Cultural competency instruction in medical education has been the thrust of several recent reports in the US and the UK [1–3]. Evidence is growing that improving cross-cultural communication skills in healthcare providers is associated with better patient outcomes [4, 5] and has the potential to reduce health disparities [6] and improve access to care [4]. However, a recent systematic review evaluating cultural competence training of health professionals concluded that lack of methodological rigor made it difficult to draw conclusions regarding the effectiveness of specific educational interventions [7].

Attitudes of students toward diversity training are equivocal, although survey-type methodologies tend to report positive attitudes toward diversity training [8, 9]. In another study, residents lamented their lack of "formal" education on this topic, and felt they were poorly prepared to deal with cross-cultural clinical encounters [10]. Similarly, a different investigation concluded that much of learners' self-reported cross-cultural competency came from their own improvisational coping [11]. Yet learners were also concerned that formal cross-cultural education might result in stereotyping of different racial and ethnic groups; and in any case was excessively abstract and theoretical [12].

While some research has provided evidence that medical students' knowledge, attitudes, and skills can be positively changed as a result of participation in a cultural competency curriculum [13, 14], other studies suggest that exposure to a cross-cultural curriculum has little or no effect on student skill acquisition [15, 16]. Further, even when learners report having adequate cross-cultural communication skills and training, they feel that both systemic and patient factors inhibit their providing quality care [12].

We still do not have sufficient information from the perspective of students regarding their cultural competence curricula. The purpose of this study was to qualitatively assess the views of third year medical students at a public university school of medicine regarding its cultural competence curriculum (CCC), which incorporated an integrated longitudinal approach [17], the concept of cultural humility [18, 19], and specific cross-cultural communication tools [20].

Participants were 16 third year medical students, 17.4% of the class. There were 6 males and 10 females (62.5%), a somewhat higher representation of women than in the student body as a whole (50.0%); and 17.7% underrepresented minorities, compared to 10.0% overall. Students were recruited via a series of emails as well as personal invitation. Students were offered the incentive of a free lunch, and participated in a raffle for which the prize was a medical textbook. Sampling was in part purposive, in that the first two authors made an effort to attract students with a wide range of attitudes toward cultural competence training, including students with intense feelings about the subject, both positive and negative, and students with less interest in the topic. Sampling was also a matter of convenience. Because of the relatively small response, we accepted all students who volunteered.

Nineteen students responded affirmatively. Two could not attend the focus groups due to scheduling conflicts, but agreed to participate in individual interviews. Three others could not arrange either option. The three focus groups contained respectively 5, 5, and 4 students. All participating students had had a high degree of contact with patients from different cultural backgrounds. This study was approved by the university's human subjects institutional review board. Following the requirements of that approval, the nature and purpose of the study was carefully explained in the recruitment email. The study was again explained at the start of each focus group, including issues of anonymity and confidentiality regarding tape-recording and transcription of tapes, as well as reporting of findings; and verbal consent was obtained from group participants. Since consent was inferred from response to the recruitment email (students could refuse to participate simply by not replying) and to the oral presentation of the study by the faculty member, our IRB considered verbal reiteration of consent sufficient.

A preliminary version of the schedule of focus group questions was developed by a researcher (JS) who had previously conducted focus group research on cultural competence with other medical learners [12, 21]. This interview guide was reviewed and modified by the second author (DL) who directs the Patient Doctor course in which some of the Cultural Competence Curriculum was embedded. The groups followed standard focus group methods, including creating an informal atmosphere, allowing conversation to flow naturally rather than adhering to a strict schedule, encouraging differences of opinion, and eliciting comments from silent members [22]. The location of the focus groups was a small, comfortable conference room. JS was the primary moderator and an assistant moderator (an undergraduate student [DG]) made process notes and observations, as well as asked clarifying and supplemental questions as needed. Each group was approximately 75 minutes in length and was tape-recorded. DG conducted the individual interviews by telephone. These interviews used the same interview guide prepared for the focus groups, and lasted about 20 minutes. They were not tape-recorded, but the interviewer typed extensive notes during the interview, as well as made summary notes immediately afterwards. All recordings were transcribed verbatim and these texts, in addition to the group process notes, and written notes from the interviews, provided the basis for data analysis.

