Despite the vast diversity of the society in which medicine is practiced, much of the standard teaching in medical schools in North America has been tied to a mainstream biomedical view of mental health. This is beginning to change, as indicated by increasing attention in the medical education literature devoted to cultural competence (1). This attention has been complemented by the rising interest in the study of health disparities, beginning with the landmark U.S. Surgeon General’s Report on Mental Health in 1999 (2) and the supplement on Culture, Race and Ethnicity in 2001, which highlighted the finding that “culture counts” and reviewed the impact of culture and society on mental health, including major differences in access to and quality of mental health care (3). Further studies such as “Unequal Treatment,” a report of the Institute of Medicine on disparities in health care for ethnic minorities, helped focus more attention on this previously neglected area (4).
While there is a growing literature about cross-cultural undergraduate medical education (5), much less attention has been paid at the postgraduate psychiatry level (6). This is an important training gap since so much in mental health relies on interpretation of both verbal and nonverbal signs and symptoms, which are dependent on accurate communication and appreciation of cultural differences and nuances in meaning. This article traces the development of a new curriculum initiative to incorporate cultural competence training in the psychiatry residency at the University of Toronto.
Canada is a country of immigrants that values the principles of multiculturalism; this has shaped the development of health services and training in our country (7). The University of Toronto, which houses the largest psychiatry residency training in North America, is responding to the needs of Canadian multiculturalism and the city of Toronto, the largest metropolis in Canada with a population of 2.48 million people (5 million in the greater Toronto area) divided into groups of 49% foreign-born residents and 43% visible minorities (defined by Statistics Canada as “persons, other than Aboriginal peoples, who are non-Caucasian in race or nonwhite in color”) (8). This makes Toronto one of the most multicultural cities in the world and its diversity is projected to increase. It also makes the city the ideal place to develop a Canadian cultural competence training model.
Defining Cultural Competence
While there not a universally accepted definition of cultural competence, Terry Cross’s definition is one of the most widely cited: “Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations” (9). In addition to recognizing different levels of cultural competence, this definition is consistent with the “tripartite framework” developed by Sue et al. (10), which recognizes three overlapping components of cultural competence, including requisite attitudes, knowledge, and skills. Another approach is to conceptualize cultural competencies as comprised of both generic and specific cultural competencies (11). Generic competence indicates an approach or preparedness to work cross-culturally with myriad groups, while specific cultural competence indicates an expertise with a particular cultural group.
The incorporation of the biopsychosocial formulation into psychiatric assessments in the 1970s and 1980s (12) was a big step forward in acknowledging the social world of the patient and mastering this model remains a core competency in resident training. However, because the biopsychosocial model does not draw specific attention to culture, issues such as cultural identity, acculturation, language preferences, beliefs about health and illness, as well as cultural issues in the relationship between the patient and clinician may be overlooked. These factors, addressed in the DSM-IV-TR Outline for Cultural Formulation, taken together with more standard approaches may form the foundation of culturally competent assessment and care (13), upon which additional clinical knowledge and skills may be built.
Canadian Context in Postgraduate Education: CanMEDS Competencies
Responding to community needs, the Royal College of Physicians and Surgeons of Canada initiated the Canadian Medical Education Directions for Specialists (CanMEDS) project in 1993 (14), which was revised in 2005 (15). The project represents a paradigm shift in the focus of training from the interests and abilities of the providers to the needs of the society, and training programs are oriented to individual patient needs within the context of the population at large. The role of specialist physician is expanded from medical expert to also include: communicator, collaborator, manager, health advocate, scholar, and professional (Table 1
). All Canadian residency training programs, including psychiatry, are moving toward adopting the CanMEDS roles in the creation of both learning objectives and evaluation measures (16). These broader roles are now being adapted for use by medical bodies worldwide, including Australia, the Netherlands, Denmark, and the United Kingdom. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) similarly endorses a broader approach to postgraduate education, identifying general competencies in six areas, including patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (17).
