http://orcid.org/0000-0002-1642-8672
Abstract
Introduction: Implementation of cultural diversity training in medical education faces challenges, including ambiguity about the interpretation of ‘cultural diversity’. This is worrisome as research has demonstrated that the interpretation employed matters greatly to practices and people concerned. This study therefore explored the construction of cultural diversity in medical curricula.
Methods: Using a constructivist approach we performed a content analysis of course materials of three purposefully selected undergraduate curricula in the Netherlands. Via open coding we looked for text references that identified differences labelled in terms of culture. Iteratively, we developed themes from the text fragments.
Results: We identified four mechanisms, showing together that culture is unconsciously constructed as something or someone exotic, deviant from the standard Dutch or Western patient or disease, and therefore problematic.
Conclusions: We complemented earlier identified mechanisms of othering and stereotyping by showing how these mechanisms are embedded in educational materials themselves and reinforce each other. We argue that the embedded notion of ‘problematic stranger’ can lead to a lack of tools for taking appropriate medical action and to insecurity among doctors. This study suggests that integrating more attention to biological and contextual differences in the entire medical curriculum and leaving out static references such as ethnicity and nationality, can enhance quality of medical training and care.
Introduction
Cultural diversity training in medical education is essential to prepare students to provide quality care for a diversifying patient population, address biases in healthcare delivery and alleviate healthcare disparities (Betancourt Citation2003; Gregg and Saha Citation2006; Seeleman et al. Citation2009). At the same time, the question of whether cultural training indeed leads to improved quality of care remains inconclusive (Betancourt Citation2003) and implementation of such training is challenging. Challenges include emotional and negative student reactions, who consider the topic ‘soft’ and irrelevant (Worden and Ait-Daoud Tiouririne Citation2018). Also, it is noted that medical curricula use different approaches to teaching and integrating cultural diversity into medical training (diverse pedagogical methods, formats and assessment practices), while medical educators hold different ideas about what teaching cultural diversity means (developing students’ knowledge, skills and attitudes when working with diverse patients; teaching them to deal with health and social disparities; gaining expertise about other cultures; or developing awareness about one’s own biases) (Dogra et al. Citation2010). Sawatsky et al. (Citation2017) and Gregg and Saha (Citation2006) noted that when culture is conceptualised in a simplified fashion, stereotypes risk being reinforced. The field struggles with the concept of cultural diversity, providing varied explicit definitions and often implicitly referring to differences in nationality or ethnicity (Betancourt Citation2003; Gregg and Saha Citation2006).
Practice points
Quality of medical education could be enhanced by leaving out static references such as ethnicity, religion, nationality in course materials.
Instead, more explicit attention to biological differences and context aspects (such as circumstances, habits, environment, lifestyle, norms, expectations, language) should be included as relevant and useful background information for making a proper diagnosis.
This attention to diversity needs to be systematically integrated into all courses, spanning both competence training and biomedical contents.
The latter calls for medical research that takes diversity in its setup into account.
These recommendations are expected to help overcome the challenges of implementing pertinent and non-stereotypical cultural trainings and contribute to equitable healthcare.
At the same time, use of a certain definition of cultural diversity – whether implicit or explicit – can have major impact, as studies and theories outside medical education have shown. These studies revealed that the notion of cultural diversity consciously or unconsciously employed influences choices and policies in practice with major implications for those involved (Bowker and Star Citation2008; Meershoek and Krumeich Citation2009; Proctor et al. Citation2011; Yanow and Van Der Haar Citation2013). Yanow and Van der Haar, for example, showed that the construction of ‘immigrant’ and ‘native’1 categories and their subdivisions used in Dutch public policy and administration processes impacted integration of immigrants. The category structure linked immigrants to attributes that drew on stereotypes of collective behaviours, placing them in the outsider position and making them a policy problem (Yanow and Van Der Haar Citation2013). The authors noted that the category structure prevented immigrants from ever moving to an insider position, regardless of the amount of culture and citizenship training they undertook (Yanow and Van Der Haar Citation2013). Similarly, the implicit or explicit creation of a certain interpretation of cultural diversity in medical education could seriously influence educational, and consequently, clinical practices and patients’ treatment.
