Growing research on mental health disparities (MHD) demonstrates that the psychiatric workforce falls drastically short in providing equitable and quality care to diverse populations. Despite increased attention in recent decades to disparities, conditions are not improving and may even be worsening.1 The reasons for this are complex and multidimensional, and include a lack of diversity in the mental health workforce (MHW) as well as providers' frequent inability to connect cross-culturally with patients from diverse populations.1 To adequately address MHD, it is imperative that we work to improve and expand culturally focused education and training of a diverse MHW. This article examines the challenges faced in education, training, and recruitment of a diverse and culturally responsive workforce. It outlines key steps to overcome the challenges highlighted in these domains.
Studies consistently show that racial/ethnic minority health care providers are more likely to provide care to the underserved.2 Consequently, increasing attention has been placed on the recruitment of underrepresented minorities into medical school. Additionally, a growing number of institutions have been incorporating some type of cultural competency curriculum into medical education.3 However, these advances have not translated into a reduction in disparities due to challenges at the interface of the curriculum, instructors, and learners.
First, creating a medical curriculum that addresses disparities is challenging due to the complexity of the subject matter. To understand disparities, one must examine the intersection of social determinants of health with political, legal, economic, cultural, and many other systems, none of which are constant over place or time. These are rapidly moving targets influenced by regional variations that inform the format and content of such a curriculum, making standardization difficult. Additionally, traditional models of cultural “competence” have been fraught with problems. Some have critiqued the conflation of culture with race and ethnicity, which fails to capture the significance of class, gender, sexuality, ability, language, and many other intersectional aspects of culture that lead to disparities.4 The term “competence” itself has been critiqued for implying that a finite level of knowledge or skills is attainable through training.5
Second, teaching a curriculum that addresses disparities is challenging when faculty have not received similar training themselves. In an attempt to teach cultural “knowledge” to medical students, instructors may unintentionally reinforce racial and ethnic stereotypes that portray minority groups as homogeneous and static rather than focusing on the complex and changing sociopolitical factors that influence their access to quality health care. Additionally, although the medical student population has grown increasingly diverse, women and racial/ethnic minorities continue to be underrepresented in medical school faculty,6 and studies about other types of diversity among faculty are lacking. The implications of these trends are that faculty may have minimal experience in working with diverse populations and may be ill-equipped to effectively teach about issues affecting diverse populations.
Third, traditional premedical requirements emphasizing only basic sciences may hinder learners' abilities to understand cultural influences on health. Because humanities and social sciences emphasize critical thinking over rote memorization when compared to basic sciences, medical students with a background in these fields may be better equipped to comprehend social determinants of health, which is an important concept in the study of disparities.7 Statistics show that premedical humanities baccalaureate programs are growing, suggesting that more students enter medical school with a strong background in humanities and social sciences.6 However, this likely differs from the education their faculty received. Within the traditionally hierarchical structure of medical education, these students may be prevented from enhancing the educational experience for their peers and faculty. Despite increasing calls to change premedical and medical education to include more humanities and social science, both premedical and medical curricula remain focused on basic science.8
To address these challenges, we must consider a paradigm shift in the fundamentals of current medical education. Any curriculum designed to address disparities must be flexible to ongoing critique and able to change in response to the ever-shifting intersection of local and national political, legal, economic, cultural, and other systems. In this vein, instead of the traditionally limited concept of cultural “competence,” alternative concepts such as cultural humility,5 cultural responsiveness,9 and cultural safety10 have been proposed to more accurately capture the ongoing reflection and flexibility required to deliver health care to diverse populations. These alternative models for teaching culture involve some overlapping concepts: (1) an examination of how lack of status, power, and privilege, which are historically and politically situated, affect ethnic/racial minority groups' access to resources that impact health; (2) an acknowledgment that every provider enters the clinical encounter with their own culturally situated beliefs, biases, and practices, and thus providers cannot simply be “objective” through intention alone; and (3) an understanding that one can never be completely “competent” in another culture and must continually self-reflect, critique, and commit to change over a lifetime of practice, tailoring care to the unique needs of specific groups or people. These models more accurately capture the complex interplay between culture and health, and may be more effective in shaping the attitudes and skills of providers to deliver more equitable care to diverse populations and reduce health disparities.
To that end, the diversification of psychiatric faculty in terms of gender, race, ethnicity, sexuality, class, ability, and other domains is vital in addressing disparities. Current faculty must receive equal training in cultural humility, responsiveness, and safety to become effective models to their students and trainees when it comes to this nuanced lifelong process. Additionally, exposure to the humanities and social sciences has been shown to not only improve providers' understanding of structural inequalities and its relationship to health disparities, but to also improve patient communication, empathy, and likelihood of students pursuing careers in primary care and psychiatry, both of which are specialties with persistent staff shortages.7 Therefore, increased diversity in premedical requirements and incorporation of key concepts from humanities and social sciences within medical education are also essential to facilitate the study of disparities.
