R ESEARCH R EPORT

First-Year Medical Students’ Attitudes toward Diversity and its Teaching: An Investigation at One U.S. Medical School

Nisha Dogra, BM, and Niranjan Karnik, MD

ABSTRACT

Purpose. To investigate whether medical students con- may live. However, with very personal issues there was a ceptualize and best within “cat- tendency to stay with the familiar. These students had an egorical” or “cultural sensibility” teaching models. impression of ethnic groups as very discrete and well Method. In spring 2002, first-year medical students at the defined. Skin color and issues of race remained a signifi- University of Illinois Colleges of Medicine at Chicago and cant barrier to dialogue regarding diversity. Students were Urbana-Champaign completed a previously developed overwhelmingly in favor of the cultural sensibility teach- questionnaire. A self-selected subset participated in focus ing model that emphasizes the fluidity and malleability of groups. The questionnaire collected data on attitudes culture. toward race, culture, and diversity education and how Conclusions. The students in this study were not famil- these concepts relate to medical practice; responses to a iar with key terms on culture and race, and struggled with case scenario; attitudes toward cultural tolerance; defini- the issues that diversity raises in medical practice. Al- tions of key terms and sense of cultural belonging; and though students held open attitudes toward equal oppor- feedback on the questionnaire. The focus groups discussed tunities and , differences among and the two models for teaching diversity. within groups indicated that all students would benefit Results. Questionnaires were returned by 111 of 153 students (72.5%). Generally, the students displayed open from a curriculum that emphasizes self-reflection and attitudes about the balance between of origin and diversity teaching. the culture of the wider community in which immigrants Acad Med. 2003;78:1191–1200.

In the late 1960s, medical schools across lead to cultural insensitivity in medi- has, therefore, become a more central the Unites States began recognizing the cine.1 Since then, how to teach medical concern for health care delivery. The effects of racism and how racism might students to understand and contend issue is made more complex because with race and culture has been a critical there is little consensus on the meaning Dr. Dogra is senior lecturer and honorary consultant focus for medical education reform. As a of such widely used terms as race, eth- in child and adolescent psychiatry, Greenwood Insti- recent study has shown, despite these nicity, and culture. In this paper, we tute of Child Health, University of Leicester, United Kingdom; she visited the University of Illinois College efforts, problems addressing race and acknowledge that individuals define of Medicine, Chicago to undertake this study. At the culture in medical practice continue. themselves in different ways and that time of the study, Dr. Karnik was a final-year medical student at the University of Illinois College of Schulman and colleagues found that race and ethnicity may have different Medicine, Chicago; he is now resident physician in women and African Americans with meanings for each individual. psychiatry, Department of Psychiatry and Behavioral the same set of signs and symptoms were The American Medical Association Sciences, Stanford University Hospital and Clinics, Palo Alto, California. less likely than white men to be referred (AMA) has a detailed Cultural Compe- 2 Correspondence and requests for reprints should be for cardiac catheterization. Teaching tence Compendium that includes a report addressed to Dr. Dogra, Greenwood Institute of Child medical students to recognize the ways entitled “Enhancing the Cultural Com- Health, University of Leicester, Westcotes House, 3 Westcotes Drive, Leicester LE3 0QU, United King- that their potential biases interact with petence of Physicians.” Training phy- dom; e-mail: ͗[email protected]͘. the cultural atmosphere of medicine sicians to work with culturally diverse

