The institutional context of multicultural education: what is your institutional curriculum?

Recently revised accreditation standards require medical schools and residency training programs to integrate multicultural training into their curricula. Most multicultural training models concern the educational outcomes of individual trainees who have received digestible "units" of multicultural education or "cultural competence" training designed for trainees' individual consumption. Few have taken a critical perspective on how an individual trainee must learn, change his or her behavior, and sustain that behavioral change within a specific institutional context. The authors discuss the educational impact of one's institutional learning environment--the institution's ethos, teachers, modeling, policies, and processes--on the multicultural education of physician trainees. A usable conceptual model is offered with which educators can identify those dimensions of one's "institutional curriculum" that may enhance or obstruct trainees' optimal learning and behavior change regarding issues of multiculturalism in medicine. Comparisons are drawn to the recent medical literature concerning professionalism education and the hidden curriculum. Distinctions are drawn between overlapping areas of planned, received, intended, and unintended learning and values, as communicated from faculty, attendings, and residents to students. Ways of maximizing ideal learning and minimizing unintended consequences are discussed. The goal is for medical educators to be able to ask, What is the institutional curriculum of my training program regarding issues of race, difference, etc? What elements of that institutional curriculum can be recaptured and reclaimed as consistent with and supportive of tenets of excellent patient care for all?