The authors describe the results of a survey they carried out in 2000 to determine the status of cultural sensitivity training in 16 Canadian medical schools using structured telephone interviews of associate and assistant deans or curriculum directors and curriculum coordinators. Their goal was to obtain a descriptive analysis of school-specific objectives, curriculum content, methods, and evaluation formats. The survey was prompted by the growing concern that in culturally diverse societies, medical education has failed to keep pace with the changing composition of the patient population.

Only one of the eight schools that integrated cultural sensitivity within their objectives made explicit mention of the topic in its clerkship evaluation form. While seven of the 16 schools did not have any statement on cultural sensitivity in their curricular objectives, they integrated cultural sensitivity in their curricula using various educational methods, with PBL cases, lectures, and small-group discussions being the commonest formats. These educational methods were primarily offered to students in their first and second years. Student participation was required, but program lengths ranged from two to 40 hours. Additional findings for each school are presented.

The authors conclude that while progress has been made, lack of adequate resources and a number of obstacles to inclusion of multicultural health content in curricula appear to remain ongoing problems. Further investment in faculty development and administrative staff support for a multicultural curriculum are needed, as is more research on effective curricular components.

In this article, we describe the results of a survey we carried out in the year 2000. Our goal was to determine the status of cultural sensitivity training in 16 Canadian medical schools at the undergraduate level by conducting a descriptive analysis of school-specific objectives, curriculum content, methods, and evaluation formats.

Our survey was prompted by the awareness that while there is a growing concern in culturally diverse societies such as those of Canada, the United States, the United Kingdom, and Australia, medical education has failed to keep pace with the changing composition of the patient population.1,2 In a series of articles, Masi stressed the importance of understanding community health-related cultures and beliefs, a good physician—patient relationship, and the benefit of an open-minded approach by physicians and other health care workers to the delivery of health care services.3,4,5,6,7 These principles are even more relevant to the training of future physicians because existing multicultural societies are becoming even more multicultural.2,8,9

Over time, the definition of culture has evolved, but the underlying understanding is that culture is the lens through which we give the world meaning and which shapes our beliefs and behaviors.10,11 In almost any medical encounter, there is interaction between the culture of the physician, the culture of the patient, and the medical culture that surrounds them.3,4,5,6,7 While physicians are not expected to fully understand all cultures, they should be sensitive to the fact that patients possess diverse health values that may be based on culture, and that neither the health care provider's nor the patient's culture offers a preferred view.11,12

To achieve the competence necessary to provide culturally appropriate health care and education, the physician needs to experience a learning process that requires time, effort, practice, and introspection.13 But giving physicians in training the opportunity to experience such a process is not easy: a report from the Multicultural Health Education Project Committee in 1991 highlights a number of obstacles to the inclusion of multicultural health content in the curricula of medical schools.14 These include insufficient numbers of faculty prepared to teach the subject, difficulties in introducing new materials and experiences into an already overcrowded curriculum, lack of specialized teaching and learning resource materials, and limited financial support.

In Canada, it is clearly stated in the Canada Health Act (1984) that all Canadians have the right to health care that is equitable, accessible, comprehensive, and both culturally and racially sensitive and appropriate.15 Yet six years later, in a 1990 survey of Ontario medical schools, Hennen and Blackman concluded that the teaching of this topic is not included in the formal curricula of these schools, nor is it included in the objectives or the evaluations.16 One of the main reasons for this survey was to see how much change had occurred since this earlier study.

We first performed a literature search using the Medline database. The following key words were entered: multiculturalism, medical school, medical education, cultural sensitivity, cultural diversity, and cultural awareness. The bibliographies of the relevant articles were reviewed for further articles.

A list of the associate and assistant deans of undergraduate medical education (UGME) of the 16 Canadian medical schools was obtained from the Association of Canadian Medical Colleges. Initial contact and follow-up with the 16 deans' offices were achieved in June, July, and August 2000. From each school, the objectives of the undergraduate medical program and the clerkship evaluation forms were collected. Information gathered from Web sites was further verified by the deans' offices for currency and validity. We conducted a structured telephone interview (sometimes supplemented by e-mails and faxes) with each of the associate and assistant deans of UGME or with each school's curriculum director or coordinator to find out:

The information collected from the medical schools was tabulated according to the site.

