With the recent influx of immigrants and the changing demographics of the North American population, there is increased need for physicians to acquire skills to provide culturally sensitive care. These skills are especially important in psychiatry, where clinical judgments are invariably influenced by the ethnicity and culture of both psychiatrist and patient (1). Leighton defined culture as knowledge, values, perceptions, and practices that are shared among the members of a given society and passed on from one generation to the next (2).
The need for such training has long been recognized by agencies accrediting residency programs. The American Medical Association's Accreditation Council for Graduate Medical Education (ACGME) has recommended that the residency program should provide residents with instruction on American culture and subcultures, particularly those in the patient community associated with the training program. Instruction should include issues such as sex, race, ethnicity, religion/spirituality, and sexual orientation (1,3). Yager suggested development of minimal national standards for clinical experience in psychiatric training (4). Moffic recommended addition of cultural psychiatry training to the list of minimal clinical experiences (5). The American Psychiatric Association (APA), the American Association of Directors of Psychiatric Residency Training (AADPRT), and the ACGME have attempted to develop a curriculum for teaching cultural psychiatry (1). Foulks (1) suggested several teaching approaches, such as sensitivity groups, didactic courses, study groups, and field and clinical experiences (t1). Lefley observed an increase in health-service utilization by minorities and a significant decrease in minority patient dropout rates after an intensive 8-day training workshop for staff (6). Moffic and Kendrick described a 4-year seminar series model that permits integration of cultural knowledge at a progressively more sophisticated level (7). Many psychiatry residency programs have attempted to formalize a training approach, but have fallen short of the above recommendations (7). The authors did a MEDLINE search and found a notable lack of literature on measures of success of cultural sensitivity training efforts in psychiatry residency education.
Some studies have evaluated different methods of teaching medical students, psychiatric staff, family medicine residents, nurses, and occupational therapists about cultural sensitivity (8—12). Mao and Bullock (8), using a student-led, small-group format and videotaped vignettes to stimulate discussion, organized a 4-hour workshop, "Ethnic and Cultural Awareness in Medicine," for second-year medical students. Students' attitudes to cultural issues in patient care were compared by use of pretest and posttest questionnaires, and paired t-tests were used to compare students' treatment choices before and after the workshop. Mao and Bullock acknowledged the inadequacy of the questionnaire design in measuring the impact of the workshop. Other studies involving nurses focused on measuring attitudes of nurses toward culturally different patients (13—16). Rooda (13) attempted to measure both knowledge and attitudes of nurses toward culturally diverse patients with the Cultural Fitness three-part survey: a knowledge test, attitude test, and demographic survey. Significant differences were noted in the nurses' knowledge and attitude toward African American, Asian American, and Hispanic patients. Of the six demographic variables—age, gender, ethnic identity, educational preparation, year of graduation, and professional experience—only level of educational preparation was significantly correlated with knowledge and biases of nurses toward culturally different patients.
In an effort to devise a method to improve residents' ability to deliver culturally sensitive care, we report on the effectiveness of a workshop model as a teaching tool. To design a questionnaire to measure change in cultural sensitivity, we searched the literature for existing questionnaires. We contacted authors of previous studies to ascertain effectiveness of various questionnaires in measuring knowledge and attitudes about cultural sensitivity. The existing questionnaires: the "Cultural Fitness Survey" (13), the "Ethnic Attitude Assessment Survey" (14), the "Cultural Attitude Scale" (15,16), and the pre- and post- questionnaires designed by Moffic in 1983 tested attitudes toward culturally different patients, but were not useful in measuring change in knowledge about cultural sensitivity in a pre- and post-workshop questionnaire format. In interviewing authors, we explored questionnaire strengths and limitations and could not find a tool in the existing literature to measure change in knowledge about cultural sensitivity (17).
Faced with this lack of known measures, we devised our own questionnaires. Since we expected that the workshop would impart knowledge about cultural issues to the residents, questionnaires were designed to measure change in residents' knowledge attributable to the workshop.
This study was done at the Department of Psychiatry at the University of Michigan, Ann Arbor. There were 40 residents (45% men) in the Adult Psychiatry residency program in Postgraduate Year (PGY)-I through -IV. Ethnicity of the residents was 52.5% Caucasian, 7.5% African American, 2.5% Latin American, and 37.5% Asian American; 76% of patients treated by the residents are Caucasian, 15% African American, 4% Latin American, and 5% other minorities.
The authors designed a 4-hour Cultural Sensitivity Training workshop for PGY-I through -IV psychiatry residents. The authors were two PGY-IV residents and two psychiatry faculty members at the assistant professor level, each of different ethnic descent. The two faculty members had previous experience leading core seminars in Cultural Psychiatry for psychiatry residents. The objectives of the workshop were
Twenty-four of the 40 residents (60% attendance, which is usual for such resident activities) in PGY classes I through IV attended the workshop, which was conducted on a weekday during normal working hours. Residents were given time off to attend the workshop, and attendance was voluntary. Consent was obtained before administration of the questionnaires.
The workshop format included the following:
1. Introduction of Objectives.
The introduction was given by two authors of the study.
