The Role of Diversity in the Training Of Health Professionals
University of Michigan
Never has higher education been so pressed to articulate, with both data and argument, the clear and compelling benefits of diversity. Social scientists and policy scholars have noted this need (Alger, 1998; Orfield, 1998; 1999), observing that after Bakke, “affirmative action was hanging by a thread” and instead of providing solid evidence about the benefits of diversity, academic researchers gave greatest attention to “examining the problems that minority students were experiencing on campuses that were racially diverse.” Because the benefits of diversity appeared obvious, higher education—and for the most part health professions education—was focused on recruitment, retention, and a full range of ways to encourage diversity (Orfield, 2001; Orfield & Whitla, 2001; Cavazos, 2001; Ready, 2001).
With the most recent challenges to affirmative action, a substantial amount of compelling evidence has emerged that demonstrates the benefits of diversity in education.3 These data articulate the important role of diversity in undergraduate
Dr. Tedesco is Vice President and Secretary of the University and Professor of Dentistry, at the University of Michigan.
Deep appreciation and recognition for assistance and support are given to the following Michigan colleagues: Dr. Patricia O’Connor, Associate Professor Emerita, School of Dentistry; Brenda Henry, doctoral student and researcher, School of Public Health, Patricia F.Anderson, Senior Associate Librarian; and Dr. Sherman James, Professor, School of Public Health.
See, for example, the expert testimony of leading scholars on behalf of the University of Michigan, in The Compelling Need for Diversity in Higher Education, available through the Office of the Vice President and General Counsel, University of Michigan, 503 Thompson Street, Ann Arbor, MI, 48109–1340, or online, http://www.umich.edu/~urel/admissions/.
education. While studies on the benefits of diversity in the training of health professionals do not exist on the same parallel, there is a substantial literature to guide our understanding of the benefits of diversity in the health professions.
This paper discusses the educational and civic outcomes of diversity for all students, and how these outcomes are related to students in the health professions. From literature that represents a number of different disciplines, I discuss what we expect to accrue from diversity in the health professions and from cultural competence, and the interdisciplinary connections that will advance teaching, clinical practice, and research. Finally, I provide recommendations for future directions that can be taken collaboratively across our academic health center disciplines.
EDUCATIONAL AND CIVIC OUTCOMES FROM DIVERSITY
In the last five years, a number of primary and secondary studies have emerged that provide comprehensive analyses on the benefits of diversity in undergraduate education. These benefits span a range of positive outcomes that not only contribute to a graduate’s success in life, but also to society’s well-being by contributing to forces that create social capital. The sections below summarize the work of Bowen and Bok reported in the Shape of the River (1998), as well as the work of Gurin (1999), Light (2001), the Astin group (Astin, 1993a; 1993b; Sax & Astin, 1998) and Orfield and others in legal education (Chambers, Lempert, & Adams, 1999; Syverud, 1999; Orfield & Kurlaender, 2001; Orfield & Whitla, 2001).
Bowen and Bok. The findings in the Shape of the River come from a large database constructed between 1994 and 1997 by the Mellon Foundation in cooperation with 28 selective colleges and universities. The outcomes discussed here represent approximately 30,000 graduates in 1976 and 1989, from the larger database. In short, the abilities and performance of minority students admitted to selective colleges and universities where race was important to the creation of a diverse student body have been outstanding.
Minority students have graduated in large numbers. In the 1989 cohort overall the graduation rate for black matriculants was 75%, while the national benchmark for this period was 40%. The graduation rate for Whites during this period was 86%, with the national rate at 59%.
Choice of academic major, as an educational outcome, provides noteworthy information as well. In the 1989 cohort, Blacks and Whites majored in biology, chemistry, mathematics, and engineering to the same degree. In the social sciences, more black students than white students majored in psychology, political science, and sociology. While the science disciplines prepare students in areas that directly tie to our health professions curriculum, it can be argued that the social sciences enhance and shape orientations that lead to civic engagement and the building of community or social capital.
A look at the data on graduate and professional school study is an area of high relevance to the subject of this symposium. In general, the matriculants at the selective schools completed a range of advanced degrees at a higher percentage when compared with other graduates nationally. In the 1976 cohort, 56% of the Blacks and Whites from selective schools earned advanced degrees, while nationally these figures were 34% and 38%, respectively. The data also show that especially large fractions from the selective schools receive professional degrees (law, medicine, business)—40% of all black graduates and 37% of white graduates. The national figures are 8% and 12%, respectively. On closer analysis, Bowen and Bok reported that black graduates from the selective schools were slightly more likely than white graduates to earn degrees in law and medicine. And when compared with the general college population, black graduates were seven times more likely to gain degrees in law and five times more likely in medicine. These patterns were sustained in the 1989 cohort data. As for Ph.D. study, the 1976 data showed that Blacks were less likely to pursue and attain the doctorate than their white cohorts in the selective schools. By 1989, this gap had all but closed by a percentage point (8% of white graduates; 7% of black graduates).
Civic engagement and community service is particularly high among minorities from the selective schools, who undertake these opportunities in greater numbers than their white counterparts. Black men in particular, were especially likely to be involved with community, social service, youth, and educational activities. Bowen and Bok reported that one-third of the black men from the selective schools participated in community or neighborhood improvement groups, and about one-third participated in youth and religious organizations. About 25% were involved with K–12 activities. For each type of activity, black involvement was several percentage points higher than white involvement. Bowen and Bok went on to emphasize that in every type of community or volunteer activity in their study, the ratio of black male leaders to white male leaders is even higher than that of black to white male participants. When these data were examined for differences within advanced degree groups, black leadership exceeded white leadership across the board, with the largest differences in law, medicine, business, and at the doctoral degree level.
One final analysis from Shape of the River must be emphasized. Bowen and Bok examined what society would have lost if race-conscious admissions had not been used at the schools in their study. They used a methodology of “retrospectively rejecting” students to see what would happen if the schools had employed race-neutral approaches. Using the 1976 cohort of matriculants, they estimated that 700 students would have been rejected. More than 225 members of the groups of retrospectively rejected black matriculants went on to attain professional degrees or doctorates. Approximately 70 are physicians and 60 are lawyers. There are about 125 business executives in the group and well over 300 are reported to be leaders of civic activities. It is clear that denying our institu-
tions the benefit of this diversity would have been at great expense to individual development and social capital.
