The population of the United States is becomingly increasingly diverse. Arab Americans, in particular, are one of the fastest-growing segments of the population, increasing by more than 43% between 1990 and 2000 (1). The largest concentration of Arab Americans in the United States resides in the Metropolitan Detroit, Michigan, area, a population of nearly half a million. Although most Arab Americans practice the Christian religion, Muslims represent the fastest-growing part of the Arab American community. Clinicians may need a special set of skills, knowledge, and attitudes to work effectively with Arab American Muslim patients. In particular, there may be cross-cultural misunderstandings regarding the role of the family in healthcare; these include paternalism, medical interpreters, the observance of Ramadan, diet, permissible medications, gender issues (including the need for modesty), nonverbal cues, and the effects of stigma post-9/11.

The Liaison Committee on Medical Education (LCME) recognizes that improving the cultural competence of providers may reduce health disparities, and it requires that medical schools teach culturally competent healthcare for accreditation (2, 3). It mandates that "students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments." LCME also expects that "medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of healthcare delivery." The Association of American Medical Colleges (AAMC) also developed the Tool for Assessing Cultural Competence Training (TACCT) for the undergraduate medical school curriculum, with content items covering cultural competence knowledge, skills, and attitudes (4, 5).

Research supports the effectiveness of active learning, including simulation-based training (6, 7). In 2009, Okuda et al. (8) reviewed the evidence for the usefulness of simulation in medical education. They found multiple studies that demonstrated effectiveness for the teaching of clinical knowledge, procedural skills, and communication. However, the cultural competence curriculum in medical school has often been limited to more traditional instructional modes, such as lectures (9).

We hypothesized that an online, interactive patient simulation involving the care of an Arab American Muslim patient would improve the knowledge, skills, and attitudes of 2nd-year medical students regarding both culturally competent healthcare in general and specific to Arab American Muslim patients, beyond the basic cultural competence curriculum.

Ethical approval for this study involving human participants was granted by the Institutional Review Board of Michigan State University.

Participants in this study included a sample of 199 Michigan State University College of Osteopathic Medicine students in their 2nd year of study (enrollment was 214 students, resulting in a 93% response rate). All students were enrolled in OST 536, a behavioral-medicine course that included readings, small group discussions, a video, and a panel related to culturally competent healthcare. Every component for the course, except the readings, also examined culturally competent care for Arab American Muslim patients. Approximately half of the sample consisted of women (N=99; 49.8%). The ethnic/racial composition was primarily Caucasian (N=156; 78.3%) and Asian American (N=24; 12.1%), with less than 3% of the sample representing other groups (African American, Latino, American Indian, Arab American, or Other). Slightly more than half of the participants (N=104; 52.3%) reported bilingual status. This pilot study was open to students for 1 week, immediately after exposure to the complete applicable course content.

Participants were randomly assigned to the control (N=102) or experimental group (N=97), using a randomizing function of Microsoft Excel. No significant differences existed between the control and experimental groups. Participants electronically signed an informed-consent page indicating that participation was completely voluntary, confidential, one of many options for 2 points' extra credit, and that participants exit the study at any time, at the their own discretion. Participants in the control group were sent directly to post-test measures, whereas participants in the experimental group were first directed to an approximately 30-to-60 minute online, interactive patient simulation that featured an Arab American Muslim woman receiving care provided by a white, male family physician; the female patient's family was also present during the simulated clinical encounter. The content of the simulation was determined and refined through an examination of peer-reviewed literature focused on sensitive healthcare for Arab American Muslim patients and input from cross-cultural consultants, as well as results of a focus group comprising local Arab American Muslim community members, physicians, and patients (12–14). After viewing an index page with a general overview of the case study and brief background information about Arab American Muslims, students were exposed to video segments and related text about the interaction. In order for the clinical encounter to proceed, at 20 different critical decision-making time-points, students were given two choices from which to decide (A or B). These 20 decision-making time-points focused on cultural competence and/or issues more specific to Arab American Muslims, including physical and verbal greetings; appropriate use of medical interpreters; family involvement, including paternalism; appropriateness of compliments; the patient's explanatory model; permissible medications; observance of Ramadan; preparing for the physical exam; being offered gifts; health insurance coverage; and treatment adherence.

