Deborah Ayuste, SLU
Medical Training, Changing Demographics, and Latino Healthcare: The Case of Saint Louis University School of Medicine

Presentation Notes: Presentation slides also available

· Since the Latino population is the fastest growing population in the United States, it has become increasingly important for medical schools to examine whether they are sufficiently preparing their students for the cultural barriers encountered in their medical career.

· Training in cultural competency is not only important because we must be sensitive to the differences among people, but it is also essential to medical training because cultural competency is an integral component of clinical competency!

· In a case study of Saint Louis University School of Medicine, I examined how the medical school prepared their students for the cultural barriers encountered in their professions. I also examined the concerns of the students regarding the growth of the Latino population and what initiatives the medical school undertakes to provide services to the growing Latino population.

· Methods of research were interviews and Surveys

· Survey: Majority of the first questions were followed by feelings of concerns. In the second question, almost all followed with a positive response.

· According to the surveys the primary concern among the students is the language barrier. Many expressed the need for specific training encountering language barriers, which includes a Medical Spanish Class. In the previous years the medical school had a choice of taking a medical Spanish elective. This year due to problems with financing the elective will not been offered. Its ironic that at a time like this when the Latino population is surging, the medical Spanish class has been cut. Some students in the survey mentioned that they wanted to take this class or something like it but nothing of its kind is even offered. As I spoke with Dr. Hickman, who runs the cultural competency seminars, he mentioned that he was working to reinstall the elective. He informed me that there were some technical problems and sponsoring issues they had to clear up. Also while talking to a 2^nd year medical school I was happy to learn that some of the students are pushing for it to be offered again. But, as we know these processes may take a while and more students move closer to graduation.

· While most felt a concern towards language barriers the majority did not express as much concern about other cultural barriers. Though, most acknowledged the key importance of acquiring communication skills.

· The second most common concern the students expressed was their Lack of Experience. We have to remember 1st and 2nd year students completed the surveys. It is not until their 3^rd year that they are fully exposed to a clinical setting. Their feeling of inadequate experience with the Latino population may be partially due to the stage of education they are in. However, quotes such as these show that students may be unaware of the differing needs of minority groups. This subject needs to be addressed because many students may be unfamiliar to environments like Chicago, San Jose and Miami and grown up in homogenized communities.

· Many also expressed that much of the education can’t be taught through lectures. They need hands on experience to gain knowledge and understanding.

· Other concerns that not only appear in the surveys but also in the interviews are compliance issues due to traditional beliefs among patients which often includes strong beliefs in alternative remedies. With that, some students further mentioned the importance of physicians to keep an open minded in dealing with the Latino population and other cultures.

· Even though students expressed concerns in their preparation in dealing with the change of demographics among the Latino population, 33/39 students agreed that the school of medicine has put forth effort and shown initiative towards producing culturally competent physicians.

· The main method in which the medical school prepares students for cultural barriers they may encounter is through mandatory units called Patient, Physician, and Society or PPS I and II.

· The 1^st year students go through PPS I. It is roughly a 4 hr workshop in which they listen to lectures and partake in a cultural exercise called BaFa BaFa.

· In the exercise students break up into 10 groups with about 15 students each.

· After an initial briefing two cultures are created: Alpha culture and the Beta culture. The cultures are deliberately made up, actually consisting of a mixture of cultural beliefs. After the participants learn the rules of their culture and begin living it, observers and visitors are exchanged. The resulting stereotyping, misperception and misunderstanding become the prompts for the debriefing.

· Most of the surveys acknowledged the importance and value of the PPS course, but a couple students specifically expressed dissatisfaction in the BaFa BaFa exercises. Educators must ask themselves whether some methods of teaching are simply “feel good” exercises or do they actually “do good.”

· 2^nd year medical school students go through PPSII. Mainly it is an all day mandatory workshop. But learning takes place throughout.

· PPSII focuses on taking culturally appropriate histories, which is extremely essential in making a correct diagnosis.

· With that they highly stress that cultural competency is an integral part of medical competency. This is important to note because focusing on and recognizing the importance of so-called “soft skills” is a relatively new idea within medical school education.

· We must remember that even though cultural competency education is important, a multitude of topics vies for the students’ time. They have a plethora of information to learn in such a short period. Efficiency and thoroughness is always competing with each other.

· In order to convey their message as effectively as possible, Medical schools often utilize models.

