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During the course of a typical day, health care professionals at Columbia University Medical Center encounter patients who speak only Spanish, making communication challenging. Even with an interpreter, the physician, nurse, dentist, or public health professional may not know enough about the patient's culture and health beliefs to circumvent communication barriers.

CUMC is working to improve the ability of its students and faculty to communicate across cultures, which is one component of an emerging national movement for teaching "cultural competence" at medical centers.

Cultural competence is the ability to provide effective care to patients with diverse values, beliefs, and behaviors with the goal of improving health care for racial and ethnic minority groups. Minority groups tend to receive lower quality of care than nonminorities, even when controlling for access-related factors such as patients' insurance status and income, according to a 2002 Institute of Medicine report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care." The report concluded that "although myriad sources contribute to these disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of health care providers may contribute to differences in care."

There are many reasons why a health care professional needs to be culturally competent. For example, if a physician decides to prescribe blood pressure medication to a woman with hypertension or asthma, the physician has to explain to the patient that she must take the medication daily, even if she feels well. The doctor needs to know what else the woman takes, such as herbal remedies that may not be listed on the patient's chart. Sometimes patients fear what their doctor might not be telling them, says Dr. Dodi Meyer, assistant clinical professor of pediatrics, who cites a study by Dr. David J. Bearison of City University of New York and Dr. Linda Granowetter, associate professor of clinical pediatrics, that found Washington Heights residents are afraid asthma medications such as steroids have hidden, dangerous effects that doctors neglect to discuss.

In some respects, CUMC is ahead of other medical centers in cultural competence because it already has substantial expertise in cross-cultural communication. But much of this know-how exists in pockets among the schools.

In 2002, with the encouragement and support of Dr. Fischbach, executive vice president and dean, CUMC's Center for Community Health Partnerships gathered senior academic officials from each CUMC school, the director of graduate medical education at NewYork-Presbyterian Hospital, and faculty from the School of Social Work to review the status of cultural competence training at the CUMC campus. The Center for Community Health Partnerships, led by Vice Dean Dr. Allan Formicola, serves all CUMC schools by establishing and supporting academic community collaborations such as the Northern Manhattan Community Voices Collaborative and the Thelma C. Davidson Adair Medical/Dental Center in central Harlem, designed to help improve equitable health care in that community.

The new group decided to create a campuswide Curriculum Development Committee for Cultural Competency, led by Dr. Meyer because of her experience in the community pediatrics program, which is part of P&S's Department of Pediatrics. Community pediatrics is a recognized leader in cultural competence at CUMC because of the curriculum it developed through its grant from the Anne E. Dyson Community Pediatrics Training Initiative, which provides funding for pediatrics departments to develop curricula and scholarly efforts concerning community-oriented and community-based health care.

The group developed a list of five competencies that curricula should teach to all medical center and School of Social Work students: self-awareness, cross-cultural knowledge, language diversity, culturally and linguistically appropriate delivery of care, and advocacy. Next, the group worked with all of the schools to integrate new programs into their curricula.

At P&S, community pediatrics already had a model of how to address delivery of care issues that stemmed from its participation in the Dyson initiative. In 1996, the division began conducting walking tours of Washington Heights, co-led by community leaders to foster closer relationships between pediatrics residents and community-based organizations such as Alianza Dominicana. That tour served as the model for a new walking tour required for all incoming medical students in fall 2003 as part of the P&S curriculum. The tour was led by Dr. Meyer, Milagros Batista, the community pediatrics liaison for Washington Heights and Inwood and a co-founder of Alianza Dominicana, and Dr. Olveen Carrasquillo, assistant professor of medicine and health policy & management and principal investigator of the Columbia Center for the Health of Urban Minorities (CHUM), a research center within the Center for Community Health Partnerships.