In one scenario, for example, the physician could misinterpret the patient's passive nonverbal cues as a sign of Attention Deficit Hyperactivity Disorder. There are two detailed examples of the clinical scenarios in app1. After making their A-or-B choice, students observed the physician's approach and were then provided with video and text describing the rationale behind the correct choices. After completing the online simulation, participants in the experimental group completed a modified Clinical Cultural Competence Questionnaire (CCCQ) to assess their diversity knowledge, cultural sensitivity, and comfort with providing culturally competent healthcare in general and specific to Arab American Muslim patients (10, 11).

Diversity Knowledge

General knowledge of diversity was measured with a 7-item scale (α=0.91) composed of 5-point Likert-type questions (1: not at all knowledgeable to 5: very knowledgeable). Sample questions included "How knowledgeable are you about health risks experienced by diverse racial/ethnic groups?" and "How knowledgeable are you about sociocultural issues in health promotion/disease prevention?" Knowledge specific to Arab American Muslims was measured with a 9-item index (α=0.95), using the same 5-point Likert scale. Questions included "How knowledgeable are you about Arab American Muslim sociocultural characteristics?" and "How knowledgeable are you about Arab American Muslim permissible medications?"

Cultural-Sensitivity Skills

General cultural sensitivity was measured with a 12-item scale comprising 5-point Likert-type questions (1: not at all skilled to 5: very skilled). Sample questions included "How skilled are you with greeting patients in a culturally sensitive manner?" and "How skilled are you with eliciting the patient's perspective about health/illness?" The scale demonstrated strong reliability (α=0.93). Cultural sensitivity specific to Arab American Muslims was measured with 14 items (α=0.97) that used the same 5-point skill scale. Items included "How skilled are you with Arab American Muslim gender issues in the clinical encounter?" and "How skilled are you with eliciting the Arab American Muslim patient's perspective about health/illness?"

Cross-Cultural Comfort

Comfort level with patients from diverse backgrounds was measured with a 9-item scale (α=0.90) comprising 5-point Likert-type questions (1: not at all comfortable to 5: very comfortable). Sample items included "How comfortable do you feel in dealing with caring for patients from culturally diverse backgrounds?" and "How comfortable do you feel identifying beliefs not directly expressed by the patient?" Cross-cultural comfort specific to Arab American Muslims was measured with 9 items (α=0.96) that used the same 5-point comfort scale. Items included "How comfortable do you feel caring for Arab American Muslim patients?" and "How comfortable do you feel identifying Arab American Muslim beliefs not directly expressed by the patient?"

The primary hypothesis was that participants in the intervention condition would score more highly on the six general and Arab American-specific outcome measures of diversity knowledge, cultural sensitivity, and cross-cultural comfort than those participants in the control condition. Bilingual status was included in the statistical model, as language skill is an individual characteristic that may influence the aforementioned outcome measures. There was a main effect for condition on knowledge about Arab Americans (F [1, 195]=4.85; p=0.029), and perceived cultural sensitivity skill level with Arab Americans F [1, 195]=7.04; p=0.009. Specifically, participants who were exposed to an online educational tool reported more knowledge (M_Treatment = 24.86; M_Control = 22.19) about Arab Americans and greater self-efficacy (M_Treatment = 2.80; M_Control = 2.45) in being able to communicate with Arab Americans than participants in the control condition.

There was also a main effect for bilingual status for five of the outcome measures, including knowledge of diversity (F [1, 195]=10.48; p=0.001), knowledge of Arab Americans (F [1, 195]=11.43; p=0.001), overall cultural sensitivity (F [1, 195]=4.44; p=0.036), cultural sensitivity skill level with Arab Americans F [1, 195]=8.90; p=0.003), and cross-cultural comfort with Arab Americans F [1, 195]=4.90; p=0.028. Across all of the measures, bilingual participants scored higher than English-speaking–only participants. No interaction effects between condition and bilingual status were revealed. (See Table 1 for descriptive information for all of the outcome measures.)