A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 1191 populations has often been seen as a illness (i.e., cultural understanding and view culture as constantly in flux and commendable goal, but not as pressing alternative treatment remedies). gain knowledge about culture through as other issues. Offering cultural issues careful and thoughtful interactions with as electives in medical school demon- patients, colleagues, and by exposure to The Categorical Approach to strates the often weak support the study various media. Teaching Cultural Issues of these topics has in the medical estab- The cultural sensibility approach fo- lishment. Since the 1970s, increased re- cuses less on specific knowledge and Many educational programs in North cruitment of minorities into medicine more on students’ self-awareness and American medical schools endeavor to has often been perceived as a sufficient reflection. This approach’s underlying teach “.”5–8 Nunez9 answer to these concerns.1 By increas- philosophy is that unless students are defines cross-cultural efficacy as the car- ing the number of minority physicians, aware of their own perspectives on the egiver’s effective interactions with indi- it is believed that medical education range of cultural issues, they are poorly viduals of different cultures. Neither the provides practitioners who can then positioned to deliver health care equi- caregiver nor the patient has the pre- work with minority populations. How- tably to patients of diverse backgrounds. ferred view. Although the term cultural ever, the shifting demographics of med- Cultural sensibility is more challenging competence is more widely used, it often icine and society will require all physi- because it attempts to go beyond super- has different meanings.10 cians to approach concepts of race and ficial understandings and asks students The “categorical” approach to teach- culture with a more critical eye. There to question their own perspectives and ing cultural competence stresses the also needs to be an acceptance of the how they might have arisen. It does not need to learn about groups that are dif- notion that no individual, irrespective attempt to judge perspectives as being ferent from one’s own group. This ap- of his or her minority status, is an expert right or wrong but asks students to con- proach views groups as discrete and ho- on culture simply by virtue of being part sider which of their perspectives might mogenous entities, and promotes of a minority. Although some minority affect their practice as future clinicians. thinking about individuals as group professionals may share the same race The assumption behind this approach is members rather than as unique individ- and/or ethnicity as their patients,4 this that we need to teach students to ask uals. As a concept, “competence” disre- does not necessarily bring with it the patients about their values and beliefs gards the many nuances that individuals skills to be sensitive to the cultural rather than teaching them to use a possess with regard to power, back- needs of these patients. Additionally, a given corpus of knowledge that is ap- ground, and experience. More impor- minority professional from one racial or plied generally to the patient based on tantly, “competence” curricula generally ethnic group may be no better equipped perceived affiliation with a group or cul- present culture as a set of static facts to understand individuals from different ture. It is more similar to the “cultural that can be learned. As part of a broader minority groups. Despite the presence of humility” approach.11 recent move in medical education to minority professionals who act as infor- It is in this context that we explored develop “core competencies” that can mal and formal educators about race, attitudes toward cultural diversity and be objectively tested, the categorical ap- culture, and ethnicity, a need remains how diversity is taught to medical stu- proach reduces cultural diversity to a to equip all professionals with a set of dents. In our study, we sought to deter- core set of beliefs and thoughts that are critical tools for approaching patients mine whether medical students concep- then extrapolated to a given minority with increasingly diverse backgrounds. tualize culture and cultural diversity group. The AMA3 stresses that medical within the categorical or cultural sensi- schools and other medical institutions bility model to help establish a focus for should offer educational programs about Cultural Sensibility medical education programs. gender, race, and cultural issues to staff, physicians in training, and students. In this article, we propose an alternative METHOD These policies reflect the AMA’s con- to the categorical approach: the broader sensus that knowledge and tolerance of concept of “cultural sensibility.” Sensi- We undertook our study in spring 2002 diversity is an aspect of effective health bility relates to a person’s moral, emo- with first-year medical students at the care delivery, and that physicians and tional, or aesthetic ideas or standards. University of Illinois College of Medi- health care organizations must be en- The sensibility model has communica- cine at Chicago and the College of couraged to respond to the social, cul- tion at its core and has a process-ori- Medicine at Urbana-Champaign. We tural, economic, and political diversity ented axis that endeavors to teach med- thought this university was a good site of their communities, including serious ical students to think critically about for our study because its demographics consideration of cultural solutions to culture. In this way, students learn to reflected the typical racial, cultural, and

1192 A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 ethnic characteristics of the United cus groups, two at each campus. All were slightly overrepresented by one States and it offered campuses with con- ethnic and racial variations were percentage point in our sample and trasting settings. We used a previously present in at least one of the four focus Asian students were underrepresented developed questionnaire12,13 made more groups. Recordings of the focus-group by four percentage points. relevant to the American audience by discussions were transcribed verbatim the use of appropriate terminology. At and themes identified. One theme, feed- the time of our study, 125 first-year back on the questionnaire, was prede- Frequency Rates for the students were registered at the Urbana- termined because it was part of the fo- Questionnaire Champaign campus and 185 at the Chi- cus-group agenda. Detailed analyses of cago campus. At the Colleges of Medi- the focus-group discussions are not pre- Part I of the questionnaire consisted of cine, attendance at lectures is not sented here. 25 statements to which the following mandatory so it was difficult to be cer- We used a standard statistical soft- answers were available: strongly agree, tain of the exact number of students ware to analyze the data and used chi- agree, neutral, disagree, strongly dis- who would be present at the general square tests to make comparisons be- agree, or unsure. There were statements meetings scheduled immediately after tween groups. related to attitudes about different cul- morning lectures. In addition, students tures and how different cultures might who were present at the meeting were interact, as well as statements on diver- not required or compelled to participate RESULTS sity education and diversity in medical in our study. practice. Table 1 shows the frequencies Following a brief presentation by one Response Rates and Respondents’ of the responses to part I of the ques- of us (ND), we asked students to com- Demographics tionnaire and those statements for plete the questionnaire at an open and which there were significant differences voluntary meeting, and we also asked The number of questionnaires the stu- when different groups were compared. the students to attend focus groups. The dents took did approximate with esti- Students showed generally open atti- focus-group participants were self-se- mated attendance of about 50% of the tudes about the balance of cultures with lected because ND was unable to con- total class size. A total of 111 students broad support for the notion that immi- trol who volunteered, the times that completed the questionnaires. Sixty- grants should be able to retain some of rooms were available, and students’ four of the 125 students at the Urbana their cultures of origin but also adapt to timetables, all factors that affected the campus took questionnaires; 54 were re- the new environment. There was strong number of students who participated. turned (84.4%). Of the 185 students at agreement that doctors have prejudices, ND asked the students to give an iden- the Chicago campus, 89 took question- but less strong agreement that doctors tification number, their gender, and the naires; 57 were returned (64%). Exam- need to be aware of patients and col- country in which they had lived for inations followed shortly at both cam- leagues with different cultures in their most of their life. (To avoid repetition, puses, and students gave this as a partial practice. For statements reflecting atti- we will detail the questionnaire con- explanation for the lowered attendance tudes about specific cultures, the stereo- tents in the Results section.) at lectures. type about Asians pushing their chil- During the focus groups, ND asked Fifty-four (48.6%) of the respondents dren to do well in school generated the the students about each part of the ques- were men and 57 (51.4%) were women. most agreement, but also a high neutral tionnaire and the questionnaire as a Forty-two percent of the first-year response. Responses to the statement whole. Students were also asked to dis- classes at the two campuses as a whole about didactic teaching of cultural di- cuss how they defined terms in the ques- were women, so women were over rep- versity were spread across the scale. tionnaire such as race and ethnicity and resented in our study sample. Race and Part II of the questionnaire consisted whether there were any concerns about ethnicity broke down into the following of an imaginary scenario: “You are in- using these terms and the way they are groups: 56 of the respondents were vited to the home of your friend’s par- generally understood. Students were white (50.5%), 27 were Asian (24.3%), ents. Your friend is of a different ethnic then asked to consider the teaching of 11 were black (9.9%), 13 were Hispanic background than yourself. How do you cultural diversity to medical students. (11.7%), three were of mixed race, and think you might prepare yourself for the Toward the end of the focus groups, ND one was “Other.” This demographic in- visit?” We made no suggestions to stu- asked the students about the two models formation was obtained from part V of dents about potential responses. Stu- of teaching diversity: categorical and the questionnaire. Compared with the dents responded in the following ways: cultural sensibility. A discussion of first-year classes as a whole, white stu- ask the friend what to do (49%), do these models followed. ND ran four fo- dents who completed the questionnaire nothing because they are a friend

