The Need for Cultural Awareness Training: A Medical Student Perspective

Demographics and the Need for Cultural Sensitivity Training

In 2013, about 17% of the United States population identified itself as Hispanic and another 14% as African American.(1) More than 5% of the population was Asian, and more than 12.5% was “foreign born,” implying they were not United States citizens or nationals at birth. The trends show that the population in the United States is becoming increasingly diverse. The minority population is expected to reach 56% of the total population in 2060,(1) with no racial or ethnic group having a majority share of the total, making the United States a “plurality” [nation] of racial and ethnic groups. This increase in diversity means that the next generation of physicians will have to be equipped with skills that help them interact with patients from varied cultural, religious, geographic, and ethnic backgrounds in both the inpatient and outpatient settings.

As medical information becomes more ubiquitous and readily available, empathy and the ability to form a strong relationship with patients is what will truly distinguish physicians from their peers. Despite the rapid population growth in “minority” populations in the United States, less than 7% of U.S. physicians identified themselves as Hispanic or African American in 2004. This glaring underrepresentation of minorities in healthcare demonstrates an even more urgent need for the current physician workforce to be culturally sensitive and take appropriate measures. The nation can strongly benefit from developing a culturally proficient and aware physician workforce—that is, one with the knowledge, skills, and behaviors required to provide optimal care to distinct populations.

Nonverbal Communication

Bendapudi et al.(2) see a medical practice as a service organization and emphasize the need for doctors to invest in their interpersonal skills. The presence of these skills, along with other tangible clues in the practice setting, reveal much about the “clinician’s and the organization’s commitment to genuinely being of service.”(2) The interaction between physicians and patients can be divided broadly into verbal and nonverbal categories. The nonverbal parts of the interaction are crucial in the establishment of an emotional connection between the patient and the physician.(3) Key elements of nonverbal communication while speaking to patients include eye contact, posture, gestures, and movements. The importance of maintaining good eye contact cannot be overstated. With the introduction of electronic medical records, the traditional “dyad” physician–patient relationship has transitioned into a triad, with the computer becoming a third wheel. It is still important for physicians to pay as much attention as before to the patient while speaking to him or her rather than focusing on the computer. Movements and gestures can also enhance the verbal component of communication and establish trust.

The posture assumed while interacting with the patient is an important part of the nonverbal and behavioral cues used by the physician. A patient’s preference can be affected by multiple factors, such as gender and cultural, ethnic, and religious background.(4) Our previous studies have focused mostly on patient’s preferences in regards to ideal physician posture when communicating with patients. We had elicited information in the outpatient setting from a predominantly Caucasian oncology patient population,(5) and in the inpatient setting from Caucasian,(6) African-American,( 7) and Hispanic(7) patients. The biggest takeaway point from these studies was that a majority of patients prefer their physician to ask what posture the patients would prefer. We also established that most patients had not been asked about their preferred posture.

Although multiple studies have evaluated patient preferences when it comes to physician postures,(8-10) a literature search failed to yield any definitive prospective study addressing how a physician’s posture or cultural origin reflected his or her preferences for nonverbal communication with patients. Our goal through this study was to examine medical student perspectives and behaviors regarding the topic of sitting on patients’ beds, with attention to their level of training and religious or cultural backgrounds.

Methods and Results

We surveyed medical students from the Mayo Clinic College of Medicine (Rochester, Minnesota), Creighton University (Omaha, Nebraska), the University of Minnesota-Duluth (Duluth, Minnesota), and the University of Pittsburgh (Pittsburgh, Pennsylvania). The surveys included 15 questions that asked about the student’s preferences in regards to posture while conducting patient interviews, along with each student’s demographics, degree program pursued, and religious and cultural preferences. A convenience sample of 121 students was chosen as the study population. The study was conducted in accordance with the institutional review board guidelines. No patient-related data were created, accessed, or stored during the study period.

Of the 121 respondents, the majority (85 [70%]) were from Mayo, with Creighton (17 [14%]), Pittsburgh (14 [12%]), and Duluth (5 [4%]) rounding out the total. Fifty-three (44%) respondents were in their preclinical years (i.e., the first and second years of medical school), and 50 (41%) were in their clinical years (i.e., the third and fourth years of medical school). Eighteen (15%) respondents were MD/PhD students in the research portion of their time in medical school. More than half of the respondents identified themselves as Christian (67 [55%]) and of North American origin (73 [60%]).

Medical students are themselves able to perform a needs assessment and understand what their current curriculum is lacking.

Ninety-seven students (80%) felt that patients would be most comfortable with their physician sitting on a chair, while 12 (10%) thought that the physician should sit on the bed and another 12 (10%) felt that the patient would prefer their physician to stand. Although most of the surveyed students (93 [77%]) were likely to ask permission before sitting on the bed, 28 (23%) never requested permission, but reported that the patients neither objected nor asked them to get up. Only a quarter of the students thought sitting on the patient’s bed was the most effective means of communication, while 48 (40%) believed sitting on the bed could potentially cause disease transmission. Forty-eight students (40%) surveyed decided to sit on the patient’s bed irrespective of the patient’s health condition; another 40% did so if they sensed the patient was despondent; and the remaining 20% only if the patient was gravely ill.

