The mandate for cultural competence in academic centers is rooted in the civil rights movement of the early sixties and stems from the desire to interpret the Declaration of Independence to extend basic rights to all citizens. More immediately at hand, the diversity in the population of the United States is increasing at a nearly exponential rate; from 1980 to 2000, the number of Asians in the United States increased by 240%, Hispanics by 125%, American Indians by 45% and African Americans by 14%, while the number of Caucasians increased only by 7% (1). The gap between the ethnic make-up of the U.S. population and physicians/medical students, reflected by data from the American Association of Medical Colleges (AAMC) (2), underscores the necessity for clinicians and researchers to understand how cultural differences affect diagnosis and treatment (Table 1
There is a burgeoning literature supporting the incorporation of cultural competence and diversity initiatives in mental health services and academic training, yet there are only a few articles in the medical journals to date that describe the development of a comprehensive diversity program. There have been examples of one-time interventions, such as a cultural awareness workshop at the University of Michigan (3), short-term postgraduate year 5 (PGY-5) fellowships, such as seen at UCLA in the late 80’s (4), a cultural curriculum in a forensics fellowship at the University of Wisconsin (5), and a 4-year curriculum at Baylor that evolved to encompass religion and spirituality (6). Of all of these models, the Baylor curriculum is the closest to ours, but is not as comprehensive as it lacks a medical student, community, or faculty component, and the article does not give a detailed explanation of how to sustain the initiative through administrative infrastructure, support, and funding. One similarity is that the Baylor program has continued APA Minority Fellowship participation (Lomax JW: personal communication, 2006).
The supplement to the Surgeon General’s Report on Mental Health, entitled “Mental Health: Culture, Race, and Ethnicity,” states that for African Americans, Asian Americans, Latino Americans, and Native Americans, “culture counts.” The report goes on to conclude that all four groups could benefit from tailoring mental health services to their specific needs, which would in turn increase access to services (7). The Institute of Medicine’s report, “Unequal Treatment,” (8) indicates that ethnic minority patients have less access to services and receive a lower quality of medical and psychiatric treatment, even when controlling for socioeconomic status. Not to be left out of the consideration of diversity is the need to address gender, sexual orientation, and spirituality issues. In other words, to be culturally competent all aspects of cultural identity formation must be considered (9). The U.S. Health and Human Services’ National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care (10), the California Endowment’s three reports on principles and recommended standards (11), resources (12), and a manager’s guide to cultural competence (13), and the Commonwealth Report (14) all suggest ways to train mental health professionals and design services that are appropriate for underrepresented patients. Finally, the Institute of Medicine’s report, “In the Nation’s Compelling Interest: Ensuring Diversity in the Health Care Workforce” (15), states that diversity of providers is a crucial element in providing quality health care for all Americans. Medical education is not ignoring the challenge: the AAMC (16), along with the Accreditation Council of Graduate Medical Education (ACGME) (17), and the residency review committee all mandate that cultural competence be included in medical school and psychiatric residency curriculum.
Initial steps in achieving these objectives include the recruitment and retention of ethnic minority faculty members, especially those who are interested in teaching all aspects of cultural competence, as well as encouraging nonminority faculty to embrace cultural competence through diversity training and personal exploration. The ethnic minority faculty members serve as role models and mentors for ethnic minority medical students who may then be more likely to be inspired to pursue a career in psychiatry. Further mentoring by ethnic minority supervisors could encourage ethnic minority psychiatry residents to become academic faculty and continue the training of the next generation of psychiatrists. There have been many articles documenting the importance of mentoring for the success of minority faculty (18–23). As mentioned previously in Table 1, data collected by the AAMC suggests that while academic departments of psychiatry have made some progress in having their faculty’s ethnic composition match that of community providers and patients, there is still a large disparity (2).
Beginnings: A Brief History of the Diversity Advisory Committee
The UC Davis Department of Psychiatry and Behavioral Sciences (heretofore referred to as the department) was established in 1969 and is a program that is dynamic and growing. Since 1995, the department has more than doubled in size from 25 faculty members to over 80 at the present time. Sacramento has also grown and diversified over the last 20 years; it was described as “America’s most integrated city” by Time magazine in 2002 (24). A diverse patient population made Sacramento a good candidate for a diversity initiative. The department has a historically close relationship with Sacramento County, placing mental health professionals in inpatient and outpatient settings throughout the county system. Currently, the Medical Director of the county is the departmental chair (REH). As the department and the county grew, it became increasingly apparent that more attention should be given to issues of diversity in order to address the needs of the patient population. In recognition of these diverse needs, the department recruited many psychiatrists and psychologists of minority/cultural backgrounds for core teaching roles and today ethnic minority faculty members represent a third of the total faculty. This is the second requirement for a diversity initiative: a broad foundation for the Diversity Advisory Committee (DAC)—a “critical mass” of interested parties. Without this “critical mass” little work can be done because the tasks of teaching and coordinating cultural psychiatry fall on one or two minority faculty. Likewise, the quality of the cultural education is diminished if the faculty does not include representatives from each of the four major federally recognized ethnic groups. Finally, the DAC has three important functions: it works together and brainstorms about ideas, provides support for its members, and represents the DAC in important committees of the department, such as the Training Executive Committee.