A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 1193 1194 Table 1

Frequency of the Responses to 25 Statements about Cultural Issues from Part I of a Questionnaire Given to 111 First-Year Medical Students at the University of Illinois Colleges of Medicine at Chicago and Urbana-Champaign and Significant Differences between Groups, 2001

Students’ Level of Agreement with each Statement % (no.) Significant Differences between Groups (p )

White White Asian Did and and and White and Strongly Strongly Not Asian Black Black Hispanic Statement on Agree Agree Neutral Disagree Disagree Unsure Answer Campus Gender Race Students Students Students Students A Attitudes about the balances between cultures CADEMIC 1. All individuals have a responsibility to learn 56.8 (63) 34.2 (38) 4.5 (5) 1.8 (2) .9 (1) 1.8 (2) 0.0 .029 .002 about how to deal with those who are different to Black2 Hispanic4 themselves 2. Minority members of a population should conform 0.0 8.1 (9) 12.6 (14) 42.3 (47) 34.2 (38) 2.7 (3) 0.0 .038 .047 .044 .037 M to the customs and values of the majority Chicago3 Female3 Asian3 Black3 EDICINE 3. Immigrants should be integrated into their new 42.3 (47) 36.0 (40) 9.9 (11) 5.4 (6) 4.5 (5) 0.9 (1) 0.9 (1) .019 .014 .042 country without having to give up their own culture White3 Asian4 Hispanic4 4. Foreigners going to live in a new country should 0.9 (1) 1.8 (2) 4.5 (5) 42.3 (47) 49.5 (55) 0.0 0.9 (1) .004 ,V let go of the culture of the country from which Female3

OL they have come

8 N 78, . 6. Foreigners going to live in a new country should 47.7 (53) 46.8 (52) 4.5 (5) 0.0 0.0 0.9 (1) 0.0 adapt to their new country, but not necessarily change their own culture 14. Different cultures can be successfully blended 33.3 (37) 45.0 (50) 9.0 (10) 8.1 (9) 0.0 4.5 (5) 0.0 .019 .025 O

11/N . Chicago2 Black3 25. It is the responsibility of the majority population 12.6 (14) 55.9 (62) 17.1 (19) 9.0 (10) 0.9 (1) 4.5 (5) 0.0 to learn about minority groups Attitudes about doctors and cultural diversity OVEMBER 5. Doctors, like all other individuals, have prejudices 72.1 (80) 24.3 (27) 2.7 (3) 0 0 0 0.9 (1) .0001 Hispanic and black4

2003 8. All doctors need to be aware of the different 36.0 (40) 55.0 (61) 6.3 (7) 0.9 (1) 0.0 1.8 (2) 0.0 .0001 cultures that exist within their practice Asian and Hispanic4

