Over the past 10 years, national attention has focused on the importance of disparities, diversity, and cultural competence in the delivery of healthcare. These three areas are interrelated, and there has been simultaneous development among them in mental healthcare.
Developments in disparities, diversity, and cultural competence have begun to impact medical student education. In the past 5 years, the Liaison Committee on Medical Education (LCME) has continuously strengthened their accreditation requirements concerning these areas (1).
In this article, we will review the key developments in disparity, diversity, and cultural competence for healthcare and then for mental healthcare; focus on the LCME accreditation standards; and conclude, with suggestions for action steps that psychiatry might employ to become a part of the continued development of the three areas discussed.
We will focus on racial and ethnic disparities in healthcare and mental healthcare. Disparities related to other population characteristics exist as well, however. For example, the 2004 National Healthcare Disparities Report (2) from the Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) focuses on the following AHRQ priority populations as specified by Congress: racial and ethnic minorities; low-income groups; women; children; the elderly; individuals with special health needs (disabilities, chronic care, end-of-life); and residents of rural areas. Additionally, disparities exist for other populations such as sexual minorities.
Since President Bill Clinton’s Presidential Initiative on Healthcare Disparities began in 1998, the topics of disparity, diversity, and cultural competence have become important stimuli for service development, training, and research for government, healthcare organizations, and foundations. The 2000 Institute of Medicine (IOM) Report "Crossing the Quality Chasm" (3) listed patient-centered care and equity as two of six objectives that need to be met in order to improve quality of healthcare in the U.S. The 2002 IOM Report "Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare" (4) was a landmark report that concluded that racial and ethnic disparities exist in healthcare and are unacceptable because they are associated with worse outcomes in many cases. The report defined "disparities" in healthcare as racial and ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.
The 2002 report focused on two levels of analysis: 1) the operation of healthcare systems and the legal and regulatory climate and 2) discrimination at the individual patient-provider level. Discrimination was defined in the report to refer to differences in care that result from biases, prejudices, stereotyping, and uncertainty in clinical communication and decision making. Twenty one recommendations relating to education were made, including:
1. Recommendation 5—3: Increase the proportion of underrepresented U.S. racial and ethnic minorities among health professionals. "The benefits of diversity in health professions fields are significant, and illustrate that a continued commitment to affirmative action is necessary for graduate health professions education programs, residency recruitment, and other professional opportunities."
2. Recommendation 6—1: Integrate cross-cultural education into the training of all current and future health professionals.
The 2004 Institute of Medicine "In the Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce" report (5) summarized the evidence demonstrating that greater diversity among health professionals is associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, better patient-provider communication, and better educational experiences for all students while in training. Diversity among professionals will help reduce healthcare disparities. Twenty-five recommendations were made in the following six sections: 1) improving admission policies and practices; 2) reducing financial barriers to health professions training; 3) encouraging diversity efforts through accreditation; 4) improving the institutional climate for diversity; 5) applying community benefit principles to diversity efforts; and 6) other mechanisms to encourage support for diversity efforts. The recommendations in sections 1, 4 and 5 were specifically addressed to health professions educational institutions (HPEIs). They included the following:
1. HPEIs should develop, disseminate, and utilize a clear statement of mission that recognizes the value of diversity;
2. HPEIs should establish explicit policies regarding the value and importance of culturally competent care and the role of institutional diversity in achieving this goal;
3. HPEIs should develop and regularly evaluate comprehensive strategies to improve the institutional climate for diversity; and
4. HPEIs should proactively and regularly engage and train students, house staff, and faculty regarding institutional diversity-related policies, expectations, and the importance of diversity.
Many professional organizations have begun to help implement the many recommendations stemming from these three IOM reports. The American Medical Association has an extensive policy concerning minority health issues, including a policy of "zero tolerance" toward racially or culturally based disparities in healthcare (6). Its House of Delegates has made the elimination of racial and ethnic health disparities an issue of high priority. In January 2005, the American Medical Association (AMA), the National Medical Association, the National Hispanic Medical Association, and more than 30 health-related groups announced the formation of the Commission to End Healthcare Disparities. The American Psychiatric Association (APA) is a member organization. The Commission will work to educate physicians and health professionals about healthcare disparities while identifying and developing strategies to eliminate gaps in care based on race and culture. Four committees were formed to focus on raising professional awareness, improving data gathering, increasing education and training, and promoting workforce diversity. One of two projects currently under way promotes selected training programs that use case study work, self-assessment activities, and video vignettes to increase physicians’ cultural competency.
