The importance of culture in medical education and training has received greatly increased attention in the last several years due to influential national reports highlighting health disparities based on ethnic and cultural origin and the improvements that are needed in training health professionals in cultural sensitivity (1, 2). A recent large national survey of several thousand resident physicians in seven medical specialties at U.S. academic health centers found that a large proportion of residents reported receiving little or no cross-cultural training in key areas beyond what they learned in medical school and approximately half reported receiving little training in understanding how to address patients from different cultures (3). Many residents also identified a gap between cultural preparedness in the general sense and preparedness to manage specific clinical situations; adequate mentorship from faculty skilled in cross-cultural care was also identified as a common deficiency. For psychiatric training programs there is significant variability in the content and structure of cross-cultural training (4). But specific cultural knowledge and clinical experience are not the only variables that determine optimal cultural competence in clinical care; another frequently neglected component of cultural training is the need for residents to become conscious of their own cultural identity and how it influences their practice (5, 6).
In this article we will describe how our cross-cultural training program at the Oregon Health and Science University (OHSU) Department of Psychiatry has addressed core elements of education and training in cultural psychiatry over the past three decades. The curriculum includes both didactic sessions and varied clinical experiences for students, residents, and forensic psychiatry fellows under the supervision of experienced academic faculty, although we will focus primarily on cross-cultural training for general psychiatry residents. We will describe the clinical settings and the core knowledge, skills, and attitudes that trainees achieve during their experiences.
Designing curricula for medical students, residents, and fellows in cross-cultural psychiatry requires the simultaneous consideration of both the wide breadth of theoretical and clinical material in psychiatry and medical anthropology and the pragmatic daily needs of trainees in confronting clinical challenges. They spend their days and nights on call in busy clinical settings and they routinely request that a firm clinical grounding is given to anything they are taught. In most general curricula, however, the time for cross-cultural material is often limited and sandwiched among other worthy topics.
One of the primary goals of cross-cultural instruction is to introduce and reinforce the idea that culture should be an integral part of every patient assessment (7). The concept of culture does not have to be viewed as exotic or related just to ethnic minorities, but as a broad concept which includes family acculturation and values (8), religious beliefs (9), and attitudes and beliefs about health and illness (10). An important consideration is the doctor-patient relationship and patterns of communication between healer and patient (11, 12). Even though this is almost always covered in general interview courses during medical school and residency training, an opportunity exists for this to be considered in even more depth during mentored cross-cultural clinical experiences because of the subtle nuances of communication that exist when the doctor and patient come from different cultural backgrounds or speak different languages. Communication is further complicated when there is an interpreter present (13).
The introduction of social science concepts from the fields of sociology and anthropology are important parts of a cross-cultural curriculum. Specific topics that can be considered are the broad impact of social factors upon illness (social networks, migration), ritual and religion, somatization, the study of family and social roles and their impact on health and illness, and professional socialization.
Topics related to culture and healing are also central. Discussions should consider the fact that cultural definitions of health and illness vary greatly and that these definitions significantly affect how and where health care is sought, various treatment approaches, and adherence to those treatments (14–17). All of these topics can then be reinforced in actual clinical settings when trainees observe and treat specific patients and families from a variety of cultures.
Certain sessions during a didactic seminar series can be devoted to specific ethnic groups most frequently encountered within that geographical area. Trainees want specific hints or instructions on how to deal with pragmatic day-to-day clinical concerns (e.g., emergency assessment or the appropriate affective tone cross-culturally in order to minimize patient anxiety and maximize compliance), but attention should also be paid to specific illness beliefs, religious beliefs and rituals, family structure, gender roles, and social values. Other specialized topics considered are cross-cultural medical and psychiatric epidemiology, cultural aspects of forensic psychiatry (18, 19), and the role of culture in child psychiatry.
Discussions of the relevance of culture in child and family psychiatry are particularly important because, in most cultures, the family serves as the core unit of socialization, beliefs, and values. For many immigrant or refugee groups, these values often change throughout the process of acculturation. The evolution of cultural values regarding sex roles and parent/child relationships can place great strain on family relationships, as each family member may acculturate at a different rate.
