Lisa M. Greenhill1, Kauline Cipriani2, William Gilles3 and Kimathi Choma4
1Association of American Veterinary Medical Colleges, USA
2Purdue University, College of Veterinary Medicine, USA
3University of Wisconsin, School of Veterinary Medicine, USA
4Kansas State University, College of Arts and Sciences, USA
Emphasis on providing graduates with the core skills necessary to work in increasingly diverse environments with colleagues and clients has been growing in healthcare education for a number of years. In human-oriented health fields, there has long been recognition of the relationship between health outcomes and disparities across differing racial, ethnic, and socioeconomic groups. As a result, the inclusion of curricular content focused on building cultural competence has been supported through specific medical school accreditation language, funding research into health disparities, and efforts to build a more diverse pipeline of health professions students.
Veterinary medicine should be no exception, and yet, as a profession, we have lagged behind our human medical counterparts in advancing the need for a diverse workforce and the development of culturally responsive curricula that help veterinary students build the necessary competence. Although the clinical emphasis in veterinary medicine focuses on providing medical services to the animal, the practice of veterinary medicine shares many fundamental similarities with human healthcare in the human interactions between providers and clients.
Including cultural competence in the core framework of a veterinary medical education cultivates more effective skills in future clinicians, researchers, and industry professionals. And in a profession that, as a whole, does not accurately reflect the racial, ethnic, and socioeconomic makeup of the United States (Thompson, 2013), the need for specific skills to reach across cultural boundaries is compounded. Without providing these skills, we leave new graduates open to a future of ineffective client interactions, resulting in a profession with less adequate patient care, reduced community engagement, and professional irrelevance. Including cultural competence as a core component of veterinary medical curricula promotes the opposite outcome. This increased ability to engage with clients leads to better medical adherence for our patients, and the potential for a vastly increased community presence for the profession as a whole.
Although the benefits of cultural competence training are clear, it can be a difficult skill set to teach and assess in students, especially considering that the methods for such training may be different from those used for teaching clinical and medical curricula. We do, nonetheless, owe it to our students and the future of the profession to provide this vital component of medical education.
As the language around this topic is ever-changing, we will not provide an exhaustive list of terms and definitions within this chapter; a few key definitions for common diversity-related concepts may be found in Box 29.2. We will instead focus on a number of major concepts that are important background for having meaningful conversations. Some of these concepts may be unfamiliar, and some of them may have a more nuanced interpretation within the context of cultural competence and/or cultural humility.
The term cultural competence denotes a collection of behaviors and attitudes that are adhered to or institutionalized within a profession and that enable effective cross-cultural engagement among all levels of interaction – such as that of professor–student or provider–client relationships (Cross, Dennis, and Isaacs, 1989; Isaacs and Benjamin, 1991; Watt, 2007). Unfortunately, this definition implies that one could become culturally competent and have no further need to think about the topic. Professionals in healthcare professions such as nursing and psychiatry specifically have criticized what has been referred to as an essentialist perspective of culture (Kirmayer, 2012; Williamson and Harrison, 2010). This perspective employs a definition of culture that is static and unchanging; thus, acquiring cultural competence is confined to increasing knowledge of cognitive cultural facts (e.g., values, beliefs, traditions) and then applying this knowledge (Williamson and Harrison, 2010). Blanchet Garneau and Pepin (2015, p. 12) have proposed a constructivist definition of cultural competence:
A complex know-act grounded in critical reflection and action, which the health care professional draws upon to provide culturally safe, congruent and effective care in partnership with individuals, families, and communities living health experiences, and which takes into account the social and political dimensions of care.
More recently, the term cultural humility has gained traction as a preferred method of describing the skill set that healthcare providers, including veterinarians, require to reach effectively across cultural gaps and engage effectively with the populations that they serve. Cultural humility differs from cultural competence in that it describes a lens through which an individual understands, processes, and implements the behaviors typically associated with successful achievement of cultural competence (Waters and Asbill, 2013). This lens focuses on the interplay among the identity, power, and privilege of individuals involved in a relationship, and depends on a deep understanding of how one’s personal identity frames one’s worldview (Waters and Asbill, 2013). Self-reflection and methods for processing life experiences are at the core of this framework, and must be practiced and applied to any interpersonal relationship. Cultural humility is a measurable personal development framework with which to engage throughout one’s professional career.
