A review on cultural competency in medical education

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Abstract

Cultural competency is a wide notion with a variety of academic bases and differing perspectives on how it should be implemented. While it is widely acknowledged that cultural competency should be an element of general practise, there is a paucity of literature in this area. It has been commonly claimed that cultural competency is a fundamental prerequisite for working well with persons from different cultural backgrounds. Medical students must learn how to connect successfully with patients from all walks of life, regardless of culture, gender, or financial background. Hence, National Medical Council (NMC) has included cultural competence as a course subject in the curriculum of medical education. The opportunities and concept of Competency Based Medical Education, the inclusion of cultural competency in medical course by NMC, various models and practice skill of cultural competence in medical education are discussed in this paper. This study will be useful to researchers who are looking at cultural competency as a research variable that influences study result.

Keywords: Competency-based medical education, cultural competence, culture awareness, healthcare quality, medical education, national medical council

Introduction of Cultural Competence, Differences Its Concepts and Characteristics

Cultural competence refers to a combination of knowledge, behaviours, policies, and attitudes that operate together in a system, organisation, or among specialists to allow successful cross-cultural work. “Culture” describes to integrated patterns of human behaviour that encompass ethnic, social, racial, and religious groups’ language, ideas, acts, conventions, beliefs, and organizations. “Competence” means to an individual’s or an organization’s ability to operate successfully in the context of patients’ and their communities’ customs, cultural beliefs, and demands.[1] Some of the research examined cultural variations as disparities in health understandings across various population groups, such as indigenous people’s holistic health understandings and how they vary from mainstream approaches to health.[2] Other research looked at communication challenges such as cultural differences and linguistic discordance, and how these effect clinical interactions, especially among Hispanic populations in the US.[3]

Cultural competence is an important technique for minimising disparities in healthcare access, as well as the quality and efficacy of treatment provided. It aims to improve the capability and capabilities of healthcare organisations, systems, and practitioners to offer more culturally responsive healthcare. Cultural competency is often about how the notion of respect is operationalized to ensure that varied populations’ cultural rights, diversity, values, beliefs, and expectations are acknowledged in the delivery of culturally relevant health care. “This right can only be protected if cultural concerns are core business at every level of the health system—systemic, organisational, professional, and individual’ in today’s culturally and linguistically varied countries”.[4] Although there is strong evidence that Cultural Competence should work, there is no information concerning how to determine what combination of Cultural Competence methods works, when and how to apply them appropriately, or how to quantify performance in health systems at all levels.

For the last two decades, major textbooks and journals in the field have paid close attention to cultural competency. Despite many publications, conference presentations and symposia, the profession struggles to move the discourse around cultural competency forward. Most professionals, for example, are unable to confirm that their clinical practises are culturally competent. The well-intentioned but sometimes misguided investigation of academics and researchers in this field, we feel, is a fundamental factor for the disturbing inertia. There have been ambitious efforts to develop tests that evaluate cultural competency, develop models that represent its most conspicuous qualities, and inject fundamental ideas of this construct into training programmes.

The ongoing lack of dedication and knowledge regarding cultural competency in the medical profession and training programmes erodes the efficacy of assisting professionals and emphasises the need of further research. This review focus on providing all important knowledge regarding cultural competence along with its history, importance and different competency models. Returning to the past with a focus on integrative self-exploration and growth in which affective, cognitive, skill development, and behavioural learning occur in the training of practising professionals and trainees could lead to a greater appreciation of cultural competence and adoption of cultural competence as a powerful and emerging force in medical education which enhances ability and knowledge to serve all people.

Culture Competency Concept

Cultural competency is a wide notion with many different perspectives on what it is and how it should be manifested.[5] It is usually characterised as “a collection of consistent behaviours, attitudes, and rules that allow a system, agency, or person to successfully function within a cross cultural environment or circumstance”.[6] The scope, duration, content, and manner of delivery of cultural competence curricular frameworks and models differ significantly.[7] Furthermore, a broad range of methods for assessing cultural competence have been created, each with its individual theories about what constitutes cultural competence.[8]

Bean R,[9] Gopalkrishnan N,[10] Graf A[11] explained component of behavioural, or the skills essential to collaborate across cultures, may vary from individual skills, which is verbal and nonverbal, and skills in dealing with interpreters, to wider community development skills, or even policy creation skills. They explained the emotive component, which includes attitudes like respect, sensitivity, and openness to diversity, helps in the growth of the healthy cross-cultural relationships. They also elaborated the cognitive element which means previous awareness of cultural differences aids in the development of better connections and the avoidance of cross-cultural misunderstanding.

