Supporting GP trainees to practice medicine in a culturally complex world

Stone and colleagues [1] have contributed to the debate of how best to prepare students to carry out effective cross-cultural consultations, where common mental health and physical problems often co-exist. They identify a number of challenges.

Their paper references, albeit tangentially, the complexity of patients’ lives when practitioner and patient meet in the consultation [1]. A changing geopolitical world means that every consultation will traverse the boundaries of education, social class, ancestry and economic income as represented in the intersectionality of every individual’s life. A patient’s class, race, gender and sexual orientation will have a direct bearing on their mental health. Higher rates of poor mental health in socially and economically disadvantaged communities, along with additional rates of suffering amongst those who are peoples of colour and/or members of the lesbian, gay, bisexual and transgender community, join to demonstrate this.

Stone et al. draw our attention to the multiple disadvantages of rural, poor communities with reduced access to specialist mental health services. These are a consequence of policies which systematically constrain access to care for those most in need- a phenomenon Julian Tudor Hart articulated as the Inverse Care Law in 1971 [2].

Preparing students to work in communities experiencing profound structural disadvantage is not a universal objective of the undergraduate curriculum. Its inevitable challenge will sit at the heart of Stone et al.’s exclamation that ‘cultural barriers and stigma may limit discussion.’[1] The groundbreaking work of the Glasgow Department of General Practice under Prof Watt’s direction addresses this vital need through the Deep End Practices collective; a GP community of practice which now includes other UK regions. The Yorkshire and Humber Deep End GPs have articulated the need to include education (undergraduate and postgraduate) and training in their focus, linked to Workforce development, Advocacy and Research to support practitioners working in areas of deprivation [3].

Barriers to detecting common mental health problems are subsumed into difficulties starting conversations with patients where GP Trainees, and indeed experienced practitioners, unskilled and unsure of ‘next steps’. ‘If I detect a psychological problem here – where are the culturally appropriate services and how quickly can patients access them?’ These unspoken questions sit behind some of the findings of this paper. They have been noted in studies with populations outside of the 18–60-year-old ‘working age’ cohort, such as GPs consulting with adolescents where services have consistently been under-funded [4].

In concert with starting to unpack the multiple, often hidden and unarticulated barriers to initiating difficult conversations with patients experiencing poor mental health, this paper also raises the unasked question regarding expectations of GP trainees in their consultations? Do we expect them ‘to master the diverse skill set for psychiatric diagnosis’ or do we aim to support their professional development so that they can feel more confident exploring a psychosocial framework in partnership with their patient?

The study reveals low levels of therapeutic activity with non-English speaking patients: both in under-identification of problems and in not offering additional consultation time. Underpinning this disengagement is an impasse between trainer and trainee to tackle these challenging and often uncomfortable clinical encounters; which likely reveals experienced GPs’ lack of confidence in this clinical arena. A qualitative study of UK medical students’ perceptions of race, ethnicity and culture [5] demonstrated how difficult undergraduates found it to traverse territory where skin colour, ancestry and social class differed from the white middle class. Students were inhibited in their articulation of cross-cultural communication; a phenomenon the authors described as ‘white fear’. This sense of social discomfort is not confined to undergraduates as Stone et al.’s study reveals [1].

In preparing doctors for the future, fit to practise in a globalised world, medical education needs to foster developing a sense of one’s own unconscious biases and cultural blind spots, as an individual practitioner and as part of the dyad: ‘Dr and Patient’ or ‘Trainer and Trainee’. From the earliest stages of undergraduate education and throughout professional development reflection must be a core part of medical education. To support GP Trainees to be more confident and effective in their consultations, we need educators who are informed by patient experience, work with patients of diverse backgrounds and are cognisant of the structural inequalities which are played out, both in patients’ daily lives and systems of healthcare.