The concept of cultural competence in healthcare has been prevalent in human medical education for more than 30 years, thanks to clear links between the practice of cultural competence, quality improvement, and the elimination of racial/ethnic health disparities justifying the necessity of including such content in the curriculum (Brach and Fraser, 2000). US human medical school curricula are required to include content on diversity and cultural competence through the Liaison Committee for Medical Education Standards of Accreditation (LCME, 2015).
The concepts of cultural competence, cultural humility, cultural sensitivity, and diversity are not only valuable healthcare principles, their inclusion in practice provides ethical and legal protections for practitioners, as client needs are put at the center of medical decision-making. Tervalon and Murray-Garcia (1998) describe how humility is a prerequisite in the healthcare process: healthcare providers and clients are equal partners, with no power differential in the process. These conceptual values enable healthcare providers to deliver services that benefit all clients and their patients in a respectful, culturally relevant manner.
Cultural competence and humility do not have a rigid evaluative performance result to be mastered (Tervalon and Murray-Garcia, 1998); rather, becoming culturally competent and practicing humility should be seen as a lifelong continual growth process in understanding difference and applying it to one’s practice in the quest to practice the best medicine available. In veterinary medicine, this requires an approach that is both patient and client centered. Associating cultural competence and cultural humility with the core healthcare principle of patient centeredness can affect how practitioners value client culture and improve the quality of healthcare delivered (Saha, Beach, and Cooper, 2008; Campinha-Bacote, 2011).
As mentioned earlier, critics of the term cultural competence argue that the concept inadvertently leads one to believe that there is an end point to the skill set associated with the concept. Historically, teaching cultural competence has consisted of didactic lectures covering general information about various racial and ethnic group cultures, for example a lecture about African Americans followed by a lecture on individuals of Jewish descent. Such approaches can never be exhaustive and at best provide learners with overconfidence in their competence, based on static knowledge that is at risk of relying on stereotypes and not universally applicable information.
So, while this chapter advocates cultural competence content in teaching and curricula, we assert that veterinary medical faculty, students, and practitioners must strive to practice cultural humility. A cultural humility framework allows learners to focus on personal development and inwardly focused skills and behaviors. It moves the focus from the specifics of different cultures to the individual student, and through this humility framework provides a much better set of skills – the ability to embrace continued personal growth and self-reflection as an intrinsic quality of the veterinarian.
The historical traditions of medicine, specifically western medicine, create a framework for how we understand the practice of appropriate and efficacious medical care for humans and animals. The framework tends to be narrowly defined and places an emphasis on the practitioner rather than the patient or client. Often characterized as a nontechnical part of the practice of medicine, cultural competence is frequently seen as an “alternative to the epistemology of science” (Kirmayer, 2012, p. 156), and thus as a less important, at best, or unimportant, at worst, component of practice.
In reality, cultural competence and humility represent an increasingly important set of technical skills directly linked to health outcomes. Ever more pluralistic communities will demand and rely on culturally engaging, relevant, and responsive medical care. Teaching cultural competence and humility requires a framework that identifies competencies on which faculty must focus to practice and teach. Based on work by Seeleman, Suurmond, and Stronks (2009), the essential competencies framework is offered for veterinary medicine in Box 29.3.
Numerous models devoted to explaining the development of cultural competence suggest that it is best conceptualized as a continuum. Wells (2000) describes three developmental stages spread across two learning models. Cognitive learning phase outcomes include cultural incompetence, cultural knowledge, and cultural awareness; while cultural sensitivity, cultural competence, and cultural proficiency are affective phase learning outcomes (Wells, 2000, p. 192).