One possible solution that would address some of these challenges simultaneously involves the inclusion of faculty and instructors from a variety of disciplines in medical education. Many authors have advocated for interdisciplinary and inter-professional teams of instructors to create and deliver curriculum on the sociocultural influences on health.11,12 Inter-professional teams may include nonphysician health care professionals such as nurses, nurse practitioners, physician assistants, psychologists, social workers, and public and other health researchers; interdisciplinary teams may include professionals from the humanities and social sciences who study medicine and health, such as sociologists, anthropologists, historians, policy experts, lawyers, and others. Such collaboration will bring additional insights and information from various experts in their fields to enhance medical education typically provided by physician faculty.
After completion of medical school, psychiatric residents need practical tools to combat mental health disparities by learning to tailor their clinical practice to the unique needs of diverse populations. The main obstacles to cross-cultural learning during training include (1) the tension between the formal and informal or “hidden curriculum” in terms of time, emphasis, and content, (2) lack of awareness of the existence of mental health disparities and how explicit/implicit biases perpetuate them, and (3) the inherent subjectivity of the psychiatric mental status examination (MSE).
The Hidden Curriculum
Residency can be described as an apprenticeship in which the majority of learning occurs informally “on the job” under the supervision of attending physicians, with only a few hours each week dedicated to formal didactics. Additionally, cross-cultural training is typically self-contained within a “cultural seminar.” Because clinical duties are rigorous, often surpass a typical 40-hour work week, and supersede formal didactic learning when time is limited, the rigor and prioritizing of didactic sessions can be compromised. Furthermore, the informal, or “hidden curriculum” that occurs during training and supervision outside of formal didactics may actively counteract the purpose and effects of more formal cross-cultural education.
Whereas formal education emphasizes compassion, service, public health-informed clinical care, accountability, and professionalism, the “hidden curriculum” emphasizes productivity, competition, rigid adherence to hierarchy, inter-professional and inter-specialty disrespect, and tolerance of unprofessionalism.13–15 Studies of the “hidden curriculum” within psychiatry suggest that attending psychiatrists are prone to unintentionally imparting negative values on students and residents.16 Psychiatry's “hidden curriculum” can also frame “culture” as something minority groups have, failing to acknowledge the culture of medicine or the dominant culture.17 This can result in the subtle message that mainstream providers (ie, providers belonging to the dominant culture) are more objective because their practice style is consistent with “standard” practice, whereas minority or culturally responsive practitioners are perceived as less objective because they tailor their behavior to the needs of individual patients or cultural group.
There are ample data demonstrating that psychiatrists have unconscious biases that affect the care of patients from minority backgrounds and ultimately contribute to MHD.18–20 A literature review of MHD by the Substance Abuse and Mental Health Services Administration18 found multiple studies linking bias to misdiagnosis, inappropriate medication administration, greater use of seclusion and restraints, and inappropriate care for racial/ethnic minority patients. Studies demonstrate a high prevalence of unconscious bias among physicians not only against racial/ethnic minorities, but also against women, the elderly, and overweight people.19 These implicit racial/ethnic biases were found to be present in physicians of all racial and ethnic backgrounds.19 Despite the strong evidence linking implicit bias to MHD, most psychiatrists have little to no knowledge of racial/ethnic disparities in mental health and attribute racial/ethnic bias to other providers and not themselves.20 This is problematic because physicians who believe they are behaving in an egalitarian manner but are found to have implicit bias against racial/ethnic minorities (“aversive racism”) may have greater difficulty building trust with minority patients compared to physicians who are aware of their biases due to discrepancies between their verbal (nonbiased) and nonverbal (biased) communication.21
The Psychiatric Mental Status Examination
The authors infer from the literature that faculty who supervise psychiatry trainees may unconsciously model biased behavior through nonverbal communication styles, which is internalized and then perpetuated by trainees despite the stated and formally taught intention to treat patients in an equitable manner. One of the ways this can occur is through the teaching of the MSE. The MSE is the purportedly “objective” portion of the psychiatric assessment in which the clinician uses his or her observations to lead them to a diagnosis, with assistance from “subjective” information obtained from the patient. It includes observations on behavior, affect, thought organization, perceptual disturbances, and cognition. The MSE is based loosely on the work of Karl Jasper, who described the importance of observation in assessing psychopathology but himself described the distinction between subjective and objective as “problematic.”22
Despite it being a hallmark of the psychiatric assessment taught universally in medical schools and residency training programs in the United States and Canada, research on the reliability of the MSE is limited. Some authors have commented on the importance of taking culture into consideration when performing the MSE,23,24 but none have examined the ways in which the MSE may perpetuate bias. However, many typical observations made in the MSE have been commonly associated with specific minority groups in research on bias. For example, physicians disproportionately perceive black patients to be uncooperative and overweight patients as unintelligent.19 This is significant because mental health clinicians often comment on patients' level of cooperation, engagement, and intelligence in the MSE, and these observations are assumed to be objective.
