Patient Education and Counseling 79 (2010) 77–82
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Education
A validated cultural competence curriculum for US pediatric clerkships§,§§ Angela P. Mihalic a,*, Jay B. Morrow a, Rosita B. Long b, Alison E. Dobbie a a b
University of Texas Southwestern Medical Center at Dallas, TX, USA University of Oklahoma Health Science Center at Oklahoma City, OK, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 February 2009 Received in revised form 12 June 2009 Accepted 17 July 2009
Objective: A 2006 national survey of pediatric clerkship directors revealed that only 25% taught cultural competence, but 81% expressed interest in a validated cultural competence curriculum. The authors designed and evaluated a multi-modality cultural competence curriculum for pediatric clerkships including a validated cultural knowledge test. Methods: Curriculum content included two interactive workshops, multimedia web cases, and a Cultural and Linguistic Competence Pocket Guide. Evaluation included a student satisfaction survey, a Nominal Technique Focus Group, and a validated knowledge test. The knowledge test comprised 6 case studies with 49 multiple choice items covering the curricular content. Results: Of 149/160 (93%) students who completed satisfaction surveys using a 5-point Likert scale, >82% strongly agreed or agreed that the curricular intervention was a meaningful experience (93%), increased their understanding of the culture of medicine (91%), increased their knowledge of racial and ethnic disparities (89%) and core cultural issues (91%), and improved their skills in working with interpreters (90%) and cross-cultural communication (82%). Top strengths identified by a focus group (34 students) included learning about interpreters, examples of cultural practices, and raised cultural awareness. Pre- and post-knowledge test scores improved by 17% (p < .0001). After six administrations, the test achieved the target reliability of .7. Conclusions: The authors successfully designed and validated a practical cultural competence curriculum for pediatric clerkships that meets the need demonstrated in the 2006 national survey. Practice implications: This curriculum will enable pediatric clerkship directors to equip more graduates to provide culturally sensitive pediatric care to an increasingly diverse US population. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Cultural competence Currriculum Medical education Undergraduate
1. Introduction In the next 25 years, US population demographics will change substantially. By 2050, fewer than 50% of persons will identify themselves as ethnically non-Hispanic White and 24% as Hispanic [1]. As ethnic diversity increases, so will the number of persons with limited English language skills. In only 10 years, between 1990 and 2000, the number of Americans whose first language is not English grew by 47% and the population with limited English proficiency increased by 53% [2]. This ethnically and linguistically diverse population will require care from culturally and linguis-
§ Financial support: Council on Medical Student Education in Pediatrics (COMSEP). Small grants program—Funding $5000, period 2007–2008. $ Manuscript presentations: Abstract presented at annual COMSEP meeting 2008 and the Pediatric Academic Societies annual meeting in 2009. * Corresponding author at: Office of Student Affairs, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 753909006, USA. Tel.: +1 214 648 2168; fax: +1 214 648 7517. E-mail address:
[email protected] (A.P. Mihalic).
0738-3991/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2009.07.029
tically competent physicians. Despite this growing requirement, only 15.2% of current medical students identify themselves as members of minority groups underrepresented in medicine [3]. In the absence of a large cohort of ethnically diverse medical students, US medical educators must prepare for the coming demographic shift by training physicians who are competent to care for patients whose ethnicity and language differ from their own. Culturally competent health care enhances the physician– patient relationship, allows respect for the patient’s health beliefs, and encourages collaborative management of the patient’s illness [4,5]. In addition, culturally effective health care may improve patient health outcomes, save health care dollars, and reduce ethnic disparities in health [6]. Both the Council on Medical Student Education in Pediatrics (COMSEP) and the Ambulatory Pediatric Association (APA) have identified cultural sensitivity and tolerance as essential medical student characteristics [7]. In 2004 the American Academy of Pediatrics (AAP) called for medical schools to develop curricula teaching students to care for patients and families with a knowledge, understanding and appreciation for cultural distinctions in order to improve patient outcomes [8].