20. A white doctor is more likely than a black doctor 2.7 (3) 38.7 (43) 17.1 (19) 18.9 (21) 11.7 (13) 10.8 (12) 0.0 0.23 .003 to be perceived by patients as a competent Black4 Black4 Attitudes about skin color and race 7. In today’s society the color of your skin does not 3.6 (4) 9.9 (11) 9.0 (10) 52.3 (58) 24.3 (27) 0.9 (1) 0.0 influence how you succeed 11. Being white carries advantages in the United 22.5 (25) 49.5 (55) 13.5 (15) 9.0 (10) 2.7 (3) 2.7 (3) 0.0 .027 .0001 States Female3 White3 18. The color of your skin does not define your 27.9 (31) 52.3 (58) 3.6 (4) 12.6 (14) 0.0 3.6 (4) 0.0 culture 19. Black people are likely to be better at sport than 0.9 (1) 9.0 (10) 11.7 (13) 44.1 (49) 29.7 (33) 4.5 (5) 0.0 .029 at academic subjects White3 (39%), read up on their culture (6%), or 4 do nothing (6%). Part III of the questionnaire consisted .044 Hispanic .036 White, unsure of nine statements based on Bogardus’

3 social distance scale and the responses means that the group .021 Asian are shown in Table 2. Bogardus’ social 2

3 distance scale gives a range of relation- ships from close personal relationship to .003 White more casual relationships to the target. 3 3 The scale measures individual accep- Asian .041 Asian tance of the different relationships

2 based on their closeness to the respon- 4

3 dent. The majority of participants were equally willing to entertain notions of Asian and Hispanic having people of different cultures both in close interpersonal relationships as 4

4 well as in more casual interactions. Asian Male Nevertheless, there was evidence that study participants grew more uncom- fortable with relationships as they moved closer to their personal sphere. For example, only 68.5% of participants believed they could marry someone of a different culture, while 91.9% thought that in general it was acceptable to marry across cultures. Students were asked to define the means that the group shown was more likely to disagree or strongly disagree withterms the statement, and culture, ethnicity, multiculturalism, 3 and race in the interactive video (IV) part of the questionnaire. There were also a number of questions relating to students’ own understanding of culture and ethnicity: 74 students (66.7%) felt they belonged to an ethnic group, whereas 30 (27.0%) did not and 7 (6.3%) were unsure. Of the 95 defini- tions given for culture, 87 defined cul- 0.0 0.9 (1) 5.4 (6) 45.0 (50) 45.9 (51) 1.8 (3) 0.9 (1) .006 0.0 1.8 (2) 5.4 (6) 20.7 (23) 65.8 (73) 6.3 (7) 0.0 0.0 5.4 (6) 8.1 (9) 58.6 (65) 27.0 (30) 0.9 (1) 0.0 ture as a one-dimensional, socially de- 36.9 (41) 48.6 (54) 5.4 (6) 3.6 (4) 3.6 (4) 1.8 (2) 0 .024 3.6 (4) 18.0 (20) 12.6 (14) 43.2 (48) 12.6 (14) 9.94.5 (11) (5) 0.0 55.9 (62) 11.7 (13) 21.6 (24) 3.6 (4) 1.8 (2) 0.9 (1) 0.9 (1) 3.6 (4)0.9 (1) 8.1 (9) 1.8 (2) 33.3 (37) 1.8 (2) 44.1 (49) 9.9 (11) 37.8 (42) 0.0 53.2 (59) 4.5 (5) 0.0 .011 61.3 (68) 27.0 (30) 5.4 (6) 1.8 (2) 0.9 (1) 3.6 (4) 0.0 .006 Asian fined concept, whereas six saw it as a self-defined concept having multiple layers. For ethnicity, 93 definitions were s cultures 0.0 5.4 (6) 6.3 (7) 48.6 (54) 36.9 (41) 2.7 (3) 0.0 ’ given and these fell into ten themes, with the three most popular being geo- nes one

fi graphically defined or country of origin (30), sharing similar backgrounds (16),

s skins de and one’s sense of belonging and iden- ’ c cultures fi tification (8). Three students defined means that the group shown was more likely to agree or strongly agree withmulticulturalism the statement, in such a way that two 4 s culture ’ of their definitions could be included in as Americans of Subcontinent Asian immigrants. that those of Anglo-Saxon descentintellectually are superior to other groups in society English, as it is thecountry national language for this understand what it is likeelse to belong to someone students facts about other cultures the classroom about other cultures Japanese people masterpieces two themes and another definition in 9. Arabs do not place as much value on human life 15. Arranged marriages indicate the cultural inferiority 22. The color of one 16. Asians push their children to do well at school 13.5 (15) 48.6 (54) 22.5 (25) 3.6 (4) 2.7 (3) 9.0 (10) 0.0 .016 .016 Black 13. There is historical evidence to support the view 17. Everyone in the United States should learn 21. Through didactic learning students can 23. Cultural diversity can be taught by just providing 24. It is possible for medical students to be taught in 10. There is little difference between Chinese and 12. Every culture is capable of producing culinary three themes. Thus, we had 101 defini- General note: shown was more likely to have the neutral response. Attitudes about Eurocentricity Attitudes about diversity teaching Attitudes about speci tions that fell into nine themes, with

A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 1195 Table 2

Responses to Bogardus-Type Social Distance Statements* on Part III of a Questionnaire about Cultural Issues Given to 111 First-Year Medical Studentsat the University of Illinois Colleges of Medicine at Chicago and Urbana-Champaign, and Significant Differences between Groups, 2001