In August 2001, the Surgeon General issued a supplement to his 1999 landmark "Mental Health: A Report of the Surgeon General" entitled "Mental Health: Culture, Race and Ethnicity" (7). It documented striking disparities in mental healthcare for racial and ethnic minorities involving access, appropriateness, quality, and outcomes. Minorities are woefully underrepresented in research studies. Taken as a whole, these disparities impose a greater disability burden on racial and ethnic minorities. Examples from the four chapters on the four major racial and ethnic groups include:
1. Disproportionate numbers of African Americans are represented in the most vulnerable segments of the population—people who are homeless, incarcerated, in the child welfare system, victims of trauma—all populations with increased risks for mental disorders;
2. As many as 40% of Hispanic Americans report limited English-language proficiency. Because few mental healthcare providers identify themselves as Spanish-speaking, most Hispanic Americans have limited access to ethnically or linguistically similar providers.
3. The suicide rate among American Indians/Alaska Natives is 50% higher than the national rate; rates of co-occurring mental illness and substance abuse (especially alcohol) are also higher among Native youth and adults. Because few data have been collected, the full nature, extent, and sources of these disparities remain a matter of conjecture.
4. Asian Americans/Pacific Islanders who seek care for a mental illness often present with more severe illnesses than do other racial or ethnic groups. This, in part, suggests that stigma and shame are critical deterrents to service utilization. It is also possible that mental illnesses may be undiagnosed or treated later in their course because they are expressed in symptoms of a physical nature.
The report concluded with "A Vision for the Future," in which recommendations were grouped in six areas: 1) Continue to expand the science base; 2) Improve access to treatment; 3) Reduce barriers to treatment; 4) Improve quality of care; 5) Support capacity development; and 6) Promote mental health. Most relevant to education was the following recommendation:
Minorities are underrepresented among mental health providers, researchers, administrators, policymakers, and consumer and family organizations. Furthermore, many providers and researchers of all backgrounds are not fully aware of the impact of culture on mental health, mental illness, and mental health services. All mental health professionals are encouraged to develop their understanding of the roles of age, gender, race, ethnicity, and culture in research and treatment. Therefore, mental health training programs and funding sources that work toward equitable representation and a culturally informed training curriculum will contribute to reducing disparities (7).
In July 2003, the President’s New Freedom Commission on Mental Health issued its report entitled "Achieving the Promise: Transforming Mental Health Care in America" (8). Of the six overall goals that were discussed as a means to transform the mental health system, two are most relevant: 1) mental healthcare should be consumer and family driven, and 2) disparities in mental health services must be eliminated. Recommendations from the Commission Report are as follows:
1. Recommendation 3.1: Improve access to quality care that is culturally competent. "The Commission recommends making strong efforts to recruit, retain, and enhance an ethnically, culturally, and linguistically competent mental health workforce. These efforts could include: a) recruiting and retaining racial and ethnic minority and bilingual professionals; b) developing and including curricula that address the impact of culture, race, and ethnicity on mental health; c) training and research programs targeting services to multicultural populations; d) engaging minority consumers and families in workforce development, training, and advocacy. All federally funded health and mental health training programs should explicitly include cultural competence in their curricula and training experiences."
2. Recommendation 3.2: Improve access to quality care in rural and geographically remote areas.
3. Recommendation 4.4: Screen for mental disorders in primary healthcare, across the lifespan, and connect treatment and supports.
4. Recommendation 5.3: Improve and expand the workforce providing evidence-based mental health services and supports. "Every mental health education and training program in the Nation should voluntarily assess the extent to which it. … emphasizes developing cultural competence in clinical practice and ensures that the diversity of the community is reflected among trainees and in the training experience."
5. Recommendation 5.4: Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.
As a result of the developments described, as well as other developments in the field, the Association of American Medical Colleges (9), under the leadership of President Jordan Cohen and Deborah Danoff among others, has led a concerted effort over the past 10 years to increase diversity in medical education and reduce disparities. Some of their initiatives have included:
1. Leadership of the Health Professionals for Diversity Coalition of over 50 professional organizations, of which the APA is a member organization. This coalition successfully advocated for the importance of affirmative action in the Grutter v. University of Michigan case before the Supreme Court. It upheld the constitutionality of narrowly tailored affirmative action applied in an individualized manner to increase racial and ethnic diversity.
2. Association of American Medical Colleges (AAMC) Medical Schools Objectives Report, Volume 3, Task Force Report on cultural competence, religion, and spirituality, 1999.
3. Tool for Assessing Cultural Competency Training (TACCT), 2005, which will support medical schools in evaluating the effectiveness of their cultural competency curriculum.
Additionally, the LCME (1) has taken a leadership role by including explicit discussion of healthcare disparities, cultural competence, and diversity in its accreditation standards as seen in the following section that contains four standards. ED 21—23 speak to educational content, and MS-8 refers to the importance of diversity in the student body. The LCME has listed the standards followed by annotations in smaller print to further explain the implementation of the standard. The first three standards are at the level of mandate, which is a "must."
ED-21. The faculty and 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.
All instruction should stress the need for students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on their health. To demonstrate compliance with this standard, schools should be able to document objectives relating to the development of skills in cultural competence, indicate where in the curriculum students are exposed to such material, and demonstrate the extent to which the objectives are being achieved.
