THE FOUR C’S OF CULTURAL
V. Faye Jones, MD, PhD, Gerald Lee, MD, Pradip Patel, MD, Karen Hughes
Miller, PhD, MEd
magine that your patient is a Hispanic child with asthma whose
family gave up traditional therapies and began working with a
spiritual healer. How would you approach this situation? What
strategies would you employ to gain their trust and have them meet
you halfway with your action plan? These are the kinds of issues
third year medical students at the University of Louisville School
of Medicine are learning to address as they prepare for their professional practices in a multicultural society.
The days of Louisville being a sleepy “mid-size, mid-western, all
American” city are gone. Just considering your own patient base,
you have probably realized that Louisville now has a very diverse
foreign-born population. In fact, more than 80 languages are spoken
within Jefferson County Public Schools, and the University of Louisville’s international student body represents 91 different countries.
As Louisville and the surrounding metro area change, the need
for physicians to relate to patients of different cultural backgrounds
becomes more important. For the past few years, medical educators
at the University of Louisville School of Medicine have used several
strategies to include cultural sensitivity in the curriculum, and we
detail the recent updates.
The contemporary concept of “culturally responsive health care”
goes beyond simply teaching about different traditions and beliefs
that affect health care. It means developing strategies to connect
with patients of diverse backgrounds in order to understand their
points of view and negotiate treatment plans and therapies they
can truly understand and support.(2) The key is establishing candid
communication with patients so they feel comfortable in telling their
physician about home remedies, spiritual support, and even taboos
that are a part of their reality, but may not always complement what
a Western trained physician recommends.
Third year medical students in their pediatric clerkship now
participate in a highly interactive module on culturally responsive
health care. The module uses the new “flipped classroom” approach
where students do the homework first (for instance, read a typical
case) then come to class ready for a lively discussion. The face-toface session is informal and personal, beginning with the teachers
sharing some of their own families’ traditional health care beliefs
and home remedies. This opens the conversation to students’ family
experiences and to experiences with their patients. The “take home”
tool from this module is “The Four C’s of Cultural Competence,”
(in reference 3) a simple mnemonic designed to help students,
residents, and physicians employ some effective conversational
tools to encourage culturally responsive healthcare.
Although this is the students’ first year of clinical experience,
many of them have already seen patients from diverse backgrounds
struggle to make sense out of what they were being told in the clinic
or hospital. For example, students who have encountered Muslim
patients now have a better understanding of why female patients
much prefer a female physician. Students who have encountered
Amish patients now have a better understanding of the paradox
of avoiding modern technology at home while accepting modern
health care, especially for their children.
Students have also met a few patients who believe their illnesses
are caused by spiritual forces (such as punishment for a wrongdoing),
or because someone has placed a curse on them. The classroom discussion often includes questions on how to deal with patients who
refuse vaccines. The faculty focuses on strategies and suggestions
for dealing with these issues in non-judgmental ways.
One of the most rewarding outcomes to faculty who teach this
module is to see third year medical students “upgrading” their
basic skills conducting a history and physical to be able to get a
more nuanced view of the whole patient. To paraphrase Sir William
Osler, students begin to understand “the person who has the disease
rather than just the disease.”
1. Population demographics: Facts about immigrants in Louisville.
City of Louisville, KY. 2003-3014. Available online at http://www.