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NHLBI: Teaching Multi-cultural Practice

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Stanford University

Integrated Immersive Approaches to Cultural Competence

Clarence H. Braddock III, MD, MPHClarence H. Braddock III, MD, MPH
Associate Dean for Medical Education
Director, Coordinating Center @ Stanford
Stanford University School of Medicine
Principal Investigator


Ronald D. Garcia, PhDRonald D. Garcia, PhD
Program Director, Center of Excellence
Assistant Dean, Minority Affairs
Physician Assistant Program/Family Medicine
Stanford University School of Medicine

Sylvia BereknyeiSylvia Bereknyei, MS
Research Assistant
Project Manager, Coordinating Center @ Stanford
Stanford University School of Medicine





  • Medical Student Cultural Competence Curriculum: We have instituted new components to the pre-clinical curriculum, all as part of a course entitled, "Practice of Medicine." This is a six-quarter sequence in which students learn the medical interview and physical examination, as well as bioethics, nutrition, evidence-based medicine, and health policy. The cultural competence curriculum includes:
    • Working effectively with medical interpreters: students are introduced to guidelines for working effectively with interpreters to overcome linguistic barriers, again as part of the communication skills sessions. They review and critique a role-play demonstration to consolidate their learning. We incorporated an online learning module (in collaboration with NYU and members of the NHLBI Collaborative) with an end-of-year Standardized Patient-Interpreter assessment.

    • Communication skills session on the Kleinman explanatory model: students review an on-line tutorial, including videotape demonstration, on incorporating these questions into the medical interview. Then students practice interviewing standardized patients (SP), attempting to gain insight into the SP's health beliefs. Students are evaluated on perspectives of cross-cultural communication by "Health Beliefs and Attitudes Survey" (HBAS), resulting in statistically significant impact in cultural competence domains.
    • Gaining perspective on the patient's perspective: students read Anne Fadiman's book, "The Spirit Catches You and You Fall Down," which chronicles the experiences of a Hmong family with a daughter with a seizure disorder and their interactions with the health care system. To consolidate the themes from the reading, students write essays on one of several themes in the book, and participate in seminar-style discussion of the reading. We also have an invited presentation with the two physicians depicted in the narrative.
    • "World's Apart" This is a series of film vignettes directed by award-winning physician/filmmaker and Director of the Biomedical Ethics in Film Project, Maren Grainger-Monsen, MD. The films examine the personal experiences of patients and families faced with critical medical decisions and the challenges they face in the health care system. Shot in patients' homes, neighborhoods, and places of worship, hospital wards and community clinics, Worlds Apart provides a balanced yet penetrating look at both the patient's culture and the culture of medicine. Accompanying the four videos is a study guide designed by cross-cultural medicine educators Drs. Alexander Green and Joseph Betancourt. "Worlds Apart" is shown to students, followed by facilitated small group discussion, with the goal of enhancing insight into cross-cultural communication and cultural sensitivity.
    • "Hold Your Breath" This is an award-winning film based on one of the characters in "Worlds Apart", directed by Maren Grainger-Monsen. We implemented a new session into "Applied Biomedical Science" seminars, a series of inter-sessions between clerkships. The session includes viewing of the film, followed by a facilitated discussion session.
    • Pediatrics clerkship implemented a newly developed Standardized Patient cultural competence curriculum involving four Standardized Patient encounters. The students are able to witness and experience various situations incorporating Kleinman explanatory model/Stewart trigger questions with additional learning objectives such as: folk illness remedies, impact of illness on family, domestic violence, and principles of effectively using an interpreter. Each student in a set of four students has a Standardized Patient encounter, while the remaining students watch the scenario through closed-circuit television, followed by an extensive debriefing session. .
    • Assessment Implementation of baseline evaluations using "Cross-Cultural Adaptability Index" (CCAI), a valid and reliable measure, which will be used across the curriculum for individual development and curricular evaluation
  • Residency Cultural Competence Curriculum: We have developed a cultural competence clinical teaching module that was implemented to all general internal medicine residents at Stanford. The module incorporates the use of reflective practice to facilitate discussion of personal cultural attitudes and emphasizes the use of the Kleinman explanatory model questions to enhance communication skills.

  • Faculty Development Program in Cultural Competence: We have developed a facilitator-training module in cultural competence for medical teachers, incorporated into the faculty development program of Dr. Kelley Skeff and the Stanford Faculty Development Center. The program, entitled "Professionalism in Contemporary Practice," prepares faculty to teach residents and other faculty concepts and skills including reflective practice, patient-centered communication, and evidence-based practice. We developed and piloted a module on cultural competence, including definitions of race, ethnicity and culture, review of data on health care disparities, and communication skills related to cultural competence. We used role-playing to enhance participants' skills using Kleinman's explanatory model in medical interviewing. In our initial presentation of this module, we were able to measure significant changes in participants' attitude towards cultural issues in practice, using the Health Beliefs Attitude Survey. Each faculty participant from the September 2005 program is now teaching this material at their respective faculty settings. A group of medical educators in Singapore were trained in this module summer 2006 and another set of faculty will attend the course in September 2006 and continue to disseminate. We evaluated faculty learners using the "Health Belief and Attitudes Survey" and found statistically significantly increases in attitudinal dimension in cultural competence. In addition, we have partnered with the Stanford Geriatrics Education Center with the Program in Health Literacy and Ethnogeriatrics and implemented cultural competence and working with interpreters sessions in 2008, 2009, and in the upcoming 2010 year.