ED-22. 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 objectives for clinical instruction should include student understanding of demographic influences on healthcare quality and effectiveness, such as racial and ethnic disparities in the diagnosis and treatment of diseases. The objectives should also address the need for self-awareness among students regarding any personal biases in their approach to healthcare delivery.
ED-23. A medical school must teach medical ethics and human values and require its students to exhibit scrupulous ethical principles in caring for patients and in relating to patients’ families and to others involved in inpatient care.
Each school should assure that students receive instruction in appropriate medical ethics, human values, and communication skills before engaging in inpatient care activities. As students take on increasingly more active roles in inpatient care during their progression through the curriculum, adherence to ethical principles should be observed and evaluated, and reinforced through formal instructional efforts.
In student-patient interactions there should be a means for identifying possible breaches of ethics in inpatient care, either through faculty/resident observation of the encounter, patient reporting, or some other appropriate method.
"Scrupulous ethical principles" imply characteristics like honesty, integrity, maintenance of confidentiality, and respect for patients, patients’ families, other students, and other health professionals. The school’s educational objectives may identify additional dimensions of ethical behavior to be exhibited in inpatient care settings.
MS-8. Each medical school should have policies and practices that ensure the gender, racial, cultural, and economic diversity of their students. The standard requires that each school’s student body exhibit diversity in the dimensions noted. The extent of diversity needed will depend on the school’s missions, goals, and educational objectives; expectations of the community in which it operates; and its implied or explicit social contract at the local, state, and national levels.
How Psychiatry Can Play a Role in the Teaching of Healthcare Disparities, Diversity and Cultural Competence
Psychiatry can contribute to the teaching effort to meet these LCME accreditation standards both within explicit teaching time allocated to psychiatry as well as in the broader medical student curriculum in the following ways:
ED-21. The DSM—IV Outline for Cultural Formulation (10) provides a clinical method to understand cultural identity, explanatory models, cultural stresses/supports, cultural elements of the clinician/patient relationship, and their impact on differential diagnosis and treatment planning. The APA Position Statement On the Use of the Concept of Recovery (11) states that "the concept of recovery enriches and supports medical and rehabilitation models." Furthermore, the position statement reiterates that "the best results come when patients feel that treatment decisions are made in ways that suit their cultural, spiritual, and personal ideals."
ED-22. Psychiatry incorporates self-reflection and attention to countertransference in our work with patients. We can assist students in understanding their intentional or unintentional biases, which impact on the doctor-patient relationship and adherence to treatment plans. The AAMC’s TACCT enumerates several knowledge, skill and attitudinal learning objectives in "Domain III: Understanding the Impact of Stereotyping on Medical Decision-Making," for which psychiatry can play an important role to help students achieve throughout all 4 years of medical student education.
ED-23. Psychiatry includes a humanistic aspect that incorporates an understanding of human values that is the basis for respect and professionalism, which is one of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies (12). Recently, England has adopted in its mental health planning at the highest level the "two-feet principle" for mental health services: evidenced-based practice and values-based practice (13). Interpersonal and communication skills, which are another of the six ACGME core competencies, are areas where psychiatry can bring forth its expertise.
In September 2001 APA President Richard Harding appointed a Steering Committee to Reduce Disparities in Access to Psychiatric Care to address racial and ethnic disparities documented in the Surgeon General’s 2001 report. The Steering Committee’s Plan of Action was approved by the Board of Trustees in December 2004 (14); it consisted of recommendations for APA and the field of psychiatry in four areas: 1) Expand the science base; 2) Support education, training, and career development; 3) Enhance access and reduce barriers; and 4) Promote mental health through collaboration and advocacy. The following is the part related to education. The authors have added a symbol [***] to those recommendations particularly relevant to medical student education (2, 5, 7).
Support Education, Training, and Career Development
The Surgeon General’s Report identifies "support capacity development" as one of six broad recommendations to reduce mental health disparities: "Minorities are underrepresented as providers, researchers, and as administrators and policymakers and consumer and family organizations. Furthermore, many providers and researchers of all backgrounds are not fully aware of the impact of culture on mental health, mental illness, and mental health services" (p. 167).
Therefore, APA should strengthen its efforts to increase representation of minority underrepresented psychiatrists in all the above roles as well as to augment medical education by including curricula that focus on the impact of race, ethnicity, and culture on mental health, mental illness, and mental health services. APA Strategic Goals (1998), which include "supporting education, training, and career development" as a strategic goal, provides guidance on implementing the Surgeon General’s recommendations in this area. Toward the goal of supporting education, training, and career development, APA should:
This article reviews important developments in healthcare policy including mental health concerning elimination of disparities, increasing diversity of the workforce and cultural competence. LCME accreditation standards have recently changed to reflect these developments. The field of psychiatry can play a role in participating in the fulfillment of these accreditation standards.