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Table 1 Content description and timeline of cultural curriculum for the pediatric clerkship. Timeline
Activity
Description/evaluation plan
Week 1 Week 2
Orientation Workshop 1
Weeks 3 and 4 Week 5
Web-based case Workshop 2
Week 8
Clerkship exam
Pre-test: cultural knowledge questionnaire Didactic: core concepts of cultural competence, culture of western medicine, normative cultural values, folk health and illness beliefs, explanatory models and negotiation, clinical case vignettes with student role play, facilitated group discussion Multimedia case exercises: student must complete the exercise and on-line quiz for passing credit Didactic: core concepts of linguistic competence (proper interpreter use) with input and panel discussion with hospital interpreters, clinical case vignette with student role play Post-test: cultural knowledge questionnaire, student satisfaction feedback session
In 2006, our national survey of pediatric clerkship directors revealed that only 25% of respondents reported having a cultural competence teaching curriculum [9]. Of those programs with a curriculum, only 14% reported any evaluation measures. Yet, on a 5-point Likert scale, 91% of clerkship directors agreed or strongly agreed that teaching culturally competent care is important, 99% that such care enhances the physician/patient/family relationship, and 90% that such care improves patient outcomes. Eighty-one percent expressed interest in sharing a validated cultural competency teaching curriculum. In this study, we addressed this educational need by designing, implementing, and validating a multi-modality cultural competence curriculum for pediatric clerkships. The goals of the study were to: (1) Create a cultural competence curriculum within the pediatrics clerkship that provided relevant training to students respecting the rotation’s other competing demands. (2) Create and validate a cultural knowledge questionnaire with a target reliability score of .7 to administer to students pre- and post-cultural competence training to demonstrate learning. (3) Demonstrate at least 15% gain scores by students on the cultural knowledge questionnaire, as measured pre- and postcultural competence training. (4) Demonstrate high student satisfaction survey results (>80% agreement) on six key measures evaluating the curriculum from their perspective. 2. Methods 2.1. Settings and subjects The University of Texas Southwestern Medical School at Dallas is a 4-year state-supported MD program with 230 students per year and an 8-week required third year pediatric clerkship. Our subjects included 160 students from four clerkship groups in academic year 2007–2008. All students included in the study completed the cultural competence curriculum as required course content, and signed consent forms to include their de-identified data in the study (no student withheld consent to include their data). Our Institutional Review Board granted the study exempt status. 2.2. Curriculum content We based the curriculum content on a 2006 literature review, the AAMC’s Tool for Assessing Cultural Competence Training (TACCT) [10], the national survey results on cultural knowledge, skills, and attitudes of pediatric clerkship directors, and input from an expert panel of medical educators from UT Southwestern Medical Center and five other US medical schools. Several experts kindly contributed curriculum content, includ-
ing the on-line multi-modality case studies [11], case vignettes in the interpreter workshop [12], and cultural role plays [13]. 2.3. Curriculum design and delivery The curriculum consisted of two interactive workshops and two multimedia web-based cases that students completed in their own time between workshops. All curriculum materials are available in full on the Family Medicine Digital Resources Library (www.fmdrl.org). The curriculum structure and timeline is summarized in Table 1. Workshop 1: The first workshop focused on steps for students to approach cultural competence. Concepts taught included: the importance of cultural competence within health care, selfawareness of personal biases and the culture of medicine, normative cultural values, disparities in health beliefs and skills in cross-cultural communication and negotiation. The workshop also included student role play scenarios and facilitated debriefing in which students put tools such as Berlin’s LEARN instrument into practice [14]. Based on the amount of student discussion, this workshop lasted approximately 60–75 min. Workshop 2: The second workshop focused on steps to becoming linguistically competent and proper use of interpreters. This session lasted approximately 45 min. In our setting, we invited our hospital’s interpreters to participate. The interpreters described their experiences with language barriers and proper interpreter use, and participated in an interactive question and answer session. On-line cases: To supplement the curricular content and provide varied learning modalities, we received permission to incorporate a set of on-line pediatric cases, core concepts in cultural competence-cross-cultural health care case studies [11]. The cases were developed by Horkey and colleagues of the Pediatric Pulmonary Center, funded by a grant from the Health Resources and Services Administration. The five cases encompass core concepts in cultural competence that include social, emotional, and religious aspects of culture, normative cultural values and folk health and illness beliefs. The cases also address interpreter services, cross-cultural communication, and legal and fiscal responsibilities of health care facilities. Each case comprises a patient case vignette, a multimedia lecture, interactive exercises and a quiz. Cases are self-paced and take approximately 30 min to complete. Cases may be accessed in full at http:// support.mchtraining.net/national_ccce/index.html. For our curriculum, students completed at least two of five on-line multimedia case exercises and printed certificates of completion for credit. Cultural Pocket Guide: In response to a request from focus group students, one author (APM) developed a culture pocket guide. This handy reference, available free on-line [15], includes steps for becoming culturally and linguistically competent and instructions for accessing interpreter services.