An online, interactive patient simulation involving care of an Arab American Muslim has the potential to improve the knowledge and skills of 2nd-year medical students regarding the care of Arab American Muslim patients beyond the basic cultural competence curriculum. However, the significant limitations of this pilot study (discussed in the next paragraph) allow for the generation of only preliminary data. General cultural competence measures were the same for the experimental and control groups, suggesting that training targeting specific relevant patient populations may be most effective. Comfort variables did not demonstrate clear improvement as a result of the online experience, and it appears likely that repeat and/or more authentic exposures are necessary for further change in this area. Bilingual status of the participant was the strongest predictor of success, demonstrating educational benefit in most of the study outcome measures. In fact, participants with bilingual status consistently outperformed the English-only group, with an effect greater than that of the online interactive simulation. It is possible that bilingual medical students may be predisposed to learn the subject matter most effectively, given their previous exposure to other cultures through language.

Limitations

The conclusions of this study could be further challenged by assessing for the longer-term, as opposed to the immediate, effects of this educational intervention. This study is also limited by the use of a self-report measure, and having only post-intervention administration of this measure. Our conclusions may be less applicable to female students, as the online scenario involved only a white, male family physician treating a female Arab American Muslim patient. There are also no demographic data for the 15 students who declined to participate in the study. In the future, student knowledge and skills could be tested more objectively through authentic assessment, possibly involving an actual observed patient-interaction. Similar modules may be constructed for other cultural groups, and by targeting more specific situations involving Arab American Muslim patients, for example, on how to address mental health issues. There also may be further study of the effects of bilingual status on the ability to benefit from cultural-competence educational interventions, with the possibility that these students may have the potential to excel in roles that require cross-cultural sensitivity.

APPENDIX 1. Two Sample Clinical Scenarios from the Cultural Competence Clinic Script

Scenario 1. The Greeting

A white, male family physician encounters a 20-year-old, unmarried Arab American woman, Ms. Khalifa, in the waiting room of his clinic. She is presenting for a new patient evaluation required by her job. She is wearing a hijab, and is accompanied by her parents and teenaged brother.

Question: How will you physically greet the patient?

Choice A: Maintain strong eye contact and extend a hearty handshake to Ms. Khalifa. To do otherwise would be rude. Avoid eye contact with the men, as it may be seen as a display of aggression.

Choice B: Follow the patient's lead regarding the handshake and gaze.

Result A: The physician walks towards the patient, sticks out his hand, makes intense eye contact and states, "Good morning, I'm Dr. Smith." Ms. Khalifa responds passively, avoiding eye contact, and reluctantly shaking hands. Her family appears displeased. Ms. Khalifa addresses the camera and explains how the doctor's approach was not proper etiquette.

Result B: The physician walks towards the patient and her family and states, "Good morning, I'm Dr. Smith." Ms. Khalifa does not actively pursue a handshake and does not make eye contact. The physician pauses then turns towards her father. The father steps forward and explains, "I am Mr. Khalifa. This is my wife, son, and daughter." The physician shakes the father's hand.

Scenario 2. Prescription Adherence

You prescribe a permissible medication. However, the patient returns in a week with an infection that has now progressed to pneumonia. She filled the prescription, but never took the medication, because it is the holy month of Ramadan.

Question: How do you handle this situation?

Choice A: It is understandable that this patient cannot receive any medicine during Ramadan – she'll need to focus on prayer and healthy living until Ramadan is over.

Choice B: Islamic law exempts sick patients from fasting. It may be helpful to consult an Imam (religious leader) to work with the family regarding the acceptability of medications in this situation. One consideration may involve taking medication in the mornings or evenings.

Result A: Pharmacologic interventions may be both acceptable and needed for your patient.

Result B: Great choice.

The authors are indebted to Dr. Farha Abbasi, John Williamson, Rose Khalifa, and Dr. Deborah Sleight for their assistance. They also thank Dr. Jed Magen, Dr. Deborah DeZure, and Dr. William Strampel for their support.

At the time of submission, the authors reported no competing interests.