The Michigan Casebook-The Gurin Analyses. Another body of work from Gurin and her colleagues provides an additional focus on academic-intellectual benefits, as well as interpersonal group relations benefits. The studies summarized in this section are from the expert testimony provided by Gurin (1999) as part of the University of Michigan’s defense of race-conscious admissions.
Based in part on classical theory in adolescent development and the now classic findings on the importance of discontinuity and discrepancy for cognitive development, Gurin uses contemporary analyses to demonstrate understanding that there are multiple views of the world, and understanding what it means to have a different life experience than your own is essential to a complete education. Equally essential is learning again and again to test your assumptions about how people view the world, and that although sometimes you expect someone to think differently, in fact they may not. Thinking through your own perceptions, becoming reflective and capable of characterizing another view when it is not your own view, and engaging in effective problem solving and critical thinking are the important, valuable benefits from an education where diversity exists in the classroom. Briefly stated, Gurin’s research shows that students with diversity experiences during college become more active and thoughtful learners and are better prepared to participate in a heterogeneous society.
With existing survey data from three different investigations, Gurin examined the impact of student racial and ethnic diversity on educational outcomes. The work included a multi-institutional analysis from data supplied by the Cooperative Institutional Research Program (CIRP) of over 9,000 students entering 184 colleges and universities in 1985; the Michigan Student Study (MSS), an extensive study of the University of Michigan entering undergraduate class of 1994 (participants included 187 African American students and 1,134 white students); and another study of University of Michigan students from a class in the Intergroup Relations Community and Conflict Program (IRCCP) with a matched group of students as controls.4
Gurin studied diversity on three dimensions: structural diversity, classroom diversity, and interactional diversity. In a college or university, structural diversity is determined by the racial and ethnic composition of the student body. Because most students still come from fairly segregated high schools, a degree of diversity on this dimension provides an essential ingredient for creating a learning environment that includes difference and discrepancy.5 Classroom diversity refers to the incorporation of knowledge about diverse groups in the curriculum. Classroom content and research on diverse groups engages and encourages a wide range of discussion when coupled with structural diversity. The third dimension—informal interactional diversity—is represented by the opportunity students from diverse backgrounds have to interact in a variety of social settings.
Structural diversity serves as the foundation or starting point but cannot, in isolation from classroom and interactional diversity, ensure that a more complete academic and social experience will occur that will contribute to the student’s overall development. The core purpose of the work was to determine the effect of diversity on the following outcome measures: learning outcomes measured by growth in intellectual and academic skill; engagement in active thinking processes; growth in intellectual engagement and motivation; and democracy outcomes, such as the preparation of students for meaningful participation in a pluralistic society. It is important to note that a number of variables, including those represented by reports of behavior and attitudes, comprised the composite outcome measures defined as learning outcomes and democracy outcomes above.
Results showed strong evidence for the impact of diversity on learning outcomes across analyses. Students who had experienced the most diversity in classroom settings and in informal interactions with peers showed the greatest engagement in active thinking processes, growth in intellectual engagement, and motivation and growth in intellectual and academic skills. For democracy outcomes results strongly supported the value of experiencing diversity in classroom and informal interactions on engagement of various kinds of citizenship and engagement with people of other races or ethnicities. Students who had experienced more diversity were also more likely to acknowledge that group differences are compatible with the interests of the broader community. As was the case with learning outcomes, there was a striking consistency across studies and across a broad range of democracy outcomes that included both values and reported behavior.
In addition to the data reported across the three analyses above, it is important to note findings from the follow-up surveys of CIRP studies, administered five years after college. Attending a college high in structural diversity and being white was positively associated with reports of diversity among current
friends, neighbors, and co-workers. Informal interaction diversity, including participation in racial/cultural awareness workshops, discussion of racial ethnic issues and interracial socializing, and having diverse close friends in college were especially influential in accounting for later patterns of social and worklife integration. Enrollment in an ethnic studies course in college was also related to diversity among friends and neighbors five years after college.
Similarly, effects of diversity observed at the time of graduation were sustained over a five-year period for both learning outcomes and diversity outcomes. Students who had experienced the greatest classroom diversity and informal instructional diversity during college continued to show the strongest academic motivation and growth in learning. They also placed the greatest value on intellectual and academic skills as part of their post-college lives and believed they were most prepared for graduate school.
For white graduates, both classroom diversity and informal interaction diversity in college were positively associated with having discussed racial/ethnic issues and having socialized with someone of another racial/ethnic group. Informal interaction diversity was associated with feeling that their undergraduate education prepared them for their current job. Students of color reported that interaction with diverse peers during college was also related to interaction with people from diverse backgrounds. Overall, the results of the post-college study show that the positive impact of racial and ethnic diversity experienced in college has lasting—rather than ephemeral—influence. As Gurin observed, the analyses confirm that the “long term pattern of racial separation noted by many social scientists can be broken by diversity experiences in higher education” (1999, p. 101).
Astin. Other in-depth analyses by Astin and his colleagues (Astin, 1993a; 1993b; Sax & Astin, 1998) provide findings related to those described above and support academic and civic benefits from diversity gained by white and black students alike. Interestingly, positive changes in areas related to cultural awareness, such as, “promoting racial understanding” and “influencing social values,” were associated with academic concentrations in the social sciences and humanities more so than in the basic sciences, engineering, nursing, or business. All of these outcomes are more prevalent on campuses that have a higher degree of institutional commitment to diversity, faculty whose teaching and research reflect diversity and multiculturalism, and student diversity experiences, such as taking courses in race and ethnicity.
Light. In a recently released publication, entitled Making the Most of College, Students Speak Their Minds, Richard Light (2001) described the results of carefully designed qualitative studies that included interviews of more than 400 Harvard students about contemporary college experiences. The data include some emphasis on the impact of racial and ethnic diversity. Among a number of findings, students from public high school experiences reported that diversity before coming to college was negative and disappointing, in that efforts were
not made to build a sense of community or shared culture. From classroom experiences in small groups to a range of social experiences outside the classroom, white students reported that their Harvard classmates who were racially and ethnically different had taught them things that they would not have learned or otherwise thought about.