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2.4. The educational intervention We presented the curriculum to all six clerkship groups during academic year 2007–2008. We included groups 1–4 in the validation study (160 students). We developed, administered and validated a multiple choice cultural knowledge test specific to our curriculum content. We administered the test as a pre-and post-evaluation to students in groups 1–4 of the pediatrics clerkship. One week before the rotation, we emailed a project description and consent form to students. During the pediatric clerkship orientation, faculty explained the study, answered questions, obtained signed consents, and asked participants to complete a cultural knowledge pre-test. After each of the first three groups, we modified the curricular content and the knowledge test based on feedback and performance. 2.5. Evaluation of outcomes 2.5.1. Student satisfaction We evaluated students’ satisfaction using a nominal group technique focus group and a 6-question student satisfaction survey on a 5-point Likert scale. 2.5.1.1. Nominal group technique focus group. One author (APM) along with faculty not involved in the study conducted a voluntary focus group of Rotation 3 students. Thirty-four of 43 students participated. Faculty used a modified nominal group technique to obtain qualitative and semi-quantitative evaluation data. The nominal group technique is an iterative focus group process that generates rank ordered and weighted semi-quantitative data on students’ most and least favored aspects of a course or curriculum [16]. 2.5.1.2. Student satisfaction survey. Three authors participated in the design of the satisfaction survey. We administered the satisfaction survey to all 160 students in the first four rotations. Each item measured student agreement with broad curriculum objectives on a 5-point Likert scale.
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The questionnaire included six cases with 49 multiple choice items covering the curricular content. Each test item consisted of four response choices with a single correct answer. Each case was delivered 6 times over the four rotations. The number of students for Rotation Groups 1, 2, 3, and 4 was 43, 32, 43, and 42, respectively. All six cases were delivered pre- and post-test to Rotations 3 and 4. To avoid any learning effect from the test or passing of answers to subsequent rotations, answers from the pretest were not revealed or discussed anytime during or after the rotation. The final analysis included scores from Rotations 3 and 4. The study psychometrician assessed point bi-serial correlation for each item. The rationale for using point bi-serial correlation was to select the subset of items that achieved optimal test reliability and validity using as few items as possible. Over three applications in 6 months, we serially assessed difficulty and point bi-serial correlation for each item. When the bi-serial correlation between item and test score is in the range of .30–.40, the ideal item difficulty level should be between .40 and .60 [17]. For our test, items with point bi-serial coefficients less than .20 were deleted or revised. We used item difficulty between .30 and .60 as our desired range. We estimated the test’s internal consistency by calculating Cronbach alpha coefficients using post-test results. We chose not to calculate test–retest reliability since practice effects would have biased the results and it is a weaker methodology than the one we employed. We determined an overall reliability coefficient for the combined Rotation Groups 3 and 4 using the post-test results. We used SPSS (version 14.0) for point bi-serial correlation. Lowerbounds reliability of the scores was estimated at .695 after removing 2 items from the scale analysis. This Cronbach’s alpha lower-bounds reliability coefficient is comparable to other established and acceptable reliability coefficients for surveys. 2.6.3. Demonstrating cultural knowledge test gain scores We measured knowledge gain on our validated knowledge test for medical student Rotation Groups 3 and 4 using a paired t-test on the pre- and post-results. Using SAS v9.1, gain scores were analyzed separately for each of the rotation groups. 3. Results
2.5.2. The validated cultural knowledge test We developed a case-based test to measure students’ increased cultural knowledge as a result of the curriculum. The test focuses on key cultural concepts using brief clinical vignettes requiring application of knowledge beyond rote memorization. The questionnaire covers content over six cases and 49 multiple choice questions. For case details see Table 2. The cases are available on the Family Medicine Digital Resources Library (www.fmdrl.org).
3.1. Student satisfaction
2.6.1. Content validity To establish content validity, the test content was reviewed by a panel of senior educators including experts in NBME test design as well as national cultural content experts. The case content mapped to the five TACCT domains as shown in Table 3.
3.1.1. Nominal group technique focus group The students highly valued the practical discussion and interaction with interpreters during the hospital interpreter workshop. They enjoyed learning about different cultural practices related to health care, and expressed the view that discussing cultural competence was important. Suggested areas for curricular improvement included providing more descriptions of other cultures and health care practices. In response to this feedback, we modified the curriculum for Rotation 4. Students specifically requested a pocket resource containing instructions on proper interpreter use and local contact numbers. We responded by creating a pocket guide to supplement the curriculum [15]. For a summary of students’ focus group weighted ratings of the curriculum’s strengths and weaknesses, see Table 4.