Theoretically, interpretations of culture can vary from static frameworks focusing on fixed categories to more dynamic ones presenting culture as continuously changing practices. Nationality, ethnicity and religion are examples of fixed categories being often used in static frameworks. An example is Hofstede’s cultural dimension framework, which defines culture on country level based on a country’s score on six fixed dimensions of culture, such as individualism-collectivism (Hofstede et al. Citation2010). Alternatively, culture can be interpreted as something that is constantly changing based on experiences in people’s daily lives, which helps them to construct a sense of themselves and understanding of their fellows (Jenkins Citation1997). According to this dynamic notion, persons do not have a cultural identity, but their identity (for example as a director, Turk, woman, Christian or diabetes patient) and the meaning attached to this identity both change depending on the context (at home, in the workplace, on holidays, abroad, in the doctor’s office, etc.), on the persons they have contact with and over time.
Given aforesaid struggles to interpret the notion of cultural diversity in medical training and the knowledge that it matters which interpretation is employed, we used the aforementioned static and dynamic theoretical notions to look at medical education with a new view. Hence, we explored in which parts of educational materials of undergraduate medical programmes cultural diversity was constructed and how. Additionally, we investigated how these constructions impacted the programmes’ learning goals and contents. The purpose of this study was to offer both curriculum designers and future doctors insights into how cultural diversity training in medical education can be improved.
Methods
Research approach
Using an exploratory, qualitative, constructivist approach, we performed a content analysis of educational materials to investigate notions of cultural diversity in medical education (Creswell Citation2014). Consistent with the constructivist paradigm, we focused on how meanings were constructed and embodied in language to increase understanding of cultural diversity (Schwandt Citation1998).
Research settings
Focusing on sites that provided comprehensive information on the notion of cultural diversity (Creswell Citation2014) and could therefore best help understand the phenomenon under scrutiny, we purposefully sampled three undergraduate medical curricula offered at different universities in the Netherlands. We looked for differences in terms of language of instruction and students’ background (see ).
Table 1. Characteristics of research settings.
Data collection and analysis
We performed a content analysis of course manuals of three bachelor curricula. lists the analysed documents.
Table 2. Overview of analysed course material.
Of each course, we analysed the course description: an electronic syllabus providing an overview of the learning objectives, course contents and educational activities of the respective course. We selected electives with an international or diversity focus. Additionally, we analysed documents such as lecture slides, articles and assignments if references in the course descriptions led us to believe that they were likely to contain relevant information about notions of cultural diversity.
We analysed the documents in an iterative process aimed at identifying patterns within the data and creating categories of emerging themes (Bowen Citation2009). One author (AZ) closely read the materials having the static and dynamic theoretical notions of culture in the back of her mind. Via open coding she looked for implicit and explicit references (or absence thereof) in the texts to differences, for instance, in patients and contexts of diseases. She sought to identify types of differences, and explicitly focussed on how these differences were directly or indirectly labelled in terms of culture. Next, the research team compared these fragments, determined their relevance and developed overarching themes. Finally, we structured the fragments, reflections and themes in order to answer the research questions. We explicitly looked for contradicting information or examples in the documents analysed and discussed interpretations of the data within the diversely composed research team. The diverse disciplinary backgrounds of the research team members (anthropology, health sciences, medical education and intercultural communication) fostered dialogue and enhanced understanding of the material. We engaged in reflexive practices during our conversations.
Ethical considerations
We obtained ethical approval from the Netherlands Association for Medical Education (NVMO) Ethical Review Board (no. 950).
Results
The analysis of where and how cultural diversity was defined led to the development of four interrelated themes or mechanisms through which a particular notion of cultural diversity was constructed. We will elaborate on these themes in the following four sections and conclude with a synthesising section.
Mechanism 1: culture is (not) relevant
We found that consideration for cultural diversity differed throughout different parts of the three curricula. On the one hand, certain curriculum materials included hardly any reference to culture, while on the other specific materials did include such references much more extensively.
The mainstream curriculum of Programmes 1 and 2 contained hardly any references to cultural diversity. The core courses dealt with a certain medical topic (cancer, genetics, infections, circulation, digestion, etc.), explaining all relevant technical information. Course elements such as learning objectives, patient cases, information on the prevalence of diseases, skills training, clinical reasoning, frequency and risk measures and pharmacotherapy overviews did not or only occasionally refer to cultural diversity. In these core courses, patients as well as diseases were unambiguously presented, seemingly proceeding from the assumption that medical knowledge applies to everybody equally, with only age and sex identified as relevant diversity aspects.
