David Schleich, PhD
In 37 years and a few months, we will hit mid-century, and how we design and deliver naturopathic medical education will be very different than it is today. About a decade ago, a widely circulated report by the Institute of Medicine (Smedley, Stith, & Nelson, 2002) revealed evidence of widespread racial/ethnic disparities in healthcare quality and outcomes. The Institute of Medicine took pains to show how these outcomes were not related to factors of access, health insurance availability, clinical need, appropriateness of intervention, or patient preference. Rather, they had much to do with cultural disparities in the United States (Smedley et al., 2002).
Cultural Competence
In recent years, many healthcare professionals and institutions have developed cultural competence initiatives to do something about that. Cultural competence, as it is called, has become a mainstream issue. Awareness is rising, but the consistency and quality of training for healthcare professionals are all over the map (Betancourt, Green, Carrillo, & Park, 2005).
Baker, Miller, Dang, Yaangh, and Hansen (2010) have worked with Southeast Asian families, with great success. The literature contains many definitions of cultural competence, but the one developed by Cross, Bazron, Dennis, and Isaacs (1989) can work well for us in the naturopathic educational field. Cross et al. defined cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations” (1989, p. ). Meanwhile, the Pew Research Center gave us a snapshot back in 2008 of what things will look like in 2050 demographically (Passel & Cohn, 2008). Those demographic realities will have a significant influence on what we teach and even on what we learn. Such demographic projections and other research can help us to plan now.
In short, the U.S. population will have hit 438 million, with 82% of the increase due to immigrants arriving between 2005 and 2050 and their U.S.-born descendants:
- Nearly one in five Americans (19%) will be an immigrant in 2050, compared with one in eight (12%) in 2005. By 2025, the immigrant, or foreign-born, share of the population will surpass the peak during the last great wave of immigration a century ago.
- The major role of immigration in national growth builds on the pattern of recent decades, during which immigrants and their U.S.-born children and grandchildren accounted for most population increase. Immigration’s importance increased as the average number of births to U.S.-born women dropped sharply before leveling off.
- The Latino population, already the nation’s largest minority group, will triple in size and will account for most of the nation’s population growth from 2005 through 2050. Hispanics will make up 29% of the U.S. population in 2050, compared with 14% in 2005.
- Births in the United States will play a growing role in Hispanic and Asian population growth; as a result, a smaller proportion of both groups will be foreign-born in 2050 than is the case now.
- The non-Hispanic white population will increase more slowly than other racial and ethnic groups; whites will become a minority (47%) by 2050.
- The nation’s elderly population will more than double in size from 2005 through 2050, as the baby-boom generation enters the traditional retirement years. The number of working-age Americans and children will grow more slowly than the elderly population, and will shrink as a share of the total population
(Passel & Cohn, 2008, pp. 16-17)
During this same period, there will be a big shift in race and ethnicity and in elderly populations, also by race and ethnicity. With regard to population numbers, 47% of the U.S. population by 2050 will be white, 29% Hispanic, 13% black, and 9% Asian; this compares with 1960, when these figures were 85%, 14%, 13%, and 5%, respectively (Passel & Cohn, 2008). With regard to the age of these groups, 63% of the white population will be 65 years or older by 2050, as will 17% of the Hispanic population, 12% of the black population, and 8% of the Asian population. In several places in the publication, the Pew Research Center did not include American Indian/Alaska Native populations during this period. In any case, by 2050, the Asian population will grow to 41 million. By 2050, 34% of Hispanics will be U.S. born, and 53% of Asians will be U.S. born.
Role of Interpretation
There are numerous issues arising from these demographic details that are useful information for naturopathic medical educators as this important focus of present and future effort emerges. At one point in the continuum, there is the present and rapidly evolving role of “interpretation” in nonwhite communities to assist in the design and delivery of healthcare. As Maria-Paz Beltran Avery points out so eloquently, there is a rapidly changing landscape in American civil society. She wrote:
Today, over 300 languages are spoken in the U.S. Political, economic and social changes worldwide continue to feed a constant stream of immigrants into the country. Their immediate and frequently urgent health care needs do not wait for linguistic adjustment or cultural assimilation. (Beltran Avery, 2001, p. 2)
Avery notes that the questions surrounding the role of the “interpreter” are tied to the issue of that person’s part in a healthcare team. A long tradition of neutrality is yielding, she explains, to varied responsibilities in healthcare and in the community served by a particular clinic, physician, or public health agency.
