The views of medical education stakeholders on guidelines for cultural diversity teaching

Abstract

Background: The General Medical Council set out the framework within which it expects medical education to develop. Educational guidelines have been developed across the world but their development is less clear in the UK. There has been little work regarding views about educational guidelines.

Aim: The research objective was to establish the views of medical education stakeholders towards specific guidelines for teaching in cultural diversity to medical students.

Methods: Sixty-one individuals were interviewed using a semi-structured interview. Thematic analysis was undertaken after the interviews were transcribed verbatim.

Results: In total, 51 respondents felt that guidelines would be useful; 17 of these explicitly stipulated that these would only be useful if they were not prescriptive and if they were applied flexibly and were practical. Four respondents, including two policy-makers holding senior positions with medical educational bodies, felt that new guidelines would not be useful, as they already existed in some form. Five respondents were unsure if guidelines would be helpful or not.

Conclusions: Guidelines were considered to be potentially useful for several reasons including to: help clarify what should be taught regarding cultural diversity and how it should be taught, provide justification for teaching the subject, help those unfamiliar with the subject, support those assigned with responsibility for developing such teaching, provide course and curriculum designers with reassurance, increase the credibility of the subject, set standards that serve as a benchmark against which schools can compare themselves with one another and highlight good practice. The reservations expressed suggest that the guidelines need to be developed using a range of stakeholders and have some degree of consensus to ensure that they will be used. The literature relating to attitudes towards clinical practice guidelines has much to contribute to the development of educational guidelines.

Introduction

By publishing Tomorrow's Doctors GMC (1993, 2003) the GMC set the framework within which it expected medical education in the UK to develop. The GMC argued then and has continued to argue that there are good reasons to allow diversity of curricula as this enables development of different ideas GMC (1993, 2003).

Educational guidelines have been developed for the delivery of undergraduate medical education across the world; for example; in the US (AAMC 1999a; Smith et al.2000; Kern et al. 2005), Canada Mandin & Dauphinee (2000), Australia Minasian-Batmanian (2002), Germany Mau et al. (2004) and Holland Martens et al. (1997). Although none offers specifics, they have tended to be slightly less general than Tomorrow's Doctors (1993, 2003), which commented little on specifics of the educational contents or delivery.

Martens et al.(1997) developed educational objectives and requirements of an undergraduate clerkship in general practice. The list of educational objectives developed was then cited in a national report on the objectives of undergraduate medical education in the Netherlands Metz et al. (1994). The Medical School Objectives Project AAMC (1999a) was designed to reach general consensus within the medical education community on the skills, attitudes and knowledge that graduating medical students should possess. As part of the project, meetings were convened to address special topics and offer their findings on the learning objectives and educational strategies for all medical students, e.g. Contemporary Issues in Medicine: Communication in Medicine AAMC (1999b). This report includes defining the way terms are used in the document and goes beyond just outlining educational objectives as done in Tomorrow's Doctors (1993, 2003). This is perhaps critical for an area such as cultural diversity. In the UK, such teaching has been shown to be fragmented with little clarity about what constitutes cultural diversity Dogra et al. (2005). It has also followed a political rather than educational agenda Dogra (2004).

Table

Practice points
•Introduction of clinical guidelines does not appear to have thwarted innovation.
•Areas such as cultural diversity may benefit from educational guidelines.
•Formulation of guidelines needs to involve individuals from a range of backgrounds and all stakeholders.
•Guidelines need to be practical and flexible.
•Guidelines would support teachers in this area.

Attitudes or views concerning educational guidelines do not appear to have been formally explored to date. This report is part of a PhD thesis Dogra (2004) on the views held by key stakeholders in medical education on the teaching and learning of cultural diversity. The aim of the paper is to report findings on a specific component of the study which addressed the research question: ‘Would it be helpful to have guidelines on what should be taught in cultural diversity and if so what form might these take and who might develop them?’

Method

Devising the interview schedule

Some structure was necessary to address the specific research questions relating to the understanding of cultural diversity, its teaching and assessment, therefore a semi-structured interview with mostly open-ended questions was devised Strah (2000).

