
Pilot project funded by the State of NJ to
train volunteer hospital medical interpreters.
 16 interpreters participated in a one day
medical interpreting and cultural
competency training program.
 curriculum focused on attitudes, knowledge,
and skills
Medical Interpreter Training
Program: Results and Outcomes
Trained interpreters received high patient and
physician satisfaction scores in the clinical setting.
Trained interpreters found that physicians do not
know how to use an interpreter appropriately.
An Interpreter Training Curriculum was submitted
to the State of NJ.
University Hospital now funds a program to train
all interpreters.
Clinicians must “check their own
pulse” and become aware of
personal attitudes, beliefs, biases,
and behaviors that may influence
(consciously or unconsciously)
the care of their patients.
Every clinical encounter is
No “one” way to treat a racial or ethnic
group given the great “sociocultural”
 Need to have a “Framework” of
interventions that can be individualized
 A “one size fits all” health care system
cannot meet the needs of an increasingly
diverse American population
Organizational and Health Care
Develop a mission statement that articulates
principles, rationale, and values for
culturally and linguistically competent
health care service delivery
Ensure consumer and community
Organizational and Health Care
Policies (cont’d)
Implement processes that review policies and
procedures to assess relevance of initiatives
Implement legislation that provides resources
(i.e. funding from Titles VII & VIII, NIH,
private sector, etc.) that supports ongoing
professional development and in-service
training for culturally and linguistically diverse
Cultural Competency Training
and Education
To succeed, we must have:
 Research Agendas
 Evaluation Tools
 Uniformity at all levels - both state and
 Legislation with appropriate levels of
funding to ensure that there is the level of
training that ensures equal access and care
for all Americans.

Piloting a Cultural Competency Curriculum for Medical