2.6.2. Cultural knowledge test validation The authors validated the cultural knowledge questionnaire using an iterative process over Rotations 1–4. Authors deleted or revised items based on statistical assessments described below, and then administered the test to the next rotation to repeat the process until the test reached the required level of validity. The study psychometrician performed serial statistical analyses for instrument validation as described below.
3.1.2. Pocket guide for teaching cultural competence One author (APM) created the Pediatric Cultural and Linguistic Competence Pocket Guide based on feedback from the student focus session [15]. The guide lists contact numbers for hospital translation services, along with an outline of steps for students to become culturally and linguistically competent. It can be personalized for any hospital’s interpretation services. It is available for download free from the Family Medicine Digital
2.6. Test validation process
A.P. Mihalic et al. / Patient Education and Counseling 79 (2010) 77–82
80 Table 2 Case details of cultural knowledge questionnaire. Case
Patient vignette
Example question
1
6-Year-old Latino boy presents to ER with abdominal pain and no interpreter is available
The hospital’s qualified medical interpreter is now available and arrives at the bedside. While using proper interpreter techniques, you address the following with the interpreter: (a) Request that the interpreter listens facing you and then interpret facing the patient (b) Request that the interpreter rephrase your words in a form that can be best understood by the patient and family (c) Request that the interpreter change your words into those that are more culturally sensitive (d) Request that the interpreter interpret in a conduit fashion, without edits
2
9-Year-old girl accompanied by her grandmother presents to clinic with asthma
Inquiring about and appreciating the degree of caregiver stress (examples: varied caregivers, transportation needs, emotional and physical health of the grandmother) is most important for this patient’s health outcome because of which the following? (a) Inquiring about the grandmother’s level of stress helps establishing rapport in the patient–physician relationship (b) Caregiver stress impacts no show rates in the clinic (c) Caregiver-perceived stress as been directly associated with increased asthma morbidity (d) Caregiver stress impacts the patient’s emotional health
3
9-Month-old South Asian girl presents to ER with seizures
In working with this South East Asian family, who of the following would be the BEST qualified person to invite to participate in the discussion with the medical team in order to bridge the gap between cultures? (a) A western-trained medical provider from their community (b) A folk healer from their community (c) The patient’s grandfather (d) A social worker who speaks their language
4
24-Month-old Mexican American boy presents for well child check
You ask if the mother is concerned about the child’s weight. The mother proudly states that her son has been a very healthy child and she has no concerns. Which of the following best explains her view? (a) Lack of awareness of risk factors associated with adult obesity (b) Belief that childhood obesity does not translate to adult obesity (c) Differences in cultural feeding practices and views on health and wellness d. Belief that obesity is determined by genetics and cannot be significantly modified
5
12-Year-old Native American male presents to clinic with knee pain
The physician ability to provide culturally sensitive health care was most affected by which of the following? (a) Specific knowledge of the Native American culture (b) Knowledge of all cultures’ normative behavior (c) Ability to apply specific knowledge of Native American culture to all patients of that cultural background (d) Ability to inquire about each individual patient’s and family’s explanatory model
6
2-Year-old Latino girl presents to clinic with ear pain
The use of the 11-year-old sister as an interpreter is referred to as which of the following? (a) Volunteer interpreter (b) Ad hoc interpreter (c) Ad lidem interpreter (d) LEP (limited English proficiency) interpreter
Table 3 Knowledge test case content according to the AAMC’s TACCT domains for clinical clerkships. TACCT domains
Cultural competence content area
Domain I: rationale, context and definition
(A) Definition of cultural competence (B) Definition of race, ethnicity, and culture (C) Clinicians’ self-assessment and reflection
Domain II: key aspects of cultural competence
(A) Epidemiology of population health (B) Patients’ healing traditions and systems (C) Institutional cultural issues (D) History of the patient
Domain III: understanding the impact of stereotyping on medical decision-making
(E) History of stereotyping (F) Bias, discrimination, and racism (G) Effects of stereotyping
Domain IV: health disparities and factors influencing health
(A) History of health care discrimination (B) Epidemiology of health care disparities (C) Factors underlying health care disparities (D) Demographic patterns of disparities (E) Collaborating with communities
Domain V: cross-cultural clinical skills cultural attitudes
(A) Differing values, cultures, and beliefs (B) Dealing with hostility/discomfort (C) Eliciting a social and medical history (D) Communication skills (E) Working with interpreters (F) Negotiating and problem-solving skills (G) Diagnosis and patient-adherence skills
Knowledge test case 1
Knowledge test case 2
Knowledge test case 3
Knowledge test case 4
Knowledge test case 5
Knowledge test case 6
X
X X X X
X
X X X X X X
X
X X X
X
X
X X X X
X X X X X X X
X
X
X X X
X
X X X
X
X
X
X X X X X X X
X X X
X X X X
X X
X X
X X X X
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Table 4 Nominal group technique focus group rank ordered weighted dataa. Strengths
Rating
Areas for improvement
Rating
Interpreter session (practical, useful, liked input of hospital interpreters, awareness of errors, etc.) Different cultural practices in different cultures/real life examples Raising awareness of cultural competence Web-based cases were informative, reinforced the workshops
146
Would like more diverse cultural examples/more cultures represented
114
Role play/interactive class participation
97 66 66 58
Would like additional resources such as a handout on interpreter use Would prefer workshops earlier in rotation and closer together Would like real patients present to discuss cultural interactions with health care Environment not ideal (need smaller room, microphones, etc.)