By contrast, in specific non-mainstream programme parts, paying attention to diversity (cultural or otherwise) was reported as essential to effectively communicate with and diagnose patients: ‘in this training you will learn to think about the question “Which differences between patients matter and how do they impact communication and treatment?”’ (Programme 1), and: ‘in order to ensure smooth communication with patients from other cultural backgrounds, we provide training in cross-cultural effectivity’ (Programme 2). Specific electives, workshops or themes of the two Dutch-language curricula consciously and intensively focused on diversity in general or cultural diversity in particular. We also found the English-language Programme, being almost identical to Programme 1 but targeting an international student population, to pay relatively much attention to culture. A first year course noted that students should ‘look at the case studies in a different way, with more emphasis on cultural differences, differences in health care, and (im)possibilities in health care in other than Western countries’ (Programme 3). The remark ‘in a different way’ referred to being ‘different from the Dutch programme’.
Some course descriptions provided an explicit definition of culture, referring to norms and values, lifestyles, traditions, habits, acts, beliefs and thoughts of people and encompassing different elements of a patient’s background (sex, generation, ethnicity, social class, etc.). Consequently, medical cases and examples in these specific curriculum parts included variable patients’ background information to consider. For example, an elective course on ‘interculturality’ (Programme 2) requested students to job shadow a general practitioner ‘in a district with patients from diverse cultures’ and prepare a presentation on topics such as: number of immigrant and native patients, cultural sensitivity of the doctor, role of culture in doctor-patient interaction, and patient’s cultural background in terms of age, sex, ethnicity, religion, etc. Students should describe ‘to what extent the patients’ age, sex, ethnicity, religion, etc. are relevant to the presentation of their complaints, diagnosis and choice of policy’.
This varied consideration indicated a contradiction with regard to the importance attached to culture: seemingly not relevant according to some curriculum parts, it was regarded crucial to take into account in others.
Mechanism 2: patients and strangers
Monitoring how explicit definitions of culture provided in some course descriptions (see mechanism 1) were applied in patient cases, we identified a second mechanism by which culture was constructed. Medical cases typically contained information about a disease or physical facts and the patient’s background, including data on age, sex, living conditions, personal characteristics and habits. In a few cases this information was accompanied by data on the patient’s nationality, ethnicity or geographic location the patient originated from. Often, this information was explicitly or indirectly characterised as culture (referring to definitions provided).
This nationality, ethnicity or geographic location was almost exclusively mentioned when it referred to groups of people or circumstances located outside the Netherlands, Europe or the Western world. References to Dutch or European nationalities were found only sporadically. For example, patient cases were mostly presented in wordings like: ‘Alice is a medical student’ or ‘a 55-year-old woman’, without any reference to nationality or place of living. Conversely, in occasional other patient cases, Josh was introduced as someone who ‘lives in the State of Mississippi in the US and weighs about 140 kg’, and Feng was presented as ‘a Chinese student who is doing an internship in the department of Gastroenterology’ (Programme 3). Moreover, besides mentioning a patient’s nationality or geographic location, references to the non-Western world included mentions of prevailing diseases or the patient’s religious background. For instance, religions such as Islam, Hinduism or other non-dominant religion in the Western world were often explicitly stated, whereas a patient’s Christian background was only rarely mentioned. For example, two patient cases were introduced in a course, one depicting the patients as Islamic Somalian refugees, whereas the other case described the patient as ‘an independent, 47-year-old woman’ with no information on her ethnic nor religious background (Programme 2).
Thus, although the explicit definitions of culture took a broad approach and did not refer to specific groups of people, the interpretations in patient casuistry suggested, albeit implicitly, that culture predominantly referred to people or circumstances located outside the Netherlands or Western world. Overall, we saw numerous ‘neutral’ patients with habits or characteristics but without a culture, and ‘different’ patients who did have a culture expressed in terms of their nationality, ethnicity or religion. This asymmetric presentation of ‘normal’ vs ‘different’ implies an inherent notion of a Dutch or Western ‘standard’ patient, and of non-Western people who deviate from this standard and are, therefore, strangers.
Mechanism 3: static stereotypes
Further comparison of explicit definitions of culture with the manner in which these meanings were incorporated in patient case descriptions led to identification of another mechanism.