Orfield, Kurlaender, and Associates. Adding to these studies is a very recent volume edited by Orfield and Kurlaender (2001). In Diversity Challenged: Evidence on the Impact of Affirmative Action, a number of authors add to the growing body of evidence about the positive impact of increasing diversity in student enrollment in higher education. From policy analyses and social science and educational data, a number of similar positive outcomes are addressed, including broadened educational experience, democracy outcomes, and enhanced preparation for graduate study in the professions. A range of findings are discussed in this volume and include the fact that greater social interaction is promoted by diversity, and that with inter-racial socialization there is more discussion of controversial issues, higher retention in college, and increased satisfaction with the college experience (Chang, 2001). Other findings are that with increased diversity, faculty tend to use a greater variety of teaching methods, including active learning (Milem, 2001), and that there are more and different opportunities for leadership, increased awareness of other cultures, and increased ability to work collaboratively (Hurtado, 2001). Orfield and associates assert that “the basic results of these studies are that diversity does make a difference, but that the differences are neither automatic or uniform (p. 7).” Campus leadership, mindful programming, adequate resources, and development opportunities for faculty are equally important.
Legal Education. Extending and echoing the findings in undergraduate education are recent data from legal education. In his expert testimony on behalf of the University of Michigan, Syverud (1999) explained how racial and ethnic heterogeneity in the classroom produces an examination of assumptions and frank discussion about the law that cannot be achieved in environments without such diversity. One example he provided is from his teaching in civil procedure, where students engage in role play for jury selection procedures. Syverud described students as shocked and enlightened when unexpected differences in assumptions about human nature, experience, and the law are analyzed in relation to jury composition.
In more formal analyses, conducted through Gallup Poll surveys at Michigan and Harvard law schools, in informal Internet studies at seven similarly competitive law schools, and in studies of graduates, equally positive results were found, supporting the educational and professional benefits of diversity (Chambers, Lempert, & Adams, 1999; Orfield & Whitla, 2001). For example, a great majority of students at Michigan and Harvard reported that conflicts related to racial differences challenged them to rethink their values, and well over half of these same students believed that conflict because of racial differences
ultimately produces positive learning experiences (Orfield & Whitla, 2001). The need for increased diversity among the faculty was also noted in these studies to further the educational benefits for all students, especially those coming from more homogeneous living and learning environments. Other studies of law graduates at Michigan (Chambers, Lempert, & Adams 1999) have shown that while all graduates, over a 27-year period, provided significant community service and pro bono work, minority graduates tended to average twice the number of hours of their white counterparts.
Amicus Briefs. A number of significant amicus briefs were filed on behalf of the University of Michigan in support of its defense for the use of race as one of several factors in the admissions process. To date, these briefs represent approximately 80 organizations, including higher education associations and academic societies, Fortune 500 corporations, and government and industry-related entities. They strongly support the University’s use of race in admissions. Citing case law, classical writings on democracy, empirical data from higher education, and business venue demographics, the briefs outlined in clear terms the necessity of diversity for a more complete education and for experiences that will foster a talented, successful workforce in an increasingly global marketplace.6
A Strengths Orientation. When taken together, there is a crucial underpinning in the new data and new argument on diversity in higher education. The discussions and discourse are framed from an orientation of strength rather than one of disadvantage and deficiency (Trickett et al., 1994). By understanding the benefits of diversity, our awareness necessarily moves away from a focus on remediation and disadvantage. Instead, cultural pluralism and cultural identity are positive elements that contribute to equally positive outcomes based on diversity in the classroom and curriculum. Diversity brings the benefit of intellectual and social growth, trust, and enriched cultural experience and understanding, with renewed meaning for a wide range of social and higher education policy (ACE/AAUP, 2000; Palmer, 2001).
Further, a strengths orientation is consistent with social science data, from multiple sources. Described most clearly by Gurin (2001a, 2001b), students who had the most experience with a diverse group of their peers, formally or informally, whether through classes, relationships, multicultural events, and intergroup dialogues, indicated a stronger sense of commonality with students not like them, racially or ethnically. Most importantly, Gurin stated, “the students with the greatest experience with diverse peers were more, not less, committed to understanding the points of view of other students (Gurin, 2001b, p. 2). These
These briefs are available through the University of Michigan, Office of the Vice President and General Counsel, or online at the addresses below.
educational outcomes can only be seen as strengths, compelling and of great benefit, in light of society’s increasing social and demographic diversity, and the essential skills for future health care providers, and professional commitment to high-quality care.
EDUCATIONAL AND CIVIC OUTCOMES FOR HEALTH PROFESSIONS STUDENTS
In the absence of parallel studies on the benefits of diversity for health professions students, what might all these findings suggest for health professions education? Assume for purposes of this discussion that there is a match for high level diversity experiences between the schools students come from as undergraduates and those they go to for health professions school, be it medicine, dentistry, nursing, or pharmacy.
Imagine how rich and lively the discussions would be in classrooms and in clinical seminars. It is also likely that these students would participate in community outreach projects, and design new opportunities to extend school-community partnerships. We might even expect the academic health center to have a vigorous HPPI (Health Professions Partnership Initiative) program with health professions students highly involved in tutoring and mentoring middle school and high school students interested in science and health careers. We might also expect these same students to engage in other forms of service learning that are health-related and community-based providing an enhanced educational experience (Seifer, 1998, 2001). And, through all these activities and orientations, we might expect these students to add a dimension of intellectual and social complexity to all those areas in the curriculum that require social analysis and clinical judgment.
The students we select for admission from undergraduate institutions with high degrees of structural diversity, classroom diversity, and interactional (informal) diversity will be those students who will provide enriched and appropriately complex approaches to patient-centered care and evidence-based practice. I would predict that these students would extend the reach of our schools into the community for preventive programs, health care, and youth services. And I would predict that it is these students who will be the best recruiters for future classes.
These examples are the ones that we would hope to capture through more formal study. Recall that in both the Gurin analyses and the Bowen and Bok studies, the effects of diversity in college carried over into later life. Civic engagement continued on in the lives of selective college graduates and attending a diverse college was associated with more diverse friends, neighbors, and work associates almost a decade after entering college.
