In this article, the second of our series on cultural humility education across Minority Fellowship Program disciplines, we look at how future psychiatrists are being trained to serve a more diverse U.S. population. In the United States, resident physicians training in psychiatry are required to master cultural psychiatry, adopt attitudes that endorse the principles of cultural competence, and acquire specific cultural competence skills that facilitate working effectively with diverse patients.1 Initially the field of psychiatry focused on acquiring basic knowledge of cultural factors that impact psychiatric symptom presentation and psychiatric care. However, this type of approach did not address how to translate cultural competency into concrete clinical skills and interventions. Additionally, many of these efforts perpetuated racial-ethnic stereotypes by “presenting lists of [minority] traits for clinicians to remember rather than clarifying the complex sociocultural environments in which patients live.”2 Today, psychiatry residency students have to master professional competencies related to cultural competence education set by the Accreditation Council for Graduate Medical Education (ACGME). This article examines ACGME’s requirements for resident students, the American Psychiatric Association (APA) position on mental health equity, and includes an interview with Mariam Rahmani, a child and adolescent psychiatrist.
Psychiatry and its subspecialties require intensive cultural competency training.1 The competencies specify what residents are expected to master before completion of training. The cultural competency framework in general psychiatry is housed within five of the six core competency domains: patient care and procedural skills; medical knowledge; interpersonal and communication skills; professionalism; and systems-based practice.1 The ACGME also maintains additional guidelines for subspecialty fields, such as child and adolescent psychiatry for which fellows must master competencies related to cultural influences on family and child/adolescent populations. ACGME psychiatry requirements for training related to cultural competence are shown in Table 1.
The APA is the main professional organization for psychiatrists in the United States. The mission of the APA is to:
The APA recognizes that psychiatrists have a key role in promoting mental health equity in clinical care, research, education, interventions, administration, and public policy advocacy. The APA’s position statement on mental health equity is as follows:
The APA also recognizes there is serious continued underrepresentation of certain ethnic minority groups among U.S. medical students, medical school facilities, departments of psychiatry and practicing clinicians. The APA supports the development of cultural diversity among its membership and within the field of psychiatry (including in undergraduate and graduate medical education, faculty education, research, psychiatric administration, and clinical practice) to prepare psychiatrists to better serve a diverse U.S. population.
Table 1 ACGME psychiatry requirements for training related to cultural competence and required program resources
|Patient care and procedural skills<
IV. A.5.a).(1). (a) and IV. A.5.a).
|Residents must demonstrate competence in: the evaluation and treatment of patients of different ages and genders from diverse backgrounds, and from a variety of ethnic, racial, sociocultural, and economic backgrounds; and must demonstrate competence in forging a therapeutic alliance with patients and their families of all ages and genders, from diverse backgrounds, and from a variety of ethnic, racial, sociocultural, and economic backgrounds.|
IV. A.5.b).(2) and IV. A.5.b).(9)
|Residents must demonstrate competence in their knowledge of: biological, genetic, psychological, sociocultural, economic, ethnic, gender, religious/spiritual, sexual orientation, and family factors that significantly influence physical and psychological development throughout the life cycle; and aspects of American culture and subcultures, including immigrant populations, particularly those found in the patient community associated with the educational program, with specific focus on the cultural elements of the relationship between the resident and the patient, including the dynamics of differences in cultural identity, values and preferences, and power.|
|Interpersonal and communication skills
|Residents are expected to: communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds (this includes effectively working with interpreters).|
|Residents are expected to demonstrate: sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.|
|Residents are expected to: assist patients in dealing with system complexities and disparities in mental health care resources.|
|General program requirements resources||The institution and the program must jointly ensure the availability of adequate resources for resident education, as defined in the specialty program requirements.
Specifically, there should be patients of different ages and genders from across the life cycle and from a variety of ethnic, racial, sociocultural, and economic backgrounds.
There should be an inpatient population that is acutely ill and represents a diverse clinical spectrum of diagnoses, ages, and genders.
To provide further insight on cultural competency in the psychiatric field, we interviewed Dr. Mariam Rahmani, a child and adolescent psychiatrist at University of Florida Health.
Dr. Rahmani stresses the importance of inserting cultural competency education in residency training and of why students should work to attain these skills before practicing. She states, “It is important to understand our patients in their context. It is quite challenging to prescribe appropriate treatment without knowing about a patient’s culture, including life experiences, financial status, literacy, and religious beliefs. We need to know which populations are genetically predisposed to certain outcomes. For example, the HLA-B1502 mutation in patients of Asian origin increases the risk of the life-threatening Steven-Johnson syndrome caused by the medicines carbamazepine (Tegretol) and lamotrigine (Lamictal). Patients from some eastern cultures are more likely to report physical than psychiatric complaints. Being culturally competent in the psychiatric field means that we don’t define our patients by their illness. That we get to know the person who has an illness instead of knowing the illness a person has. Without cultural competence, we risk missing opportunities to help our patients.”
Dr. Rahmani also recognizes the need for improvement in cultural competency training in psychiatry. “…the biggest barriers in learning and teaching cultural competency in psychiatry, in my opinion, are limitations on time and reimbursement. Billing codes cannot always capture the importance of spending time to learn, teach, and use the model of culturally informed care. We need to invest this time in ourselves, our trainees, and our patients who come from diverse backgrounds.” She also highlights that cultural competency training should consider the dynamic nature of culture. “We need to provide our trainees the tools to work with culturally diverse patients, including those who have experienced historical or personal trauma, and families who have experienced separation of children from their parents,” she remarked.
Dr. Rahmani offers these words of advice to help graduate students preparing to interact with diverse populations in the psychiatric field, “Learn about different cultures and communities. Remain curious. One way to curiously explore a patient’s background is using genograms. The more curious people are, the less judgmental they appear. If I start to experience negative feelings about a patient, I consider whether it’s related to my own implicit bias. I often check with my colleagues and my patients if I am understanding them or their situation accurately, and to help me understand if I am struggling.” She also shared several educational resources available online for free, including the American Academy of Child and Adolescent Psychiatry Practice Parameters, National Institutes of Health, Centers for Disease Control and Prevention, the Department of Health and Human Services and SAMHSA websites:
1Corral et al., “Psychiatry Resident Training in Cultural Competence: An Educator’s Toolkit,” Psychiatric Quarterly 88, no. 2 (2017): 295–306, https://doi.org/10.1007/s11126-016-9472-9.
2N.K. Aggarwal et al., “Does the cultural formulation interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site,” Ethnicity & Health 20, no. 1 (2013): 1–28, https://doi.org/10.1080/13557858.2013.857762.
3American Psychiatric Association, Position Statement on Diversity. APA Official Actions. (2017), https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2017-on-Diversity.pdf.
4American Psychiatric Association, Position Statement on Mental Health Equity and the Social and Structural Determinants of Mental Health. APA Official Actions. (2018), https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Mental-Health-Equity.pdf.
As the United States becomes more diverse, it is essential that students are exposed to culturally congruent education and environments so that they may better care for the consumers for whom they will provide care and support. Increased levels of cultural competency and enhanced patient-provider communications will make important contributions toward reducing racial and ethnic disparities in health care.