Some of the explicit definitions referred to before described culture as ‘changeable throughout your life’, implying that culture is dynamic. A few elective courses embraced this dynamic approach, by noting that categories are constructions (Programmes 1 and 3), that the idea of ‘normal values’ is an artificial concept and that there are no biological boundaries (Programme 2). An elective stated: ‘this unit introduces some theoretical concepts that can help to understand that diversity in medicine is not merely based upon diversity in human biology (such as diversity in hormonal or in genetic make-up). After all, the fact that there is a biological ‘standard’ and, subsequently, that there are variations of (or ‘deviances’ from) this standard is equally based upon social, cultural and political drives. To understand how the biological is entangled with the social, the cultural and the political, you will therefore look at concepts such as ‘sex’, ‘gender’, ‘race’, ‘ethnicity’ and ‘normal’ from different perspective’ (Programme 1). In contrast to this occasional dynamic approach, we observed that descriptions of a patient’s cultural background throughout the three programmes regularly referred to large ‘cultural entities’ that were presented as fixed, uniform and absolute. These large and definite cultural groups or parts of the world were presented without paying attention to relevant differences within these entities or making comparisons with other entities. For example, in a Programme 3 course, Aya is introduced as student and refugee from Sudan: ‘Aya is wondering how to comfort the little boy, because in her culture pain behaviour is very different from the behaviour displayed by the people in the Netherlands.’ By referring to Sudan and the Netherlands, culture is presented in terms of fixed, large and uniform categories, suggesting that all people in each of these countries behave similarly. Moreover, in most cases these entities referred to nationality, ethnicity, geographic location or religion. Other diversity aspects such as educational attainment, socio-economic status or lifestyle aspects were included only sporadically.
In sum, most of the patient cases presented culture as static concept, depicting non-Western persons as stereotypical ‘others’ using fixed and broad categories.
Mechanism 4: correlation or causation
Building on the results of the previous sections, we identified how the constructed notions of culture were linked to medical issues. What connection between the patient’s cultural background and the described medical concern was created?
We found that the link provided between a medical issue and the cultural group or location presented was often imprecise, indirect and lacking clear explanation (biomedical or otherwise). The patient’s religion, nationality or ethnicity was often explicitly or implicitly presented as underlying cause of a medical issue, while in fact some other associated factor (or factors) was the culprit. As illustrated by a Programme-2 course description, which – in order to explain ‘founder mutations’ – stated: ‘it is to be expected that founder mutations can be different in different ethnic/racial populations. For example, certain founder mutation only prevail with Ashkenazi Jews and in Japan (relatively isolated island)’. In this fragment explanations for founder mutations were initially provided by referring to a religion or ethnicity, however, the real medically relevant criterion seemed to be ‘living in isolation’. Another example comes from a workshop on ‘diversity in the doctor’s office’ (Programme 1), describing in separate paragraphs how diversity aspects (such as sex, age, life circumstances, character) may play a role. The paragraph on the aspect ‘culture’ stated: ‘Also differences in life circumstances are important. Asylum seekers and refugees often experienced horrible things. They are here homeless, and often without family and friends. The latter also applies to migrants. Building up a life in another country can cause unhealthy stress.’ Apparently, the medical issue is stress caused by certain life circumstances. However, by including it in a paragraph on ‘culture’, the information was presented as matter of culture, referring to people coming from abroad, rather than of life circumstances.
The fact that somebody practises a certain religion, carries a certain passport or is from a specific country of origin cannot be the immediate and direct cause of an increased risk of a disease. In most patient cases there seemed to be a related underlying aspect (living in isolation, having certain norms and values, dietary habits, etc.) that was seemingly the actual cause of the medical issue, although it was linked to a patient’s religion, ethnicity or nationality. It appears as if links made between medical issues and culture are examples of a causation versus correlation misconception: although a correlation between a patient’s nationality, ethnicity or religion and the medical issue seems to exist, an intermediate step is implicated (lifestyle, circumstances, living conditions, habits, etc.).
Analogous to the mechanisms described in the previous sections, the established links between culture (a certain group or location) and a medical issue were typically made when a patient was perceived as being different from the Dutch or Western norm.
Synthesis: culture as exotic problematic ‘other’
The abovementioned interrelated four mechanisms together resulted in a notion of culture as something or someone unfamiliar and exotic. More specifically, culture was variously and constantly constructed as an exception: it only deserved attention in separate courses or electives and a special international programme, and was related to patients and diseases that were presented as outsiders and deviant from an implicit Dutch or Western standard. By presenting patients as culturally different and deviant from the norm, they were portrayed as problematic, difficult to deal with and requiring specific attention, illustrated by the following quote from a Programme-1 course: ‘All those differences in culture, language, ethnicity and religion don’t make the doctor’s life any easier’. Differences in age or sex were not presented as problematic.