The DAC consists of faculty and trainees interested in diversity issues related to training, clinical services, and research who meet regularly to address these needs in the department. The first incarnation of the DAC came into being at the 1999 Psychiatry Department Faculty Strategic Retreat, where the absence of diversity issues in reports by the various departmental groups was noted. At that meeting, the department chair authorized the creation of a workgroup whose charge was to examine diversity issues in the department. This represents the third and final requirement for a successful diversity initiative: administrative support. Interested minority and nonminority faculty members were eager to join the workgroup, which met over the summer of 1999, and developed a document called “Recommendations for the Strategic Report and a Proposal for a Diversity Workgroup,” which was reviewed and approved by the Departmental Executive Committee (Table 2
). In response to the recommendations, the Diversity Advisory Workgroup was formed, and began to meet monthly in February 2000. In June 2000, the name of the workgroup was changed to the DAC to reflect the ongoing process of development and recognize its integration into the department administrative structure. The department chair also gave the DAC a yearly budget to invite nationally recognized experts in cultural psychiatry to come to UC Davis and present culturally oriented topics at Grand Rounds (Table 3
). These speakers raised the DAC’s profile in the department and academic community, enlarged the DAC’s network of collaborators, and facilitated our committee’s academic work with thoughtful consultations.
Paving the Way for a Diversity Committee
Before discussing other projects that the Diversity Advisory Committee has initiated, we will discuss some of the barriers to a diversity initiative, and how the DAC at UC Davis has overcome them. Because of the growing size of our department, our faculty has become spread out over the Sacramento area to approximately 22 different sites. Most of the minority faculty are relatively junior and thus are not well established in the formal infrastructure of the department. A new mentoring initiative led by our faculty development director partnered junior and senior faculty, but there was a need for a forum to discuss issues of cultural competence in training, services, and research, and the DAC fulfilled that need. In addition, the DAC also performs a support function—creating a safe environment for faculty and residents to explore similar values and interests, as well as giving them helpful advice about promotion and jobs after residency.
Funding is always a major barrier to new initiatives, but since most of the teaching done by the DAC is part of the core curriculum and the faculty members are the instructors, there are few costs involved. Our teaching faculty and committee chair receive credit in the faculty compensation plan for the time and energy spent on the DAC (25). In addition, funding from the department has been received to develop annual retreats, to invite consultants with national reputations for advice and grand rounds, and to support CME symposiums which help spread our mission to teach cultural psychiatry throughout the medical school and community. Funding for the CME symposiums were supplemented by unrestricted educational grants from pharmaceutical companies. The APA Minority Fellows support the DAC indirectly with their funds, as their academic projects can be funded through their stipends, and on two occasions those stipends have been used to offset CME symposium expenses. CME symposia can also provide another source of financial support for the committee. Finally, being a part of the departmental yearly budget ensures that diversity issues will always be a focus of the department.
Though resident participation is valued, the DAC initially did not include residents. The group recognized that residents’ schedules are hectic and unpredictable and it was thought that their inconsistent attendance would detract from the momentum needed to get the group off the ground. Once the group had developed an identity through regular attendance of core members, residents were invited to attend the meetings as their schedules allowed and now medical students are welcome as well.
Diversity topics can sometimes be divisive and can arouse powerful emotions. The group is run by consensus and mutual respect, creating an atmosphere where people feel comfortable sharing potentially controversial ideas and opinions. The group was large enough to need a director, so a chair was selected by committee vote to facilitate communication with the department and to organize the members. The chair capitalizes on the informal structure of our department by meeting briefly and frequently with the department chair, the residency-training director, and residency clerical administrators, either by e-mail or personal contact. The department chair also supports the DAC’s chair by giving him academic credit and financial support in the faculty compensation plan (25) for leading the group, which is critical because of the time commitment needed to sustain the group.
Products and Accomplishments
The Diversity Advisory Committee has been the recipient of many awards and honors. Three members of the DAC have been recognized for their community service to UC Davis by receiving the Chancellor’s Achievement Award in Diversity and Community in 2004, 2005, and 2006, and many other members have received recognition for teaching. The 4-year Religion and Spirituality curriculum won the Templeton Award in 2003. The DAC recently received the American College of Psychiatrists’ Award for Creativity in Psychiatric Education for 2007. We have also had the good fortune to be granted an endowed Professorship of Cultural Psychiatry, The Luke and Grace Kim Professor of Cultural Psychiatry, which was approved by the School of Medicine as of spring 2007.