All 16 Canadian medical schools participated in the study through their UGME offices, although Laval University did not provide all the requested information. Eight of the 16 schools had integrated one or more statements on cultural sensitivity within their general objectives. The University of Alberta was revising its curriculum objectives, and thus was not assessed; however, its representative provided information based on the existing curriculum.

Only one of the eight schools that integrated cultural sensitivity within its objectives made explicit mention of cultural sensitivity in its clerkship evaluation form (University of Saskatchewan). From seven of these eight schools we were able to obtain descriptions of the various teaching methods that were used to integrate culturally sensitive topics into the curricula. A broad spectrum of teaching methods was used at each site, with the commonest being lectures, PBL cases, and small-group discussions. Examples of creative teaching methods included the use of simulated patients with diverse cultural backgrounds at the University of British Columbia and student visits to aboriginal health centers at the University of Manitoba. An overview of our findings is presented in Table 1.

The table shows that while seven of the 16 schools did not have any statement on cultural sensitivity in their curricular objectives, they integrated cultural sensitivity in their curricula using various educational methods, with PBL cases, lectures, and small-group discussion being the commonest formats. These educational methods were primarily offered to students in their first and second years. Student participation was required, but program lengths ranged from two to 40 hours.

Despite lacking culturally relevant curricular objectives, two of these seven schools (the University of Ottawa and Dalhousie University) had explicit statements evaluating cultural sensitivity in their clerkship evaluation forms. Different examination methods were also used to assess the students, e.g., an OSCE station or oral and written approaches such as a question incorporated into a course exam.

The teaching staffs for these sessions were predominantly physicians. We were unable to capture through our survey whether these physicians had culturally diverse backgrounds or what types of training they had had for this subject.

The diversity of the cultural and racial orientations of the people of Canada means that those who provide health and social services increasingly interact with others of diverse cultural, social, racial, linguistic, and religious backgrounds. In keeping with this awareness, there has been an effort to change the medical education systems in Canada.17,18,19 In comparison with the 1990 survey of Ontario medical schools,16 our survey shows that Canadian schools in year 2000 had made moderate gains in cultural sensitivity training, such as inclusion of the topic in curricular objectives and content, and evaluation in the form of oral and written questions (multiple-choice and essays) and OSCE stations. These changes are part of an increased institutional commitment in all North American medical schools to improve students' abilities to provide culturally sensitive clinical care when they become practicing physicians. Data indicate that this commitment has already taken hold in 68% of these schools.20

Our survey showed that eight of the 16 Canadian medical schools listed explicit criteria on cultural sensitivity in their curricular objectives and three of the schools included cultural sensitivity in their clerkship evaluation forms. Interestingly, two of the schools that had cultural sensitivity in their evaluation forms had not incorporated it in their course objectives. Although these findings indicate improvements in the integration of cultural sensitivity training in Canadian medical schools, they also reveal, as previously demonstrated by Loudon,21 that gaps continue to exist in teaching this important skill. To achieve cultural competence, an organized and systematic approach to the loop from needs assessment to objective development, curriculum planning, learning methods, and then to program evaluation is needed but is still missing.

Limitations of this survey may include under-reporting, since we have no account of the informal teaching of culturally sensitive topics that may have occurred. It is possible that medical students and faculties from different cultural backgrounds learn from each other and share their beliefs and attitudes with respect to health practices on an informal basis. Also, exposure to patients from other cultural backgrounds in practice might bring culturally sensitive issues to the individual learner.

In this survey, we looked at general objectives and evaluation forms of the undergraduate curriculum, and communicated with the curriculum directors or coordinators and associate deans to assess the teaching of cultural sensitivity. A thorough study of lectures, workshops, seminars, and objectives of courses taught to students throughout their years in medical school would allow for a better description of the extent of such teaching. Also, obtaining feedback from teaching faculty's and students' experiences would be of great value in the assessment of cultural sensitivity training.

As highlighted by Toumishey,14 lack of adequate resources and a number of other obstacles to inclusion of multicultural health content in the curricula appear to remain ongoing problems. As such, further investment in faculty development and administrative staff support for a multicultural curriculum are needed. Additional research is needed to identify effective components of educational programs on cultural competence (such as ways to connect awareness of cultural diversity with the appropriate behavioral responses) and valid methods of student assessment and program evaluation.

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