Seventy-nine students (65%) noted that their teachers did not address how posture could facilitate an effective medical interview, and 103 students (85%) believed their curriculum should include some form of discussion on the appropriate posture for physician–patient interaction.

Discussion

Our research found that students have well-formed preferences regarding nonverbal communication across all demographic categories, and their views did not change as they progressed through medical school. A recent study from Brazil found that medical students believed strongly in the need to establish empathetic, trusting relationships with patients,(11) and any difficulty in establishing these relationships adversely affected their confidence in their own professional capabilities. It is not surprising that medical students nowadays are themselves able to perform a needs assessment and understand what their current curriculum is lacking. Eighty-five percent of the students stated that they would like some sort of formal training in nonverbal communication in the curriculum, and two-thirds of them stated that they had received no training or guidance about this issue in all their years of training. Our results highlight a definite need for the inclusion of curriculum that helps educate students at the medical school level on the nuances of nonverbal communication with patients.

In 2016, a total of 22,946 seniors from U.S. allopathic and osteopathic medical schools and an additional 1849 previous graduates from U.S. allopathic medical schools registered with the National Resident Matching Program (NRMP)(12) for 27,860 post-graduate year (PGY) -1 positions available in the Main Residency Match.(13) Given the volume of medical students entering residency, the Accreditation Council for Graduate Medical Education (ACGME) has been making efforts to update its residency accreditation requirements to make sure physicians in training are adequately prepared to work in varied settings.

No physician can be fully competent, aware, and anticipatory of all cultures and the needs of every distinct social group.

The Outcome Project and the Next Accreditation System (NAS)(14) are initiatives by the ACGME that ensure that residents gain proficiency in six clinical competency domains: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Three of the six competency domains defined by the ACGME are directly associated with the physician–patient encounter. Although the past two decades have seen efforts at the graduate medical education level to develop and improve the nontechnical aspects of a physician’s skill set, very few if any standardized guidelines have been established to improve the same at the medical school level. We (the authors of this study) attended medical school in various settings, both in the United States and outside, in different decades, and can confirm that formal or even informal teaching regarding appropriate posture while interviewing patients was virtually nonexistent.

Formal education in the nonverbal aspects of physician–patient interaction at the medical school level is not only desired, but may be necessary to help medical students adjust their intrinsic behavior when interacting with patients from varied cultural, ethnic, and religious backgrounds. This would ideally begin in the preclinical years of medical school itself. A brief discussion on cultural awareness in the preclinical or clinical years of medical school may have far-reaching consequences on a student’s ability to get through to the patient and improve the quality of the patient interview and overall patient care. Of the 126 medical schools interviewed in 1994, only one reported that it had a non-optional program for cultural sensitivity training.(15)

Although we have come a long way since then, there is still work to do. The American Medical Student Association (AMSA) has initiated the Cultural Sensitivity Scholars Program,(16) through which they plan to “encourage students to shift their goals from being just culturally competent to being continually adaptive and responsive, and hence culturally sensitive.” It is a six-month program running from October to April with a special monthly focus requiring approximately six hours of work each month. A final project and submissions to the AMSA publication are encouraged.(16) Such initiatives of the AMSA are to be lauded, and further projects assessing the participation and results of this program should be conducted. They have also astutely noted that cultural competence is not an endpoint by itself, and no physician can be fully competent, aware, and anticipatory of all cultures and the needs of every distinct social group.(16) It is the effort and interest to acquire cultural knowledge, dissolve our bias, and maintain an open and relative perspective that will help us to achieve cultural sensitivity.

Although upcoming physicians are expected to establish their own practice patterns, medicine remains one of the fields where trainees learn and absorb a lot of what they see their professors and mentors do. Formal training for current physicians should also be initiated so they may be able to teach and advocate the “right way” to their students. Exposure to racial and ethnic diversity in medical school along with the different needs, thoughts, behaviors, and appropriateness needed to respond to different cultures, will contribute importantly to the cultural competence of all of tomorrow’s doctors.

References

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7. Gupta A, Madhavapeddi S, Das A, Harris S, Naina H. Physician posture at the bedside: a study of African-American and Hispanic patient preferences at a teaching hospital. J Med Pract Manage. 2015:31:144-146.

8. Harris S, Naina H, Beckman T. What physician behaviors are preferred at the bedside? A survey of hospitalized patients. J Gen Intern Med. 2007;22 (suppl 1):78.

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11. Nogueira-Martins MC, Nogueira-Martins LA, Turato ER. Medical students’ perceptions of their learning about the doctor-patient relationship: a qualitative study. Med Educ. 2006 Apr;40(4):322-8

12. NRMP. The match: NRMP match advanced data tables: 2016 main residency match. www.nrmp.org/wp-content/uploads/2016/03/Advance-Data-Tables-2016_Final.pdf . Accessed April 28, 2016

13. NRMP: Results of 2016 NRMP main residency match largest on record as match continues to grow. www.nrmp.org/wp-content/uploads/2016/03/2016-MRM-Match-Day-Press-Release.pdf . Accessed April 28, 2016

14. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med. 2012:366:1051-1056.

15. Lum CK, Korenman SG. Cultural-sensitivity training in U.S. medical schools. Acad Med. 1994;69:239-241.

16. American Medical Student Association. Cultural Sensitivity Scholars Program. www.amsa.org/members/career/scholars-programs/cultural-sensitivity/. Accessed April 28, 2016