Formal vs. informal curriculum
All of the focus groups spontaneously noted that the CCC consisted of both formal and informal elements. Formal elements included a required reading assignment [28], standardized patient modules containing a cultural component, and lectures. The informal curriculum included learning about cultural competence from residents, attending physicians, and patients in clinical situations as well as from the diversity of fellow students.
Overall, most students evaluated both the formal and the informal CCC as useful and relevant. Of note is that the two students interviewed separately were more negative about the CCC. One student described the formal curriculum as "not that great, superficial, it didn't provide any concrete skills. There was nothing new. Honestly, I was very frustrated with the superficiality."
Most students considered the informal curriculum to be superior to the formal curriculum in terms of teaching cultural competence because of the direct link it provided between knowledge presentation and skill acquisition. As one student expressed it, "I think the greatest part [of CCC] is seeing by example how to act, or act in a certain situation." Another student said, "I'm learning more on the go [about CCC], in clinic from my preceptor. And I've learned more in the clinic actually than I ever did in any lecture that I had, if I think back." A third student commented: "I guess what I'm trying to say is that you really learn when you're thrown in these situations. Like right now...I'm learning for the first time about Vietnamese and their culture and just different ways that they need to be treated as a patient, things you need to be sensitive about. But it's only because I'm working with these patients."
However, several students noted that attending physicians rarely had time to talk about cultural issues and even more felt that opportunities for clinical teaching about cultural issues in the patient environment were significantly underutilized. Students reported that while some of their best, most practical cultural competence teaching took place in the clinics or hospital, these experiences happened randomly, varying significantly from one rotation, one clinic, or even one resident or attending to another. As one student noted, "I'm sure I do [make culturally insensitive mistakes], but I don't know what they are because no one's ever watched me and said you're doing this and how to be constructive about it."
Many students mentioned that one of the strongest aspects of the informal curriculum was the diversity of the student body. They seemed to feel that, because they were surrounded by diversity, they could not be biased. As one student put it, "A different generation might not have had this advantage. But young people nowadays, we're all so diverse, we're used to being with people from other backgrounds since elementary school, so it's no big deal."
Awareness vs. intervention regarding bias
As the above quotation suggests, it was initially difficult for students to acknowledge self-awareness as relevant to culturally competent patient care. Students described self-awareness exercises as "a waste of time" and "too touchy-feely." After some probing, however, several students were able to give specific examples of how they had become aware of their own biases as a result of exposure to the CCC. One student (himself Vietnamese) commented that the CCC had enabled him to develop a more professional perspective: "And that [the CCC], when I was talking with them [Vietnamese patients], kept me from like... just laughing you know, making an inappropriate response when they would express these unscientific beliefs." In the words of another student: "... [This was] something that the [CCC] originally made me aware of, because that never would have occurred to me [i.e., the possibility that she could have personal prejudices]. I think that I'm an empathetic person and that I would go into every encounter with an open heart but as it turns out I really do have a harder time with certain patients."
Students also commented that faculty and residents sometimes demonstrated stereotypic, denigrating attitudes toward patients of a specific ethnicity. "Some residents talk about patients doing the Macarena, which means Latina women in labor who are loud." Examples of unfair positive bias in faculty were also observed: "Sometimes you see, like examples of physicians who are kind of more biased toward patients who are of their own culture. I remember this one rotation where this doctor would spend half an hour on one patient that was of his culture, the whole time speaking that language... and then in comparison he would spend 5 minutes with patients of various different cultures..."
Students had no difficulty identifying such examples as race- or culture-based stereotyping, and attributed part of this awareness to learning that occurred in the CCC. But they varied in their ability to address or respond to these situations. The majority felt similarly to a student who said she found it impossible to say anything to faculty or residents who made culturally insensitive remarks because the situation was too "intimidating." These students were concerned about the possible adverse effects of action on their course evaluations and/or grades. On the whole, students across the three groups did not feel well-prepared to deal with such culturally biased statements in clinical contexts.
The search for cultural "balance."
Many students wanted group-specific knowledge about as many different cultures as possible. In the words of one student, "I always feel like part of my knowledge is lacking... I know I should be sensitive to different things of their healthcare but I don't really know what they are..." A student from a different group said, "I mean I know the task may be very daunting, but it would be insightful if I knew about as many cultures as possible..."
However, students also expressed concern that such presentations might stereotype different ethnicities. One student said, "Sometimes I think it's better when I go into a [n exam] room and figure the patient out for myself without any preconceived notions of 'Oh, this patient is Hispanic so she's going to act this way."' Another noted, "As soon as you start you know, painting a certain ethnicity as, you know, look out for these, you're basically saying every person who is this ethnicity has this."
These students expected the CCC to help them achieve a "balance" between acquiring appropriate cultural knowledge and approaching each patient as an individual, but they were often disappointed. One student summarized this point of view in the following way: "To me it's hard to find the balance, because we're told on one hand that you treat all these patients as patients, you know it doesn't matter where they're from... On the other hand, we're told if they have a certain ethnicity there are all these other things we need to think about."
Did the CCC promote political correctness?
There was a difference of opinion about the openness of the student body to discussing sensitive issues of culture. On the one hand, some students' perception was that their peers felt comfortable expressing their cultural and religious beliefs. "My experience is that people have been themselves and let their religion or their culture or whatever, come out." However, other students felt that the whole discussion of culture was overlaid by a strong degree of political correctness, so that it was difficult for people to state their true opinions or feelings. "We're all taught to be so politically correct these days and no one wants to say how they really feel. Like it was hard for me to admit I had certain biases about certain cultures but I do..."
The CCC and humanism
Several students were concerned about the decline in humanistic values during their third year. In the words of one student, "When I go home I just don't think about patients, I think about their medical issues. There have only been a few times when I actually start to think about what I call 'personal connection,' where I go you know I wonder how it's affecting their life, I wonder how they're really feeling."
As a kind of antidote, students felt it was important that "... [The CCC] showed that the medical school actually cares about culture and people, you know." The implication was that the CCC could reinvigorate students with a more patient-centered approach.
Finally, although these students all valued the concept of cultural competence, none suggested that we test for this competency through either written or clinical examination.