Competency Based Medical Education (CBME)

CBME is the inclusion of cultural competency in medical course by NMC. CBME, which is an outcomes-based approach to the implementation, design, evaluation, and assessment of doctors and physician training programmes, has sparked a lot of controversy and discussion.[12] The opportunities and constraints of CBME are discussed in thought papers, conceptual frameworks, implementation documents, consensus statements and institution-specific descriptions.[13] With the growing implementation of CBME, medical education is experiencing a transition. It is education is dependent on the outcomes method for creating, executing, measuring, and evaluating medical education programmes that uses competences as an organisational framework. Programme delivery is directed by competences that are clearly described, sequenced progressively, and gained in workplace-based learning contexts, which are the practical day-to-day differences for both clinical instructors and learners.[14]

Inclusion of Cultural Competency in Medical Education by CBME

Over the last 20 years, a recent educational paradigm known as competency-based medical education has arisen, and many healthcare training programmes throughout the globe have embraced it. CBME’s mission is to create “a health professional who can practise medicine at a set degree of skill, in accordance with local circumstances, and to address local requirements”. Van Melle et al.[15] utilised a two-step strategy to determine the important and necessary parts of CBME. To ensure CBME authenticity, they recognised five critical components that must be involved in the implementation process. The degree of exactness with which anything is replicated or reproduced is characterised as fidelity, and it is regarded essential for the success of competency-based medical education implementation.

Health professionals that are skilled in taking care of patients and demographic groups that vary in age, gender, socioeconomic level, migratory status, and ethnicity are required in a health system that serves diverse communities. Cultural competence (CC) amongst healthcare professionals is seen as one technique for ensuring equitable access to healthcare for people of all races and ethnicities, as well as ensuring that patients get treatment tailored to their specific requirements. NMC established a one-month foundation course for MBBS students in 2019. The goal of this course was to assist organizations and teachers in preparing new medical students with the necessary knowledge and abilities for human exposure interactions and interpersonal connections in a variety of contexts, such as hospitals, communities, and clinics.

How is Cultural Competency Established?

Two decades ago, the necessity of cultural competency in healthcare was recognised. Then, to address this issue, several investigations were conducted, and various hypotheses were established. The terms culture and competence make into the phrase cultural competency. Cross (1989)[1] coined the phrase “cultural competency” to describe a collection of acceptable attitudes, behaviours and policies that come together in an organisation or among professionals to allow them to function in cross-cultural circumstances. Some research focused on the term competence, defining cultural competence as a spectrum or a process, while others focused on the word culture, referring to cultural competence development approaches. For example, Campinha-Bacote (2002)[16] described cultural competency as a process that includes the five components of cultural knowledge, cultural awareness, cultural contact, cultural skill, and cultural desire. Leininger (2002),[17] on the other hand, characterised cultural competency in terms of the many components of culture, such as health beliefs, values, philosophy, and religion. To refer to the cultural competency idea, several research utilised the terms culturally congruent care, cultural congruence, congruent care interchangeably, and culturally competent care.

In General Practice, there are many different strategies to acquire cultural competency, and rigorous assessment.[18] In general practise, formal cultural competency training tends to be undeveloped and uneven, and most parts of cultural competence are acquired via, experiential and informal learning, and in-practice exposure.[15,19,20] Cross-cultural consultations were shown to be extra stressful for general practice registrars owing to their reported lack of knowledge, confidence, and abilities in this field.[21] Cultural diversity has been found to help in the development of cultural competence via experience and training over time, which is particularly important in general practice training.[22,23] Exposure to diversity may motivate for learning and operate as a trigger and developing cultural competency of the practise as well as the system or individual may be a synergistic process. Through modelling cultural knowledge, incompetent attitudes, and abilities of further clinical supervisors or staff, there is also the potential of perpetuating existing obstacles in the treatment of patient.[24] Stronger role models and exposure to a more diversified case of cross-cultural mix during training appear to enhance general practice registrars’ readiness and ability to give cross-cultural care.[25]