Several aspects of these discussions with third year medical students were illuminating. One was the strong preference expressed across all three groups for the majority of the CCC to be integrated into the informal curriculum, especially during the third year of training, when students start their clinical rotations. Students appeared to feel that they learned best in this type of integrated environment, where knowledge had immediate and direct application. Although this is an attractive proposition, it faces the perpetual challenge of how to systematically train large numbers of attendings and residents in all the steps of cultural awareness, sensitivity, knowledge, attitudes, and skills; and how to simultaneously attend to medical and cultural issues in any given patient encounter.

Also of concern to medical educators may be students' tendency to minimize the importance of self-awareness in developing cultural competence. This finding was reported almost a decade ago [17] and confirms the difficulty of convincing students that they need to carefully reflect on and confront their own potential for bias. Students seemed to find reassurance in the fact that they were training with culturally diverse peers. However, there tends to be more homogeneity than heterogeneity in terms of academic ability and socioeconomic status in medical school. In addition, the medical school experience is known for its capacity to "stamp out" the diversity of those who succeed in matriculating [29].

Although the CCC was helpful in making students aware of expressions of bias in others, it was less effective in giving them useful tools for addressing these situations. This finding suggests the importance of providing students with concrete, skill-based training in confronting bias, while ensuring that the medical education system provides protections for students who exercise such skills.

Students did not appear to have theoretical models other than cultural difference within which to understand the relationship between doctors and patients. This dearth of explanatory mechanisms may have contributed to students' confusion about how to "balance" knowledge of specific cultural groups with respect for individual differences. One partial solution to this dilemma might be greater attention to the concept of cultural humility [30]. Although our curriculum already included such exposure, it appeared students by and large ignored its implications. This suggests the need for more explicit and systematic training to enable students to adopt a position of respectful curiosity about a person's background, regardless of his or her particular culture, thus positioning themselves as learners and their patients as teachers. This approach also has the advantage of helping students be aware of and partially rebalance power dynamics within the doctor-patient relationship [18].

Because of differences in opinion as to whether the CCC operated in a context of political correctness, it was unclear to what extent students either confronted their own biases or developed respectful understanding of culturally different perspectives. While some participants maintained that students could "be themselves" and express opinions openly, a significant minority maintained that they were constrained by certain norms that made it unacceptable to verbalize culture-based negative attitudes. Such beliefs could seriously impede the ability of the CCC to penetrate more than superficial levels of student attitudes, leading to external conformity to perceived norms rather than genuine respect and understanding of difference. Occasionally, an article raises questions regarding whether political correctness can compromise the quality of physician training or patient care [31], and it seems a more open discussion of this issue is needed.

Despite concerns about the CCC, many students regarded it as a method for humanizing their medical education. This link between the CCC and humanism is an interesting one, and has been noted by others. For example, one author suggests that culturally competent care and patient-centered care (based on several humanistic properties) are philosophically similar and both contribute to patient empowerment [32] It is possible that the CCC helped connect students to the life stories of their patients, particularly as these were manifested in the informal curriculum, and this experience had a rehumanizing effect.

The fact that no student advocated assessment of the cultural competence curriculum deserves some reflection as well. This omission may mean nothing more than students' understandable aversion to yet more examination in an already test-intensive academic environment. It may also intimate that students do not perceive cultural competence as "real learning" on a par with the basic sciences and clinical knowledge. Students may also see cultural competence in much the same way good communication used to be viewed, as something one either has or doesn't have. Finally, it is possible that students' attitudes toward assessment reflect those of many medical educators who also have concerns about how to meaningfully conduct evaluation of culturally competent knowledge, attitudes, and skills [33].

Students in this study wanted more integration of cultural competence training in the clinical setting as part of the informal curriculum. They also needed more specific assistance in learning how to deal with situations that expressed prejudice or bias. Further, students hoped for better guidance in achieving a balance between learning about specific cultures while respecting individual differences. Despite some concerns as to whether political correctness permeated the CCC, it was also perceived as one way of rehumanizing the medical education experience.