Significant Differences between Groups (p value)

White and Hispanic and White and Did Not Answer Black Black Hispanic Statement Yes % (no.) No % (no.) % (no.) Campus Ethnicity Students Students Students

I would be happy for two people of any two 91.9 (102) 8.1 (9) 0.0 different cultures to marry, including my own culture

I would be happy if people only married within 8.1 (9) 91.0 (101) 0.9 (1) .001† their own culture

I would be happy for a person of a different 97.3 (108) 1.8 (2) 0.9 (1) .037§ culture to live next door to me

I would be happy for a person of a different 91.9 (102) 7.2 (8) 0.9 (1) .001‡ culture to marry someone of my own culture

I would be happy to marry a person of a different 68.5 (76) 27.0 (30) 4.5 (5) .035‡ culture

I would be happy for a person of a different 99.1 (110) 0.9 (1) 0.0 culture to live in the same part of town

I would be happy for a person of a different 87.4 (97) 10.8 (12) 1.8 (2) .014‡ .0001‡ .019‡ culture to marry someone in my family

I would be happy for a person of a different 99.1 (110) 0.9 (1) 0.0 culture to live in the same country

I would be happy to have 76.6 (85) 18.9 (21) 4.5 (5) .026¶ mixed-race (dual–ethnic heritage) children

*Bogardus’ social distance scale gives a range of relationships from close personal relationship to more casual relationships to the target. The scale measures individual acceptance of the different relationships based on their closeness to the respondent. †Black students were more likely to respond “Yes” to this statement. ‡Black students were more likely to respond “No” to this statement. §One Hispanic student responded “No” to this statement. ¶Students on the Chicago campus were more likely to respond “No” to this statement.

the three most common being mixing or tion to responding to set questions, stu- generalizations.” The other ten com- blending of different cultures (21), the dents were given the option to write ments were made regarding personal understanding individuals have of other comments. Seventeen students com- perspectives and students were uncom- cultures (18), and different cultures co- mented on whether the questionnaire fortable about considering potentially existing (14). Race received 89 defini- had made them feel uncomfortable; one difficult subjects including their own tions with ten identifiable themes, the student made two comments. The com- prejudices and limitations (7). Of the 28 three most popular being genetically de- ments varied, but eight related to the students who made comments about fined (18), color of one’s skin (17), and way the questionnaire was worded (6) omissions in the questionnaire, 14 made country of origin/nationality (17). or how the responses might be inter- comments such as “Affirmation [sic] is Part VI was feedback on the ques- preted (2). One student in the former the work of Satan” and “How about cul- tionnaire itself (see Table 3). In addi- group commented: “Angry due to stupid ture and its use for political purposes?”

1196 A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 Table 3

Feedback on Questionnaire about Cultural Issues Given to 111 First-Year Medical Students at the University of Illinois Colleges of Medicine at Chicago and Urbana-Champaign, 2001

Question Yes % (no.) No % (no.) Did Not Answer % (no.)

Was it clear how to complete the questionnaire? 92.8 (103) 5.4 (6) 1.8 (2) Was the questionnaire too long? 27.0 (30) 71.2 (79) 1.8 (2) Was the questionnaire too short? 2.7 (3) 94.6 (105) 2.7 (3) Was the questionnaire too simplistic? 24.3 (27) 73.0 (81) 2.7 (3) Did any of the issues raised make you feel uncomfortable? 21.6 (24) 76.6 (85) 1.8 (2) Have any issues you consider important been omitted? 24.3 (27) 64.9 (72) 10.8 (12) Has filling in the questionnaire made you think about cultural diversity? 53.2 (59) 42.3 (47) 4.5 (5)

Students also commented about the fol- likely to define the terms ethnicity and naire. Students’ responses and com- lowing specific omissions: multicultural is- race (p Ͻ .037 and p Ͻ .013, respective- ments centered on whether the ques- sues (3), white (3), prejudice ly). When groups of numbers large tions were to be answered theoretically (3), religion (3), and sexuality (2). enough to allow comparisons were com- or based on personal experience. Stu- Forty-five students commented that pared, black students were the most dents also revised some of the terms in the questionnaire made them think likely to respond and Asian students the questionnaire to terms more familiar about diversity; of these, 37 were self- least likely to respond to definitions for in the United States. For instance, a reflective statements with students ethnicity and race. student would be “okay with” rather questioning their preconceptions and There were minimal differences be- than “happy” with a given situation. understanding. Six students felt that tween the Asian and Hispanic students. Race issues. Some students felt that they were very culturally aware and had Compared with white students, Asian affirmative action means black individ- already considered the issues raised in and Hispanic students were significantly uals in high posts are often considered the questionnaire. The other two com- more likely to have been born outside of less competent, and “are only there be- ments were: “I think cultural diversity is the United States (p ϭ .0006 and p ϭ cause of affirmative action.” very important and should be taught in .043, respectively) as were their parents Interaction between cultural groups. all medical schools” and “The current (p Ͻ. 0,001 for both), and Asian and Students noted that there is often little trend in multiculturalism, if drawn to its Hispanic students themselves were less social mixing among different ethnic logical conclusion, leads to a dismissal likely to have U.S. citizenship (p Ͻ groups. Some students felt this was a ϭ of the notion of any absolute truth. .0001 and p .009). Compared with result of few common interests. Other Such a conclusions is arguably absurd, white students, the parents of black stu- students felt that students of different thus showing that there must be flaws in dents were significantly likely to have ethnicities could be intimidating and our current understanding of multicul- been born outside of the United States generally there was less interaction than ϭ turalism.” (p .008). Asian and Hispanic stu- there could be among groups. Black stu- dents were also more likely to have a dents expressed a feeling that because sense of belonging to an ethnic group white individuals are often the majority, Differences between Groups ϭ ϭ (p . 034 and p .018) compared with no questions are asked if they stick to- white students. Differences between groups for part I of gether, whereas other groups are criti- the questionnaire are shown in Table 1. cized for doing the same. Black students As for other differences between Focus-Group Themes in the focus groups also felt that, on the groups, the parents of Chicago-based whole, white individuals have no under- students were significantly more likely In the focus groups, five themes emerged. standing of what it is “to feel out of to have been born in India (p ϭ .014). We will discuss these briefly below. place in sea of whites,” and that white Asian students were significantly less Students’ feedback on the question- individuals are rarely in marginal posi-