Shattering Stereotypes

The medical students listened to a half-hour lecture about the assets of the community and visited local schools, community centers, and botanicas - home remedy shops - to learn more about the culture of the Washington Heights and Inwood population and how culture affects patients' health and health care. Dr. Meyer and Dr. Ayxa Calero-Breckheimer, assistant professor of clinical educational psychology and head of the Office of Scholarly Resources, measured the effect of the tour by asking students for a list of adjectives that describe the Washington Heights community before and after the tour. Students' perceptions of the community changed drastically from homogeneous stereotypes of an inner city population to a wide range of positive attributes of this community.

The School of Dental and Oral Surgery is addressing the issue of cross-cultural knowledge by videotaping student-patient interactions and discussing them in small groups with guidance from Dr. Vicky Evangelidis-Sakellson, associate professor of clinical dentistry. The Mailman School of Public Health is pursuing the same goal with an academic exchange program that is now open to all CUMC students. The program, led by Dr. Marilyn Aguirre-Molina, professor of clinical population and family health, is a 10-week internship that places CUMC students with nongovernmental organizations in the Dominican Republic.

To develop provider self-awareness, Dr. Dolores Bacon, assistant clinical professor of medicine and assistant dean at P&S, led a lecture, film and discussion session for faculty and students about race and health care issues raised by a PBS documentary, "Partners of the Heart." The film examines the lives of Vivien Thomas, an African American lab technician, and Dr. Alfred Blaylock, a white surgeon at Johns Hopkins University Hospital, who together pioneered a procedure to alleviate a congenital heart defect that ultimately saved the lives of thousands of so-called "blue babies." The film depicts the hardships Mr. Thomas had to endure because of racism within the medical institution. A survey done before and after the session showed that many faculty and students found themselves facing up to their assumptions about racial groups other than their own.

Faculty development is set to continue with a new $42,000 grant from the Aetna Foundation, says Dr. Robert Lewy, senior associate dean and medical director of the Center for Community Health Partnerships. One part of the grant will pay for cultural competence experts to visit Columbia and train faculty in the skills necessary to deliver culturally competent care.

"To be a culturally competent practitioner, you must be aware of your own biases and feelings that you bring into the patient relationship," Dr. Formicola says. "You also need to learn how to communicate with all types of patients so they understand and can participate in the treatment and so that you understand how they view the treatment to foster compliance. The programs that the various schools and departments are adding are already moving us closer to those goals."

—Matthew Dougherty

The School of Dental and Oral Surgery has achieved immediate results from a 1-year-old minority pilot recruitment program, whose goal is to train more African American, Latino and Native American dentists. These groups are typically underrepresented in dental schools and the hope is that some of the dentists will practice in underserved geographic areas after graduating.

Supported by funding from the Robert Wood Johnson Foundation, the Summer Medical Education Program/Dental Pilot is a six-week program that introduces college students to dental school and dentistry.

Four of the eight students who participated last summer have enrolled in the incoming SDOS class, says Dr. Martin Davis, associate dean for student and alumni affairs and professor of pediatric dentistry. They had to meet the same entrance requirements as other applicants.

These four new students, along with another four who have enrolled, have increased SDOS's percentage of underrepresented minorities to 10 percent in the class of 2008. The school's previous highest percentage was 5 percent.

Dr. Marlene Klyvert, special lecturer in dentistry, and Dr. Allan Formicola, professor of dentistry and vice dean of the Center for Community Health Partnerships, deserve much of the credit for developing the program, says Dr. Davis. Dr. Klyvert, the first director of the summer program, retired last month as assistant dean for special projects and multicultural affairs but remains actively involved in this summer's program and in her new role as senior adviser to the Office of Multicultural Affairs and special lecturer. Dr. Dennis Mitchell has taken over as assistant dean for diversity and multicultural affairs and director of community-based education.

"We're acting on the urgent need to increase diversity in dentistry," Dr. Davis says. "We know that some graduates from underrepresented minority groups decide to practice in communities where there are not enough dentists and access to care is low."

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