· They use the Kleinman model in order to teach students how to take culturally competent medical histories.

· There are three different domains in which they acquire their experience: 1) Collective Experience- Events and social processes that help define the lives of generations of people 2) Cultural Representation – collective patterns o f meaning that inform the style of narrative 3) Subjectivity – personal dimension where expression of illness typically occurs

· 8 questions – The Kleinman models suggests discovering the narrative by asking questions. There are 8 questions medical caregivers may find helpful to use.

· The students also partake in-group exercises in which they are given cases studies.

· They go over different scenarios. A student plays the patient. They are not allowed to reveal the information on the sheet until specifically asked. The student playing the physician must ask appropriate questions, avoid judgmental statements, maintain neutral facial expressions avoid making assumptions, and avoid alienating terms.

· The way in which the medical school teaches cultural competency is very broad. The different scenarios do not represent a single culture. They often use hybrid cases and avoid culture specific cases. The reason they do this is to avoid stereotyping and falling into the trap of the ‘cook book’ approach. It would be great to look at someone and say ‘ok the patient is female, in her 50’s, from Mexico, and complains of a fever”, the ‘cookbook’ tells me she must believe in the hot/cold food diet and we must treat her in a certain way’, but that may not be the case. Often situations are issue specific not cultural specific.

· This global approach to teaching may beat out other methods but we must be aware of the flaws. We have to constantly question the effectiveness of taking a general approach and not addressing specific demographic changes among Latinos within our home environment.

· We may be brushing over the call for the specific needs among the Latino community and thus this approach may be unintentially alienating them.

· As I stated earlier, the surveys showed that the students were fairly satisfied with the effort their school took in producing culturally competent physicians but they also acknowledge holes in which lectures and exercises cannot fill.

· The students understand this and have moved to do something about it.

· La Clinica

· Mission trips are also popular among the students. Many have traveled to such places as Guatemala, Mexico and El Salvador. The school also offers a mission trip to Southern Texas on the Mexican boarder and offers a medical clinic. The 3^rd year student I interviewed partook in this trip. In fact, this week some students from SLU undergrad, which include some pre-med students are traveling down to El Salvador for a spring break service trip. Service trips to impoverished Spanish speaking areas not only provide service to underprivileged populations but also more importantly provide students with the experience and knowledge of the Latino culture that they can translate into better serving the Latino population within their own community.

· There are also current efforts at SLU to create a Latina/o Student Association and one of their primary concerns are health issues affecting the Spanish speaking population in the area.

· The school has also put forth effort in other ways besides the PPS classes. They have a GEM program in which the medical school takes in 8-10 disadvantaged or underrepresented students who otherwise would not qualify for medical school. The conditions are the student must apply for medical school, but not accepted. For them to be selected into the GEM program they must fall into one of three categories: financially disadvantaged, educationally disadvantaged, or underrepresented. They first work on skills enhancement such as proper note taking and then ease them into the regular 9-month academic year. If they do well then they matriculate into medical school. The program does not specifically cater to Latinos but they are particularly aware of the Latino presence. They often recruit in the California area in which there is a large Latino population. Often 1 or 2 of the individuals chosen for GEM are of Latino decent.

· By increasing the number of Latinos in the medical sector we are also increasing the likelihood of better health care services for the Latino population. It is a fact that Latinos and other minorities practice in underserved areas with greater predictability. Many of them go back to their own communities to help increase the quality of care among Latinos. Also, by having more Latino health professionals we are allowing future physicians to learn culturally competent care with and from those who themselves are representative of our societies diversity.

· As much as the medical school and students are doing to respond to the changing demographics among the Latino Population, I received a feeling that they are still inadequately prepared. We have to ask “Are we actually touching reality with these exercises, lectures and programs?” and “ How do we push towards more improvement?”

· Some suggestions from the students were placing additional books in the library addressing overall Latino Themes

· Mandatory medical anthropology books

· Encouraging students to serve Spanish speaking populations

· Educating medical school professors and staff about cultural competency through workshops

· Medical Spanish Elective

· A professor is working on a grant to research the epidemiology of health disparities, which would help understand diseases that specifically affect the Latino population in great numbers

· SLU to start their own clinic catering to the Spanish speaking population on top of the Southside Catholic services in which SLU students assist .

· Finally, along with the global approach to educating students towards cultural competency, the school can include more information about the specific needs of the Latino population and the specific barriers health professionals may encounter.