To address these complications, education on implicit bias and MHD should be present within all psychiatry residency curriculums, and a bias-informed perspective must be integrated into teaching all parts of the psychiatry curriculum, including a culturally-informed practice of the MSE and discussions of counter-transference. Integration of culturally responsive approaches throughout training is important because the difference between what is taught in the classroom (ie, the formal curriculum) and what is modeled and practiced in training (ie, the hidden curriculum) likely contributes to the loss of emotional engagement, empathy, and idealism that occurs during the rigor of residency.13 Psychiatrists who supervise trainees should also be educated on how to recognize and respond to explicit and implicit bias to avoid unintentionally perpetuating them.
The ability to connect empathically with patients from diverse cultures has been identified as a crucial step in reducing the influence of bias in medical providers' decision-making.19 Thus, the preservation of empathic skills through alignment of formal and informal curricula is important in reducing bias and MHD. Similarly, a recent study demonstrated that greater exposure of trainees to lesbian/gay/bisexual/transgender (LGBT) faculty resulted in less negative explicit and implicit bias towards LGBT patients, which suggests that exposure to a diverse faculty body can also help to reduce bias.25
We have alluded to the importance of recruiting a diverse MHW as a necessary requirement of reducing MHD. This is supported by the US Office of Minority Health,26 which states that organizations must “recruit, promote, and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area” to improve health care quality and advance health equity. Unfortunately, women and certain minority groups continue to be underrepresented in medical school and academia.5 Data from the American Association of Medical Colleges (AAMC)27 demonstrate that people from Hispanic/Latino, Black/African American, American Indian/Native Alaskan, and Native Hawaiian/Pacific Islander backgrounds continue to be underrepresented in medical schools and academic psychiatry (Table 1). The data also show that although women comprise roughly one-half of US psychiatric department faculty, women of color represent only 10% of faculty, and only 3.9% of senior faculty27 (Table 2); data on other types of diversity are lacking. Overall, these statistics suggest that greater efforts are needed to recruit and retain women and ethnic minorities into psychiatry, especially academic psychiatry, to achieve a diverse MHW.
Representation of Racial/Ethnic Minorities in Medical School and Psychiatric Departments in 2016
Representation of Women and Women of Color in US Departments of Psychiatry 2016
The lack of diversity among academic psychiatric faculty and lack of recruitment of diverse populations into academic psychiatry is likely a self-perpetuating cycle. Previous research demonstrates that medical faculty from ethnic minority backgrounds are uniquely able to offer mentorship to students of similar backgrounds.28 Although strong mentorship has been identified as important to academic success and career satisfaction, underrepresented racial/ethnic minorities in medical school and residency are less likely to receive such mentoring.28 Thus, having ethnic/racial minority faculty is essential to the recruitment of students of similar backgrounds into psychiatry and academia.
Ethnic/racial minority faculty also face many other barriers that potentially affect their retention within academia. Underrepresented faculty tend to have greater medical school debt, increased clinical duties, less time for research and publications, and decreased academic opportunities.29 However, even when controlling for academic productivity, racial/ethnic minorities are less likely to be promoted or receive tenure in academic medicine.30 In addition, racial/ethnic minority faculty may experience loneliness and may have less networking opportunities because of cultural barriers.28 Unsurprisingly, racial/ethnic minorities in academic medicine are more likely to perceive bias as negatively affecting their careers and thus experience less career satisfaction.28
These data suggest that an atmosphere of inclusion within psychiatry is imperative to increasing the diversity of the MHW. Unless we are able to support the unique struggles that minorities face during their medical training and careers, efforts to diversify the MHW will be superficial at best. Rather, faculty from diverse backgrounds must be specifically mentored and recruited into positions of leadership such that they can use their experience of adversity to change the culture of medicine and psychiatry.
The scope of this article does not allow for in-depth discussion of other types of diversity, such as sexuality, gender identity, class, immigration, ability, and many others. Because available data on diversity in medicine focus mostly on race/ethnicity and gender, this article reflects those trends. Other concepts that are important in creating an inclusive atmosphere, such as awareness of privilege, microaggressions, and stereotype threat, were not covered but are still crucial to understand when recruiting for diversity. Lastly, when discussing racial/ethnic minorities, grouping such as “Asians” and “Latinos” fail to capture the full extent of diversity within these groups; however, these groupings were used because they reflect the data collection categories of our sources.
