Diversity and Cultural Competency Case Studies

Copyright material provided with permission of the American Academy of Family Physicians

An African-American female medical student walks into a study group of three Caucasian-American male medical students. One of them is overtly hostile to her, saying that by her receiving a scholarship he was prevented from getting one. He says that "It's unfair that you get treated better than everybody else, just because you're a minority..." The female student protests that she just wants to be treated like any other person, but the male student continues to harass her saying, "You're going to have to prove yourself to me."

Possible Questions for Discussion:

1. Why would the Caucasian student have the perception that the Black student is "treated better than everybody else?"
2. What are reasons that no one spoke up during the discussion?
3. If you were an observer to this scene, would you intervene? If so, how?
4. What kinds of psychological preparation and counseling should a person of color have prior to becoming a student at a predominately Caucasian medical school? What kind of support system might this person need?
5. How should a class of medical students become sensitized to issues of racial and cultural bias in medicine?
6. What is the Black student feeling? The white student?
7. Are non-minority students at your institution resentful of minority students regarding special programs specifically designed for minorities?
8. If you are a student, do you feel welcome at your school?

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A Hispanic female medical student is doing a case representation of a Hispanic female patient to a white male attending physician. The presentation includes a sympathetic recounting of the patient's beliefs, including naive ideas about illness, ideas of spirit possession and exorcism, and comfort from religious faith. The attending finds the presentation "excessively informal and unscientific," and suggests that the student includes this material because, "You're from her race, and are sympathetic to her." He scolds her that they are working at a prestigious medical center and suggests she make more conventional presentations.

Possible Questions for Discussion:

1. Why would the attending physician be so unsympathetic to this style of presentation and these aspects of a patient's life? Is his behavior appropriate?
2. If you were the student how would you feel? How would you react?
3. How can medical school faculty become better informed about the relevance of racial and cultural issues in patient care?
4. How can a resident or medical student best learn to incorporate both scientifically and culturally relevant issues within a brief presentation?
5. Since understanding cultural factors appears crucial for patient compliance, how should a resident or medical student become knowledgeable about these cultural factors considering the vast diversity of cultures currently within the United States?
6. What is the attending physician accomplishing with his attitude? What value is given to the knowledge possessed by the Hispanic physician regarding Hispanic culture? What other responses are possible?
7. Does your school have an established protocol for minority students to report racially-related incidents?

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A middle-aged, Caucasian faculty member reassures a Native American student that no matter what kind of performance the student does, his work will be accepted, because "It's important that we have at least one Native American student matriculate each year, and you're the only one this year."

Possible Questions for Discussion:

1. How do you imagine the student feels?
2. If you were the student, what would you say to the faculty member?
3. What is your opinion about whether disadvantaged students should be accepted and maintained preferentially in training programs, even if their performance is poor?
4. Has a situation like this ever occurred in your experience?
5. Do faculty think that there are different admissions criteria for minority students? If so, in what ways?
6. If you are a student, how does this affect your interaction with faculty in the classroom, laboratories, and clinical rotations?
7. How much should medical students be allowed to participate in the selection process of applicants including ethnic minority students?

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Two Caucasian-American third year medical students are talking in a casual conversation. Along comes a peer African-American male who overhears their conversation. One of the white students says that she doesn't think that Black and Hispanic students are very bright and "all of them are here only because there is a quota system."

Possible Questions for Discussion:

1. How prevalent is this student's attitude? Is it racist?
2. If you were the Black student, how would you have responded to overhearing this?
3. How could you help the white student develop a more balanced perspective about fellow students?
4. Do you think this student developed her stereotyped ideas from current classmates or had biases prior to medical school experiences?
5. Would there be any way to anticipate and reduce this cultural and racial bias?
6. If you were the other white student, what would you say to her?
7. Do your classmates think that there are different admissions criteria for minority students? If so, in what ways?
8. How does this affect your interactions with classmates in the classroom, laboratories, and clinical rotations?
9. How does the presence or absence of other minority students affect you?
10. Has your self esteem changed since entering medical school? How? Why?