A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 1197 tions. This was not something that DISCUSSION standing of the amount of money that Asian students commented on. goes to support affirmative action. Teaching diversity issues. Most of Our study reflected the general difficul- Responses to statement 25 on the the students felt cultural diversity was ties of undertaking surveys. Practical de- questionnaire—“It is the responsibility insufficiently taught or not taught at all. tails such as students’ timetables and of the majority population to learn They felt that classroom teaching is of- room availability meant that we had to about minority groups”—may have re- ten not linked to the practice of medi- conduct the research when the students flected the majority view in the United cine. Generally students felt cultural di- were able to attend, rather than being States. Although the majority popula- versity teaching was needed and able to compose either homogenous or tion is expected to learn about minority perhaps “whites need it more.” There completely heterogeneous groups. Exact groups, this is not always seen to be a was an impression that minorities were response rates were difficult to report reciprocal arrangement, and some better informed regarding diversity al- because attendance was not mandatory groups can be marginalized from the though this was challenged by one and students were free to come and go as debate. Asian male student who believed that they pleased throughout the question- The questionnaire statements about exposure to others depended on where naire administration. Focus-group par- specific cultures are interesting in that you had grown up rather than on your ticipation was through self-selection. students responded they were neutral own ethnic background. Despite stressing that we wanted to hear or uncertain, such for as statement 9: Toward the end of each focus group, all perspectives, it is likely that only “Arabs do not place as much value on ND explained the categorical and cul- students sympathetic to the idea of di- human life as the Americans.” Re- tural sensibility approaches to teaching versity within the curriculum partici- sponses to this particular statement may pated. Conversely, those students who also have reflected students’ attitudes in cultural diversity. The students identi- did not see the relevance probably ex- the wake of international events, partic- fied with the cultural sensibility ap- cluded themselves from both the ques- ularly the attacks on the World Trade proach, partly because they felt increas- tionnaire and focus groups. Another Center and the Pentagon on September ing recognition of different groups limitation is the lack of consensus on 11, 2001, which occurred several makes the categorical approach difficult. how terms in this area are used and months before we conducted our survey. As one student said, “One cannot per- understood. Notwithstanding the limi- Such events can bring about acute sonally learn about 110 cultures or tations, our study has some interesting changes in attitudes toward certain eth- whatever, . . . but one can become aware findings. nic groups and raise vital concerns of the issues and step outside of one’s own Students were generally positive about the ways in which the American experience.” Students accepted that nei- about the project, possibly because one health care system responds to needs of ther they nor their patients were one di- of us (ND) was a practicing doctor and diverse population in a time of crisis. mensional. Students often had limited a visitor to the university, as well as The variation among the groups’ re- exposure to different groups as equals in because they had a genuine interest in sponses to statement 3—“Immigrants a way that allowed dialogue. subject matter of the study. should be integrated into their new Students’ own sense of belonging. Generally the students displayed country without having to give up their Some students of color often identified open attitudes about the balance be- own culture”—highlighted tensions themselves with a culture of origin tween cultures of origin and the culture about what immigrants should do to rather than with their American na- of the wider community in which im- adapt to a new environment. Students tionality. All black students born and migrants might be living. Students gen- from backgrounds where immigration raised in the United States did not nec- erally disagreed with statement 7 in the may have been a common experience essarily identify themselves as Ameri- questionnaire that skin color does not disagreed more strongly with the idea can, feeling that “American to most influence how you succeed; it is possible that immigrants should adapt to a new people means a white, redneck, and that nonwhite students saw white indi- culture at the cost of their original cul- blue-eyed blond person.” One black stu- viduals in general as advantaged and ture. The Chicago-campus group had dent felt that the stereotypes about white students saw nonwhite individu- significantly more students whose par- them being good at sports compared als as advantaged, particularly through ents had been born outside the United with academic areas are strongly held. affirmative action. Our focus groups re- States and also significantly more Asian Black students felt there was no acknowl- vealed the perceived resentment of students who were not U.S. citizens. edgment that assessment instruments some groups about affirmative action This finding in itself may suggest that such as admissions tests are biased toward and nonwhite students expressed con- recently settled immigrants are likely to certain groups in their basic design. cern at white Americans’ misunder- seek cosmopolitan university campuses,