Veterinary students may achieve these learning outcomes in a variety of ways. In the classroom setting, teaching methodologies may focus on the use of lectures, case-based learning, and online modules, coupled with reflective writing and student peer engagement. Faculty must also model these competencies for students in the clinical learning environment. As students are learning various clinical skills, there is an informal kind of teaching that occurs when students observe faculty behavior, including interactions with clients. This behavior models how veterinarians behave, how they are expected to practice, and whether skills like cultural competence and humility are valued in the practice of medicine. Arguably, the behaviors found in the “institutional curriculum” are a reflection of the college’s values as well.
Institutional or Hidden Curriculum
The institutional or “hidden curriculum,” a term coined in the 1980s, refers to the “subtle, less officially recognized” (Hafferty and Franks, 1994, p. 861) lessons taught in the academic environment. These are the informal lessons on how to be a professional, and more specifically how to be a veterinarian, taught from the modeled behavior of administrators, faculty, and staff. The hidden curriculum is an important part of student learning; it supports the formal curriculum and the reinforcement of appropriate professional behaviors (Keengwe, 2010). Discordant role modeling by members of the college community can have a deep impact on students; a hidden curriculum showing students how to be a “doctor” can inadvertently increase cultural insensitivity and the reconsideration of student career paths, among other outcomes (Murray-Garcia and Garcia, 2008). Further dissonant institutional curricula may also spurn more openly hostile campus climates that have a chilling effect on student learning in general.
Institutions have a responsibility to require training on diversity for faculty and staff in and around the college of veterinary medicine (Nazar et al., 2015). Academic leaders should facilitate institutional investment in diversity as a core value, and the maintenance of consistent educational and clinical environments that demonstrate the importance of this value (Nazar et al., 2015). Administrative leaders should ensure that the institutional climate and its hidden curriculum do not serve to undermine the other, more formal learning experiences of veterinary students, described in what follows.
The increased cultural competence that we seek within veterinary medical education should be manifested as a lifelong quest for increased cultural humility, evidenced by how veterinary practitioners ultimately affect the communities in which they live and practice. Specifically, we seek to provide an education that will guide and support the veterinarian who wishes to move beyond the role of professional healer to the role of social change agent, within and perhaps even beyond the field of veterinary medicine. Can this be done? Is effective multicultural education in the veterinary medical curriculum even feasible, given an already full and rigorous curriculum?
We submit that not only is it possible, it is critical. Wear (2003) argues, and we agree, that medical education has been getting it wrong for years, first by limiting the curricular approach to additional content, rather than infusion into existing courses, and second by expecting one-time visits to or participation in free clinics, and/or pop-up lectures, to produce a sustained cultural humility. We should not expect increased cultural competence to emerge miraculously from intermittent participation (whether voluntary or required) in a series of disconnected events, lectures, and activities. Teaching cultural competence and humility is a process requiring multiple educational experiences across the veterinary medical curriculum. The institutional goal should be to ensure that the curriculum provides numerous opportunities for learning through required and elective coursework, clinical simulation, and online learning, as well as other educational methodologies (Lipson and Desantis, 2007).
The goal of a preclinical medical student curriculum focused on cultural competence and cultural humility should be to help students in their “individual diversity development” (Chavez, Guido-DiBrito, and Mallory, 2003). This involves engaging in work on personal development, including, but not limited to, lessons in social privilege, bias, epidemiological data on various demographic groups, and critical race and gender theories. Preclinical coursework must emphasize students’ ability to become more self-aware of personal values, to become interpersonally sensitive, and to develop a willingness to learn from their clients. Further, students should learn to “value and [choose] to validate those who are other, as well as otherness within [themselves]” (Chaves, Guido-DiBrito, and Mallory, 2003, p. 457).
These courses may utilize a variety of approaches. While standard didactic lectures can be used to teach basic diversity and cultural concepts, they are also often employed to cover general cultural themes and customs of various social groups. While such content can be enormously helpful, it should sequentially follow material that focuses on enhancing student personal identity development with respect to diversity. Again, the goal of this coursework is specific to the development of the individual student. In addition to lectures, workshop or seminar courses offer opportunities for a high amount of student engagement with the material. Small groups using faculty as facilitators can be especially useful in teaching cultural competence and humility content. Students need many opportunities to engage with their colleagues as they wrestle with this content and its relationship to the practice of veterinary medicine.