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Journal Articles:

  • Carter-Pokras O, Acosta DA, Lie D, Bereknyei S, DeLisser H, Haidet P, Gill A, Hildebrandt C, Crandall S, Kondwani K, Glick S. for the National Consortium for Multicultural Education for Health Professionals. “Curricular Products from the National Consortium for Multicultural Education for Health Professionals.” MDNG: Focus on Multicultural Healthcare (In Press)
  • Lie D, Bereknyei S, Braddock CH, Encinas J, Ahearn S, Boker J. “Who Should Assess Medical Students for Interpreter Use Skills? A Validation Study.” Academic Medicine. 2009 May;84(5):643-50.
  • Lie D, Bereknyei S, Kalet A, Braddock CH. “Learning Outcomes of a Web Module for Teaching Interpreter Interaction Skills to Pre-clerkship Students.” Family Medicine. 2009 Apr;41(4):235-5.
  • Lie D, Boker J, Bereknyei S, Ahearn S, Fesko C, Lenahan P. Validating Measures of Third-Year Medical Students’ Use of Interpreters by Standardized Patients (SP) and Faculty Observers. Journal of General Internal Medicine, Language Barriers Supplement, 2007 November; 22(Suppl 2): 336–340.

Oral Presentations

  • Hooper K, Bereknyei S. (March 2009). Stanford Faculty Development Train-the Trainer Program in Ethnogeriatrics and Health Literacy. Oral Presentation for the Society for Applied Anthropology Annual Meeting, Santa Fe, NM.
  • Bereknyei S, Nevins A, Gesundheit N, Arnall J, Grant J, Basaviah P, Braddock CH. (November, 2008) Working Effectively with Interpreters: The Relationship Between Student Self-Ratings and Examination Performance Measures. Research in Medical Education (RIME) Oral Presentation for Association of American Medical Colleges Annual Meeting, San Antonio, TX
  • Stuart AE, Bereknyei S, Long M, Blankenburg R. (November, 2008) Evaluation of a Standardized Patient Exercise in Cross-Cultural Interviewing. Research in Medical Education (RIME) Oral Presentation for Association of American Medical Colleges Annual Meeting, San Antonio, TX
  • Nevins A, Bereknyei S, Gesundheit N, Arnall J, Grant J, Basaviah P, Braddock CH. (November, 2008) Volunteering in Community Clinics and Emergency Departments Enhances the Acquisition of Clinical Skills by First-Year Medical Students. Research in Medical Education (RIME) Oral Presentation for the Association of American Medical Colleges Annual Meeting, San Antonio, TX
  • Grant J, Arnall J, Bereknyei S, Bryant M, Basaviah P, Nevins A, Gesundheit N, Braddock CH. (April, 2008) Preparing Medical Students to Work with Interpreters: Successful Team Training Techniques to Enhance the Effectiveness of Standardized Patients. Presentation at WGEA Regional Conference, Asilomar, CA
  • Bereknyei S, Hooper KM, Medrano M, Braddock CH. (November, 2007) Effectiveness of a Faculty Development Curriculum in Cultural Competence. Research in Medical Education (RIME) Oral Presentation for Association of American Medical Colleges Annual Meeting, Washington DC
  • Bereknyei S, Garcia R, Medrano M, Braddock CH. (November, 2007) Impact of a Multifaceted Curriculum in Multi-Cultural Practice on Medical Student Attitudes. Research in Medical Education (RIME) Oral Presentation for Association of American Medical Colleges Annual Meeting, Washington DC

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Stanford's Coordinating center Responsibilities

In order to support the dissemination mandate of the original RFA, we have developed and implemented a web-based curriculum portal for cultural competence education. This web-based resource will provide a platform to highlight and disseminate the curriculum products from investigator-educators funded through the NHLBI RFA in cultural competence education.

We also coordinate monthly conference calls with the other investigators in the collaborative. These conference calls have fostered sharing of ideas in areas of curriculum, evaluation, and implementation strategies, as well as enabling us to develop several small working groups among the members. The coordinating center has enabled these small groups to overcome significant challenges across institutions, and can be used as a model for future collaboratives. The small working groups have preliminary results that are currently being analyzed. We expect that each of these groups will lead to significant curricular interventions, as well as adding the medical education literature in this area.

Additionally, we have formed collaborations with national organizations (AAMC through TACCT and MedEd Portal, the California Endowment, NYU, and Office of Minority Health).

We also coordinated the first annual conferences of all the program investigators in Washington, DC in September 2005. At this meeting, we had the opportunity for more face-to-face discussion of shared interests and activities. Existing working groups presented their progress reports, and new awardees were invited to join these efforts. In addition, we collaboratively developed several new working groups, as well as developing a mission statement and work plan for the coming year. We also conducted planning for manuscript preparation as well as upcoming conference presentations

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  • NCME @ Health Literach Annual Research Conference
    • Two workshops on cultural competency and MedEdPORTAL
    • October 17-18, 2011, Chicago, IL
  • RWJ National Health Plan Collaborative Toolkit
    • This toolkit has resources, lessons, best practices and case studies to assist health plans reduce disparities.
  • AHRQ Health Literacy Toolkit
    • The toolkit can help your practice and communicate with patients.
  • Stopping Discrimination Before it Starts: The Impact of Civil Rights Laws on Healthcare Disparities
  • Curricular Products from the National Consortium for Multicultural Education for Health Professionals
  • Conferences:
    • AAMC annual meeting 2010
      • November 5-10, Washington, DC
    • APHA annual meeting 2010
      • November 6-10, Denver, CO