by Rick Krupinski and Ryan Sherriff

Illustration: Shayne Davidson

Reaching the Cultural Communication Station, one of 13 staged but very real clinical situations that comprise a thorough examination of her medical skills, a fourth-year U-M medical student finds Mr. Chan, a standardized (highly trained surrogate) patient representing an immigrant from China. Mr. Chan came to the U.S. three years ago to live with his daughter; he was diagnosed two years ago with late-onset diabetes and was prescribed oral medication. Mistrustful of Western medicine, Mr. Chan has not been taking the medication and has been treating himself through diet and exercise. His daughter, more assimilated into Western culture and the values of Western medicine, is concerned about the health problems her father could face in not taking the medication.

“What brings you in today?” the student asks.

“I don’t know,” says Mr. Chan. “My daughter told me to come.”

“Why did your daughter want you to come in?”

“She thinks I am not taking care of myself.”

The student asks Chan if he has been taking his medication. “No,” Chan says. “I don’t need pills yet. My diabetes is yin, only need to watch food and exercise and not get too excited. Not bad yet, not yang.”

Asked to explain yin and yang diabetes, Chan says, “Yin diabetes is not bad yet...only thirsty, want to go to the bathroom a lot, sometimes feel hot. There is combustion in body, so more heat and less water in body. Yin diabetes doesn’t need medicine, only to watch diet and exercise better and not get excited emotionally. If I do this, there will be more liquid in body, less heat. Yang diabetes is serious...then I need medicine. I don’t have yang. I have yin.”

After learning that Chan eats a diet of vegetables, bamboo shoots and bitter melon, the student asks about exercise. “I did Tai Chi three times a week before,” Chan says. “Now I do Tai Chi every morning. It helps the flow of chi.”

“What is chi?” the student asks.

“Like energy. Life force. We all have chi.”

The student finally succeeds in gaining Chan’s agreement to try the medication, Diabeta, for one month by promising benefits in Chan’s terms: “It will help your body make more liquid and less heat.”

This is the University of Michigan Medical School’s Comprehensive Clinical Assessment, a key, sweeping examination of student clinical skills that was established in the Medical School 11 years ago and is now a model of clinical testing nationwide. The Assessment evaluates students’ knowledge and ability at the end of the third year in areas such as taking histories on chest pain, pediatric and other complaints; performing abdominal, breast, cardiac, pulmonary and ophthalmologic exams; presenting cases and diagnoses in psychiatry and EKG and X-ray readings; and evaluating and managing the unconscious and critically ill patient. Many stations in the Assessment include standardized patients portraying specific roles, and students are videotaped or observed by a faculty member. Feedback — from a faculty member or a simulated patient — completes the circle of learning.

The Cultural Communication Station is one example of steps the U-M Medical School is taking to assure mastery of complex and comprehensive clinical and communication skills in all graduates. The larger context for this effort is an improved curriculum for the M.D. degree, which was overwhelmingly approved by the U-M Medical School faculty in September after a curriculum reassessment and revision more than two years in the making. The new curriculum will be put in place in August 2003, formalizing the integration of social and cultural factors into learning outcomes developed by the faculty. A patient-focused approach to learning, earlier and more frequent clinical experiences, and a second-year comprehensive assessment of clinical skills represent the kinds of changes that will be adopted.

Why this curriculum, why now? One important impetus is to strengthen the School’s efforts to do something about what the National Academy of Sciences’ Institute of Medicine says is “among this nation’s most serious health care problems” — disparities in health care. The Institute has issued a report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, which documents a multitude of inequalities. The report highlights specific disparities, for instance that minorities are less likely to be given appropriate cardiac medications or to undergo bypass surgery, and are less likely to receive kidney dialysis or transplants. It also cites significant racial and ethnic differences in access to cancer diagnostic tests and treatments, as well as higher-level HIV treatments. What’s especially surprising is that many of these disparities occur even when age, insurance status, income and severity of conditions are comparable.

“Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable,” says Alan Nelson, M.D., a retired physician and former president of the American Medical Association who chaired the committee that wrote the report. “The real challenge lies not in debating whether disparities exist, because the evidence is overwhelming, but in developing and implementing strategies to reduce and eliminate them.”

