Meeting on common ground: training tomorrow’s doctors

by Melanie Evans

The yellow school buses do not travel far: two and a half miles to the west. The destination lies less than 10 minutes away from the entrance of Mayo Memorial Building auditorium.
The six buses intersect and weave across Lake Street and Franklin Avenue through one of Minneapolis’ most culturally diverse and economically depressed neighborhoods. A volunteer from the Phillips community guides the first-year University medical students as they circle the neighborhood for two hours.
It is the second of two days the school dedicated to teaching cultural dynamics to the incoming class.
These two days, plus a handful of hours sprinkled throughout their four years of medical training, will serve as the students’ only formal preparation for working with diverse cultures.
Students board the bus, admittedly cautious yet enthusiastic. Throughout the morning, they question if the bus trip is the best way to bridge cultural gaps.
The students aren’t they only apprehensive participants in the venture. Community members, traditionally wary of academia, are concerned their needs won’t be heard. Educators, wrestling tight curricula in the first two years, fear sacrificing these hours usually dedicated to basic science. And despite more than three decades of civil rights initiatives, teaching cultural communication skills in medical education remains largely uncharted territory.
Yet all parties agree on what is at stake: Cultural misunderstanding between a patient and a physician can lead to medical emergencies or mistakenly set in motion state welfare and social service agencies.
Minnesota saw a 32-percent rise in its minority population between 1990 and 1996. In 1996, Minnesota’s minority population hovered at an estimated 7.8 percent.
And with 70 percent of the state’s doctors trained at the University, medical educators are struggling to make the transition from treating cultural education as a point of political controversy to a matter of medical necessity.
Unfamiliar territory
A February 1998 report issued by the Association of American Medical Colleges found that only one of the 141 undergraduate medical programs in the United States and Canada teaches multicultural medicine as a separate required course.
Schools often work lessons on cultural sensitivity and communication into existing courses, citing an integrated method of teaching as more effective than isolating cultural lessons outside the curriculum.
Pointing to grueling and rigid schedules, administrators argue that medical students’ plates are already full with four years of basic science and clinical medicine.
Minnesota is among the 86 percent of North America’s medical schools that offer some type of formal cultural training to their students.
Required cross-cultural education is limited to a two-day seminar titled “Cultural Dynamics in Health Care,” and lectures in Human Sexuality dedicated to gay and lesbian issues, said Sara Axtell, a research associate in the Medical School’s Office of Educational Development and Research. Axtell is currently conducting a survey on the school’s curriculum.
“Really, after the first year, there is currently very little (cultural education) that I’ve been able to find in the curriculum that’s actually required,” Axtell said.
After the first year, emphasis on cultural education is largely luck of the draw depending on the location of a student’s clinical training, she said.
But initiatives added this year, largely promoted by students, have shifted support in favor of adding more diversity in the curriculum, she said.
As medical students begin meeting patients earlier in their education, administrators at the University are searching for the time to squeeze communication skills into the first two years.
“The issue is, how do you do it?” said Ilene Harris, director of the Medical School’s Office of Educational Development and Research.
“A basic and universal right”
The medical school’s efforts to teach cultural education in previous years were insufficient, said third-year medical student Anne Lent.
“It was always kind of half-assed. The University is very committed to diversity, and committed to integrating the school. I just don’t think anybody knew how to do it,” she said.
Lent’s extracurricular work with members of the Phillips neighborhood served as a foundation for the school’s day-long event.
Second-year student Alex Cho’s involvement in the September program in Phillips stemmed from frustration from his own experience with the school’s one-day foray into ethnic studies the previous year.
“In claiming it was a cultural diversity day, it didn’t have a lot of reach,” Cho said.
It was the letter Cho co-authored with classmate Karen Hendershott that caused Dr. Greg Vercellotti to invite students to curriculum revision meetings for the next eight months.
Bearing 25 signatures, the letter informed the Medical School’s senior associate dean for education that the first-year class was frustrated with the lack of preparation demonstrated by their experience.
During the following months, several students complied recommendations from classmates for changing the curriculum.
Five months later their work sparked a letter to the incoming class, requesting that they read Ann Fadiman’s “When the Spirit Catches You and You Fall Down” before arriving in the fall.
The book chronicles a tragic story of miscommunication between a Hmong family and their western doctors at California’s Merced County Medical Center. The story centers around Lia Lee, who developed epileptic seizures three months after birth.
For the Hmong, the seizures were a sign of spiritual distinction. For the doctors, Lia’s condition was a matter of biochemical imbalance.
The two convictions came to a disastrous head as both sides attempted to care for the young girl without considering cultural differences. Lia eventually suffered a two-hour convulsion that destroyed her brain, placing her in a permanently vegetative state.
“The doctors thought the Hmong didn’t understand the body; the Hmong thought the doctors didn’t understand the soul,” Fadiman told the students during a recent visit to campus.
The group cross-referenced the book with the first-year curriculum, finding ways to work the medical references in Lia’s story into classes like anatomy and physiology.
To illustrate the need for more in-depth cultural education for physicians, Cho cited studies tying deaths and health problems to poor communication between doctor and patient.
“Physicians, across the board, seem disproportionately unable to relate,” said Cho. “Physicians are taught that we are the masters of this system, yet at the same time appear to be powerless to make health care what it is supposed to be: not the province of the rich and educated elite, but a basic and universal right.”