Diverging Paradigms of Core Competence and Cultural Competence
Compared with the United States, Canada has historically favored the multiculturalism “mosaic” over the “melting pot” in dealing with its immigration and refugee issues, with relatively greater acceptance of the preservation and integration of diverse cultures of origin (18). Canadians have not experienced such landmark events in their history as the American civil rights movement that polarized the population beginning in the 1950s. While Canada has no single dominant visible minority population, but many varied groups in smaller numbers, the United States has several populous minority groups, leading to the broad demographic categorizations of Hispanic, African American, Asian American, Caucasian, and Native or Pacific Islander. The significant demographic and historical differences between the United States and Canada lead to divergence in developing core competencies in health care, approaches to providing mental health services for minorities, and training in cultural psychiatry.
Implementation of CanMEDS, a competency based psychiatry curriculum, is similar to the U.S. ACGME mandate that all postgraduate medical specialty programs document trainee’s proficiency in the six general competencies (19). Instead of “Health Advocate,” a CanMEDS competency, the U.S. ACGME describes “advocate(ing) for quality patient care” as an element of “Systems-Based Practice” (17). In contrast, the subspecialty of cultural psychiatry in the United States puts major emphasis on advocating for reduction of health disparities and inequities. Cultural psychiatry in the United States also places emphasis on specific cultural competencies targeting the recognized major ethnic categorizations. In developing the cultural psychiatry program at the University of Toronto, we put relatively greater emphasis on generic cultural competencies, while incorporating some aspects of specific cultural competencies training.
Structures and Processes Facilitating Cultural Psychiatry Curriculum Development at the University of Toronto
The Department of Psychiatry at the University of Toronto is one of the largest in the world, with over 680 active faculty members. It is subdivided into 14 divisions, including the Culture, Community, and Health Studies program, which specializes in cultural psychiatry. The department trains about 130 residents each year through its seven fully affiliated teaching hospitals. The Canadian psychiatry residency is 5 years in length. The first year, postgraduate year 1 (PGY-1), is equivalent to a general internship year, rotating through different medical specialties with exposure to emergency psychiatry, addictions, and consultation-liaison psychiatry. The second to fourth years typically consist of outpatient, inpatient, chronic care, child, geriatric, and consultation-liaison psychiatry. The fifth year is an elective year.
The cultural psychiatry curriculum project was spurred by both the interest of residents and the perceived needs of the faculty in the Culture, Community, and Health Studies program. Residents began requesting training in this area and the project was supported by the results of a survey conducted in January 2004. Fifty-seven residents responded from convenient sampling across the teaching hospitals. The results indicated that 70% never attended any formal teaching session on cultural psychiatry, 85% did not consider cultural factors in psychotherapy, and 75% avoided psychotherapy in preference of pharmacotherapy with minority patients. The residents endorsed the importance of cultural sensitivity on the survey and indicated interest in having conferences, individual supervision, lectures, rounds, consultations, and specialty clinics in this area. Concurrently, the faculty of the Culture, Community, and Health Studies program identified the need to enhance cultural competence training in the curriculum. Further, enhancing cultural competence in the program was deemed one of the priority areas by the Chair of the Department of Psychiatry as well as by the Postgraduate Education Director. Thus, a curriculum working group within the Culture, Community, and Health Studies program was formed and met on a regular basis.
Early developments included having the Culture, Community, and Health Studies program represented on the Residency Training Committee and from this vantage point advocate cultural issues in the curriculum. A retreat of interested faculty members was held in January 2004 to develop a plan to integrate cultural content into the curriculum. A report was then circulated from the proceedings of the retreat with an outline of the curriculum proposal. In March 2004, the Culture, Community, and Health Studies program formed a steering committee, inviting faculty from the different teaching hospitals to participate. To lay the groundwork, a comprehensive literature review of clinical cultural competence, including definitions, key components, standards, and selected trainings was completed in June 2004 (20). The systematic review of published literature was conducted through database searches including PubMed, PsycINFO, PsycArticles, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Social Science Abstracts, and Sociological Abstracts; through government and professional association publications; and though on-site visits to local cross-cultural training programs. In May 2005, the proposed curriculum framework was presented at the Postgraduate Education Retreat. The curriculum working group began to work closely with the Postgraduate Education Director and the Resident Training Committee to incorporate cultural competence training and evaluation into the curriculum.
