Ethnographic Studies in the Principles of Clinical Medicine

Oregon Health and Sciences University (OHSU) introduced the Principles of Clinical Medicine (PCM) course in 1992 with the intent of providing medical students early in their training with a patient-centered care context. Students are enrolled in this two-year, longitudinal course at the same time they are learning basic sciences. PCM consists of two components: a weekly preceptorship in which students spend four hours a week with a community physician and four hours in classes focusing on the knowledge, skills, and attitudes involved in providing patient-centered care. Classes are taught with large-group presentations followed by small-group discussions, and include an introduction to patient examination and diagnostic reasoning as well as to key patient-care issues drawn from epidemiology, medical ethics, organization of health care systems, and the behavioral and social sciences. We believe this curriculum better prepares our students for their third-year required rotations, as well as for their relationship with patients throughout their medical career. One of the goals of this curriculum is to help students develop cultural sensitivity. This is not an easy task. Some students come to medical school feeling that they are open-minded about other cultures; therefore they are culturally competent. Nevertheless, we wish all students develop the kind of knowledge of and experience with other cultures that they will need as physicians. To do this we must walk a fine line between teaching salient characteristics of various cultures, which students dismiss as “stereotyping,” and giving them vague advice about the importance of treating all patients with equal respect and trying to understand their worldviews. Another goal is to develop students' ability to reflect thoughtfully upon key issues affecting their future practice of medicine. Students engage in group discussions with their peers and physician group leaders; they also are required to write a quarterly essay. Essay assignments vary in structure and content. Specific requirements have evolved over the years along with the curriculum but the overall goal of encouraging self-reflective thinking and writing remains unchanged. In 2001, we attended a national meeting of the Society of Teachers of Family Medicine at which we were inspired by the work of Dorothy Mull, PhD, a medical anthropologist at Keck School of Medicine at University of Southern California. Dr Mull taught students more about the patients they were seeing from the Los Angeles Latino community by assigning them an “ethnographic interview.” With her assistance, each student found a patient from the Latino community, arranged for a home visit, and interviewed the patient with the assistance of a list of specific questions she had prepared for them. As we all know, we never learn as well from books as we do from lived experience and this method of introducing students to patients with lives and worldviews very different from their own was innovative and intriguing. We wondered if it would work in Portland, where ethnic communities are far less defined and where few students work with preceptors that see ethnically diverse patient populations. With Dr Mull's permission, we adapted the assignment. At first, we framed the assignment as an opportunity for students to interview a patient who would be considered “underserved.” We also asked for more personal reflection on the experience—that is, to relate their individual patient's situation to what they have learned during the PCM quarter devoted to discussion of US health care policy and economics. Some students did interview patients of different cultures and ethnicities and their experiences greatly impressed the small-group leaders who read the essays on the basis of their experiences. However, finding a patient was difficult for some students and they opted to interview friends or next door neighbors, who are “underserved” simply because they had no health insurance. Although this could be a valuable learning experience, it did not meet the goal of increasing students' cultural sensitivity. So last year, we rethought the assignment and reworded it to specifically ask that students interview a patient “from an ethnic or cultural background other than your own.” Because this assignment involved sending medical students out into the community, we initially had to obtain permission from OHSU legal affairs and the School of Medicine. The activity was approved, provided we added a requirement to the assignment that students obtain written permission from patients to be interviewed, advised students who arranged home visits not to go alone, and reminded students that in visiting homes as health care professionals they were required to report any suspicions of child abuse. These guidelines seemed sensible for any home visit, no matter what the socioeconomic or ethnic status of a patient. Nonetheless, some students perceived these precautions as culturally insensitive with an implicit assumption that patients of other cultures are more dangerous or more prone to domestic violence. Sometimes students teach their faculty as much as we teach them! Their concerns have been heard. Appropriate revisions to the wording of the assignment are complete and we will strive to communicate these changes more effectively to next year's students. That said, most of our students in this and past years have responded quite favorably to this assignment, acknowledging that it can be among the most valuable and memorable experiences of their first two years. It moves them out of their comfort zone and enables them to learn things about patients and cultures that they never would otherwise. We consider it to be the best opportunity we offer to promote the practice of culturally sensitive medicine. Our faculty continue to be amazed not only that students learn so much, but that they often write so eloquently about these experiences. When I matriculated in medical school more than three decades ago, no time was devoted to these important issues. Our medical school curriculum has been revised to address many of these shortcomings. The insights, capacity for self-disclosure, and openness to growth reflected in these essays by second-year students suggest that our efforts have been worthwhile. These “Voices of the Future of Medicine” give me great hope and confidence—hope for the future of our profession and confidence in the exceptional quality of care these future physicians will ultimately provide their patients. I am grateful to Dr Janisse for suggesting and making it possible to publish some of our most-talented students' writings in The Permanente Journal, and to the Collegium for the Study of the Spirit of Medicine, a group within The Foundation for Medical Excellence (TFME), a Portland, OR organization, for recognizing the worth of this experience and for developing a scholarship program in 2007. This truly exemplifies the spirit of medicine.