Clearly, more questions than answers emerge when discussing the benefits of diversity in health professions education. What other benefits might we observe in our academic health centers and communities from students who fit the
educational and experiential profile described in the undergraduate studies? Even if the entering classes of students across health disciplines represented structural diversity at our institutions, would the attendant classroom (curricular) diversity and interactional (informal/social) diversity exist to benefit the maturing health care providers, their patients, and the community’s health? With incomplete or weak diversity along the dimensions studied in the work of Gurin and others, do health professions schools attenuate, or even squander, the investment made at the undergraduate level?
DIVERSITY, SOCIAL CAPITAL, AND TRUST
There is a substantial and poignant literature on health disparities and the positive contributions that are made by increasing diversity in the health professions (Nickens, 1992; Diez-Roux, 1998; Nickens & Ready, 1999; Yen & Syme, 1999; Berkman & Kawachi, 2000; Fiscella, et al., 2000; Stoddard, Back, & Brotherton, 2000; Carlisle, Tisnado, & Kington, 2001). Because of the relationship of health status with social, economic, and environmental influences, the construct of social capital adds to the discussion of benefits from diversity in ways that could enhance our understanding and thereby our teaching, clinical practice, and research when it comes to benefits from diversity in the health professions.
Social capital has been defined (Cohen & Prusak, 2001) as “the stock of active connections among people; the trust, mutual understanding, and shared values and behaviors that bind the members of …communities and make cooperative action possible.” Berkman and Kawatchi (2000) defined social capital as “those features of social structures—such as levels of interpersonal trust and norms of reciprocity and mutual aid—which act as resources for individuals and facilitate collective action.” James, Schulz, and van Olphen (2000) suggested that most agree that the construct “connotes mutual trust, a sense of reciprocal obligation, and civic participation aimed at benefiting the group or community as a whole.” A fair amount of work is emerging that connects social capital to the health of communities and those characteristics that can be used to describe successful public health interventions to improve the health of communities.
With each student we graduate from programs that have maximized diversity experiences, in either the classroom, in social interactions, or in the composition of our classes, we enhance and extend the democracy outcomes discussed earlier. Can these student outcomes then in turn contribute, over a longer term, to the creation of social capital? While a great deal of research remains to be done to understand social capital and its role in interventions to remove health disparities, it seems reasonable to also place the benefits of educational benefits of diversity somewhere in the explanatory mix. Does the undergraduate diversity experience create an orientation or a pattern that is strengthened and extended in medical school or dental school to contribute to the health of diverse communities, and to communities of the unserved and underserved? What are our schools doing to
capitalize on or to diminish this orientation? Should we extend or disrupt the arc of engagement that our undergraduates bring to our programs?
If diversity experiences can build social capital, then by definition diversity experiences are building trust. Building the trustworthiness of our health professions and institutions has great potential to increase the health and well-being of individuals and communities, thus extending the benefit of diversity in health professions. Low rates of patient satisfaction, regimen compliance, low rates of service utilization, and non-participation in clinical research have all been linked to medical mistrust (Gamble, 1993, 1997; Crawley, 2000; LaViest, Nickerson, & Bowie, 2000; Cohen & Prusak, 2001). Crawley (2000), writing on participation in clinical trials, urged us to resituate the issue of trust—from the individual who does not trust to the institution that has bred the mistrust. From the literature in organizational studies, we know that social trust and civic engagement are strongly correlated (Cohen & Prusak, 2001). Extending this notion then, we should expect that our students will bring with them readiness, sensitivities, and skills to help our institutions become more uniformly trustworthy.
In summary, the benefits of diversity in the undergraduate experience create an expectation of similar benefits that can and should extend to health professions education. From an accumulation of diversity experiences, including civic engagement and other democracy outcomes, our students would be expected to contribute to social capital and trustworthiness and to further the well being and health of individuals and communities.
ENHANCING CULTURAL COMPETENCE
Learning how to provide care and serve communities across a broad range of racial and ethnic diversity is a lifetime’s work. Beyond the traditional disciplines in anthropology, sociology, and psychology, an amazing wealth of information has emerged across all the health professions. Between the Internet and traditional print sources, the literature on cultural competence in health care is abundant (Leininger, 1995; Mason, Braker, & Williams-Murphy 1995; Talabere, 1996; AMA, 1999; Cohen & Goode, 1999; Nash, 1999; Salimbene, 1999; Goode et al., 2000; Goode & Harrisone, 2000). Interestingly, except for nursing and social work, this literature has matured only during this last decade.
I have repeatedly suggested that students are entering our programs with more and more diversity experiences. As they acquire the cultural rules and cultural identities of their chosen health profession, their earlier diversity experiences will no doubt influence their development in some way. In terms of access and use of health care, lack of cultural competence on the part of service providers has become a barrier to care. In particular, mental health services and child health services have documented (Satcher, 1999) the growing need for cultural competence in care delivery. Broadly, there is an acknowledged need to include cultural competence knowledge and skills in the regular and in the continuing
education curriculum for students as well as faculty to contribute to addressing health disparities. Through our own lack of crosscultural knowledge and skills, we can contribute to patient noncompliance, premature ends to treatment, poor followup, and non-optimal treatment outcomes. Increased attention is also being given to language needs in the clinical encounter as well as to linguistic competence (AMA, 1999; Goode et al., 2000).
Among the health professions there are a number of opportunities for gaining experience and the skills needed for cultural competence. Programs that place students in community-based primary or general care settings are increasingly important (Mullan, 1992; Zwiefler, 1998). From these settings and with supporting, curriculum students quickly learn about the connections that exist among cultural competency, public health, and primary care.
Definitions and Approaches. The American Medical Association has prepared an extraordinary resource, the Cultural Competence Compendium (AMA, 1999). This rather powerful volume calls on the reader to understand the special needs of patients along a number of dimensions—patients as women, men, children, seniors, African Americans, Hispanics, Asians, Whites, people with disabilities, and those facing chronic illnesses, end of life illnesses, and socioeconomic constraints (AMA, 1999, p. iii). The text provides resources, bibliographies, lists of agencies and professional societies, virtual resources, patient support and education materials, and information on practices complementary to traditional medicine. The nursing profession is acknowledged for having devoted a great deal of attention over many years to cultural competence, more than most other professions, and these resources can be readily used or adapted for teaching across health disciplines. The volume is designed to support the ultimate long-term goal of eliminating racial and ethnic disparities in health with competence representing an important milestone in reaching this goal.