The University of Toronto Cultural Psychiatry Curriculum: An Integrative Approach
In developing the educational program at the University of Toronto we endeavor to build a program with an emphasis on a generic approach to cultural competence and utilize an integration framework at multiple conceptual levels, including both content and process.
Integrated Content: Attitudes, Skills, Knowledge, and CanMEDS Frameworks
At the content level, the conceptualization of cultural competence itself is seen as an integrated construct with components of attitudes, skills, and knowledge within the tripartite model. As a unique University of Toronto elaboration, the tripartite model is integrated with the seven roles of CanMEDS framework. Specifically, learning objectives consisting of attitudes, skills, and knowledge components were identified within each of the CanMEDS roles.
Using the CanMEDS role of medical expert as an example, the attitudinal component includes the ability to reflect and recognize one’s own biases and assumptions. The knowledge component includes both basic science and clinical knowledge that is relevant to the practice of culturally competent psychiatry, and includes knowledge of specific constructs which describe how culture may interact with symptom and syndrome presentations, such as cultural idioms of distress, illness explanatory models, and culturally bound syndromes. Skills include assessment-related issues, such as conducting culturally competent interviews, and treatment-related issues, both psychological and pharmacological interventions.
Specific learning objectives are similarly identified among the other six CanMEDS roles. Examples include the use of interpreters under the role of communicator; skills in collaborating with the ethnic communities and available resources under collaborator; critical appraisal and culturally informed research skills under scholar; respect for diversity under professional; skills in addressing power inequities within teams under manager; and skills in addressing the impact of racism, access barriers, and social factors leading to disparities under the health advocate role.
Integrated Process: Across Disciplines and Time
To achieve true integration at the process level, developed objectives cannot be taught in isolation in a typical clinical rotation. Our vision is to integrate cultural psychiatry teaching objectives across the other 14 divisions at the department of psychiatry. This is important in that it recognizes the expertise of the other specialized programs, such as the schizophrenia or mood disorders programs. For example, the schizophrenia program seminars can effectively include information about the more favorable prognosis of schizophrenia in developing countries, misdiagnosis of traumatic symptoms as psychosis, differences in diagnostic issues among different countries, involuntary detainment and other treatment biases, and ethnic differences in psychopharmacology. The importance of fostering a collaborative and inclusive working relationship with other programs is consistent with the principles of cultural psychiatry—the need to negotiate multiple perspectives and bridge differences to ultimately decrease disparity and suboptimal clinical care.
Finally, the curriculum of cultural psychiatry needs to be integrated longitudinally throughout the length of residency. In Canada, this will begin in PGY-1 and extend toward PGY-5. This will enable the curriculum to be more responsive to the differing developmental needs of the residents. It also prevents the danger that cultural competence be misperceived as knowledge and skills that can be easily attained.
In many respects, cultural competence (or cultural-mindedness) is more akin to psychological mindedness, a quality one aspires toward but can never perfectly achieve in a lifelong journey of development and maturation. Training in cultural competence needs to begin in medical school and continue at the staff level as faculty development. The latter is especially crucial to ensure that residents can work in an environment which fosters the development of cultural competence, and that staff can effectively teach, model, and evaluate cultural competence. We have a funded project to specifically develop cultural competence training for the faculty, and it is scheduled to be implemented within the year. Ultimately, cultural competence needs to extend beyond individual providers into pragmatic and organizational levels, as well as at the university and its teaching sites.
Different education strategies are needed to address different types of learning objectives, including attitudinal shifts, skill development, and knowledge. Major educational opportunities, which are in place or being developed, include: core lectures, cultural psychiatry rounds, clinical teaching, electives, cultural psychiatry day, and conferences.