1198 A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 which may have implications for the may have on the way the students per- unshared assumptions that groups have university’s recruitment policy. Recent ceive others. about others and themselves. There ap- immigration may also explain why the Female students in our study com- peared to be much frustration in some Chicago-campus group disagreed more mented that there were more advan- groups at the way other groups see strongly that the minority should con- tages to being a man than to being themselves. The focus groups showed form to the customs and laws of the white. The women seemed to be less that there needs to be an openness and majority. sure about those coming into the coun- willingness to talk about these issues, Statement 16—“Asians push their try having to conform to local customs because failing to do so does not resolve children to do well at school”—elicited and letting go of their own cultures. dilemmas. Lack of dialogue may allow an unsure response from some students This may reflect the pressure on immi- views that affect clinical practice to go suggesting that students were aware of grant women to maintain family tradi- unchallenged. For instance, if the white the stereotype. The minority students tions after emigration; in some cultures, students did not see themselves as hav- seemed more likely to agree with stereo- it is often the man who interacts most ing any advantages in the United typical views of other minority groups. with the external world. These findings States, they may not have realized that These findings indicate that racial and may also reflect women’s greater aware- others do view them as advantaged. If a ethnic stereotyping need not be nega- ness of the complexity of the issues. white doctor were to see a black patient tive. Positive stereotypes, while cer- Compared with white students, black and both parties were unaware of the tainly less damaging, can still lead to students seemed more aware of issues spectrum of views and assumptions the altered expectations and beliefs on the related to skin color than the other other might hold, a constructive dia- part of clinicians. Such assumptions minority groups. White students did not logue is less likely. It is arguable that the should therefore also be challenged and appear to perceive themselves as advan- responsibility of ensuring that all in- critically evaluated. taged, while the other groups did per- volved are aware of the potential diffi- At one level students were open- ceive white students as such. The re- culties is greater for health care staff minded, as indicated by their responses sponses of the white students appeared than for patients. to the 25 statements in part I of the to challenge the notion that racism is We received a great variety of re- questionnaire; however, when it came present in that they were less likely to sponses when students were asked to to the very personal such as whether a think that doctors have prejudices or define key terms. Eighty-seven of 95 student would marry someone from a that white doctors might be perceived respondents who offered definitions de- different culture, the students chose to to be more competent on the basis of fined culture as a one-dimensional, stay with what was familiar. Black stu- color alone. Affirmative action in the static socially defined concept. Six stu- dents were significantly different from United States may make white individ- the other groups and least likely to be uals feel that being white carries no dents thought culture is a self-defined okay with someone of another culture advantage. However, it is an interesting concept with potentially multiple lay- marrying into their families. These re- view when the wider contexts of polit- ers. The responses indicated that stu- sults suggest the presence of lingering ical and economic power are consid- dents varied in their understanding of sentiments about racism and discomfort ered. Black students felt patients are these terms. To us, students’ definitions with individuals outside of one’s own more likely to perceive a white doctor as showed a great variability and misun- culture in a small subgroup of our study. being more competent than a black derstanding of concepts related to cul- We can only speculate on the effects doctor, which may reflect the students’ ture and diversity which is perhaps un- that these findings may have in medical negative experiences. However, the dif- surprising given the debates about the practice. However, they might suggest ference between the white students and meanings of these terms. Although few that when faced with critical questions the black students suggests that the students appeared to use patently bio- about race and ethnicity, many students white students may have been unaware logical definitions, very few seemed to showed the ability to distance their own of some of the racism that black indi- have complex or multidimensional un- personal beliefs from what is best in viduals may experience. To acknowl- derstanding that better reflected mod- general. This may be a more hopeful edge that black individuals may experi- ern thought on this subject. This may sign than the data showed at first. There ence racism may have been difficult for suggest that the present curricula are in is no right or wrong answer about mar- some students, or it may have been that line with categorical teaching of cul- rying someone from a different culture. some students did not believe that rac- tural diversity and perhaps do not chal- However, further investigation is war- ism exists in the United States. lenge students to examine their precon- ranted on the underlying reasons be- These differences among the groups ceptions. However, the responses hind this response and the effect this suggest that there are unspoken and suggest that students’ understanding