The literature is vast, and there are any number of definitions and lists defining cultural competence. Communication skills, listening skills, and understanding stereotyping, power, dominance, social identity, and privilege, and familiarity with a number of cultures and histories are but a few of the characteristics described as aspects of cultural competence.
Interdisciplinary Necessities. Three concepts in clinical psychology suggested by Stanley Sue (1998) are particularly helpful in framing some basics to define cultural competency. In his approach to “uncovering the essence of cultural competency,” he promotes three critical ingredients: scientific mindedness, skills in dynamic sizing, and culture-specific expertise. By scientific mindedness he is referring to hypothesis-forming skills rather than coming to quick conclusions about the status of a patient who is culturally different from his or her health care provider. Scientific mindedness is accomplished by awareness and checking for the potential of cultural meaning attached to symptoms. For example, do other symptoms match? Are other individuals in the culture unfamiliar with the symptom? Can experts in the culture indicate that the symptom is un-
usual for that culture? Dynamic sizing, like the fluctuating cache in computers, is a concept that can be applied to cultural competence. This concept suggests that appropriate skills are needed in knowing when to generalize and to be inclusive, and when to individualize and to be exclusive, or “flexibly generalizing in a valid manner.” This skill defends against stereotyping on the one hand, and on the other hand, while not ignoring cultural group characteristics that may be helpful in understanding the patient or clients’ condition. It works to avoid stereotypes for individuals while appreciating the importance of culture. The third ingredient Sue describes is culture-specific expertise. This expertise requires helping professionals to have knowledge and understanding of their own worldviews, specific knowledge about cultural groups with which they work, possess an understanding of the social and political influences faced by culturally different groups, and have specific skills for interventions and therapeutic strategies needed when working with culturally different groups.
Social Epidemiology and Clinical Social Work. There are two disciplines crucial to providing a more complete education for our health professions students along the dimension of cultural competence—social epidemiology and clinical social work. Both disciplines represent distinct knowledge bases, providing a wide array of intellectual and behavioral skills that have been used by a number of researchers and teachers to define aspects of cultural competence.
Public health experts assert that the the driving question of “social epidemiology—how social conditions give rise to patterns of health and disease in individuals and populations—has been around since the dawn of public health” (Berkman & Kawachi, 2000). But with the maturing of work in physiology, social and preventive medicine, medical sociology, and health psychology, new and different connections have been made that have added to a rediscovery of social epidemiology. Berkman and Kawatchi listed a number of public health researchers, who from the late 1960s and 1970s through to the present “began to develop a distinct area of investigation centered on the health impact of social conditions, particularly cultural change, social status, and status inconsistency (for example, social class, race, power, and control), and life transitions” (Berkman & Kawachi, 2000, p. 4). A dizzying collaboration of areas comes into play with emphasis on a number of social phenomena such as social class, social networks and support, discrimination, racial and ethnic bias, work demands, and control and disease. From health psychology and the companion disciplines, behaviors are no longer viewed as exclusively within the realm of individual choice. Instead, choices are understood as occurring in a social context that constrains or enhances health-protective behavior. And because of the everbroadening diversity in the “social context,” the discipline of social epidemiology must be at the center for preparing the culturally competent health professional. Research and teaching in social epidemiology is necessarily collaborative and interdisciplinary, offering yet another opportunity for diversity, both intellectual and academic, to emerge.
Clinical social work, as a discipline, endeavors to define cultural competence in a similar way. From the varying literature on cultural competence, there seems to be none as coherent and clear as that in clinical social work. Just as social epidemiology provides a framework for understanding health and illness in a social context, clinical social work provides a framework for clinical interactions that are sensitive to social conditions and context.
From adaptations of clinical social work practice, we know that health professions students can be exposed to a number of constructs critical to working with people in their social environments (Glover-Reed et al., 1997; Ewalt et al., 1999). Age, race, sexual orientation, ethnicity, gender, social class, and disability status define social groupings for the patient/client and for the practitioner. Throughout work in this discipline, special attention is paid to power imbalances and the influence they might have on treatment outcomes. Of critical importance is how difference and dominance come together in the clinical relationships. We are called on to recognize that each individual has a complex self-definition based on multiple social identities, and that reducing the patient or client’s identity to a singular dimension can influence the quality of the doctor-patient relationship and the effectiveness of treatment.
As mentioned earlier, a number of our students are coming to our programs with substantial diversity experience, and extending these experiences should be related to developing cultural competence as a health care provider. Students, through more formal instruction, observation, reflection, and practice must come to understand their new social role and the added dimension of “power” and “position” that inextricably comes as a part of their health care provider role. As critical consciousness develops and through careful reflection, students understand how we are advantaged and disadvantaged by aspects related to social identities. Learning how one can be privileged by location along one social identity dimension but disadvantaged because of another is essential for culturally competent interactions in the course of the patient/client and provider relationship. For example, there are status privileges to being a physician or dentist or pharmacist, but in certain social contexts, this status may be diminished by gender and race.
The language and constructs of clinical social work are complex, specific, and different, in part, from some of the other cultural competence literature. At the same time, the discipline has a coherent approach, developed over a 30-year period, to understanding and modeling cultural competence (Green, 1995). Part of what makes this discipline so appealing for greater adaptation in health professions education is the emphasis it places on race and ethnicity and power in relationships, social privilege, and the development of critical consciousness for cultural competence (Glover-Reed et al., 1977).
Critical consciousness creates the ability to undergo a process of continual self-reflection and examination of how an individual’s position in society and his or her viewpoint shapes and impacts how he or she engages with others and
views others. Through this examination, people are better able to understand their status in society and how their position influences how they treat and are treated by others. In many ways, critical consciousness skills extend and deepen understandings essential to the popularized approaches in patient-centered care (Laine & Davidoff, 1996).
