A. Cultural Competence Accreditation Standards

The accreditation standards regulating medical education that are directly related to cultural competence both at the undergraduate and graduate levels are governed by the Liaison Committee on Medical Education (LCME) and Accreditation Council on Graduate Medical Education (ACGME), respectively. “Medical schools and graduate residency programs simply cannot operate if they fail to fulfill these minimum requirements.”

a. The LCME

The LCME is a body composed of the American Medical Association (AMA) and AAMC that judges medical schools, including their curricula, facilities, and faculty, against a set of public standards. It is responsible for the accreditation of medical schools in the U.S. and Canada.

*169 Two measurable accreditation standards that U.S. and Canadian medical schools must fulfill to stay in operation, which are directly related to cultural competence and the undergraduate medical education minimum standards, are as follows: ED-21. The faculty and students must demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.

The LCME governing policy further explains ED-21:Instruction in the medical education program should stress the need for medical students to be concerned with the total medical needs of their patients and the effects that social and cultural circumstances have on patients' health. To demonstrate compliance with this standard, the medical education program should be able to document objectives relating to the development of skills in cultural competence, indicate the location in the curriculum where medical students are exposed to such material, and demonstrate the extent to which the objectives are being achieved.

ED-22. Medical students . . . must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery.

The LCME governing policy further explains ED-22:

The objectives for instruction in the medical education program should include medical student understanding of demographic influences on health care quality and effectiveness (e.g., racial and ethnic disparities in the diagnosis and treatment of diseases). The objectives should also address the need for self-awareness among medical students regarding any personal biases in their approach to health care delivery.

Additionally, the LCME's mandate to provide students with instruction in medical ethics is embodied in ED-23: “A medical education program *170 must include instruction in medical ethics and human values and require its medical students to exhibit scrupulous ethical principles in caring for patients and in relating to patients' families and to others involved in patient care.”

Pursuant to ED-23:The medical education program should ensure that medical students receive instruction in appropriate medical ethics, human values, and communication skills before engaging in patient care activities. As students take on increasingly more active roles in patient care during their progression through the curriculum, adherence to ethical principles should be observed, assessed, and reinforced through formal instructional efforts.

In medical student-patient interactions, there should be a means for identifying possible breaches of ethics in patient care, either through faculty or resident observation of the encounter, patient reporting, or some other appropriate method.

The phrase “scrupulous ethical principles” implies characteristics that include honesty, integrity, maintenance of confidentiality, and respect for patients, patients' families, other students, and other health professionals. The program's educational objectives may identify additional dimensions of ethical behavior to be exhibited in patient care settings.

b. The ACGME

The ACGME is the accrediting body responsible for the accreditation of post-MD medical training programs within the United States. The accreditation process is governed by established standards and guidelines. Pursuant to the ACGME's by-laws, its purposes “are to develop the most effective methods to evaluate graduate medical education, to promote the quality of graduate medical education, and to deal with such other matters relating to graduate medical education as are appropriate.”

In 1999, the ACGME endorsed competencies for all residents in the *171 following six (6) areas:

• Patient Care

• Medical Knowledge

• Practice-based Learning and Improvement

• Interpersonal and Communication Skills

• Professionalism

• Systems-based Practice

It is mandatory that all programs integrate the general competencies into the curriculum. McGaghie notes that “[a]ll graduate medical education programs must be responsive to measurable cultural competence issues in at least two of the six areas.” Pursuant to the ACGME's Common Program Requirements: General Competencies:

i. Interpersonal and Communication Skills:

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:• communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;

• communicate effectively with physicians, other health professionals, and health related agencies;

• work effectively as a member or leader of a health care team or other professional group;

• act in a consultative role to other physicians and health professionals; and,

• maintain comprehensive, timely, and legible medical records, if applicable.

*172 ii. Professionalism:

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:• compassion, integrity, and respect for others;

• responsiveness to patient needs that supersedes self-interest;

• respect for patient privacy and autonomy;

• accountability to patients, society and the profession; and,

• sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

A major difference between undergraduate and graduate medical education is that the latter generally operates “under auspices of hospitals and academic medical centers affiliated with medical schools and is usually not managed by the schools themselves.”

“In graduate medical education, residents are both students and doctors,” thereby further promoting the need for a culturally competent medical education due to the direct physician- patient interaction and the promotion of trust for the healthcare system. Pursuant to the Report on Racial and Ethnic Disparities in Health Care, Updated 2010:

Evidence that cultural competency training can lead to improved patient outcomes and fewer liability claims exists, although more research is needed. To understand and treat racial and ethnic minorities better, physicians must engage in cultural competency training at all medical education levels. An increasing number of medical schools offer pathways to cultural competence development, but more needs to be done.

Both the undergraduate and graduate medical accreditation standards *173 relating to cultural competency are designed to ultimately address existing health care disparities.