The Medical School’s cultural consciousness is not new, and it has well exceeded requirements imposed by accreditation guidelines. From early beginnings nearly a decade ago as a three-hour segment of Introduction to the Patient during first-year orientation, Michigan’s sociocultural programs have consistently examined the impact of a diverse culture on health and health care delivery. And the diversity of the Medical School classes is itself helpful in allowing students to share and learn from different life experiences in a trusting environment, reflective of the larger, changing world in which they will go on to deliver health care.

The 2003 curriculum propels those efforts forward with a learning approach focused on a strong foundation in biomedical and clinical sciences in a patient and clinical context that underscores health care implications related to ethnic and racial backgrounds, language barriers, spiritual and other belief systems, genetic and environmental factors, and economic, educational and geographic status. These skills are essential for a medical school with specific educational goals that include training future leaders in medicine.

Left to right: Priya Pullukat, Casey White and Joe Fantone Photo: Gregory Fox

Joe Fantone, M.D., professor of pathology and associate dean for medical education, demurs from labeling the curriculum “new.” “What we’ve done,” he says, “is continue to evolve over time and to expand the role of the patient as the focal point for learning, especially in the first two years of medical school. We believe that medical education is most effectively learned within the context of patient care, from the patient’s perspective, and in the integrated manner in which patients present to their physicians. We’re emphasizing for our students what it means to treat the patient as a whole person and as a unique individual.

“As an institution, we are responding to the needs of our patients in society. We’ve known about health care disparities for 15 or 20 years, and momentum to address them is increasing. Over the last 10 years society has highlighted — and research has documented — the critical importance of the cultural and social environments within which patients exist to their overall health. Our curriculum will continue to evolve to meet the needs of our patient population in an effort to provide the most effective health care and continue to work to eliminate disparities.”

Casey White, assistant dean for medical education and director of the Medical School’s Learning Resource Center, works with faculty to facilitate and assure integration of these themes into the Medical School’s curriculum. It was she who wrote a successful grant to the Arthur Vining Davis Foundations that provides additional support for integration of culturalism, spirituality and end-of-life care into the curriculum. The Vining Davis Foundations support, among other educational programs, projects that develop caring attitudes in health care. In fact, Michigan is at the forefront in securing external funding for educational programs focused on social and cultural issues.

“One of the things we constantly work toward,” White says, “is integrating these aspects into the curriculum in a way that helps students see where it all fits into patient care.

“Transferability of skills is something we want to assure. We’re not just teaching students how to approach Chinese patients with diabetes, we’re teaching them how to approach patients of different cultures with different beliefs.”

“We hope that students can move to any part of the country and apply knowledge and skills to that area’s specific ethnic, cultural and spiritual makeup,” Fantone says.

Student-written vignettes are central to the integrated curriculum, illustrating how cultural and other differences — and the need to discuss and understand them — can and do affect quality and outcomes of medical care. In the clinical clerkship phase, medical students are invited to write two such vignettes themselves, one in which a sociocultural issue was addressed in a positive manner, and one in which the issue could have been handled in a better way.

“One of the things that sets Michigan apart from other schools is that we have been able to recruit faculty from almost every single specialty of medicine to help teach these issues,” says Tricia Tang, Ph.D., an assistant professor of medical education recruited by U-M in 2000 from Mount Sinai Medical School in New York City to help the Medical School develop a more comprehensive and integrated approach to multiculturalism.

“Faculty can effectively ‘model’ the issues for students,” she says, “and show them that those issues are important in every aspect of medicine — it’s creating models and mentors for students at the same time.

“Our efforts are designed to help students understand the implications of cultural and social factors in relation to health, health care delivery and patient care.”

The following student-written vignette focusing on a patient with limited financial resources and abuse within the family demonstrates the levels and complexities of sociocultural learning:

A five-year-old girl presented to our surgery service for abdominal pain. She was born with multiple congenital defects of her gastrointestinal and genitourinary tracts, and had undergone many surgeries at U-M, including repair of an omphalocele and eventual colostomy. She had received all of her care at U-M since her birth, and was seen in the Pediatric Surgery Clinic every three months for follow-up. She lived in Ypsilanti with her mom, dad, and younger sister, and it was known to our team that the family had limited financial means and the child’s health care was paid by Medicaid and other state funding.

The girl stayed in the hospital for about a week, and it was determined that no additional surgery was needed at that time. While planning her discharge, the mother was advised that the child should follow up with the Pediatric Surgery Clinic in about one week. The mother said that she was not sure that would be possible because she had been thinking of moving with her two children to Alabama to live with other family members. She hadn’t discussed the move with her husband and did not know when she was leaving or how she was going to get to Alabama, so we reinforced the idea that she should return one week after discharge and we sent the child home. The child did not return for follow-up the next week, and she missed her next previously scheduled three-month follow-up appointment.

