The data show that women don’t receive total hip or knee replacements at the same rate as men, even though the indications may be there. Nor do minority patients receive as much pain medication for their injuries as do white patients.“Both a gender bias and a racial bias—whether conscious or unconscious—exist,” points out Dr. White. And for nearly a decade, he has spearheaded efforts at HMS to integrate cross-cultural care education into the school’s existing curriculum.


Published 12/1/2008
Jennie McKee

Changing the culture of medical education

At Harvard Medical School, students learn basics in cross-cultural care

“I’ve been asked whether cultural competence education is just the latest manifestation of political correctness,” says Augustus A. White III, MD, PhD, professor of orthopaedic surgery at Harvard Medical School (HMS). “I respond by pointing to the data on healthcare disparities.”

Augustus A. White III, MD, PhD

The call to action
Thanks to the efforts of the HMS Cross-Cultural Care Committee, HMS students and faculty are becoming increasingly knowledgeable about and sensitive to the critical role that cultural literacy plays in optimal physician-patient communication.

Healthcare disparities do not generally result from blatant bias, explains Dr. White. “In my experience, it’s subtle.”

But as the evidence of disparities accumulates, the need for teaching cultural competency increases. New requirements for cultural competency have been incorporated into standards established by the Liaison Committee on Medical Education, the accrediting body for medical education programs. In addition, cultural competency training is increasingly being required in continuing medical education courses and for obtaining and/or maintaining a medical license (see “Cultural literacy requirements” below).

Shifting to cross-cultural care
“Several HMS faculty members were interested in the challenge of instituting culturally competent care education,” recalls Dr. White. “We organized and started raising funds. We had support from HMS leadership and help from organizations such as Blue Cross Blue Shield of Massachusetts, Harvard’s Department of Minority Health, and the J. Robert Gladden Orthopaedic Society.”

The original 10-member, ad hoc committee now has more than 100 members focused on cross-cultural care. In 2007, Dr. White handed over leadership of the committee to Alexander R. Green, MD, MPH, associate director of the Disparities Solutions Center at Massachusetts General Hospital and instructor of medicine at HMS.

“Because we’re practicing medicine in a changing environment, a ‘one-size-fits-all’ model of health care doesn’t really work,” says Dr. Green. “We need to find ways to adapt to the needs of different people.”

Training the trainer
The committee created a core cohort of faculty to teach cross-cultural care to HMS students and other healthcare providers. Faculty learned to integrate cross-cultural care education into classroom and clinical teaching and help students become more aware of their own cultures and potential biases. Cross-cultural issues have been addressed during grand rounds, and case studies examining the cultural biases of medical professionals have been used in clinical and nonclinical settings as part of faculty development sessions.

Helen M. Shields, MD, an associate professor of medicine at HMS and an internist specializing in gastroenterology at the Beth Israel Hospital in Boston, has been involved in faculty development activities since the committee’s inception. In 2007, she helped design a five-part, interactive program on teaching cross-cultural care as part of a gastroenterology course.

“After the faculty course was implemented, the course’s rating on cultural competence improved significantly,” says Dr. Shields. “Students rated most tutors as actively teaching cultural competence and felt that the course addressed issues of culture and ethnicity.”

According to Dr. Shields, the instructors who make the effort to incorporate cross-cultural care education into their courses receive the highest ratings from their students on course evaluations.

“The best teachers provide cultural competency training—they are honored with prizes and awards for it,” says Dr. Shields. “New faculty members don’t have to worry that teaching science and cultural competency at the same time will lower their performance because we can show them that they will actually end up with better performance evaluations.”

Roxana Llerena-Quinn, PhD, an HMS instructor of psychology and cross-cultural care educator, has also served on the committee since 2001. She has helped develop cross-cultural care curricula for medical students and faculty.

“We hope that more faculty members will become leaders in cross-cultural care, which will help increase integration of cultural competence education into the curricula,” says Dr. Llerena-Quinn.

Teaching students about cross-cultural care
According to Dr. White, the committee analyzes the curriculum and works with course directors to determine how to integrate cross-cultural education into courses. The objective structured clinical examination (OSCE) is one way.

“The OSCE involves a simulated patient,” explains Dr. White. “Actors portray patients with various conditions. The medical students take the patients’ histories, question them, and attempt a diagnosis. In one case, the medical student has an opportunity to display his or her cultural competency skills. This is a very effective teaching tool because it provides direct experience and ensures that students understand the importance of this particular aspect of their education.”

“The OSCE is a very powerful learning experience for students,” agrees Dr. Green. “They really want to do a good job, but they may assume that they are dealing with a standard medical issue, rather than one that requires cross-cultural care skills. When they receive feedback and learn that cultural literacy was an issue, they have an ‘ah-ha’ moment.”

Some of the many educational offerings at HMS that promote cultural literacy are elective courses—including one that emphasizes self-awareness and recognition of one’s cultural identity. Clerkships that incorporate cross-cultural care training, courses that teach foreign language skills for medical professionals, and opportunities to engage in local and international service projects are also available.

Documentary films about healthcare disparities experienced by real-life patients provide yet another teaching method.

“Dr. Joseph Betancourt and I helped develop the series,” says Dr. Green. “These short, compelling films are about patients’ experiences interacting with the healthcare system. They showcase the perspectives of the patient, the family, and the healthcare providers. After the students watch the films, they break into small groups to discuss the cross-cultural issues.”

According to Dr. Shields, HMS students have pushed for cross-cultural care education in the curriculum.

“Their interest in cultural sensitivity—as well as Dr. White’s dedication to this topic—have been instrumental in encouraging us to incorporate cross-cultural care training into our courses and to create the best faculty development programs possible,” she says.

Looking to the future
As HMS and other groups expand their efforts to promote cultural literacy, Dr. White says that they must “apply the physiology test” when developing programs and initiatives.

“The same amount of effort that’s put into teaching courses such as physiology, biology, and biochemistry should be put into teaching culturally competent care,” he says. “We must give cultural competence education the same status and importance.”

Dr. White is optimistic about the growing acceptance of cross-cultural care education at HMS and other institutions.

“Feedback on the committee’s efforts is positive,” said Dr. White. “Progress is occurring on all fronts.”

“When I first began teaching about cross-cultural care 11 years ago, it seemed that both students and faculty—particularly faculty—were resistant to teaching in this area,” recalls Dr. Green. “Now, students are very enthusiastic about learning about these issues. In addition, the number of faculty mem­bers who come to the committee’s meetings and workshops on a regular basis has grown.”

“Today, the challenge is to improve how we teach cross-cultural care,” adds Dr. Green. “Rather than teaching stereotypes, we must give students a set of skills they can apply in any cross-cultural interaction.”

“I think that physicians have the insights and understanding to be in the vanguard of support for cultural competency,” says

Dr. White. “It’s not our fault that biases and healthcare disparities exist, but it is our responsibility to do something about them.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at

Cultural literacy requirements
The Liaison Committee on Medical Education, the accrediting authority for medical school programs, has established two educational directives that require faculty and students to demonstrate cultural competence and to address gender and cultural biases in themselves and others in the healthcare environment.

Cultural competency requirements have also been implemented in several states. New Jersey requires all physicians who want to obtain or renew a medical license to obtain six credits of continuing medical education in cultural competency. New Mexico requires higher education institutions with health education programs to provide cultural competency training, although how this law will be implemented has not been determined. In California, all continuing medical education (CME) courses must include training in cultural and linguistic competency. Washington has similar requirements for education programs that train health professionals; other state laws promoting cultural competence training as part of CME are pending in Illinois, New York, and Ohio.