A CADEMIC M EDICINE,VOL. 78, NO . 11/NOVEMBER 2003 1199 about these issues needs to be chal- doubt on genuine faculty commitment REFERENCES lenged in educational programs. to addressing diversity beyond a super- Our results indicate that the first-year ficial level. 1. Ludmerer KM. Time to Heal: American Med- medical students in our study had an Our questionnaire clearly challenged ical Education from the Turn of the Century impression of ethnic groups existing as many students. Although a minority to the Era of Managed Care. New York: Ox- ford University Press, 1999. very discrete and well-defined groups. clearly felt threatened and were of the 2. Schulman KA, Berlin JA, Harless W, et al. Students acknowledged different ethnic opinion that issues related to cultural di- The effect of race and sex on physicians’ groups within the color white. How- versity are an attempt to placate political recommendations for cardiac catheterization. ever, color and the issues around race constituencies, most students appeared to N Engl J Med. 1999;340:618–26. and perceptions of race remained a sig- favor teaching this subject. The fact that 3. American Medical Association. Enhancing the nificant barrier to dialogue regarding di- some students felt uncomfortable may in- cultural competence of physicians: Council on ͗ versity and seemed to cause greater con- dicate that the questionnaire itself served Medical Education Report 5-A-98 http://www. ama-assn.org͘. Accessed 7 February 2002. cern than the issue of ethnicity. When a teaching purpose by bringing conscious American Medical Association, 1998. discussing the categorical and cultural and subconscious biases to the surface, 4. Gurung RAR, Mehta V. Relating ethnic sensibility approaches, students were requiring students to reflect on fundamen- identity, and attitudes toward overwhelmingly in favor of the latter tal issues related to diversity. treating minority clients. Cultur Divers Eth- which suggests a disparity between this nic Minor Psychol. 2001;7:139–51. preference and the way they believed 5. Cross T, Bazron B, Dennis KW, Isaacs MR. CONCLUSIONS they viewed culture. Towards a culturally system of care. Vol. 1. Washington DC: Georgetown University Focus-group students intimated the Our study found that medical students Child Development Center, CASSP Techni- cultural sensibility approach was the at this university were not familiar with cal Assistance Centre, 1989. one that they were drawn to when they key terms and often struggled with the 6. Family Resource Coalition. Family Resource were asked about the two models. How- Coalition Report on Culture and Family- issues that diversity raises. Although ever, the questionnaire responses indi- CentredPractice,Fall/Winter1995–1996͗http:// students held open attitudes toward ͘ cated that conceptually students may www.casanet.org/library/culture/competence . equal opportunities and multicultural- Accessed 11 September 2001. have been more comfortable with cul- ism, differences between and within 7. Deloney LA, Graham CJ, Erwin DO. ture as defined in the categorical ap- groups indicate that all students would Presenting cultural diversity and spirituality proach. Before attempts are made to benefit from self-reflection and diversity to first-year medical students. Acad Med. teach medical students about diversity, 2000;75:513–4. teaching. This would improve patient– our study indicates that they would ben- 8. Kamaka ML. Cultural immersion in a cultural doctor communication, which remains efit from exploring their own perspec- competency curriculum. Acad Med. 2001;76: at the heart of good practice irrespective tives and sense of belonging as well as 512. of the cultural background of the pa- 9. Nunez A. Transforming cultural competence exploring the concepts of culture, race, tient or doctor. into cross-cultural efficacy in women’s health ethnicity and diversity. These exercises education. Acad Med. 2000;75:1071:1080. may help them identify their personal Dr. Nisha Dogra would like to thank all the staff 10. The Henry J Kaiser Family Foundation. Com- biases and the ways in which they un- and students at the University of Illinois College pendium of cultural competence initiatives in of Medicine at Chicago and the College of Med- health care. Menlo Park, Calif.: The Henry J derstand their patients, which may ulti- icine at Urbana-Champaign who facilitated this Kaiser Family Foundation, 2003. mately influence their clinical practice. project, particularly those students who also par- 11. Tervalon M, Murray-Garcia J. Cultural hu- This may also help physicians realize ticipated in the focus groups. Dr. Dogra also mility versus cultural competence: a critical thanks the International Health Society and Crit- that their patients are as complex as distinction in defining physician training out- ical International and Transnational Health and they themselves are. In addition, it is comes in multicultural education. J Health Medicine Reading Group in Urbana, who hosted difficult to be clear how effectively the part of her visit and provided excellent discussion Care Poor Underserved. 1998;9:117–25. questionnaire identified which model forums; the University Medical Student Council 12. Dogra N. The development and evaluation of best fit the students’ conceptualizations. for the opportunity to share this project; Dr. Susan a programme to teach cultural diversity to Medical students could also be more Roth, Dr. Jenny Bloom, Dr. Joe Goldberg, Jim medical undergraduate students. Med Educ. 2001;35:232–41. explicitly challenged on their under- Hall, Dr. Jorge Girotti, and Dr. Jobe Payne, who took the time to meet with her during the visit; 13. Dogra N, Stretch D. Developing a question- standing of “others” and questioned and especially Jim and Jorge for their comments on naire to assess student awareness of the need where this understanding has come an ear lier draft. Finally, Dr. Dogra thanks Dr. Rajni to be culturally aware in clinical practice. from. Some students expressed some Dogra, who provided comments on later drafts. Med Teach. 2001;23:59–64.

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