Approximately four months after her hospital discharge, she presented to the U-M ER with nausea, vomiting and abdominal pain. She was admitted and underwent an operation for small bowel obstruction. It was learned that the mother and two children had moved to Alabama immediately after the child’s previous discharge. In fact, they had not even gone home after leaving the hospital; they had driven straight to Alabama. When a health care worker inquired about the father, we learned that the father had been physically abusing the mother, and this was the reason she did not feel safe staying at home and returning for the follow-up a week later. The mother had no money, and she felt that her only option was to return home to her family, even if it meant sacrificing the health care her daughter desperately needed.

The medical student, reflecting on this experience, wrote, “...we should have listened when the mother said she might move to Alabama. She had not made plans or informed her husband...and we dismissed the idea. That she was thinking of moving without informing her husband should have been a red flag...Had we referred her to an Alabama hospital, or simply given her a copy of her child’s medical records to carry with her and told her to report to an ER in Alabama, the child could have possibly gotten the care that she needed...A social worker would have been very helpful in this situation to determine how the medical care could be paid for. I also learned that had a better social history been taken at the time of the hospital admission, then perhaps the situation would have been recognized earlier...and the family could have been referred to SafeHouse or a similar organization.”

“Culturalism is not just differences based on ethnic heritage,” says Tang, “it includes social groups, sexual orientation, economic circumstances, poverty, environmental conditions patients live in, different belief systems, different family structures, as well as how the family as a whole thinks about health. I think these issues are sometimes more influential in health care delivery and utilization than ethnic issues.”

Effective communication about treatment approaches and end-of-life care can become particularly complex, as this student learned:

A 56-year-old Arabic male presented unconscious to the ER with six members of his extended family. Two months prior he presented to the ER with mild gastrointestinal complaints. Because of the language barrier, and no translator, a full work-up was done and an 8x12-inch tumor was found in his right lower abdomen, along with seven smaller tumors. His family decided they wanted to first try herbal remedies to cure the cancer, and he did not present for any follow-up appointments. His family states he was in his usual state of fairly good health until the night before presentation, when he was very sleepy and retired around 7 p.m. He was found early the next morning, unconscious.

He was intubated and transported to the ICU. Neurological exam revealed only a questionable cornea reflex. A head CT scan revealed multiple contrast-enhancing lesions. Do not resuscitate/do not intervene conversations were begun with his oldest son, who spoke English well. He had not known the full extent of the cancer because it was not talked about among family members. The patient was in the ICU for about eight hours, unconscious but stable, then developed a pulseless heart rhythm which did not recover after more than 40 minutes of code. Prior to withdrawing support, his family was allowed into the room, the patient’s bed was turned toward Mecca as the family wished, and a holy man said a prayer for him. The family was allowed to grieve in the manner that was their custom.

Observed this U-M student: “I learned that even in situations of death and dying when nothing can be done for the patient, a physician can still assist the living. It is easy for simple gestures to be done to follow the patient’s customs...”

Susan Urba and Tricia Tang Photo: Martin Vloet

In fact, one of the very first experiences first-year medical students have is gathering together as a full class to listen, observe and ask questions as Susan Urba, M.D., interviews one of her patients. Urba, associate professor of internal medicine, is an animated, enthusiastic, cheerful woman; one might not guess that she’s an oncologist who daily helps patients battle some of life’s most treacherous illnesses, often without positive outcomes.

Urba’s patients, often accompanied by a spouse, partner or other family members, describe the history of their illness. They tell the medical story from the patient’s point of view: how the physician broke the news, how the patient and loved ones felt upon and after hearing it, what the course of care was, what the course of care was like. Issues of faith often enter into the sometimes two-hour interviews. Urba says the patient interview engenders a lot of thoughtful and pertinent questions from the new medical students. For many, this is their first exposure to issues surrounding the end of life.

One such interview in particular stays with Urba. “The patient, who was very ill, managed to be both funny and poignant during the interview, and the class reacted with great interest and genuine affection. They so warmed to this man that they got a huge thank-you card and every member of the class signed it and they sent it to him. When he died just two weeks later, the emotional impact ran deep with the entire class.” Urba learned that in talking with others during the days before his death, the patient referred proudly to his appearance before the new group of medical students as “his legacy to future physicians.”