Supporting Pedagogy. Clearly, social epidemiology and clinical social work provide strong content bases that would be useful in the design of a curriculum for cultural competence. Content- and discipline-based information in the curriculum is clearly necessary, but not sufficient. The curriculum must be presented within an appropriate pedagogy.
The importance of an appropriate pedagogy cannot be overstated. As described above, cultural competence is not simply about an individual’s ability to know behaviors and practices specific for a cultural or ethnic group. Instruction focused on teaching specific practices and behaviors will lead only to stereotyping of individuals and groups. Rather, cultural competence strives to develop and make mature an individual’s ability to be sympathetic and knowledgeable of differences that exist between practitioner and patient/client and to deal with such differences in culturally relevant ways (Glover-Reed, Newman, Suarez, & Lewis, 1997).
One of the more important elements contributing to the needed pedagogy links to the ideas and data presented by Gurin (1999), Light (2001), and others (Morey & Kitano, 1997; Hurtado, 2001; Orfield, 2001). An obvious and quite tangible element for pedagogy in support of cultural competence is the diversity of students in the classroom. Diverse classroom settings provide a unique contribution to learning, discussion, and understanding that is not necessarily attainable elsewhere. It is equally important to have an instructor who can facilitate the discussions, analyses, and examination of conflicting ideas that will necessarily arise, and to maximize interaction among learners. An interactive pedagogy will maximize exposure of all individuals to the full range of thinking, experience, and perspectives from the students’ lives.
Another teaching skill that enhances cultural competence is the instructor’s ability to foster critical thinking among students. Encompassed in this skill is the conscious uncovering of causes or relationships among differences that may be based on individual and group characteristics. For example, when speaking about African Americans in the United States having poorer health outcomes when compared with Whites, a discussion of factors that may have contributed to this disparity being observed must follow. Such critical examination allows individuals to see that there are underlying processes or causes for the observed circumstances. It is also important that each phenomenon observed is often influenced by a multitude of factors, often outside the control of the group or individual.
Pedagogy designed to develop critical thinking is an important tool. When used with discipline knowledge represented by social epidemiology and the other process skills from clinical social work, such as critical consciousness, a
more complex and more complete examination of data or background information for understanding health and illness would emerge. Coupled with the instructor’s ability to model skills for critical thinking and critical consciousness, students are better prepared to think about their own prejudices and position in society and their influence on how they view and interact with others (Glover-Reed et al., 1997).
There is a mature literature on pedagogy for critical thinking, and it emerges out of teaching approaches that encourage active learning (Astin, 1973; Hurtado, et al., 1999; 2001; Guitierrez & Alvarez, 2000; Milem, 2001). Active learning is characterized by teaching methods that minimize lecturing, with greater emphasis placed on cooperative learning, group projects, student critiques and evaluations of other students’ work, experiential learning, and reflection. Common to all these approaches are discussion and dialogue that are rich with complexity and difference.
TRANSFORMATION AND POTENTIAL: MODEST RECOMMENDATIONS
In Diversity Challenged, Gudeman (2001) cited the work of Martha Nussbaum (1977) on narrative imagination and its role in the cultivation of humanity. As one of the essential abilities of the citizen, narrative imagination is “the ability to think what it might be like to be in the shoes of a person different from oneself, to be an intelligent reader of that person’s story, and to understand the emotions and wishes and desires that someone so placed might have” (Gudeman, 2001, p. 252).
Within the context of the Nickens Symposium, this passage carries an urgency and poignancy for the benefits of diversity in health professions education. With the practitioner-patient relationship as a constant, Nussbaum’s statement is filled with implication and purpose. The modest recommendations below are related to the ideas presented in this paper.
Behavioral Sciences. It would be impossible to become a researcher in molecular genetics without rich exposure and understanding of a number of basic sciences, like biochemistry, for example. It is only reasonable then, to expect that effective clinical practice in areas of health care, cannot be achieved without a rich exposure and understanding of a number of social sciences. Working collaboratively across the behavioral science disciplines is essential to investing in the benefits of diversity and to providing high-quality care to a diverse population of patients.
There is extraordinary potential for new learning and new ways of teaching and working that resides in the experiences of our entering students. By creating classroom and clinical encounters that reflect the relevant content from public health, social work, and social sciences, and by including community outreach, an investment in the entering students’ diversity will have great and positive
impact for our institutions and for those people our institutions serve. What is crucial, though, is that the diversity represented among students and our faculty (viz., structural diversity) create the fundamental conditions for the diversity that must be mindfully planned in the curriculum and in clinical education teaching and learning contexts (Gurin, 1999, 2001a, 2001b). As such, these conditions lead to further benefit in terms of cultural competence, increased quality of patient care, and community well-being. National initiatives, through academic and clinical societies in the health professions and social sciences, would have the natural agency to design and disseminate materials for teaching both students and faculty.
External Standards, National Guidelines. While consensus on definitions for cultural competence may be a distant goal, a mindful dialogue on creating curriculum, supportive materials, and training for faculty must have higher priority and increased focus. For example, accreditation standards in social work and clinical psychology (APA, 1996; CSWE, 2001) can serve as a basis for revising and enhancing cultural competence in medicine, dentistry, and pharmacy. National guidelines, in a less formal format than accreditation standards, would be useful for institutions to draw on as they design programs for students and faculty. These guidelines for education programs could include best practices and facilitation through collaborations with behavioral scientists.
Benefits of Diversity Task Force. As the data emerge on the benefits of diversity in health professions education, it will be important to synthesize and disseminate the information widely. Where efforts are started on these studies, they should be continued; and in the places where efforts are needed, they should be programmatically defined and supported through start-up funding. This work should be designed to examine the broad range of benefits, shaped from the findings in undergraduate education, that extend to a number of areas particularly relevant to health care and community wellness.
American Council on Education and American Association of University Professors. (2000). Does diversity make a difference? Three research studies on diversity in college classrooms. Washington, DC: ACE/AAUP.
Alger, J.R. (1998). Unfinished homework for universities: Making the case for affirmative action. Journal of Urban and Contemporary Law, 54, 73–91.
American Medical Association, (1999). Cultural competence compendium. Chicago, IL: AMA.