We believe that the recruitment, training, and education of a diverse workforce in psychiatry is necessary to address MHD. Education in cultural humility and MHD should be incorporated throughout psychiatric training and as part of continuing medical education. Instruction from interdisciplinary and inter-professional teams on concepts from humanities and social sciences is crucial to the understanding of MHD and should be included in formal and informal psychiatric training. Psychiatrists should be trained to recognize and address bias in clinical work and in the MSE with emphasis on cultural responsiveness, emotional engagement, and empathy for patients from diverse backgrounds. Finally, retention and promotion of women and underrepresented ethnic/racial minorities through mentoring and a culture of inclusion in academic medicine is essential if we are to move forward as a field to eradicate MHD in our patient population.
- Ault-Brutus AA. Changes in racial-ethnic disparities in use and adequacy of mental health care in the United States, 1990–2003. Psychiatr Serv. 2012;63(6):531–540. doi:. doi:10.1176/appi.ps.201000397 [CrossRef]
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- Chun MB. Pitfalls to avoid when introducing a cultural competency training initiative. Med Educ. 2010;44(6):613–620. doi:. doi:10.1111/j.1365-2923.2010.03635.x [CrossRef]
- Powell Sears K. Improving cultural competence education: the utility of an intersectional framework. Med Educ. 2012;46(6):545–551. doi:. doi:10.1111/j.1365-2923.2011.04199.x [CrossRef]
- Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–125. doi:10.1353/hpu.2010.0233 [CrossRef]
- Castillo-Page L. Diversity in medical education: facts & figures 2016. http://www.aamcdiversityfactsandfigures2016.org. Accessed February 10, 2018.
- Berry S, Lamb EG, Jones T. Health humanities baccalaureate programs in the United States. http://www.hiram.edu/images/pdfs/center-litmed/HHBP_8_11_16pdf. Accessed February 10, 2018.
- Muller D. Reforming premedical education–out with the old, in with the new. N Engl J Med. 2013;368(17):1567–1569. doi:. doi:10.1056/NEJMp1302259 [CrossRef]
- Sue S, Fujino DC, Hu LT, Takeuchi DT, Zane NW. Community mental health services for ethnic minority groups: a test of the cultural responsiveness hypothesis. J Consult Clin Psychol. 1991;59(4):533–540. doi:10.1037/0022-006X.59.4.533 [CrossRef]
- Papps E, Ramsden I. Cultural safety in nursing: the New Zealand experience. Int J Qual Health Care. 1996;8(5):491–497. doi:10.1093/intqhc/8.5.491 [CrossRef]
- Carpenter-Song EA, Schwallie MN, Longhofer J. Cultural competence reexamined: critique and directions for the future. Psychiatr Serv. 2007;58(10):1362–1365. doi:. doi:10.1176/ps.2007.58.10.1362 [CrossRef]
- Satterfield JM, Carney PA. Aligning medical education with the nation's health priorities: innovations in physician training in behavioral and social sciences. In: Kaplan R, ed. Population Health: Behavioral and Social Science Insights. Rockville, MD: Agency for Healthcare Research and Quality, Office of Behavioral and Social Science Research, National Institutes of Health; 2015:385–410.
- Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: a cross-sectional qualitative study. Med Teach. 2016;38(4):410–418. doi:. doi:10.3109/0142159X.2015.1073241 [CrossRef]
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- Wear D, Skillicorn J. Hidden in plain sight: the formal, informal, and hidden curricula of a psychiatry clerkship. Acad Med. 2009;84(4):451–458. doi:. doi:10.1097/ACM.0b013e31819a80b7 [CrossRef]
- Llerena-Quinn R. A safe space to speak above the silences. Cult Med Psychiatry. 2013;37(2):340–346. doi:. doi:10.1007/s11013-013-9321-3 [CrossRef]
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Representation of Racial/Ethnic Minorities in Medical School and Psychiatric Departments in 2016
||Percentage of US Population31
||Percentage of US Medical School Enrollees5
||Percentage of Faculty in US Departments of Psychiatrya
|American Indian/Alaskan Native
|Native Hawaiian/Pacific Islander
Representation of Women and Women of Color in US Departments of Psychiatry 2016a
||Percentage of Women
||Percentage of Women of Color
|Overall faculty in US departments of psychiatry
||20.9 (10.3% of overall faculty)
|Senior professors in US departments of psychiatry
||13 (3.9% of senior professors)