There were three half-hour-long interactive presentations, as follows: a) The 1996 University of Michigan Medical School (UMMS) Cultural Diversity Assessment Survey (18) was presented by the Assistant Dean for Faculty Affairs at the Medical School, who was the coordinator of the survey initiative. The discussion focused on results of the survey and the importance of developing and reinforcing respect and sensitivity for diverse populations; b) A presentation on issues involved in delivering culturally sensitive care to African American patients was given by the Associate Director of the Academic Multicultural Initiatives Program at the medical school. This began with an overview of cultural assessment of a patient and definitions of specific terms like "cultural paranoia" and "stereotyping". Common characteristics of the African American culture and key events in African American history were discussed, along with their impact on the African American patient's approach to health care and treatment approaches by the culturally sensitive provider; c)A presentation on issues involved in treating Latin American patients was given by a Psychiatry faculty member who was the coordinator of the migrant farm worker treatment initiative at the University of Michigan. Migrant farm workers' problems in obtaining adequate healthcare were discussed. Terms like "stereotyping" (vs. "generalization") were defined. The "CLEFS" model (Cultural, Linguistic, Environmental/educational, Follow-up care, and Strengths) was discussed as a method for providing culturally sensitive care: The patient's culture (including family structure, use of home remedies, beliefs about illness), language/literacy, environment/educational factors (work-site, location of clinic, availability of transport, financial resources), follow-up (short- and long-range considerations in treating chronic conditions), and recognition of strengths are important considerations in culturally sensitive care. The gender/ethnicity of the speakers was male African American, female African American, and female Latin American, respectively.
The workshop ended with a 1-hour role-play using a facilitator-led small-group format. Facilitators were Psychiatry faculty with experience in cultural sensitivity training. Residents volunteered to role-play "Psychiatrist" and "Patient" in one or two patient vignettes. One vignette depicted a Caucasian psychiatrist trying to understand a suicide attempt by an academically competitive young Korean woman living in the United States. Issues included high expectations of students in the Korean culture, being in another country away from family, and the student's own guilt and perception of failure. Role-play highlighted culturally relevant clinical issues and problems related to differences in ethnicity between psychiatrist and patient. Alternate approaches were discussed, along with potential therapeutic implications.
To evaluate the program, we devised a pretest and posttest questionnaire (Appendix 1 and Appendix 2), a simple evaluation of the workshop's strengths and areas for improvement, and a demographic survey. Questionnaires were numerically coded to facilitate anonymity. Paired questions were designed on Questionnaires A and B to test participants with two different questions on each issue (Appendix 3). Participants were randomly assigned alternately to two subgroups receiving questionnaires at the start of the workshop. Each resident was tested with different questionnaires before and after the workshop, to control for repeated exposure. Twelve residents received Questionnaire A as pretest and Questionnaire B as posttest. The other twelve residents received Questionnaire B as pretest and Questionnaire A as posttest.
All 24 residents returned completed questionnaires. Answers were scored in multiple-choice format by an independent evaluator, and we compared means of raw scores obtained by the residents on each questionnaire. Average performance on questionnaires was calculated for the group before and after testing, and two-way analysis of variance (ANOVA; questionnaire type and pre- vs. post-training as independent factors) was used to examine overall effect of training on residents' performance.
Twenty-four of the 40 residents in PGY-I through -IV participated in the workshop. Their ages ranged from 26 to 47 years, and 58% were women. Ethnicity of the participating resident group was 58% Caucasian, 4% African American, and 38% Asian; 79% graduated from United States medical schools, and 21% were international medical graduates. Attendees comprised 21% PGY-I, 29% PGY-II, 37% PGY-III, and 13% PGY-IV residents. Fourteen residents did not attend, and two residents attended but did not participate in the evaluation process (having been involved in the design of the study). There were no significant differences in demographics between residents who attended the workshop and those who did not.
Overall, irrespective of the order of the questionnaires administered, the mean pretest score for all residents was 4.9, and the mean posttest score was 7.23 out of a possible score of 11. On two-way ANOVA, we found a statistically significant improvement in performance on the questionnaires after the workshop (F=30.6; P<0.001). The improvement in scores was not significantly different on one questionnaire as compared with the other (Interaction effect F=2.2; NS).
Course evaluation comments were generally positive. On a Likert scale from 1—10 (1=Poor; 10=Outstanding), the mean rating subjectively assigned by residents for perceived usefulness of the workshop in improving cultural awareness was 5.9. Specific feedback revealed that 58% of residents wanted coverage of a wider spectrum of cultural diversity, and 41% requested a longer workshop.
The workshop provides a moderately successful teaching model that significantly improves residents' knowledge about cultural sensitivity. This model was chosen for brevity and ease of administration in the residents' busy schedules. We were faced with a choice as to whether to take an approach that sensitizes residents to cultural issues in general (a generic/structural approach) vs. one that teaches residents details about specific subcultures. A generic/structural approach may be more useful with the vast range of subcultures one is likely to encounter in clinical practice, as one cannot be expected to learn an individual approach for each subculture. However, the latter approach may be more useful in coordinating knowledge gained during such a workshop with the actual mix of patients the resident is likely to treat in the geographic setting of the program. In this workshop, a mix of the above two approaches was chosen. Residents were taught more generic concepts, such as stereotyping, generalization, and cultural paranoia. They were also taught specifics about common subcultures they were most likely to encounter during their residency (i.e., African American, Latin American, and Asian American). Speakers were chosen on the basis of their experience with culturally diverse populations, their ethnicity, and expertise in providing culturally sensitive care.