American Psychological Association, (1996). Guidelines and principles for accreditation of programs in professional psychology. Committee on Accreditation. Washington, DC: APA. (see also, http://www.apa.org/ed/g&p.html).
Astin, A.W. (1993 a). What matters in college? Four critical years revisited. San Francisco, CA: Jossey-Bass Inc.
Astin, A.W. (1993b). Diversity and multiculturalism on the campus: How are students affected? Change, March/April, 44–49.
Berkman, L.F., & Kawachi, I. (2000). Social epidemiology. New York: Oxford University Press, Inc.
Bowen, W.G., & Bok, D. (1998). The shape of the river: Long-term consequences of considering race in college and university admissions. Princeton, NJ: Princeton University Press.
Carlisle, D., Tisnado, D., & Kington, R. (2001). Increasing racial and ethnic diversity among health professionals: An intervention to address health disparities. Symposium on Diversity in the Health Professions in Honor of Herbert W.Nickens, M.D. Washington, DC: National Academy of Sciences/Institute of Medicine and Association of American Medical Colleges (in press).
Cavazos, L.F. (2001). Strategies for enhancing the diversity of the oral health profession. Journal of Dental Education, 65, 269–272.
Chambers, D.L., Lempert, R.O., & Adams, T.K. (Summer, 1999). Doing well and doing good: The careers of minority and white graduates of the University of Michigan Law School, 1970–1996. Law Quadrangle Notes. Ann Arbor: University of Michigan Law School.
Chang, M.J. (2001). The positive educational effects of racial diversity on campus. In: G. Orfield & M.Kurlaender (Eds.). Diversity challenged: Evidence on the impact of affirmative action, pp. 175–186. Cambridge, MA: Harvard Education Publishing Group.
Cohen, D., & Prusak, L. (2001). In good company: How social capital makes organizations work. Boston: Harvard Business School Press.
Cohen, E., & Goode, T.D. (1999, Winter). Rationale for cultural competence in primary health care. Georgetown University Child Development Center-National Center for Cultural Competence, Policy Brief 1. Washington, DC: Georgetown University, (see also http://gucdc.georgetown.edu/nccc/.
Crawley, L.M. (2000, November). African American participation in clinical trials: Situating trust and trustworthiness. In For the health of the public: Ensuring the future of clinical research, 2, 17–21. Washington, DC: Association of American Medical Colleges Task Force on Clinical Research.
CSWE (2001). Educational policy and accreditation standards. Alexandria, VA: Council on Social Work Education.
Diez-Roux, A. (1998). Bringing context back into epidemiology: Variables and fallacies in multilevel analysis. American Journal of Public Health, 88, 216–222.
Ewalt, P.L., Freeman, E.M., Fortune, A.E., Poole, D.L., & Witkin, S.L. (1999). Multicultural issues in social work: Practice and research. Washington, DC: National Association of Social Workers, NASW Press.
Fiscella, K., Franks, P., Gold, M.R., & Clancy, C.M. (2000). Inequality in quality: Addressing socioeconomic, racial and ethnic disparities in health care. Journal of the American Medical Association, 283, 2579–2584.
Gamble, V.N. (1993). A legacy of distrust: African Americans and medical research. American Journal of Preventive Medicine, 9, 35–38.
Gamble, V.N. (1997). Under the shadow of Tuskegee: African Americans and health care. American Journal of Public Health, 87, 1773–1778.
Glover-Reed, B., Newman, P.A., Suarez, Z.E., & Lewis, E.A. (1997). Interpersonal practice beyond diversity and toward social justice: The importance of critical consciousness. In: C.D.Garvin & B.A.Seabury (Eds.). Interpersonal Practice in Social Work: Promoting competence and social justice. Needham Heights, MA: Allyn & Bacon.
Goode, T., & Harrisone, S. (2000, Summer). Cultural competence in primary healthcare: Partnerships for a research agenda. Georgetown University Child Development
Center-National Center for Cultural Competence, Policy Brief 3. Washington, DC: Georgetown University. (see also http://gucdc.georgetown.edu/nccc/).
Goode, T., Sockalingam, S.Brown, M., & Jones, W. (2000, Winter). Linguistic competence in primary healthcare systems: Implications for policy. Georgetown University Child Development Center-National Center for Cultural Competence, Policy Brief 2 . Washington, DC: Georgetown University. (see also http://gucdc.georgetown.edu/nccc/).
Green, J. (1995). Cultural awareness in the human services: A multi-ethnic approach. Boston: Allyn & Bacon.
Gudeman, R.H. (2001). Faculty experience with diversity: A case study of Macalester College. In: G.Orfield & M.Kurlaender (Eds.). Diversity challenged: Evidence on the impact of affirmative action, pp. 251–276. Cambridge, MA: Harvard Education Publishing Group.
Gurin, P. (1999). Expert report of Patricia Gurin, Gratz, et al., v. Bollinger, et al., No. 97– 75321 (E.D.Mich.; Grutter, et al. v. Bollinger, et al., No. 97–75928 (E.D.Mich.). In: The compelling need for diversity in higher education, pp. 99–234. Ann Arbor: University of Michigan, Office of the Vice President and General Counsel.
Gurin, P. (2001a). Evidence for the educational benefits of diversity in higher education: Response to the critique by the National Association of Scholars of the Expert Witness Report of Patricia Gurin, Gratz, et al, v. Bollinger, et al., No. 97–75321 (E.D. Mich.; Grutter, et al. v. Bollinger, et al., No. 97–75928 (E.D.Mich.). Ann Arbor: University of Michigan, Office of the Vice President and General Counsel. (see also, http://www.umich.edu/~urel/admissions/new/gurin.html)
Gurin, P. (2001b). Evidence for the educational benefits of diversity in higher education: An addendum, Gratz, et al, v. Bollinger, et al., No. 97–75321 (E.D.Mich.; Grutter, et al. v. Bollinger, et al., No. 97–75928 (E.D.Mich.). Ann Arbor: University of Michigan, Office of the Vice President and General Counsel. (see also http://www.umich.edu/~urel/admissions/new/gurin_add.html).
Gutierez, L., & Alvarez, A.R. (2000). Educating students for multicultural community practice . Journal of Community Practice, 7, 39–56.