Medical colleges attempt to educate doctors who can treat patients from a variety of socioeconomic and cultural backgrounds. Medical students must learn how to connect successfully with patients from all ages of life, regardless of gender, culture, or financial background. Communication skills are related with clinical competency and the skill to elicit, analyse, and interact appropriate clinical details to patients in relation to being essential to physician-patient interactions in terms of patient satisfaction and involvement during the physician encounter.[26] During medical school, physicians’ subjective judgments of medical students’ clinical knowledge, interpersonal and communication skills and patient engagement are used to evaluate their clinical performance.[27] Assessment of knowledge, attitudes, and skills is challenging due to the complexity of conceptualising cultural competency. Cultural competency instruments and tests often contain reflect biases or assumptions. Cultural competence assessment among general practice registrars, on the other hand, might motivate them to learn and reflect a supportive training environment. The majority of educational intervention assessment research were process-oriented, even though complex behaviour evaluations must be multi-faceted.[28] Multiple confounders, like as other environmental and social determinants of health access, and other systemic obstacles outside the individual control clinician contacts, are often present and must be taken into consideration, making assessment even more challenging. This information has been included into a suggested strategy for evaluating educational interventions on patient outcomes.

Importance of Cultural Competence in Medical Education

We are surrounded by people of different ethnic or racial origins, migrants, immigrants, and refugees. Cultural competency is critical since it is hard to form such connections without it. We’ll instead co-exist with individuals we do not understand, improving the likelihood of damaged emotions, misunderstandings, and bias—all of which can be avoided. Beyond the obvious instructional messages, the most essential socialisation mechanisms in medical education exist. The official curriculum, the informal curriculum, and the Hidden Curriculum are three possible sources of influence in medical school, according to Hafferty.[29] The Hidden Curriculum’s norms are largely communicated via structural and cultural variables such as institutional regulations, “slang” or colloquialisms, assessment systems, and resource allocation. The Hidden Curriculum’s messaging may contribute to a loss of idealism and a loss of ideals, which can lead to a lack of concern about unconscious prejudice.[30] The structural norms of an organisation may be significant guides for conduct, but they are typically unarticulated until they are challenged. Efforts to teach doctors to deliver high-quality, culturally aware treatment have steadily increased in medical education. Many countries are growing more diverse, cultural competency training has pushed to the forefront of medical education. Ethnic minorities today make up roughly demographic trends and 30% of the population, indicate that by 2050, they will be the majority.[31] Furthermore, there is a clearer understanding of the role of culture on health care and health inequalities.[32] Cultural norms influence health-seeking behaviour.[33] Some patients may put off seeking treatment because of a sense of cultural insensitivity, apprehension that they will get worse care, or the belief that they have been handled unjustly because of their ethnic or race origin.[34] Furthermore, inequities in health care have long been noted, with racial discrepancies in treatment remaining even after accounting for income level, health condition, and insurance status.[35,36] The most popular paradigm in medical education for addressing culture and race as social determinants of health is cultural competence. By training medical students and professionals to better understand their patients’ culture and ethnicity, cultural competence attempts to enhance patient–provider communication. To assist alleviate the stigma of a mental health diagnosis for a patient in an Asian immigrant household, students may be trained to utilise sensitive terminology or work with cultural liaisons.[37,38,39]

Bourgois et al.[40] have released a systematic evaluation tool to help healthcare practitioners, address socioeconomic factors of health in their clinical practises. A practical guide for medical educators based on this paradigm might help with attempts to enhance race and culture education in medical school curriculum, as well as culture and race representation in national examinations, question banks, board preparation courses, and virtual-case-based learning modules. “A collection of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals that allow that system, agency, or professions to perform successfully in cross-cultural contexts,” according to Cross et al.[1] This term encompasses a variety of intervention strategies aimed at improving healthcare systems’ cultural competency. When it comes to getting health care, health professionals have a critical role in influencing the patient experiences and type of interactions. Miscommunication,[41] as well as service user distrust,[42] disempowerment, and poor satisfaction may emerge from cultural and language disparities between health service consumers and healthcare practitioners.[43] The majority of workforce interventions cultural competence have centred on training and educating health care professionals in the essential and significant educating attitudes, skills, and knowledge to appropriately react to socio-cultural barriers that emerge in clinical encounters.[44]

