Posted by: barn owl | March 4, 2008

Teaching Tuesday: Cultural Competencies in Medical Education
I respect a government official who, in testimony before the US House Committee on Oversight and Government Reform, makes statements such as “the problem with this approach [Bush administration censorship/interference on issues such as embryonic stem cell research and abstinence-based prevention initiatives] is that in public health, as in a democracy, there is nothing worse than ignoring science or marginalizing the voice of science for reasons driven by changing political winds.” Therefore, I read with interest Dr. Richard Carmona’s foreword (2007) in a recent supplemental issue of the Journal of General Internal Medicine, covering topics of health care disparities and access to health information, in the context of an increasingly diverse US population. He describes the communication and cultural barriers between patients and health care providers, and encourages us to improve methods of disseminating health care information to diverse populations.

My own interests are in disability rights and access issues, particularly for individuals with neurodevelopmental disorders, cerebral palsy, or traumatic brain injury, but the approaches developed to overcome language and cultural barriers are nevertheless instructive. Saha and Fernandez (2007) ask the reader to imagine falling ill in a foreign country, where you are unable to speak the language, and your guide has only limited facility with the English language. The examination by the doctor seems cursory, odd, and low-tech, and you are given a bottle of pills of unknown composition, with a label that you cannot read. This communication-compromised health care situation is faced by millions of Americans every day, and can lead to fear, poor quality of health care, and even medical errors.

Lie and colleagues (2007) describe evaluation of measures developed to assess how well third year medical students employ interpreters, in the teaching context of a clinical practice examination with standardized patients. Standardized patients are actors who receive training to “present” with certain complaints and symptoms, and are widely used in US medical schools for clinical teaching and examination settings. In this study, the standardized patient and the standardized interpreter were both bilingual in Spanish and in English, but the standardized patient was instructed to present as a monolingual Spanish-speaking individual. The clinical case scenario, therefore, was a monolingual Spanish-speaking Latino patient who wished to quit smoking, and the medical students were required to use the interpreter to obtain the patient history, and to advise him on smoking cessation. The students were rated on their abilities to use the interpreter by the standardized patient (using the interpreter impact rating scale, IIRS), and by several bilingual faculty observers (using a faculty observer rating scale, FORS).

The IIRS included such items as “trainee showed direct eye contact with me instead of with the interpreter”, and “trainee acknowledged and responded to my beliefs, concerns, and expectations”, whereas the FORS included such items as “trainee explained the role of the interpreter”, and “trainee presented information at a pace easy to follow for both patient and interpreter”. The IIRS and the FORS were compared and validated using a common scale for assessing physician-patient interaction (PPI). The researchers found good correlation between the IIRS, which they had developed, and the standard PPI scale, indicating that the IIRS may provide a reliable measure for assessing interpreter use skills. However, there was an absence of correlation between the items on the IIRS and the items on the FORS, and the researchers propose that the discordance may in part be due to the emphasis on verbal communication in the FORS. The standardized patient is likely to respond to emotional, interpersonal, and nonverbal nuances that would not be detected by faculty observers. Lie and colleagues suggested that their assessment tools could be applied to patient encounters (both standardized and real) in other languages and cultural competency settings.


Photo: Westminster Free Clinic

To prevent myself from being consumed completely by outrage over social and environmental injustice, I’ve learned to practice a sort of issue triage, and my triage criteria are determined by my environments at work and in my South Texas community. Perhaps if one lives in a homogeneous enclave in the Midwest or East, and teaches and interacts primarily (or exclusively) with people from socioeconomically privileged backgrounds, such triage may sort out the teaching of evolution in public schools as The Most Important Issue. From my perspective in a very different type of community, it’s not an unimportant issue, but I think that access to healthcare, especially for children, and eliminating healthcare disparities and communication barriers, are much more important. If, through my interactions with students, I can contribute to reducing these serious problems, even in a small way, then that’s where I will focus my efforts, unsolicited political advice from the Blogminati notwithstanding (Help us, Obi Wan Gabacho, you’re our only hope…).


Carmona, R.H. (2007) Improving language access: a personal and national agenda. J. Gen Intern. Med. 22 (Suppl 2), 277-278.

Saha, S., and Fernandez, A. (2007). Language barriers in health care. J. Gen. Intern. Med. 22(Suppl. 2), 281-282.

Lie, D., Boker, J., Bereknyei, S., Ahearn, S., Fesko, C., Lenahan, P. (2007). Validating Measures of Third Year Medical Students’ Use of Interpreters by Standardized Patients and Faculty Observers. Journal of General Internal Medicine, 22(S2), 336-340. DOI: 10.1007/s11606-007-0349-3


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