Hurtado, S. (2001). Linking diversity and educational purposes: How diversity affects the classroom environment and student development. In: G.Orfield & M.Kurlaender (Eds.). Diversity challenged: Evidence on the impact of affirmative action, pp. 187– 204. Cambridge, MA: Harvard Education Publishing Group.
James, S.A., Schulz, A.J., & van Olphen, J. (2001, in press). Social capital, poverty, and community health: An exploration of linkages. In: S.Saegert, P.Thompson, & M. Warren (Eds). Building and using social capital in poor communities.
Laine, C., & Davidoff, F. (1996). Patient-centered medicine: A professional evolution. Journal of the American Medical Association, 275, 152–156.
LaViest, T.A., Nickerson, K.J., & Bowie, J.V. (2000). Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. Medical Care Research and Review, 57, 146–161.
Leininger, M. (1995). Transcultural nursing: Concepts, theories, research and practices. New York: McGraw Hill Publishers.
Light, R. (2001). Making the most of college: Students speak their minds. Cambridge, MA: Harvard University Press.
Mason, J.L., Braker, K., & Williams-Murphy, T.L. (1995). An introduction to cultural competence principles and elements. An annotated bibliography. Portland, OR: Portland State University, Research and Training Center on Family Support and Children’s Mental Health.
Milem, J.F. (2001). Increasing diversity benefits: How campus climate and teaching methods affect student outcomes. In: G.Orfield & M.Kurlaender (Eds.), Diversity challenged: Evidence on the impact of affirmative action, pp. 233–250. Cambridge, MA: Harvard Education Publishing Group.
Morey, A.I., & Kitano, M.K. (1997). Multicultural course transformation in higher education: A broader truth. Needham Heights, MA: Allyn & Bacon.
Mullan, F. (1992). Community-oriented primary care. New England Journal of Medicine, 307, 1076–1078.
Nash, K.A. (1999). Cultural competence: A guide for human service agencies. Washington, DC: Child Welfare League of America, Inc., CWLA Press.
Nickens, H.W. (1992). The rationale for minority-targeted programs in medicine in the 1990s. Journal of the American Medical Association, 267, 2390, 2395.
Nickens, H.W., & Ready, T. (1999). A strategy to tame the “savage inequalities.” Academic Medicine, 74, 310–311.
Nussbaum, M. (1997). Cultivating humanity: A classical defense of reform in liberal education. Cambridge, MA: Harvard University Press.
Orfield, G. (1998). Campus resegregation and its alternatives. In: G.Orfield & E.Miller (Eds.). Chilling admissions: The affirmative action crisis and the search for alternatives, 1–16. Cambridge, MA: Harvard Education Publishing Group.
Orfield, G. (1999). Affirmative action works—But judges and policy makers need to hear that verdict. The Chronicle of Higher Education, December 10, 1999, Washington, DC.
Orfield, G. (2001). Introduction. In: G.Orfield & M.Kurlaender (Eds.), Diversity challenged: Evidence on the impact of affirmative action, pp. 1–30. Cambridge, MA: Harvard Education Publishing Group.
Orfield, G., & Kurlaender, M., Eds. (2001). Diversity challenged: Evidence on the impact of affirmative action. Cambridge, MA: Harvard Education Publishing Group.
Orfield, G., & Whitla, D. (2001). Diversity in legal education: Student experiences in leading law schools. In: G.Orfield & M.Kurlaender (Eds.), Diversity challenged: Evidence on the impact of affirmative action, pp. 143–174. Cambridge, MA: Harvard Education Publishing Group.
Palmer, S.R. (2001). A policy framework for reconceptualizing the legal debate concerning affirmative action in higher education. In: G.Orfield & M.Kurlaender (Eds.), Diversity challenged: Evidence on the impact of affirmative action, pp. 49– 80. Cambridge, MA: Harvard Education Publishing Group.
Ready, T. (2001). The impact of affirmative action on medical education and the nation’s health. In: G.Orfield & M.Kurlaender (Eds.), Diversity challenged: Evidence on the impact of affirmative action, pp. 205–219. Cambridge, MA: Harvard Education Publishing Group.
Salimbene, S. (1999). Cultural competence: A priority for performance improvement action. Journal of Nursing Care Quality, 13, 23–35.
Satcher, D. (1999). Surgeon General’s report on mental health. Washington, DC, (see also http://www.surgeongeneral.gov/library/mentalhealth/home.html).
Sax, L.J., & Astin, A.W. (1998). Developing “civic virtue” among college students. In: J.N.Gardner, G.VanderVeer, & Associates (Eds.), The senior year experience: Facilitating integration, reflecting closure, and transition, pp. 133–151.
Seifer, S.D. (1998). Service-learning: Community-campus partnerships for health professions education. Academic Medicine, 73, 273–277.
Seifer, S.D. (2001, March). The Center for Health Professions newsletter: From the director. San Francisco.
Stoddard, J.J., Back, M.R., & Brotherton, S.E. (2000). The respective racial and ethnic diversity of U.S. pediatricians and American children. Pediatrics, 105, 27–31.
Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American Psychologist, 53, 440–448.
Syverud, K.D. (1999). Expert report of Kent D.Syverud, Grutter, et al. v. Bollinger, et al., No. 97–75928 (E.D.Mich.). In: The compelling need for diversity in higher education, pp. 265–267. Ann Arbor: University of Michigan, Office of the Vice President and General Counsel.
Talabere, L.R. (1996). Meeting the challenge of culture care in nursing: Diversity, sensitivity, competence, and congruence. Journal of Cultural Diversity, 3, 53–64.
Trickett, E.J., Watts, R.J., Birman, & Birman, D. (1994). Toward an overarching framework for diversity. In: E.J.Trickett, R.J.Watts, & D.Birman (Eds.). Human diversity: Perspectives on people in context, pp. 7–26. San Francisco: Jossey-Bass Inc.
Yen, I.H., & Syme, S.L. (1999). The social environment and health: A discussion of the epidemiologic literature. Annual Review of Public Health, 20, 287–308.
Zweifler, J., & Gonzalez, A.M. Teaching residents to care for culturally diverse populations. Academic Medicine, 73, 1056–1061.