Cultural Competency Development

Interventional majority of trials evaluated workshops of standalone delivered by certified medical educators.[45] Educators believed that training and experience in cultural competency teaching was essential due to the subject’s complexity. Cultural competence training is regarded to have the potential to perpetuate existing myths, prejudices, and stereotypes in society,[46] especially if it is completed without the supervision of the cultural group and direct involvement in question. Patients, educators, and students recognise the benefit of cultural mentors in several research.[47] Cultural mentors are recognised as community advocates who may share their knowledge while encouraging connections between communities and healthcare professionals. Community ownership of cultural knowledge is also respected by other community members and ensuring cultural mentors play a prominent role in training. Pessimistic attitudes of learners, competing community, and family responsibilities, and an expertise in training and lack of confidence are all barriers to community people participating in GP registrar training. However, there is a need among culturally diverse groups to train with general practice registrars, which should be encouraged.[47]

The researchers went on to say that cultural competence refers to “the integrated pattern of human behaviour that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group,” as well as “having the capacity to function effectively” among people with “the integrated pattern of human behaviour that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group.” Leininger (1991) defined the term as “the application of culturally based care knowledge in facilitative, assistive, creative, sensitive, safe, and meaningful ways to individuals or groups for beneficial and satisfying health and well-being or in the face of death, disabilities, or difficult human life conditions”.[17,48]

Self-awareness and Health Professionals

Health practitioners are influenced by culture in an unconscious way. Self-awareness and comprehension foster strong professional perspectives, allowing healthcare workers to connect with others while maintaining personal integrity and respecting the individuality and diversity of each client. Self-awareness, also known as self-exploration, is the first step in the process of professional growth and diversity competency. Self-examination or knowledge of personal biases and prejudices, according to many theorists and diversity trainers, is a key stage in the cognitive process of gaining cultural competence.[24,49,50] However, considering the possible effect of emotions and conscious sensations on behavioural outcomes, considerations of emotional responses evoked by this cognitive awareness are rather restricted.

Cultural Competence Models

In a 2001 HRSA research, two theoretical and methodological methods to understanding cultural competency were discovered in the literature. Cultural competency is characterised as a process or continuum by Cross et al. (1989)[1] and Campinha-Bacote (1999). Leininger (1993a), among others, “provide a more methodical perspective that focuses on the strategies that a professional may employ to become culturally competent and deliver culturally competent treatment”.

The focus on either the culture or competence component is evidently mirrored in the creation of the domains of the models, as previously described in defining cultural competence. While the methodological models appear to be equally focussed on the culture component, with domains such as ethnicity, religion, healing practises and beliefs, and value orientations, the theoretical models appear to be focussed on the competence component, with domains such as knowledge, awareness, skill, and sensitivity.

In other words, if the traits of cultural competence are clearly specified with one component in focus, domains of a model, whether methodological or theoretical, may be drawn from them. In this manner, the domains of a cultural competency model may easily be determined by a well-defined idea.

The following are the goals of this model:

In the framework of historical viewpoints, define the conditions that influence a person’s cultural worldview.

Connect cultural features to create congruence and make it easier to provide competent health care and deliberately attentive.

The features of the other component of cultural competence remain abstract in both kinds of models since they focus on only single component of cultural competence and describe its domains openly. The areas of cultural skills, cultural sensitivity, and cultural knowledge are shared by most theoretical cultural competency models in Table 1 for example, yet the definition of culture is anything from apparent.

Table 1

Different models of cultural competence

Prescription for success in Cultural Competence Medical Education

Utilize interactive educational methods, like self-reflective journal assignments, standardized patient encounters, and role play

Traditionally, cultural competency programmes have taken a knowledge-based approach.[32] Lists of recommended phrases, pictures, or ways for handling minority groups are often included in such courses, depicting for every single group as having distinct beliefs, values, and behaviours depend on culture. As mentioned in Table 2 this simplistic approach ignores variation within groups while emphasising contrasts between them, thereby perpetuating stereotyping.[83] Cultural competency programmes, on the other hand, should recognise variation in social groups and educate medical students how to use socio-cultural information at the personal level. Clinicians observe various behavioural patterns and health beliefs even within a family unit, depending on individual preferences, experiences, and acculturation degree.[84,85] The capacity to extract an individual’s impressions of sickness and health, also their treatment preferences and explanatory model, and skills that are transferable across cultures and patients.

Table 2