The results of the UMMS Cultural Diversity Assessment Survey were thought to have special relevance because this was a study recently conducted at the medical school to assess culturally important perceptions of all faculty, residents, graduate students, and medical students. We thought that giving the residents a better understanding of the cultural perceptions in their own training program would lay the framework for a discussion of cultural issues. Also, as residents often treat several college students on their clinical rotations, such information would have direct relevance in providing culturally sensitive care. Treating such patients would give residents further opportunity to apply and consolidate knowledge gained in the workshop. The survey results were therefore discussed, along with their relevance to culturally sensitive clinical care.
Residents were taught common characteristics of African American and Latin American cultures in a lecture format followed by interactive discussion. The speakers were African American and Latin American, respectively, and were able to give both information and personal insights into culturally relevant material for these subcultures.
Role-play vignettes were intended to give an immediate experience of cultural issues in patient care and reinforce generic concepts about culture taught in the previous lectures. The vignette of the Korean woman was used to teach residents about Asian American subcultures, which was a topic not addressed in the workshop lectures. Residents treat several Asian patients during their training, and this would give them an opportunity to apply generic issues in cultural sensitivity and learn about specific issues in an Asian subculture.
Questionnaires were devised to test change in residents' knowledge about cultural sensitivity after the workshop. Each speaker was asked for three to four concepts that they thought were most important for the residents to learn, and these were used as the basis for questions. The paired-question format was selected to eliminate bias involved in residents' having to answer exactly the same questions on the pretest and posttest. Paired questions on the same concept ensured that residents' knowledge on each concept would be measured before and after the workshop.
Our study has some limitations. First, the 4-hour workshop format had severe time constraints, and objectives had to be limited at the outset. We could not give a comprehensive overview of each subculture, but the lectures served as a broad overview to teach important highlights of major subcultures that residents were likely to encounter. The role-play at the end was chosen in order to give the residents a more direct experience of how to incorporate the knowledge in actual clinical practice. Second, the questionnaires were devised by the authors and could not be formally tested for reliability and validity because of a lack of standardized tests to measure improvements in cultural sensitivity due to educational intervention. Also, the results could not be compared with other cultural sensitivity training efforts for psychiatry residents because no formal reported studies exist. In that sense, our study was a pilot to evaluate the workshop format as a tool for teaching psychiatry residents about cultural sensitivity in a brief, time-efficient manner. Third, workshops and questionnaires of the type we devised can only affect or measure residents' knowledge about cultural sensitivity but not their attitudes about culture and its impact on clinical care. Existing questionnaires in the literature test residents' attitudes toward culturally different patients but are unable to measure changes in residents' knowledge about cultural sensitivity. Fourth, the questionnaires were specifically related to material taught during the workshop. It is not clear whether changing the questions, based on different course material, would affect measured outcome. Finally, the workshop was voluntary, which may lead to a question of selection bias. It is possible that only residents interested in cultural issues chose to attend. The fact that there were more women attendees raises the question whether gender is another variable affecting measured outcome. We wonder whether making the workshop a required part of the curriculum would result in different measured effectiveness.
Follow-up studies are required in order to determine whether change in residents' knowledge is long-lasting. Our assumption is that lack of cultural sensitivity is, to some extent, based on lack of knowledge about culture. We did not test whether improvement in knowledge immediately after the workshop translates into change in residents' attitude toward culturally diverse patients or into changed clinical behavior. This question may not be answerable until resident—patient interactions are monitored in a valid and reliable manner.
Another question is whether there is value in the use of such a workshop as a teaching tool when used alone. At the time of this study, there were no residency core lectures expressly designated to teach Cultural Psychiatry. There were lectures on topics such as Gender/Sexuality and Religion/Spirituality during the PGY-III core lecture series. Residents identified cultural psychiatry as an area in which they would like more didactic instruction. We would suggest that this workshop be used as part of a comprehensive curriculum in Cultural Psychiatry, using some of the methods in t1. Possibilities to enhance teaching include providing the workshop to faculty supervisors of residents rather than directly to residents and taking advantage of the multi-ethnicity of the average residency program by encouraging faculty and residents from relevant subcultures to provide on-the-spot consultation regarding patients from their culture.
The workshop is a quick and moderately successful method for increasing residents' cultural sensitivity. We recommend that it be incorporated as a part of an integrated core curriculum to teach Cultural Psychiatry. Further studies are necessary to evaluate the efficacy of various methods of training. This will "facilitate our inclusion of the cultural dimension as an essential integrative component of scientific psychiatry." (19).
The authors thank David Gordon, M.D., Gloria Edwards, Ph.D., and Lucila Nerenberg, M.D., for conducting the workshop; and James Lomax, M.D., and Mark Kunik, M.D., for editorial assistance.