Discussion
The aim of this study was to investigate the construction of cultural diversity in medical curricula and how this construction influenced curriculum contents and learning goals. We identified four mechanisms through which culture was constructed as something or someone exotic, an exceptional ‘other’ deviant from the implicit Dutch or Western standard and therefore problematic.
The mechanisms of othering and stereotyping identified in this study are not new in medical education research. Consistent with our observations, others have argued that medical curricula are not ‘culture-neutral’ but unconsciously and predominantly based on ‘white’ Western cultural worldviews (Taylor Citation2003; Kuper Citation2014; Krishnan et al. Citation2019) and that stereotyping based on static categories negatively influences treatment decisions and doctor-patient interaction (Wear Citation2003; Stone and Moskowitz Citation2011; Teal et al. Citation2012). Similarly, previous research has stated that othering presents non-dominant groups as exotic and deviant (Wear Citation2003) and that it ‘creates barriers between neutralised doctors and their culture-laden patients, distancing doctors from understanding their patients’ lived experiences of health and illness’ (Kuper Citation2014). It has been noted before that ‘language is not innocent’ but imposes a viewpoint about our own position in relation to another (Pratt and Schrewe Citation2016) and that nobody is immune from othering and non-conscious bias, thereby making prejudice and discrimination an inevitable phenomenon in healthcare settings (Dharamsi Citation2011).
This paper adds new insights to these discussions. By applying a constructivist methodology examining the notion of cultural diversity itself and how this notion was presented in educational materials, we made visible how the mechanisms of othering and stereotyping were embedded in these materials. We argue that the embedded mechanism of othering based on static categories has consequences for the quality of medical education. The inconsistent message that culture is both relevant and irrelevant may have caused students to perceive culture negatively and consider it a ‘soft’ topic, as referred to previously. Also, the asymmetric presentation of the ‘normal Dutch or Western patient’ versus the ‘deviant from this implicit standard patient’ attaches an implicit label to the latter as odd, problematic and difficult to deal with. By portraying such patients as ‘problematic strangers’ and presenting culture in terms of broad and fixed categories, medical curricula may be offering students insufficient leads on how to take appropriate action. We realize that our presentation of the category ‘Dutch or Western patient’ is again an instance of a static construction, which we critique but were compelled to make in order to present our findings. Categorization is something that humans inevitably do (Bowker and Star Citation2008). The crucial question is: which categories are appropriate in which situation? We argue that in medical curricula, referring to cultural aspects that are seemingly not the actual biomedical cause is unlikely to provide the clear guidelines needed for accurate medical diagnosis and treatment of individual patients. By presenting certain patients as ‘exotic’ and ‘deviant’ in diverse ways (language, religion, nationality, ethnicity, etc.), medical curricula reinforce their ‘otherness’ diverting attention away from the factors that actually do matter, thereby leaving the future doctor empty-handed. When prospective doctors face a patient who is presented or experienced as someone with a non-Dutch or non-Western background, they will likely feel less competent to adequately treat this patient (real or simulated) and hesitate about whether the standard medical information is sufficient and applicable. It is our contention that in educational documents researched, culture becomes a proxy, a container that prevents current and future doctors from noting the person behind the patient.
While most studies in medical education have explored the application of cultural diversity in training of soft skills such as professional development, competence training, awareness and empathy (Betancourt Citation2003; Gregg and Saha Citation2006; Seeleman et al. Citation2009), this study also revealed how culture was constructed in ‘technical’ biomedical knowledge materials. Considering that biomedical knowledge is based on biomedical and health research, it is interesting to note that research on the construction of culture and ethnicity in this field produced similar results. Helberg-Proctor, for instance, reported examples in which ‘race’ and ‘ethnicity’ were used as prescription guidelines, although in fact intracellular lithium and muscle size had been identified as actual underlying individual clinical variables (Citation2017). In a similar vein, Hsu contested the use of standard racial and ethnic categories in health disparities research to predict health outcomes in the increasingly racially ambiguous US population (Hsu et al. Citation2019). Other studies, too, have questioned the validity of using ‘ethnicity’ as meaningful research variable (Epstein Citation2007; Proctor et al. Citation2011; Bradby Citation2012). Along the same lines, we argue that culture in the sense of broad fixed categories may not be a useful aspect to pay attention to in medical education.