In that same continuum, McCubbin, Thompson, Thompson, McCubbin, and Kaston (1993) almost 2 decades ago examined critical factors in childhood chronic illnesses and disclosed important cumulative data about culture, race and ethnicity, and family as factors influencing not only treatment but also capacity for treatment because of potential cultural barriers. As well, Cross et al. (1989) speculated even earlier than that on a more culturally competent system of care in the allopathic field. This challenge has been before the field of primary care for decades and is ramping up.
There is the parallel challenge of unequal treatment confronting racial and ethnic disparities in healthcare. A consensus report released in 2002 called for increasing awareness about disparities among the general public, healthcare providers, insurance companies, and policy makers (Smedley et al., 2002). That same report called for “more minority health care providers” and “interpreters,” indicating that “they are more likely to serve in minority and medically underserved communities” (Smedley et al., 2002, p. ).[AU: PLEASE PROVIDE PAGE NUMBER FOR QUOTATION.] Nora Ellen Groce and Irving Zola had pointed out this fermenting problem a decade earlier, emphasizing that “integration and acculturation, social articulation with the greater American society, stress, cross-cultural misunderstanding, and outright prejudice can all compound the problems encountered for the chronically ill . . . in a multicultural society” (1993, p. 1048). McCubbin et al. (1993) focused on Native American cultures and their influence on family response to chronic illness and disabilities. The need to factor in cultural competency variables into educational design and delivery in healthcare has been accumulating for a long time. The literature is, in fact, abundant and expanding, including Dunn (2002), Satcher (2001), Groce and Zola (1993), Chan (1992), and Willis (1992).
There are numerous implications for these demographic projections for naturopathic medical education planners, most particularly in cultural competency, clinical and didactic curriculum design, clinical education settings, and treatment method (Beach, Price, Gary, et al., 2005; Risser & Mazur, 1995). Numerous commentators point out that many Hispanic community values, for example, lend themselves to a naturopathic framework for lifelong wellness and care, values such as personalismo, respeto, dignidad, and espiritismo. It is well known among NDs who provide care in Hispanic and Latino communities that these families and individuals are as familiar with chamomile or star anise for colic in infants as they are with naturopathic principles of balance and prevention. The key educational point here is that increased cultural competence within the naturopathic curriculum can prepare the profession to provide appropriate care for this rapidly growing segment of the population. As Risser and Mazur point out, “the importance of cultural beliefs in persons of Hispanic descent [are very important] in [shaping] a patient’s concept of disease, treatment, and even the existence of certain illnesses” (1993, p. ).
Transforming Allopathic Medical Curricula
Yet another factor that we will need to take into account is the gradual transformation of allopathic medical curricula to embrace so-called integrative medicine. At the University of Texas Medical Branch at Galveston (UTMB), this initiative has been under way since 1998, in fact, with dozens more universities joining the parade since. These universities are training primary care physicians to understand and support populations in communities that, as the Pew Research Center projections indicate (Passel & Cohn, 2008), will be massive in less than 4 decades. At UTMB, as a case in point, three classes embracing this model were already in progress between 2003 and 2005. Of interest is that, among underrepresented minorities during this period, the Step 1 failure rate decreased by 80%, from 16.5% to 3.3%, among minority students preparing for careers as physicians in their own communities; African American students showed the greatest improvement, with the failure rate decreasing by 94%, from 25% to 1.6% (UTMB website).
Key Initiatives
A quest to update a long-standing approach to teaching physicians has become almost a vanguard program. Steven Lieberman, MD, vice dean for academic affairs and professor of internal medicine at UTMB, reports that since 2005 “UTMB has held the highest overall medical board passage rate in the state, with nearly 98 percent of students passing” (UTMB website).
There are other initiatives that can guide us. The Cultural Medicine Training Center at White Memorial Medical Center (Los Angeles, Calif.) is another progressive venue paying attention to cultural competency curriculum for primary care professionals. The family medicine faculty is offering this year and next (March 2012 through February 2013) a 1-year fellowship zeroing in on cultural competence scholarship and teaching.
It may well be time, then, for the Association of Accredited Naturopathic Medical Colleges to launch an all-school and all-program initiative that propels us toward these curriculum challenges. Addressing gender and culture bias is essential given the rapidly transforming nature of the populations we will be serving.
Oakland University’s (Rochester, Mich.) cultural competency strategy was embraced by its William Beaumont School of Medicine and is a useful model to consider as we chart this course (Oakland University William Beaumont School of Medicine website). Oakland University developed a systematic organizational framework for action that drilled right down into business operations and programs. Every key sector of the university was affected, including policy making, infrastructure building, program administration and evaluation, the delivery of services and enabling supports, and the individual.
