What Matters in Health Disparities Education—Changing Hearts or Minds?
All medical educators face this question when planning curricula and in the daily course of teaching: “Is it enough to give our students the cognitive tools they need to function effectively, in the form of knowledge or skills, or should we also focus on their attitudes and motivation—their affective inclination and desire to use these tools?” In other words, should we focus on students' hearts or minds? As several of the manuscripts in this Supplement illustrate, this question is particularly contentious in the context of teaching about health disparities and cultural competency, when addressing students' attitudes and motivation can be seen as an educator passing judgment.
The hearts and minds question is especially relevant when teaching interpersonal aspects of care, such as respect and empathy. Some educators prefer to teach specific skills–greet the patient when you come into the room, reflect back the emotion expressed by the patient, etc. An appealing aspect of skills-based teaching is the direct correlation between what is taught and what can be observed as outcomes. However, others believe it is important not only to teach students how to demonstrate empathy and respect, but also to foster a predisposition towards emotional engagement, or one of unconditional positive regard for others. Mostow and colleagues endorse this approach in their description of a model for teaching learners how to bridge racial, ethnic, and cultural differences in the clinical encounter. After finding that existing models focused mainly on behaviors rather than attitudes, they developed an approach that explicitly targets both. Interestingly, their approach to fostering empathy and positive regard for patients involves demonstrating empathy and positive regard for trainees, implying that effective approaches will engage the hearts and minds of both learners and educators.
There is an almost metaphysical aspect of the hearts and minds debate that asks if it is morally sufficient for doctors to care for patients, or if we must also care about them. Not surprisingly, ethicists have delved into this issue deeply. Common theories of ethics approach the issue very differently, with virtue-based theories emphasizing emotion and relationships6, and principalism focusing on the cognitive processes involved in resolving dilemmas. Yet most scholars, even those who strongly endorse the preeminent importance of one theory, wouldn’t entirely disregard the merits of certain aspects of the others.
From a practical perspective, the hearts and minds debate is important in that it influences how we will choose to spend valuable time with students. Intuitively, it is easier to focus on teaching knowledge and skills than it is to change attitudes, and it seems more efficient to do the former than the latter. Lessons from social and cognitive psychology, however, suggest that teaching knowledge and skills alone, without attending to underlying attitudes, may in some circumstances be an ineffective approach. For instance, studies have found that our attitudes, including implicit attitudes of which we may not even be aware, can “leak” in our interactions with others8, such that even if we display a particular behavior, patients may be able to see that our heart is not it. For behaviors intended to create a connection between doctor and patient—e.g., respect, concern, empathy, understanding—the perception of disingenuousness may reduce the effectiveness of the behavior and even have deleterious effects on a patient’s trust. Dissonance between attitudes and behaviors may also, over time, create resentment or burnout in a student or physician who may fatigue from acting in a way that does not reflect his or her true feelings or identity. ...
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Elizabeth A. Jacobs, 