77 72 42 41
a
One author (APM) along with faculty not involved in the study conducted a voluntary focus group of Rotation 3 students. Thirty-four of 43 students participated. Faculty used a modified nominal group technique through an iterative focus group process that generates rank ordered and weighted semi-quantitative data on students’ most and least favored aspects of a course or curriculum; this table presents the highlights of their responses.
Table 5 Cultural knowledge test gain scoresa,b. n
Mean
95% CI for means difference Lower limit
Std. Dev.
Std. error
Prob > t
Upper limit
Rotation 3
Pre Post
44 44
55.13953 71.81395
19.71
13.64
9.7255 7.7857
1.4662 1.1737
p < .0001
Rotation 4
Pre Post
41 41
54.19512 70.92683
19.39
14.07
8.8578 8.9454
1.3834 1.397
p < .0001
a
Paired t-test for each rotation analyzed using SAS v.9.1. The authors administered all six cases of the cultural knowledge test to students in Rotations 3 and 4. The pre-test was completed at the clerkship orientation and the post-test was completed at the departmental exam at the conclusion of the clerkship. A total of 85 students were included in assessment of test gain scores. b
Resource Library website at www.fmdrl.org. Between 12/28/07 and 6/11/09 there were 181 downloads of the guide. 3.1.3. Student satisfaction survey Of the 160 participating students, 149 (93%) completed satisfaction surveys for the combined four pediatric rotations. Overall, students evaluated the curriculum highly as shown in Fig. 1. On a 5-point Likert scale, students strongly agreed or agreed that the curricular intervention was a meaningful experience (93%), improved skills in working with interpreters (90%), improved skills in cross-cultural communication (82%), increased knowledge of racial and ethnic disparities (89%), increased their knowledge of core cultural issues and their impact on health care (91%), and increased their level of awareness and understanding of the culture of medicine (91%). 3.2. The validated cultural knowledge test We delivered each case 6 times over four rotations of students (n = 160). After each administration, we modified poorly perform-
ing cases and individual items as described above. By Rotation 4, the test achieved the target reliability of .7 for combined pre-and post-tests (reliability = .703 for n = 98 items). 3.3. Demonstrating cultural knowledge test gain scores Pre- and post-test gain scores of 17% were significant (p < .0001) for Rotations 3 and 4, as described in Table 5. 4. Discussion and conclusion 4.1. Discussion We successfully designed, implemented and validated a cultural competence curriculum for pediatric clerkships. The curriculum is practical, generalizable, and meets the need demonstrated in our 2006 national survey of pediatric clerkship directors [9]. The cultural knowledge assessment tool represents the first validated cultural knowledge test for pediatric clerkships. The curricular materials may also be generalizable to Family
Fig. 1. Student satisfaction results. The authors administered a 6-item questionnaire to all 160 students in the first four rotations of which 149 (93%) were completed. Each item measured student agreement with broad curriculum objectives on a 5-point Likert scale, as summarized above.