Another important activity has been the recruitment of medical students, residents, and faculty. The DAC has been active in encouraging minority medical students to enter psychiatry, thus increasing the ethnic diversity of our own program as well as that of the medical specialty in general. The recruitment of medical students fosters the development of ideas for research and supports education in cultural psychiatry at the trainee level. In addition, recruiting psychiatry residents to become academic faculty and recruiting senior faculty to mentor our junior faculty is part of the continuing process toward developing diversity across the domains of research, teaching, and clinical services.
In order to stimulate academic discussions, the DAC started a journal club as well as a works-in-progress meeting to stimulate the production of publications and projects. The journal club has been an excellent stimulus for discussion of issues such as resident training in cultural psychiatry, mental health services utilization, and national policies. The DAC’s latest initiative is a monthly case conference using the DSM-IV-TR Outline for Cultural Formulation (26), which has been a stimulus for one published paper (27) and several manuscripts in preparation. In addition, these meetings have been vital in providing a forum for discussion and review of research projects and other scholarly work, as well as a venue for resident psychiatrists to see the benefits of a career in academic psychiatry. The mentorship relationships built during our meetings encourage residents to strongly consider a career in academic medicine because they are integrally involved in many of the educational and clinical influences of the DAC. Faculty members, in turn, have developed informal mentoring relationships with each other and, with the more junior members, learning valuable teaching and mentoring skills through their own mentoring process. For more formal relationships, the DAC uses the resources of the faculty development office, which pairs faculty in a department-recognized mentoring relationship with more structured goals and expectations for both parties.
The Diversity Advisory Committee has been quite active in developing new curricula for the residents by virtue of its role on the Training Executive Committee. Our residents’ exposure to cultural psychiatry has been increased over the years by creating a first-year course entitled Introduction to Cultural Psychiatry and then expanding the first-year course from one hour to five. Residents continue their exposure to diversity issues in their second year, with a 10-hour course that focuses on the DSM-IV-TR Outline for Cultural Formulation (26) as well as presentations on various ethnic groups and ethnopsychopharmacology. We also have a 6-hour course in the third year on psychotherapy and culture and, in the fourth year, we provide an average of 6 hours for the advanced course, where residents present a case using the Outline for Cultural Formulation to a cultural consultant. The committee has also supported the development of the 4-year Religion and Spirituality curriculum, which won the John Templeton Award for Spirituality and Medicine in 2003. The success of the committee in developing courses has led to the creation of a cultural track that is part of the curriculum’s organizing priniciples. The DAC is also involved in medical student education by giving lectures on how to use interpreters, cultural aspects of schizophrenia and psychopharmacology, and 2 hours of Case Interactives in the psychiatry clerkship, which involve a cultural identity exercise and uses cases to teach cultural issues in a small group format. In addition, all of the DAC faculty members incorporate principles of cultural competence in their supervision with residents. The vice chair of the DAC is a coprimary investigator of an AAMC grant to study the adoption of cultural competence principles in medical education, one of four schools in California to participate in this program that provides funding of $150,000 a year for three years. As part of the full spectrum of cross-cultural psychiatric education, the DAC plans to develop a postgraduate fellowship for psychiatry residency graduates seeking further training in cultural psychiatry. The DAC has also sponsored four annual CME symposia that were all well attended and well received (Table 4
The faculty development seminars that were held in 2004 were an exciting program enhancement. Five cultural psychiatry experts were invited to come to Sacramento to present half-day training, which was a repeat of training done at the University of California at San Francisco (UCSF) the day before. There were five plenary sessions, one on the DSM-IV-TR Outline for Cultural Formulation, another on ethnopsychopharmacology, and three case discussions (African American, Asian American, and Hispanic American) using the Outline for Cultural Formulation. Using this framework, 60–80 faculty and staff at UCSF and 15 at UC Davis were trained in one day in the use of the DSM-IV-TR Outline for Cultural Formulation and educated about specific considerations within ethnopsychopharmacology. The training was based on a course that the first author has run for 13 years at the APA Annual Meeting, which also led to the publication of the Clinical Manual of Cultural Psychiatry in 2006 (28).
The Diversity Advisory Committee has also promoted improvements in the delivery of care in clinical settings by supporting the development of a Cultural Consultation Service for Sacramento County. The service provides consultation for patients receiving care from the county’s mental health system whenever the lack of attention to culture has been identified as a possible barrier to care (29). The Cultural Consultation Service provides an ideal vehicle for the development of cultural case formulation presentations for meetings and publication. All Sacramento County-contracted mental health providers are able to request a consultation, which consists of an extensive interview or interviews with the patient, clinical team, and caregivers, if applicable. The consultant uses the DSM-IV-TR Outline for Cultural Formulation as a format in which to present a formulation and to inform the treatment team about possible ways to improve the care of the patient in a culturally informed manner (30). This clinical service was specifically cited by the dean in the school of medicine’s 2005 Outstanding Community Service Award from the American Association of Medical Colleges.