As possible solutions to the challenges of dealing with cultural diversity, othering and stereotyping, scholars have proposed the concepts of ‘intersectionality’ (Tsouroufli et al. Citation2011; Mclean Citation2012; Powell Sears Citation2012; Monrouxe Citation2015; Verdonk et al. Citation2015; Muntinga et al. Citation2016), ‘critical consciousness’ (Kumagai and Lypson Citation2009; Dao et al. Citation2017; Halman et al. Citation2017) and ‘insurgent multiculturalism’ (Wear Citation2003). The intersectionality framework, introduced as concept to alleviate health disparities, ‘maintains that racial and ethnic minority groups hold multiple social statuses, called social locations, which interact with one another to uniquely shape the health views, needs and experiences of the individuals within the groups’ (Powell Sears Citation2012). By recognising that identities are more dynamic and based on multiple dimensions (Mclean Citation2012; Verdonk et al. Citation2015; Muntinga et al. Citation2016), the concept indeed challenges the mechanism of static stereotyping. However, the framework still focuses on these identities as fixed categories, albeit more complex, and does not consider that they may change over time or are influenced by the perception of the individual patients and doctors concerned. In our opinion, it is the health views, needs and experiences that matter when making an informed decision, not a patient’s ethnicity, race or social status. Also, by focusing specifically on ‘underrepresented groups’ such as women and ethnic minorities, this framework runs the risk of presenting patients from these groups as deviants and outsiders who need special action, thereby hampering equitable treatment.
The concept of critical consciousness takes a broader perspective, by placing medicine in a social, cultural and historical context; fostering a critical awareness of the self, others and the world; and by consciously focusing on all patients (Kumagai and Lypson Citation2009; Dao et al. Citation2017; Halman et al. Citation2017). Insurgent multiculturalism is a critical approach that focuses on structural inequality embedded in the curriculum (Wear Citation2003). These two concepts seem to be more in line with what we propose as practical solutions. Based on the insights of the present study, we suggest that references to static elements (such as country, continent, nationality, religion) be eliminated from patient cases and other descriptions in medical curricula and that more explicit attention be paid to biological differences and context aspects (such as circumstances, habits, environment, lifestyle, norms and expectations, language) as relevant and useful background information for making a proper diagnosis. Also, we recommend that this attention to diversity be systematically integrated into all courses, spanning both competence training and biomedical contents. In that sense our recommendations go one step further than Dogra et al. (Citation2016), which advocates diversity teaching to be an integral curriculum part, but still in a separate syllabus (Dogra et al. Citation2016). We suggest to make diversity ‘the norm’ in medical education and research. This last point calls for medical research that critically monitors how diversity is integrated into its setup.
Remarkably, the mechanism of othering and being ‘deviant from the norm’ seems to reflect a concern voiced by other studies about the neglect of age- and gender-related differences: medicine implicitly takes the middle-aged man as the norm (Dresser Citation1992, Wenger et al. Citation1993). Although these findings have been known for some time, application of these insights in medical education seems to be slow (Dijkstra et al. Citation2008). This study provides new input to these discussions.
Limitations and further research
This study focused on educational materials as crucial element in medical education. Since written texts do not reveal underlying intentions, and a lot of training occurs via teacher-student contact, peer-to-peer interaction, clinical rotations, simulated patient training and hidden curriculum, current insights may be further developed by investigating how the course materials play out in these interaction settings and how notions of cultural diversity are constructed in class, simulation trainings or the doctor’s office. Given their performative effect, though, the study of texts is important.
Furthermore, this study focused on medical curricula in a Dutch context, and for historical reasons it may be logical that the curricula unconsciously use Dutch or Western viewpoints and patients as reference point. Nevertheless, combating health disparities and dealing with cultural diversity in medical education is a topic of concern in more contexts, for which the outcomes of this study may be inspirational. It may be worthwhile to investigate whether the same mechanism of othering also occurs in medical curricula in other countries or parts of the world with a similar implicit bias towards the Western world (Heleta Citation2016) or to their own context and region and with similar effects on curriculum contents. What is the role of location, history, policies and context in the construction of cultural diversity? How to deal with the omnipresent paradox between ‘paying no attention to diversity’ and ‘paying stereotypical attention to diversity’? More research in these directions, in which reflexivity of the researcher is essential, will feed existing discussions on ‘whiteness-based norms’ and global medical competency (Martimianakis and Hafferty Citation2013).
Conclusion
We showed that culture in medical education is constructed as an outsider deviant from the implicit Dutch or Western standard and therefore problematic. Awareness of how these mechanisms of othering and stereotyping that are embedded in medical curricula problematise large sections of the patient population is crucial to enhance the quality of medical education. Based on this awareness, we suggest curriculum modifications that may help overcome challenges of implementing pertinent and non-stereotypical cultural trainings and contribute to equitable healthcare.