Veterinary administrators and faculty may find that this type of coursework focused on personal identity development may be better suited to the preveterinary curriculum and/or to being taught and facilitated by faculty with expertise in these scholarly areas. In the case of the former, the authors would strongly urge college faculty then to require evidence of such coursework in the prerequisites for admission into the professional veterinary medical program. In the case of the latter, we recommend offerings that are co-facilitated by expert faculty from the appropriate disciplines, who may be found in colleges outside of the college of veterinary medicine. It is critical to note that student cognitive development is the essential precursor to curricular content that facilitates effective behavioral change in practice. Either evidence of this curricular content is required for admission, or it is integrated as required course components in the Doctor of Veterinary Medicine (DVM) program.
The use of online learning technologies is certainly not new, but little has been published on its applicability to teaching cultural competence or cultivating cultural humility among health professions students (Wiecha et al., 2010). That said, online learning technologies can be an important component of the teaching of elements of the veterinary medical curriculum, and student responses to online learning are very favorable (Pasin and Giroux, 2011). As professional students, veterinary students are more likely to be able to maximize the potential of online learning environments and to participate more fully in self-directed learning (Hung et al., 2010). It is very likely, however, that online learning modules, particularly those addressing diversity and inclusion content, will be part of a blended learning environment that involves both online and face-to-face components. Although veterinary students have the skills to support self-regulated learning, there is a need for face-to-face engagement to underscore the importance of interpersonal relationships, as well as to provide students with the opportunity to verify and validate what they have learned in the online components (Paechter and Maier, 2010).
Online learning modules that create virtual worlds, such as the game Second Life, have been shown to be effective at creating safe environments for students to explore content related to diversity and inclusion (Games and Bauman, 2011). Virtual worlds in games provide students with the opportunity to try on different identities and make decisions based on those identities (Games and Bauman, 2011). This safe practice improves students’ ability to approach sensitive cross-cultural issues with clients (Mack, 2013). Mack (2013) writes that the use of online gaming to facilitate the achievement of cultural competence or humility can require more time than other learning methodologies; students need time to work through scenarios fully, possibly repeating them several times, and there is a continued need for face-to-face meetings and other reflective assignments to facilitate the related learning.
Moving students from the confines of the classroom to the field is an important component of developing competence and the appropriate level of humility in multicultural settings. Experiential learning, or for these purposes a clinical externship, provides students with the opportunity to apply directly knowledge gathered in both the formal and informal curricula. While most of the rotations in the final year of the professional DVM curriculum are devoted to developing and refining Day One clinical skills, which include client communication, these rotations are rarely nuanced enough deliberately to provide students with the opportunity to practice navigating cross-cultural engagements.
Numerous factors will influence students’ ability to leverage cultural learning opportunities in clinics; some students will express a natural motivation to seek out these experiences, while others will do so in order to conform behaviorally to the outcomes prescribed in the curriculum (Ng, van Dyne, and Ang, 2009). Clinical experiences enable faculty to utilize learning models that assist veterinary students in moving from simply experiencing a diverse interaction with clients and colleagues to achieving learning outcomes in cultural competence and humility.
Due to client pool limitations, faculty may find challenges in cultivating intentionally diverse learning situations for veterinary students. As faculty and administrators assist students in developing their clinical experience schedules, it is critical for students to be reminded that experiences should provide the opportunity to achieve learning objectives related to diversity, cultural competence, and cultural humility. Helping students find opportunities to engage with a wider clientele outside of the college or even the country may be necessary in achieving these goals. Additionally, novel approaches like virtual gaming, Sims for example, provide faculty with effective opportunities for targeted, project-based learning in these areas (Jarmon et al., 2009).
The hinge point in experiential learning is the need for student reflection before and after experiences. Regular journaling and reflection papers are essential to facilitate student learning; they are not merely assessment tools, although their use as such will be discussed shortly. Reflective assignments assist students in developing a greater sense of self and understanding of the experimental situation; such assignments are also necessary for developing the competencies that lead to positive client relationships (Sandars, 2009). They are time consuming for both faculty and student; however, they are an important teaching tool in programs seeking to develop culturally competent and culturally humble health professionals.