The DAC’s members have published articles about qualitative research involving the development of the Cultural Consultation Service (29), as well as the study of Hispanic elderly caregivers (31–32). A future project is the development of standardized patients for the training and evaluation of cultural competence skills in psychiatry residents. Our curricula is monitored and adjusted yearly and we plan to spend some time developing ways of helping trainees explore their cultural identities, as in previous programs (6). A more immediate goal is to encourage the development of research skills and encourage collaborations with other groups. A proposed partnership includes the department of psychology at UC Davis, which has faculty members that lead the Asian American Center on Disparities Research, formerly known as the National Research Center for Asian American Mental Health (NCRAAMH), or the National Center for Minority Health and Health Disparities (NCMHD). The challenge is to find projects that appeal to both collaborators and make the best use of combined resources: access to patients, special expertise in psychological measurements, or ethnography.
Residents as the Future of Cross-Cultural Psychiatry
To develop future leaders in cross-cultural psychiatry as well as to increase the number of minority physicians in leadership roles, the Diversity Advisory Committee began to nominate residents for the APA/Center for Mental Health Services (APA/CMHS) Minority Fellowship in 2001, now known as the APA/Substance Abuse and Mental Health Services Administration (APA/SAMHSA) Minority Fellowship, and the APA Minority/AstraZeneca Pharmaceuticals Fellowship. These efforts have been very successful with nine resident fellows in 8 years: seven APA/CMHS and APA/SAMHSA Minority Fellows from 2001–2008 each received between $10,000 and $42,000 for the development of cross-cultural education and research, and two APA/AstraZeneca Pharmaceuticals Minority Fellows for 2005–2008 received travel support to attend APA meetings. The fellowships not only increase the resources available for research and training, but also provide residents with an excellent introduction to APA governance and invaluable networking opportunities at APA Fall Components, Institute for Psychiatric Services, and APA Annual Meetings. Beyond the nomination process, the DAC members mentor the fellows in their research, education, and service interests and facilitate their activities in APA. One of our former fellows (SS) is now a member of the Volunteer Clinical Faculty, is a training site director, and is active in the residency-training program’s curriculum.
Arrendondo (33) suggests that a strategic plan is essential for the development of a successful cultural competence program, and this is the approach used by the Diversity Advisory Committee. The first step in planning was to build a consensus. The DAC was started with a framework of clinical services, education, and research to mirror the mission of the department of psychiatry. The group was broken up into smaller groups of persons interested in each area, and those groups developed needs analyses for each domain.
Another task was to analyze each group’s presentation at the retreat and suggest how they could address diversity. A statement of purpose was developed, along with short and long-term goals (Table 2
). Finally, the group agreed to meet on a regular basis to develop ideas for education, services, and research. Many group members have expressed that meeting regularly gave them a sense of belonging that they could not find in other places, as well as mentorship and faculty development. Although some of the DAC’s members have left the department, the vast majority have been with the department for at least four years. In addition, due to recruitment efforts there continues to be an influx of new minority faculty to maintain a critical mass. The DAC has been successful in creating an infrastructure for strategic planning with an annual retreat to set our goals for the next year.
Being a part of the department infrastructure has been an essential component to the early and impressive success of the diversity initiative. The DAC has representatives on the Training Executive Committee, the Departmental Executive Committee, the Grand Rounds Committee, the Psychiatric Academic Council, and the Resident Selection Committee. Because of these successes, the DAC has become a recruiting tool for our department to attract ethnic minority psychiatrists to join our faculty as well as to encourage ethnic minority medical students to join our residency-training program. At the medical school level, the DAC has two representatives on the dean’s Diversity Advisory Council, which was modeled after our own DAC.
The Diversity Advisory Committee has been a challenging and wonderful experience in administration and education in psychiatry, showing that a special interest group can be a powerful way to create organizational change in teaching, clinical services, research, and organizational culture. Several key elements for success were a critical mass of ethnic minority and mainstream faculty interested in diversity; a diverse patient population and service commitments to that population; financial and salary support from the department chair; an identified leader who can build consensus and coordinate people and activities; representation in the infrastructure of the department; a strategic plan, statement of purpose, and a list of ongoing objectives; a willingness to invest in the future by recruiting medical students and faculty to join our department and increase our ethnic representation; and an interest in networking with faculty from other institutions.
Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has” (34). We believe that the DAC is making a difference and encourage other departments of psychiatry to adapt this model to further the development of long-lasting diversity initiatives within their own institutions.