Historically, didactic cultural psychiatry training consisted of two sessions (six hours total) of core lectures in PGY-2. With the impetus of the Curriculum Working Group, working collaboratively with the Residency Training Committee, this has increased to five sessions (15 hours total), three sessions in PGY-1, and two sessions in PGY-2. A brief description of the main topics covered and the CanMEDS roles emphasized is listed in Table 2
During PGY-1, residents rotate mainly through nonpsychiatric services. Therefore, we have strategically placed an early emphasis on increasing self-reflection of attitudes and assumptions inherent in the traditional medical model, as well as knowledge about psychiatry in its wider sociocultural context. To avoid an overly pathology driven model, the first session is devoted to “Culture and Health” from microscopic individual perspectives to macroscopic societal perspectives. This is followed by a session examining “Culture and Illness,” the influence of culture on various aspects of the illness and healing experience and systems used to codify these phenomena. The third session explores the historical development of psychiatry and introduces concepts of cultural competence. It also focuses on intercultural communication skills, as this is most immediately applicable for PGY-1 residents. In the PGY-2 seminars, there is a major emphasis on laying down core cultural knowledge and skills to prepare residents to enter into their clinical psychiatric rotations. The first session focuses on “Culture and Assessment,” issues such as psychiatric interviewing and formulation, recognition of cultural bound syndromes, and use of interpreters. The second session focuses on interventions, including psychotherapy, psychopharmacology, addictions treatment, and systems issues, each revisited with ethnic and cultural considerations. The format of the lectures has also evolved into a workshop format, making use of case studies and interactive group work to facilitate learning.
Regular cultural psychiatry related rounds have been established at four teaching hospital sites, three of them with a clinical focus and one with a research focus. The rounds are attended by staff and multidisciplinary team members from their respective hospitals, and residents are encouraged to attend and present. The formats vary from didactic presentations on specific topics to case-based discussion using DSM-IV-TR Outline for Cultural Formulation.
Culturally competent clinical skills development is an on-going process as the residents rotate through their successive blocks of training. The Culture, Community, and Health Studies program began meeting with the General Psychiatry Program to explore ways to increase cultural psychiatry teaching at core rotations in the PGY-2 year, and plans to meet with the other programs, such as schizophrenia and mood disorders, to ensure that teaching responsibilities are truly integrated across programs. Additionally, opportunities to learn cultural formulation and to work with cultural interpreters are available through the establishment of cultural consultation clinics.
Clinical elective experiences are made available through local teaching hospital programs and community agencies that are dedicated to serving specific ethnic populations. This includes outpatient programs for serving the Asian, Portuguese, and Hispanic communities and an ethno-specific Assertive Community Treatment Team. There are also opportunities for residents to arrange for electives outside of Toronto. For senior residents, there is a 1-month elective to travel to Ethiopia with two faculty members to teach in a recently developed residency program through a formal collaboration between the University of Toronto and Addis Ababa University.
Course evaluations about the core seminars from PGY-1 and PGY-2 residents are available through voluntary feedback forms, with 18 and 10 completed evaluations respectively (see Table 3
). These evaluations were based on generic forms used in all core resident seminars. Most questions were rated on a 5-point Likert scale (1=unsatisfactory, 2=needs improvement, 3=okay, 4=good, 5=excellent). On questions related to the presenters’ skills, the averaged responses were all rated above 4. The presenters’ ability to convey clinical significance on the topics were rated as 4.4 (PGY-1) and 4.3 (PGY-2). All respondents thought that the topics and seminar leaders should remain the same next year. On a 5-point scale (1=very low, 5=very high), the initial expectation/motivation about the seminar topics before the actual seminar was 3.9 (PGY-1) and 4.0 (PGY-1). On a 5-point scale (1=much more negative, 2=a little more negative, 3=unchanged, 4=a little more positive, 5=much more positive), the reported feelings about the topics after the seminar were 3.7 (PGY-1) and 4.3 (PGY-2). In addition, we are conducting a study together with a psychiatry resident using an instrument specifically developed at the Culture, Community, and Health Studies program (21) to formally assess cultural competence and attitudinal and behavioral shifts before and after the sessions, and the data are being analyzed.
Evaluating Cultural Competence of Residents: Why, When and How?