Glossary
Culture: Although very many definitions and interpretations of this concept exist, a possible description relevant for medical education could be: A complex layered framework that gives shape and meaning to our material, mental and social worlds. It is a constantly changing pattern of customs, convictions and meanings that are learned, shared and passed on through interpersonal transactions and based on experiences in people’s daily lives. It helps people (patients, doctors) to construct a sense of themselves and understanding of others. A person’s cultural identity (for example as a director, Turk, woman, Christian, general practitioner or diabetes patient) and the meaning attached to this identity both change depending on the context (at home, in the workplace, on holidays, abroad, in the doctor’s office, etc.), on the persons they have contact with, and over time.
Cultural diversity: Refers to the existence of a variety of cultural meanings, customs, convictions and beliefs within (a certain part of) society (region, institution, setting, etc.).
Acknowledgments
We are grateful to the two medical schools for participating in this study and sincerely thank them for granting us access to educational materials. We are thankful to the members of the Globalization Research Group of the School of Health Professions Education, Maastricht University, for their valuable feedback. Editing of the manuscript by Angelique van den Heuvel, Department of Educational Development and Research, Maastricht University, is gratefully acknowledged.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Note
Additional information
Notes on contributors
Albertine Zanting
Albertine Zanting, MA, PhD, researcher and Senior policy advisor on Cultural diversity at the School of Health Professions Education, Maastricht University, Maastricht, the Netherlands.
Agnes Meershoek
Agnes Meershoek, MSc, PhD, Associate Professor at the Health, Ethics and Society Department, School Caphri, Maastricht University, Maastricht, the Netherlands.
Janneke M. Frambach
Janneke M. Frambach, PhD, Assistant Professor at the School of Health Professions Education, Maastricht University, Maastricht, the Netherlands.
Anja Krumeich
Anja Krumeich, Professor in Translational Ethnographies in Global Health and Education, at the Health, Ethics and Society Department, Maastricht University, Maastricht, the Netherlands.
Notes
1 The term ‘native’ has different connotations in diverse contexts. In Yanow and Van der Haar’s study, it refers to ‘autochthons’, that is, the original Dutch people whose parents were both born in the Netherlands.
References
- Betancourt JR. 2003. Cross‐cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med. 78(6):560–569.
- Bowen GA. 2009. Document analysis as a qualitative research method. Qual Res J. 9(2):27–40.
- Bowker GC, Star SL. 2008. Sorting things out: classification and its consequences. Cambridge (MA): MIT Press.
- Bradby H. 2012. Race, ethnicity and health: the costs and benefits of conceptualising racism and ethnicity. Soc Sci Med. 75:955–958.
- Creswell JW. 2014. Educational research: planning, conducting and evaluating quantitative and qualitative research. Harlow (UK): Pearson.
- Dao DK, Goss AL, Hoekzema AS, Kelly LA, Logan AA, Mehta SD, Sandesara UN, Munyikwa MR, Delisser HM. 2017. Integrating theory, content, and method to Foster critical consciousness in medical students: a comprehensive model for cultural competence training. Acad Med. 92(3):335–344.
- Dharamsi S. 2011. Moving beyond the limits of cultural competency training. Med Educ. 45(8):764–766.
- Dijkstra AF, Verdonk P, Lagro-Janssen ALM. 2008. Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology. Med Educ. 42(10):1021–1028.
- Dogra N, Bhatti F, Ertubey C, Kelly M, Rowlands A, Singh D, Turner M. 2016. Teaching diversity to medical undergraduates: curriculum development, delivery and assessment. AMEE GUIDE No. 103. Med Teach. 38(4):323–337.
- Dogra N, Reitmanova S, Carter-Pokras O. 2010. Teaching cultural diversity: current status in U.K., U.S., and Canadian medical schools. J Gen Intern Med. 25(S2):164–168.
- Dresser R. 1992. Wanted single, white male for medical research. Hastings Cent Rep. 22(1):24.
- Epstein S. 2007. Inclusion: the politics of difference in medical research. Chicago (IL): University of Chicago Press.
- Gregg J, Saha S. 2006. Losing culture on the way to competence: the use and misuse of culture in medical education. Acad Med. 81(6):542–547.
- Halman M, Baker L, Ng S. 2017. Using critical consciousness to inform health professions education: a literature review. Perspect Med Educ. 6(1):12–20.