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Medicine clerkships, where students also interact with pediatric patients. The satisfaction survey indicated student enthusiasm for the curriculum. At least 89% of students agreed that they gained skills and knowledge from the curriculum for 5 of 6 items. They scored ‘‘My skills in cross-cultural communication’’ lowest, although over 82% were satisfied with this item. This is not surprising at this early stage in their training, and underscores our reasoning for including at least two role playing workshops in the curriculum. This study is limited to medical students from a single large state institution. Also, although we demonstrated changes in students’ cultural knowledge and attitudes, it was beyond our scope to demonstrate students’ behavior change in clinical settings. Such behavior change could be demonstrated by addition of a formative culture OSCE such as conducted with residents in Maimonides [18]. However, we rigorously evaluated our curriculum using a large sample size and were able to demonstrate high student satisfaction and significant knowledge gains as measured by our validated cultural knowledge test. Finally we do not claim that our limited curricular content, delivered over 4–6 h, can make students fully culturally competent. However, we used robust methods to select important cultural content that was practical to deliver within a clerkship curriculum and was immediately relevant to students’ clinical activities. This practicality and relevance are reflected in students’ high satisfaction with the curriculum and in their knowledge gains on a validated test. 4.2. Conclusion The study adds to the literature by contributing a cultural curriculum including a validated knowledge test for pediatric clerkships. This curriculum allows clerkship directors to teach cultural competence and culturally sensitive pediatric care as called for by AAP, COMSEP, and APA national policy statements. Our prior national survey demonstrated that in 2006 few pediatric clerkship directors were providing such teaching, despite their widespread belief in its importance [9]. 4.3. Practice implications We demonstrated high student satisfaction and increased cultural knowledge with our curriculum, although further studies are needed to demonstrate improvement in patient outcomes from cultural education in the clerkship setting. Culturally competent care has been shown to have a positive impact on the patient
physician–therapeutic relationship and collaborative management of illness [4,5]. Our pediatric cultural competency curriculum provides clerkship directors with a practical toolbox to teach cultural competence, and equip more graduates to provide culturally sensitive pediatric care to an increasingly diverse US population. References [1] U.S. Census Bureau. Current population survey. Population by sex, age, Hispanic origin, and race [August 15, 2008]; available from: http://ww.census. gov/ipc/www/usinterimproj. [2] U.S. Census Bureau. Current population survey. Language use [August 15, 2008]; available from: http://www.census.gov/population/www/socdemo/ lang_use.html. [3] Association of American Medical Colleges. Minorities in medical education: facts & figures 2005. Washington, DC: Association of American Medical Colleges; 2005. [4] Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patientbased approach. Ann Intern Med 1999 May 18;130:829–34. [5] Nunez AE. Transforming cultural competence into cross-cultural efficacy in women’s health education. Acad Med 2000;75(November):1071–80. [6] Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev 2000;57(Suppl. 1):181–217. [7] Council on Medical Student Education in Pediatrics. Ambulatory Pediatric Association. General Pediatric Clerkship Curriculum and Resource Manual. Washington, DC: Bureau of Health Professions, Division of Medicine; 1995. Publication HRSA-240-BHPr-49 (3). Revised 2002 and 2005. [8] Committee on Pediatric Workforce, American Academy of Pediatrics. Ensuring culturally effective pediatric care: implications for education and health policy. Pediatrics 2004;114:1677–85. [9] Mihalic AP, Dobbie AE, Kinkade S. Cultural competence teaching in U.S. pediatric clerkships in 2006. Acad Med 2007;82(June):558–62. [10] Association of American Medical Colleges. Cultural competence education for medical students. Washington, DC: Association of American Medical Colleges; 2005. [11] Horky S, Tribby R. Core Concepts in Cultural Competence-Cross-Cultural Health Care Case Studies. Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, United States Department of Health and Human Services [October 2, 2008]; available from: http://support.mchtraining.net/national_ccce/index.html. [12] Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: case studies from the Latino community. J Pediatr 2000;137:842–8. [13] Goleman MJ. Teaching pediatrics residents to communicate with patients across differences. Acad Med 2001;76:515–6. [14] Berlin EA, Fowkes Jr WC. A teaching framework for cross-cultural health care. Application in family practice. West J Med 1983;139(December):934–8. [15] Mihalic AP. Cultural and Linguistic Competence Pocket Guide. Society of Teachers of Family Medicine [October 2, 2008]; available from: http:// www.fmdrl.org. [16] Dobbie A, Rhodes M, Tysinger JW, Freeman J. Using a modified nominal group technique as a curriculum evaluation tool. Fam Med 2004;36(June):402–6. [17] Nunally JC. Pschometric theory. New York: McGraw Hill; 1967. [18] Aeder L, Altshuler L, Kachur E, Barrett S, Hilfer A, Koepfer S, et al. The ‘‘Culture OSCE’’—introducing a formative assessment into a postgraduate program. Educ Health (Abingdon) 2007;20(May):11.