Resident course evaluations have indicated that although they appreciate academic and research-oriented information, they put a premium on specific, step-by-step information on how to diagnose and treat patients from diverse ethnic backgrounds. Cross-cultural knowledge and pragmatic clinical skills can definitely be taught and applied (20–23). Table 1
summarizes the cross-cultural knowledge, skills, and attitudes taught at the OHSU.
Culture in Community Psychiatry Training
Attention to cultural issues is an essential part of community psychiatry and residents receive their initial formal exposure to cultural psychiatry in their third year community psychiatry core rotation at OHSU. In those clinical rotations, residents spend 2 days/week for 6 months in a community mental health center somewhere in Oregon. These rotations range in geographical and ethnic diversity from the largely white rural communities of the Oregon Coast to the wider ranging ethnicity of inner NE Portland to the Warm Springs Indian Reservation in the plateau region of Central Oregon. Not only are psychiatry and psychiatrists viewed differently in all these regions, but the diverse cultural and socioeconomic makeup of patients and clinical staff cause residents to reevaluate their identity and role as a psychiatrist and also their beliefs about psychiatric illness.
Community psychiatry is based on the assumption that sociocultural conditions in one’s family and community significantly influence the definitions, manifestations, and course of mental illness. Training in community psychiatry brings home to trainees the role of the social environment in mental health and illness. At OHSU, numerous faculty members who have special training and experience in cultural psychiatry work in diverse roles in community settings, including urban community health centers, rural county clinics, state hospitals, and the Intercultural Psychiatric Program. All of these clinical settings have provided a rich training ground for residents over the years (24, 25). We emphasize in training that the community psychiatrist has an important educative role in working with nonpsychiatric physicians in academic and community settings and with allied medical and mental health personnel in settings ranging from hospital emergency rooms to university student health services. Residents are supervised by psychiatry faculty at their specific community site and also receive weekly supervision from community psychiatry faculty at the main OHSU campus in order to discuss their clinical work and their consultant relationship with staff at the community site. Supervision of the resident’s consultant experience is based upon Caplan’s classic work in mental health consultation (26).
In providing cross-cultural community-based training experiences for residents, we encourage them to recognize a number of important processes and dynamics in their work:
1. Getting to know the environment of the center is similar to general clinical settings, but it frequently takes longer.
2. Not only will the staff at the center be wary of the trainee as a new consultant, but those cautions will be heightened because of possible cultural differences between the trainee consultant and the clinic staff.
3. The consultant’s personality vis-a-vis the “culture” of the center is an important variable. Potential value conflicts include the relative importance placed on work pace, schedules, punctuality, boundaries, and confidentiality.
4. The way cases are presented to the consultant can be influenced by the personal experiences of the consultee and subtle bias based on the consultee’s own perspectives of his or her own culture or what he or she expects the consultant wants to hear.
5. Because the trainee consultant is an outsider, he or she is more likely to be asked by patients to be a primary therapist rather than a consultant. This is especially true in a rural area. Also, the consultant may be asked by the center’s clinicians to be their own therapist, again because he or she is an outsider. One must be careful to maintain a consultant role.
6. In cross-cultural settings, it is important not to attribute symptoms or behavior necessarily to culture, but to first do a thorough psychiatric evaluation, with culture as a backdrop.
7. In cross-cultural community settings, it can be very helpful to gain experience conducting home visits. The trainee can see the environments that patients and families inhabit and this can provide important insights for designing optimal clinical care.
8. It is important to emphasize to the trainee that the consultant is a potential educator to staff and patients and can provide in-service training and informal teaching.
The Core of Cross-Cultural Training at OHSU: The Intercultural Psychiatric Program
Although residents and students learn general cultural concepts during their community psychiatry rotations, it is during third- and fourth-year elective rotations in the Intercultural Psychiatric Program, founded in 1977, that residents and students learn more advanced concepts and skills in cross-cultural assessment and treatment. We emphasize skill acquisition geared to the trainee’s level of experience ranging along a continuum from student to resident to fellow. Observation of the clinical work of experienced faculty is a key aspect of the education process for all trainees, with gradual acquisition of more clinical responsibility as residents and fellows gain more experience.
Brief Description of the Program
The Intercultural Psychiatric Program currently treats about 1,200 refugee and immigrant patients from 18 language groups. Most have low incomes and many are indigent. The conditions and disorders affecting about 80% of our refugee patients, particularly posttraumatic stress disorder and depression, are directly attributable to the events that caused them to flee their home countries.