The Association of Accredited Naturopathic Medical Colleges could develop guidelines to help our naturopathic programs examine the following: mission statements; policies and procedures; administrative practices; staff recruitment, hiring, and retention; professional development and in-service training; translation and interpretation processes; family, professional, and community partnerships; healthcare practices and interventions (including addressing racial and ethnic health disparities and access issues); health education and promotion practices and materials; and community and state needs assessment protocols.
The planners could encourage teachers, students, and administrators, as individuals, to check out their attitudes and values, as well as the acquisition of the values, knowledge, skills, and attributes that are going to be part of working as physicians appropriately in cross-cultural situations. In fact, several of our college programs have offered workshops, seminars, and other educational opportunities to zero in on the kinds of priorities Oakland University has championed. These include the following initiatives:
- Value diversity and similarities among all peoples
- Understand and effectively respond to cultural differences
- Engage in cultural self-assessment at the individual and organizational levels
- Make adaptations to the delivery of services and enabling supports and institutionalize cultural knowledge
However, we would not stop there. There are numerous other dimensions to content related to specific populations (Hispanic, Latino, African American, Asian, Native American, and others) that will need to be understood, developed, and delivered. The details of healthcare values and practices in these cultures will be of strong interest, as will language skills to serve these populations.
There is much to do.
David Schleich, PhD is president and CEO of NCNM, former president of Truestar Health, and former CEO and president of CCNM, where he served from 1996 to 2003. Other previous posts have included appointments as vice pres-ident academic of Niagara College, and administrative and teaching positions at St. Lawrence College, Swinburne University (Australia) and the University of Alberta. His academic credentials have been earned from the University of Western Ontario (BA), the University of Alberta (MA), Queen’s University (BEd) and the University of Toronto (PhD)
References
Baker, D. L., Miller, E., Dang, M. T., Yaangh, C. S., & Hansen, R. L. (2010). Developing culturally responsive approaches with Southeast Asian American families experiencing developmental disabilities. Pediatrics, 126(suppl 3), S146-S150.
Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., Smarth, C., Jenckes, M. W., Feuerstein, C., Bass, E. B., Powe, N. R., & Cooper, L. A. (2005). Cultural competence: A systematic review of health care provider educational interventions. Medical Care, 43(4), 356-373.
Beltran Avery, M. (2001). The role of the health care interpreter: An evolving dialogue. Chicago: Illinois Department of Human Services, Bureau of Refugee & Immigrant Services. The National Council on Interpreting in Health Care Working Papers Series.
Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs (Millwood), 24(2), 499-505.
Chan, S. (1992). Families with Asian roots. In E. W. Lynch & M. J. Hanson (Eds.). Developing cross-cultural competence: A guide for working with young children and their families (pp. 181-257). Baltimore: Paul H. Brookes.
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: CASSSP Technical Assistance Center, Georgetown University Child Development Center.
Dunn, A. M. (2002). Culture competence and the primary care provider. Journal of Pediatric Health Care, 16(3), 105-111.
Groce, N. E., & Zola, I. K. (1993). Multiculturalism, chronic illness, and disability. Pediatrics, 91(5, pt 2), 1048-1055.
McCubbin, H. I., Thompson, E. A., Thompson, A. I., McCubbin, M. A., & Kaston, A. J. (1993). Culture, ethnicity, and the family: Critical factors in childhood chronic illnesses and disabilities. Pediatrics, 91(5, pt 2), 1063-1070.
Oakland University William Beaumont School of Medicine website. Embracing diversity and inclusion. Retrieved February 11, 2012, from http://www.oakland.edu/medicine
Passel, J. S., & Cohn, D. (2008). U.S. population projections: 2005-2050. Washington, DC: Pew Hispanic Center, Pew Research Center.
Risser, A. L., & Mazur, L. J. (1995). Use of folk remedies in a Hispanic population. Archives of Pediatrics and Adolescent Medicine, 149(9), 978-981.
Satcher, D. (spring 2001). Our commitment to eliminate racial and ethnic health disparities. Yale Journal of Health Policy, Law, and Ethics, 1. Retrieved February 11, 2012, from http://www.yale.edu/yjhple/issues/vi-spr01/docs/satcher.pdf
Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
University of Texas Medical Branch (UTMB) website. (2010). Model for 21st century medical education: Integrated medical curriculum proves beneficial for future doctors. Retrieved February 11, 2012, from http://www.newswise.com/articles/model-for-21st-century-medical-education-integrated-medical-curriculum-proves-beneficial-for-future-doctors
Willis, W. (1992). Families with African-American roots. In E. W. Lynch & M. J. Hanson (Eds.). Developing cross-cultural competence: A guide for working with young children and their families (pp. 121-150). Baltimore: Paul H. Brookes.
