Using standardized patients to teach cross-cultural communication skills

Dear Sir

US medical education requires cultural competence training, yet educators know how challenging this requirement can be to implement. Pre-clinical students may not believe that a patient's culture can affect medical care, or may believe that to be “culturally competent,” one must somehow understand every different racial or ethnic group – an impossible task. Traditionally, cultural competence training used a categorical approach which stressed the acquisition of cultural knowledge about specific, ethnicity-based groups of patients. In contrast, the skills-based approach provides tools for students to uncover and explore their patients’ own sense of culture and their explanatory models of disease, followed by the negotiation of a treatment plan that includes input from the patient. This method avoids the pitfalls of “knowledge-based” approaches by avoiding stereotyping of ethnic groups, while providing the skills to successfully navigate clinical encounters with patients from all ethnic backgrounds.

We developed a four-hour cultural competence workshop for pre-clinical students that consisted of several components, largely modeled on the work of Kleinman (1980). It included role plays focused on eliciting the health care beliefs of standardized patients. The workshop was evaluated using a modified Cultural Competence Assessment Tool (CCAT) in a pre/post-test design.

Of the 228 students who attended, 54.4% were female, 65% were white, 12.1% were Asian/Pacific Islander, and 8.9% were Hispanic/Latino. Pre- and post-CCATs could be matched for 157 students. Total CCAT score increased significantly from pre- to post-administration (109.62 pre-test to 114.18 post-test, p < 0.001). The greatest increase was seen in the subscale that measured elicitation of health beliefs (average subscale score of 3.34 pre-test to 3.71 post-test, p < 0.001) Role plays using standardized patients were rated more highly than other workshop components and may be the most effective means to deliver cultural competence content in a short period of time.

This workshop demonstrated that a brief, skills-based curriculum can help students understand cross-cultural patient dynamics. The built-in flexibility of this approach is more suitable to the increasingly diverse population of the US, and offers a better method for teaching cultural competence than knowledge-based models. A detailed version of this study is available from the first author.