- Helberg-Proctor AEG. 2017. (Un)doing ethnicity: analyses of the socio-scientific production of ‘ethnicity’ in health research in the Netherlands. Maastricht: Universitaire Press Maastricht.
- Heleta S. 2016. Decolonisation of higher education: dismantling epistemic violence and Eurocentrism in South Africa. Transformation Higher Educ. 1:1–8.
- Hofstede GH, Hofstede GJ, Minkov M. 2010. Cultures and organizations: software of the mind. Maidenhead (UK): McGraw-Hill.
- Hsu P, Bryant MC, Hayes-Bautista TM, Partlow KR, Hayes-Bautista DE. 2019. Racially ambiguous babies and racial narratives in the United States a growing contradiction for health disparities research. Acad Med. 94(8):1099–1102.
- Jenkins RPOS. 1997. Rethinking ethnicity: arguments and explorations. London (UK): SAGE.
- Krishnan A, Rabinowitz M, Ziminsky A, Scott S, Chretien KC. 2019. Addressing race, culture, and structural inequality in medical education: a guide for revising teaching cases. Acad Med. 94:550–555.
- Kumagai AK, Lypson ML. 2009. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. 84(6):782–787.
- Kuper A. 2014. When I say… cultural knowledge. Med Educ. 48(12):1148–1149.
- Martimianakis MA, Hafferty FW. 2013. The world as the new local clinic: a critical analysis of three discourses of global medical competency. Soc Sci Med. 87:31–38.
- Mclean M. 2012. Broadening our perceptions of diversity in medical education: using multifocal lenses. Med Educ. 46(6):536–538.
- Meershoek A, Krumeich A. 2009. Multiculturalism and the construction of ethnic identities in labour and health practices: avoiding the culturalistic fallacy in applied research. Health Care Anal. 17(3):173–197.
- Monrouxe LV. 2015. When I say… intersectionality in medical education research. Med Educ. 49(1):21–22.
- Muntinga ME, Krajenbrink VQ, Peerdeman SM, Croiset G, Verdonk P. 2016. Toward diversity-responsive medical education: taking an intersectionality-based approach to a curriculum evaluation. Adv Health Sci Educ. 21(3):541–559.
- Powell Sears K. 2012. Improving cultural competence education: the utility of an intersectional framework. Med Educ. 46(6):545–551.
- Pratt D, Schrewe B. 2016. When I say… culture. Med Educ. 50(2):167–168.
- Proctor A, Krumeich A, Meershoek A. 2011. Making a difference: the construction of ethnicity in HIV and STI epidemiological research by the Dutch National Institute for Public Health and the Environment (RIVM). Soc Sci Med. 72(11):1838–1845.
- Sawatsky AP, Beckman TJ, Hafferty FW. 2017. Cultural competency, professional identity formation and transformative learning. Med Educ. 51:462–464.
- Schwandt TA. 1998. Constructivist, interpretivist approaches to human inquiry. In: Denzin NK, Lincoln YS, editors. Landscape of qualitative research: theories and issues. Thousand Oaks (CA): Sage.
- Seeleman C, Suurmond J, Stronks K. 2009. Cultural competence: a conceptual framework for teaching and learning. Med Educ. 43(3):229–237.
- Stone J, Moskowitz GB. 2011. Nonconscious bias in medical decision making: what can be done to reduce it? Med Educ. 45(8):768–776.
- Taylor JS. 2003. Confronting “culture” in medicine’s “culture of no culture”. Acad Med. 78:555–559.
- Teal CR, Gill AC, Green AR, Crandall S. 2012. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Med Educ. 46(1):80–88.
- Tsouroufli M, Rees CE, Monrouxe LV, Sundaram V. 2011. Gender, identities and intersectionality in medical education research. Med Educ. 45(3):213–216.
- Verdonk P, Muntinga M, Leyerzapf H, Abma T. 2015. Strategisch pendelen tussen gestolde categorieën en fluïde identiteiten. Tijdschr Genderstudies. 18(4):433–450.
- Wear D. 2003. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med. 78(6):549–554.
- Wenger NK, Speroff L, Packard B. 1993. Cardiovascular health and disease in women. N Engl J Med. 329(4):247–256.
- Worden MK, Ait-Daoud Tiouririne N. 2018. Cultural competence and curricular design: learning the hard way. Perspect Med Educ. 7(S1):8–11.
- Yanow D, Van Der Haar M. 2013. People out of place: allochthony and autochthony in the Netherlands’ identity discourse — metaphors and categories in action. J Int Relat Dev. 16(2):227–261.