Evaluation Promotes Credibility and Drives Learning
To promote curricular change, cultural competence training programs, which are both labor and resource intensive, must include an evaluative component. Without empirical support, cultural competence training risks losing credibility and being viewed as a fad. It is sobering that in a recent systematic evaluation of cultural competence training since 1990 (22), there were only 59 published studies and fewer than 40% involved physician health professionals. In the studies involving physicians, only 5% involved an adequate comparison group, only 32% used objective evaluation approaches, and only 27% reported the magnitude of the group difference. Further work in this field is clearly necessary to demonstrate that cultural competence training can successfully affect change in the trainees.
Another rationale for evaluating training is that the evaluation process itself may facilitate acceptance of a new curriculum. Enhancing cultural competency within psychiatric residency training inevitably requires altering the status quo. Creating significant change in any medical educational curriculum can be extremely daunting because there are multiple and often competing stakeholders with divergent perspectives on what should be learned, when and how the new material should be taught, and what evaluation should be performed. This institutional resistance may be partially explained by the observation that the health care industry itself is generally more conservative, change-averse, and less open to innovation than almost any other modern industry (23). An illuminating example is the case study describing how problem-based learning was successfully adopted at Harvard Medical School (24). This case study demonstrates that successful curriculum change requires political astuteness, effective communication, and a willingness to relentlessly persevere against institutional resistance.
Attempting to achieve a consensus prior to proceeding can doom curriculum reform to failure as mounting resistance delays the entire project and meaningful educational change proceeds at a glacial pace. One strategy to overcome institutional drag is to initially focus on changing student evaluations before the new curriculum is formally adopted, implemented, and institutionalized. As noted by Andrews and Burruss: “Assessment measures used in training will measure the education objectives that have been prioritized based on the educational philosophy of the residency program…The faculty and trainees will progressively focus more over time on these objectives and the circular nature of testing, evaluating, modifying, and retesting will steer the curriculum ever nearer to the desired outcome” (25). This strategy assumes that motivation to learn is contextual and based in part on the wish to perform well. This “teaching to the test” strategy actually capitalizes on the “hidden curriculum” to achieve institutional curricular change (26). Through evaluation itself, the core beliefs of an educational institution about what is really important to learn are conveyed to the student through the powerful symbolism of evaluation and testing (27).
Challenges in Cultural Competency Evaluation: When and How?
Postgraduate training has shifted from a time-based apprenticeship paradigm to a competency paradigm (28). At the same time, the culture of assessment has shifted from an emphasis on summative or final testing to an emphasis on formative assessment through feedback (29). These two changes in postgraduate medical education theory and practice have important implications for the timing and method of evaluation of cultural competence within the psychiatric residency.
Frequent Feedback through Formative Assessment of Cultural Competence
Contemporary educators view formative assessment as an important approach to both enable and support effective learning, particularly higher-order types of learning associated with self-reflection, knowledge synthesis, and evaluation (30). Formative feedback has been defined as “information about how successfully something has been or is being done” in order to facilitate the identification of strengths and weaknesses and to improve overall performance (31, 32). Educational experts believe that feedback itself is actually the most important component of effective formative assessment (29). Rather than emphasizing factual knowledge about cultural syndromes in final exit exams, psychiatric educators should instead closely observe their residents in action and provide them with ongoing, frequent, specific, and meaningful formative feedback about real patient interactions involving individuals from diverse ethnic backgrounds.
In our program, formative feedback about cultural competence has recently been facilitated by the deliberate revision of the marking sheet for the annual departmental patient interview oral examination to more explicitly include issues related to culture and diversity. Key descriptive anchors reflecting cultural considerations in assessment, diagnosis, formulation, and management are provided for examiners to evaluate the residents’ performance as satisfactory or unsatisfactory. For example, cultural identity and explanatory models of illness are added as items to be explored in the history. Additional anchor descriptors for the mental status examination now include “aware of cross-cultural considerations in the mental status examination, for example speech, nonverbal communication, and cultural norms.” Other formative assessment tools are currently being developed to facilitate more frequent feedback to residents.
Assessment techniques vary in their capacity to evaluate different knowledge, attitudes, and skills. A multiple-choice or short-answer examination may be an excellent way to evaluate knowledge but a very poor technique to evaluate specific attitudes associated with professionalism. Blueprinting is the process by which a competency is defined and an appropriate assessment methodology is specifically linked or tailored to assess that particular competency (33). Blueprints ensure content validity and ensure that the assessment actually tests material that it is supposed to test.