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An African American student on the trauma surgery service is hurriedly sent to perform a discharge physical on a patient the student about whom has been told nothing. The student enters the patient's room to start the physical without first reading the patient's chart, and finds upon entering that the patient is an African American male whose right arm and shoulder are bandaged. Giving the student his history, the man says that he was in a car accident. As the student concludes his interview and begins to examine the patient, a team of Caucasian male orthopedic surgeons enters the room. Without acknowledging either the student or the patient, they approach the patient and manipulate his shoulder to determine its range of motion. Informing the patient that he should call to schedule an orthopedics appointment next week, the chief surgeon assures the patient that, "These gunshot wounds always heal fast," and then leaves. The student feels that he should be furious with the orthopedic surgeons, and almost corrects them, but then wonders whether the man has lied to him. The student excuses himself to go read the patient's chart, which documents the man's car accident.

Possible Questions for Discussion:

1. Why might the student have been furious with the surgeons initially? How might the student have felt towards the surgeons after reading the chart?
2. Would the student's anger be less justified if the incident had occurred in a busy inner city hospital that admits many minorities secondary to violent trauma? Would his anger be more justified if the incident had occurred in a suburban community hospital that admits few minorities?
3. How might the student have felt towards himself after reading the chart? Why might he have doubted the patient?
4. Is the student's failure to read the chart before seeing the patient evidence of poor clinical skills?
5. How should the student have dealt with the surgeons? Should he have spoken to them directly? Should he speak to one of his attendings about their behavior?
6. How might the student's response to the surgeons have affected the patient?

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While preparing to get her microscope and slide set to study for a histopathology test, a Mexican American student enters her assigned lab to find a small group of Asian American and Caucasian American students studying slides from a projector. Inviting herself to join the group, she sits down while the group's apparent leader, a talkative and friendly Caucasian American male, leads the discussion. Being a late arrival, the Mexican American student sits quietly and watches the other students identify the slides. Although there is some debate, the other students seem to differ to whomever speaks most authoritatively. As the other students get stumped by one of the slides, the Mexican American student volunteers what she is certain is the right answer. To her surprise, the group leader says he's got to look it up. Asking him why he feels the need to look up her answer but no one else's, he says, "We should know the answer. We all went to top ten schools for undergrad." Packing up her microscope, she says, "Too bad you don't know how to recognize the right answer."

Possible Questions for Discussion:

1. Does the Mexican American student seem excessively offended? Does she seem justifiably offended?
2. How do you think the Caucasian American student leading the discussion feels about this exchange?
3. How do you think the other students in the room feels about this exchange? How might they describe it to their friends?
4. How do you feel about this exchange? Would it change your impression to know that the Mexican American student rarely has her answers challenged? Would it change your impression to know that this student and her friends feel that they're always having their answers challenged?
5. Did you make any assumptions about who her friends might be as you considered the preceding question? Is there any relationship between your assumptions about who her friends might be and the group leader's assumption that her answer was untrustworthy?

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A Native American M.D., Ph.D. student attending a conference on binary fission in bacteria unexpectedly bumps into two of his classmates, an engaged Caucasian American couple whose parents are well-known faculty members at the school the students attend. In response to the Native American student's surprise at their attendance, the female member of the couple says that her father found grant money to pay for the couple's attendance, and that he's lined the couple up with research positions for the next year. At this, the Native American expresses interest in bringing a proposal to the woman's father, to which she says, "What are you worried about? Minorities get all the cushy research positions, anyway."

Possible Questions for Discussion:

1. If you were the Caucasian American woman, would you take advantage of your familial connections in the same way that she apparently does? Why or why not?
2. Were the Native American man to be in the position to grant opportunities like the ones described above, how should he grant them? Should he give opportunities to his family members and acquaintances? Do you think that medical professionals in general have a tendency to grant opportunities to those whom they know?
3. Are there any similarities between the opportunities the students like Native American man may receive through affirmative action programs and the opportunities students like the Caucasian American woman receive through personal contacts? Are there any differences between the opportunities the two aforementioned group of students receive?
4. Are the qualifications of the medical students who are children of faculty members questioned to the same degree that the qualifications of minority students sometimes are?
5. How should the Native American student react? What should he say to these two classmates?
6. Assuming that the woman's father is a famous researcher with whom the Native American student has been eager to work, how might he react to the woman? Why?

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