Changing demographics
Nearly half of the University’s Medical School graduates remain in the state of Minnesota to practice medicine; California ranks a distant second choice, claiming 8 percent of the school’s alumni.
The minority populations of each state vary greatly; Minnesota’s minority population is one-fifth the size of California’s.
Yet both states claim a sizable Hmong population. In the last 9 months, Minnesota surpassed California and Wisconsin to claim the largest Hmong refugee population in the United States, said Tim Gordon, Minnesota Department of Human Services policy analyst.
A combination of statistical and anecdotal evidence point to a Minnesota Hmong population of 50,000, Gordon estimates. During the past five years, the state has seen an additional wave of refugees from Somalia, Sudan, Liberia and Bosnia.
Minnesota’s changing population is justification enough for expanding social and health services, Gordon said.
Ellen Rau, interpreter services specialist and community liaison for Hennepin County Medical Center, can testify to the need for Twin Cities doctors to prepare for a multilingual, multicultural practice.
Hennepin County Medical Center is one of four large teaching hospitals where University Medical School students and residents train.
Three interpreters worked on staff at the medical center at the time of Rau’s arrival in 1980. Today 40 work on staff, translating the 40 languages and dialects for the 55,000 non-English speaking patients who visit the hospital annually.
“It seems to be growing all the time,” she said. “We are consistently adding dialects.”
Language is only the first hurdle, she said. Doctors often don’t know how to work with interpreters, occasionally passing off clerical or administrative duties like consent forms to the untrained language brokers.
Dr. Amos Deinard, director of the Community/University Health Care Center, began working with refugee patients in 1979.
Nearly 30 University medical residents train at the University clinic, where Caucasian patients are the minority. Thirty percent of the clinic’s patients are Southeast Asian, 20 percent are African-American, and 10 percent are Native American.
Deinard works with interpreters, community members and spiritual leaders to provide treatment for patients, he said. Doctors’ initial reliance on social services for leverage to administer health care was a mistake, he said. Families would leave the state or not return to the clinic, he said.
Students who enter his clinic come prepared with limited experience and learn on the job, he said.
A better understanding
Shifting on the dark green plastic seats, students turn from one bank of windows to the other as they ride through the Phillips neighborhood. The voice of the Rev. Norma Patterson directs their gaze from North to South.
For some, the territory is foreign; the geography and the scenery of Phillips are entirely unfamiliar. Others are intimately acquainted with a school, a business, or a family in the neighborhood.
For Patterson, it is home. Born in St. Louis, Patterson was brought to Minnesota by marriage 30 years ago. Her years first as a pulpit minister, and then as community wellness coordinator for the YWCA, have made her life’s work aiding the residents of Phillips to better health care, safety and comfort.
Patterson coaxes the students to recognize the signs of pride apparent throughout the tour: murals, community gardens and window displays announce safe houses.
She welcomes the students. She hopes they will one day return the favor, expressing the same sensitivity to nervous and alienated patients in their waiting rooms that she now demonstrates for them.
Tension erupts into laughter as several students attempt to shake off the feeling they are overrunning Phillips.
Betsy Karschnia, a 34-year-old first-year medical student, said her initial reaction to the day was mixed.
“I felt like it was an invasion, like we were invading them,” she said.
A better understanding of how the day was organized — as a joint project between Phillips community members and University staff and students — set some of her fears at ease, she said.
Karschnia, who is raising a daughter in St. Paul, plans to practice in Minnesota. Some education is better than nothing, she said. Eight self-conscious hours are worth gaining an introduction to a community she hopes someday to join as a physician.