Urba stresses the importance of working within a patient’s belief system and notes that cultural attitudes toward death vary greatly. For those who believe, like the Dalai Lama does, that death is like shedding worn-out clothing for new and that one comes back to a fresh life, death is not devastating. Western cultures have far different views. Urba says a physician must be prepared to work with the patient, not only on end-of-life, palliative issues where the intent is to relieve suffering, but also on treatment protocols. And this sometimes means accepting the patient’s wishes when physician recommendations run contrary.

She recalls one dying patient under her care whose condition had deteriorated beyond the need for nutrition; indeed, the nutritional tubes were causing the patient great distress, a point at which they are typically removed. The most conservative followers of Orthodox Judaism, however, do not condone this measure. “Life is full of suffering,” her patient told Urba. The nutritional tubes remained.

Susan Goold Photo: D.C. Goings

What about the ethical implications for health care that incorporates patient beliefs into treatment protocols and end-of-life care? “We teach students about the important legal cases and issues, and about the definition of death,” says Susan Goold, M.D., associate professor of internal medicine and director of the Medical School’s Bioethics Program. Lectures, small group role-play exercises, and simulated patient instruction are all learning tools for the ethics of patient-based medicine.

“We cover the ethics of end-of-life care and decision-making, including such topics as advance directives and withdrawing or withholding life-sustaining treatment, focusing heavily on how to discuss these sensitive, emotional issues with patients and family members. Cultural, spiritual and other influences feature prominently, and there is a very explicit focus on language. When religious beliefs arise, students are encouraged to involve clergy, counselors and families. They struggle with how to communicate — or whether to communicate — their individual opinions.”

Students also see the play Wit! – a powerful portrayal of a woman’s diagnosis with cancer and her journey toward death. The play is part of a national program using Wit! and small group discussions to improve students’ knowledge about, and interest in, care of the dying. “I use it primarily to motivate students to learn how to care for the dying. It is incredibly moving,” Goold says.

The lessons can be hard, and may sometimes be very personal. One student wrote:

I saw a 57-year-old white male patient in Psych Urgent Care at the VA. The patient was clearly being manipulative in trying to convince me that he needed certain medications known to be addictive. After a 40-minute interview, the patient could tell that I was not convinced he needed this medication. I told him I would talk things over with the attending and we would come up with a plan. The patient said, “Well, is the doctor black? I don’t talk to black doctors. I don’t want them to know my business.”

I asked him why he did not talk to African-American physicians and the patient had no concrete reason. He simply said, “I don’t think they are on the same page as I am.” Finally I said, “You’ve been talking to me for almost an hour and I’m black.” The patient looked very surprised and exclaimed, “You are? I thought you were Indian!”I told him I would talk to the attending and return shortly.

I told the attending about the situation and the attending was supportive, saying that we do not tolerate racial preferences by patients.

“From this,” the U-M student wrote, “I learned that stereotypes about certain groups are alive and well. For whatever reason, the patient did not want to be cared for by a black person. I have to understand that as a young black woman I will probably encounter many patients like him. However, I will have to continue to try to be the best health care provider I can be, and hopefully my knowledge, confidence and interpersonal skills will help...”

The reasons for health care disparities in American society are, as the Institute of Medicine terms them, “multifactorial.” They are rooted deeply in cultural unawareness, poor communication and information channels, economic circumstance and the social stratification it causes, geographic location, levels of education, and a multitude of other factors. Disparities are also the unfortunate outcome of a social history that includes lack of tolerance, understanding and respect for diversity.

“This is a terribly serious national problem,” says Dean Allen S. Lichter (M.D. 1972), “and as an academic institution, especially a public university, we need to be sure we are bringing all our resources to bear on its solution. Anything short of that is just unacceptable. We must produce physicians who better understand and respect the cultural differences they will face in their careers.”

Faculty working to integrate multiculturalism, spirituality, complementary medicine and end-of-life care into the curriculum recognize that a vital component of health care requires understanding each patient in the context of his or her whole life, and providing care based on that context and respect for the individual. It is the Medical School’s goal to prepare future physicians ready to provide complete care to all patients and, in the process, help end the history of health care inequality that has haunted a nation of plenty throughout its history.

“It’s not only the right thing to do,” says Lichter, “it’s simply better medicine, and I would like to see this mentality pervade everything this School does, at every level. Great universities like Michigan and its Medical School have a responsibility to stand up to the great challenges of their time.”

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