Contemporary educators view competence as a developmental process in which multiple types of assessments are conducted over time to discern development. According to Miller (34), within knowledge, attitudes, and skills, there are four levels at which a trainee may be assessed and this paradigm can readily be applied to cultural competence training: knows (e.g., recall of facts and theories about cultural competence), knows how (e.g., problem-solving, procedures to deal with a patient from a cultural minority who is suspicious of physicians), shows how (e.g., demonstrates the skill of using an interpreter in a controlled setting such as an Objective Structured Clinical Examination), and does (e.g., observation of a resident interviewing a patient from a minority culture in real practice). These four levels provide a useful way of thinking about resident learning and provide a meaningful and comprehensive framework in order to select techniques to assess psychiatry resident cultural competency.
Cultural psychiatry curricula should be linked to health outcomes and a comprehensive assessment approach should be applied to evaluate cultural competency (35). Three critical questions can help to frame the evaluation of the cultural psychiatry curriculum:
1. Do students learn what is taught?
2. Do students use what is taught?
3. Does what is taught actually have an impact on health care?
Betancourt (35) proposed linking each of these three different educational outcomes from a cultural psychiatry curriculum to specific assessment techniques such as multiple-choice tests, videotaped patient encounters, and medical chart reviews (Table 4
). Although demonstration of the impact on health care outcomes is challenging, it is important that more proximal educational outcomes, like generalization of skills from classroom to the office, be closely monitored. Ultimately, we endeavor to examine the evidence for these three questions successively over the course of postgraduate residency training.
Utilizing a Postgraduate Retreat to Address Evaluation of Cultural Competence
Ultimately, the goal of having psychiatry residents become more culturally competent will be realized when the entire postgraduate education system encourages resident self-assessment and provides frequent and specific feedback about observed performance. To achieve this goal, the Postgraduate Director at the University of Toronto recently organized a special postgraduate retreat for faculty and residents focusing specifically on strategies to enhance the formative assessment of resident performance within each of the seven CanMEDS roles. By strategically including key faculty highly involved in cultural psychiatry postgraduate teaching in the retreat, the new formative resident assessment techniques being developed will more effectively evaluate resident performance in the CanMEDS roles with respect to cultural competence.
The postgraduate retreat also addressed immediate and longer-term evaluation strategies to assess cultural competence. An immediate strategy would be to modify the Interim Training Evaluation of Residency to include more items that specifically pertain to cultural competence (e.g., within the communicator role). Longer-term evaluation strategies would include patient portfolios and 360° evaluations. Portfolios have the capacity to qualitatively and quantitatively capture the diversity of patient experiences during the residency program and can also track the contact that the psychiatry resident has with community groups, interpreters, and patients who speak English as a second language (36). A form of multirater feedback, 360° evaluations ensure that resident performance is assessed by multidisciplinary health professionals as well as the patient and the patient’s family (37). This type of egalitarian assessment lends itself nicely to cultural competence evaluation, given the fact that cultural competence requires the resident physician to navigate effectively within a highly complex and at times conflicted health system. Finally, future assessment of cultural competence should also extend to the faculty, since evaluation of faculty by residents will promote further faculty development in cultural competence.
Competence in transcultural psychiatry should be assessed repeatedly over time and by multiple observers as all aspects of this competency are put into practice (38). Two excellent overviews of competency assessment, both from a CanMEDS and an ACGME perspective, are available to consult (38, 39). In our own program, we have emphasized the use of a mock oral examination with a real patient interview in order to assess general cultural competence skills. The advantage of this approach is that it provides immediate feedback to the resident learner and can be used to confirm the resident’s knowledge and reasoning in greater depth (38). Other educators have suggested using an Objective Structured Clinical Examination to assess cultural competence (40). We have not adopted the Objective Structured Clinical Examination because, although reliable, it is too checklist-driven and does not adequately capture the increasing expertise of a resident compared to a medical student (41). We are also in the process of developing and implementing 360° evaluations and psychotherapy portfolios as described above to provide our residents with a richer source of formative feedback in the future.