For the majority of the ethnic or language groups we treat, ours is the only program in Oregon capable of providing culturally appropriate psychiatric care. Consequently, our program is the designated provider for county- and state-funded mental health services for members of several of these language groups. The Intercultural Psychiatric Program’s range of services include comprehensive psychiatric evaluation and treatment of adults and children, individual and group psychotherapy, socialization group therapy, case management, vocational rehabilitation, treatment of physical illness, and assistance with asylum. As part of the OHSU Hospital, emergency and inpatient services are readily available on the same campus.
The scale of our clinics and the diversity of our patient groups provide broad experience to psychiatric residents, allied mental health professionals, medical students, and fellows. During the past 30 years, our program has helped train 32 psychiatric residents and 35 allied mental health professionals. In addition to these residents and allied mental health workers, one or two medical students rotate through the program every 5 weeks. Several years ago we also funded a Fellow in Traumatic Stress. This year we are hosting our second forensic psychiatry fellows, who rotate in the Intercultural Psychiatric Program to learn immigration and asylum law and conduct asylum evaluations, as part of their core fellowship experience. We have published extensively on the subjects of posttraumatic stress disorder, cross-cultural psychiatry, and related topics (27–40).
Exposure of Trainees to Interstaff Professional Collaboration and to Community Liaison
The program provides an opportunity for psychiatric residents to work extensively with members of a variety of ethnic groups in a community mental health setting. This educational initiative began many years before national initiatives for cultural competence in education and health care services.
Residents, supervised by the program director, are paired with an experienced ethnic mental health worker. These two-person teams conduct weekly clinics for members of a particular ethnic or language group. Of our two combined current residents, for example, one treats about 80 Vietnamese patients and the other carries a similar caseload of Mien patients. As a result of these weekly clinics, residents become quite familiar with members of a specific ethnic group. Residents also have on-call and covering duties that expose them to a variety of other ethnic groups. Many continue to treat ethnic minority patients after their training and some are now national leaders in cross-cultural psychiatry. We also have had child psychiatry fellows rotate through the program, seeing children and families from a number of ethnic groups.
Another innovative aspect of our program that has training benefits is our collaboration with community partners. We have developed working relationships with two agencies, the Asian Health and Services Center in Portland and Amigos de los Sobrevivientes in Eugene, Oregon, in which Intercultural Psychiatric Program psychiatrists and counselors treat members of the Chinese and Hispanic communities, respectively, at off-site locations. This has exposed trainees to yet another level of community practice.
Lastly, we have developed our own off-site Intercultural Socialization Center, where we provide reintegration assistance to patients as they attempt to find jobs and function within the broader society. This environment exposes residents and students to yet another portion of the mental health service continuum.
For psychiatric residents and students, all program sites provide exposure to clinically appropriate ways to treat patients from diverse cultural backgrounds. Because so many of our patients came to the United States as refugees, trainees receive extensive exposure to disorders often associated with people who have had to flee their home countries. These include posttraumatic stress disorder (PTSD) and depression. Trainees often have regular contact with refugees who have chronic PTSD, such as Cambodians, as well as contact with people whose trauma is more recent, such as Somalis or Bosnians. This clinical experience also allows students and residents to be more sensitive to cultural, ethnic, religious, and family dynamics among all patients and reinforces for them the importance of both lifelong professional education and the integration of clinical research with direct clinical care.
The residents rotating through the Intercultural Psychiatric Program most commonly are assigned a half-day clinic and a 60–80 patient caseload for an entire year. For about 10 of the last 30 years, however, we have had two residents each rotating for 6 months at a time. Most commonly, the resident works with the Mien (an ethnic group from highland Laos) patients and the counselor. The resident is the primary clinician for that group of patients, conducting evaluations and follow-up treatment for Mien individuals and families. Over the years we occasionally have had a Vietnamese resident who staffs a Vietnamese clinic during a 1-year rotation.
The resident meets weekly with the Intercultural Psychiatric Program director (PKL) for supervision. Supervision focuses not only on patient care management, but also on cultural issues specific to the Mien and on general issues in cross-cultural psychiatry. The most commonly asked questions by residents and the most frequent challenges they discuss include:
1. Diagnostic and treatment issues cross-culturally (for example, varied ways that mood disorders or PTSD can present in the clinical setting)
2. How to effectively treat chronic patients
3. How to integrate Western cosmopolitan medicine with acceptance of patients’ use of herbal and alternative healing approaches
4. Family dynamics (acculturation and changes in marital roles, raising children in the United States, relationships with family remaining in Southeast Asia)
5. The impact of historical events and trauma on mental health and current functioning
6. Community mental health systems and health policy affecting immigrants and refugees
7. Interactions and collaborative treatment relationships with multicultural program professionals
8. Rapid pace of treatment in the Intercultural Psychiatric Program
9. How to balance knowledge and skills learned in general psychiatry training with specialized knowledge and clinical skills required in the Intercultural Psychiatric Program
10. Countertransference feelings inherent in working with patients and families who have experienced trauma.
Supervision has also included discussion and integration of other unique resident experiences, such as attending weddings and funerals in the ethnic community and Intercultural Psychiatric Program-supported travel to cultural psychiatry meetings in the United States and overseas.
Evaluation is based primarily on verbal and written feedback from, and ongoing supervision with, each year’s residents. Residents also regularly evaluate the cross-cultural seminar series, which influences the design of the series in future years. Over time the most prominent change in the cross-cultural seminar series in response to resident evaluations has been the inclusion of sessions that focus on diagnosis and treatment of specific cultural groups that the residents are most likely to encounter in their general psychiatry clinical rotations. This has been very well received by residents and the global evaluations of the entire didactic series over the past 10 years, on a scale ranging from poor to excellent, have been overwhelmingly good or excellent, whereas before these changes the evaluations were fair or good.
In the clinical Intercultural Psychiatric Program rotations, on an evaluation scale of poor to outstanding, residents have rated their experiences as good to outstanding, with the majority being outstanding. Individual items that the residents most commonly highlight include the amount of supervision and support, the smooth running of the rotation, satisfaction with resident role and responsibilities in patient care, attitude and performance of nonmedical clinic personnel, and overall learning value of the experience.
Looking at this training experience from a longitudinal perspective over several decades, we feel that the continuing commitment of graduated residents both to minority communities and to community mental health programs illustrates the positive educational and clinical experiences our residents have had in the Intercultural Program. Of the 32 residents who have rotated through the Intercultural Psychiatric Program over the years, four have worked in the program as faculty from 2-20 years, and one (PKL) is the current director. Six residents worked in the program for 1-10 years following their training and fourteen others went on to focus their careers in community psychiatry, working in state hospitals and community mental health centers throughout Oregon, in the Indian Health Service, and in New Zealand. Several graduates have also held leadership positions nationally in cross-cultural and community psychiatry organizations during their academic careers.
Providing cross-cultural psychiatric training is an essential foundation for the education of the next generation of clinicians and health care leaders. Because of the rapid demographic changes in the U.S. population, education in cultural aspects of health care is no longer optional, but instead is a core aspect of clinical education and training. Although didactic seminar series and clinical supervision certainly can be centered on the specific cultural and ethnic groups that trainees will encounter, it is also important to center training on core knowledge, skills, and attitudes in cultural psychiatry that the trainee will carry to any work setting or geographical area. At Oregon, we have developed and sustained a cross-cultural training program over several decades that meets those goals and expectations. This training is centered on experiential knowledge and skills attained from direct work with patients and supervision from faculty psychiatrists whose careers have centered on cross-cultural clinical work and research.
Our program’s success can be seen by the number of residents continuing to work at the Intercultural Psychiatric Program and in community cross-cultural settings. While this is not the only outcome measure that can be used, it is certainly an indication that the faculty provide effective role modeling and the Intercultural Psychiatric Program’s academic productivity further reinforces for residents that positive job satisfaction can occur by combining patient care and research in a busy clinical setting. Of course, residents who choose to work in the Intercultural Psychiatric Program or in other community cross-cultural settings may be a self-selected group who have a particular interest in working in those settings; this is often the case in many elective clinical rotations during residency training. However, we have been able to reinforce, not discourage, this interest among trainees, in contrast to what sometimes occurs in chaotic and overwhelming public mental health training settings. Overall, we believe it is vitally important to provide for residents an important foundation of cultural knowledge and clinical experience. Yet, even more so, we want to encourage independent learning and a lifelong desire to serve diverse, and frequently underserved, populations with skill and compassion.