The interview schedule drew on the literature base in sociology, medical education, education and intercultural studies Dogra (2004); previous research (Dogra2001; Dogra & Karnik 2003); clinical, educational and personal experience; earlier interviews with members of the GMC Education Committee responsible for the first edition of Tomorrow's Doctors; and an Internet search of all UK medical school websites.

After an introduction the interview was conducted in three parts:

• Part I collected basic demographic data (age and gender), as well as roles and experience.

• Part II explored participant views on the teaching and learning of cultural diversity.

• Part III asked for the ways in which respondents used or understood key terms such as race, ethnicity and multiculturalism.

The interview concluded by asking respondents about their experience and/or training in cultural diversity, including the place of guidelines. The questions relating to guidelines were:

1. Would it be helpful to have guidelines on what should be taught?

2. What form might these take and who might develop them?

The interview was piloted with two policy-makers and one diversity teacher and minor modifications were then made to the schedule.

Sample and sample size

There were two stages of sampling. The first sampled different groups of stakeholders; the second sampled different individuals from these groups. Selection was not random as key individuals were targeted. The sample group included:

• policy-makers: members of organizations that decide or influence policy on medical education;

• those who implement policy: heads of medical education and curriculum committee members;

• teachers: teachers responsible for developing and delivering cultural diversity, including those responsible for communication skills training;

• researchers in ‘cultural diversity’ and associated areas: including researchers actively teaching on ethnicity;

• medical students;

• users/patient representatives.

Included in the sample were medical schools:

• where cultural diversity was taught in a clearly identifiable way;

• where no specified programme regarding cultural diversity was taught.

The sampling strategy ensured that interviews continued until at least saturation was achieved and the sample large enough to enable comparisons between different stakeholders. Using sampling and ‘snowballing’, a total of 61 individuals were interviewed. Formal association with a medical school was defined as being employed by the medical school (including clinical NHS staff appointed as honorary teachers and external examiners), or being a student at a UK medical school. Individuals from 14 of the 26 established medical schools in the UK were involved (two schools have campuses at two sites; therefore 12 curricula were effectively covered).

Members from 11 policy-making organizations and six medical disciplines were interviewed. Other ‘clinical’ perspectives included pharmacy, social work, community youth work and nursing. Non-clinical participants came from sociology, anthropology, accountancy, research and advocacy work.

Procedure

Interviews took place face to face as a first preference and by telephone if the former was not possible, and averaged an hour. Initial contact was through a formal introductory letter that invited the respondent to contact the researcher if there were any queries. The letter also stated that the interviews would be confidential and that the local research NHS ethics committee had approved the project. If there was no response, the initial letter was followed up by email or by a second letter until the target number was achieved. No one was contacted more than twice if they failed to respond. Most respondents replied by letter or email to agree to take part; copies of these were kept, making written consent forms unnecessary.

Table 1 gives a summary of the demographics of the participants.

Table 1.  Summary demographics of participants

	Men (n = 39)	Women (n = 22)
Role
Communication teachers	3	3
Curriculum heads/leads	4	3
Cultural diversity teachers	5	9
Policymakers (included  individuals from the General  Medical Council, British Medical  Association, Medical Royal Colleges  and Department of Health)	17	1
Researchers	2	0
Students	4	3
Service users	4	3
Age, years
Under 30	4	3
31–40	7	3
41–50	13	8
51–60	14	7
Over 60	1	1
Ethnic origin
White British	30	20
Black British	0	1
British Indian	6	0
British Bangladeshi	1	0
British Pakistani	1	1
Mixed	1	0
Currently clinical active
Yes	21	10
No	18	12
Medical school association
Yes	27	18
No	12	4

The researcher's part in the research and interview process

This research was undertaken by a female, of Indian origin, aged 40, brought up and educated in the UK, who works as a senior clinical academic in child and adolescent psychiatry at an East Midlands medical school. Having undertaken the development of a module in ‘cultural diversity’, she had some professional familiarity and experience with the topic. As Robson (2002) has highlighted, all these factors may influence the research.

Analysis

Interviews were audiotaped and transcribed verbatim. Field notes were also written up after each session, recording reflections on the interviews and initial analytic comments. Key themes were identified from the texts as a whole and from collations of responses to specific themes. The process of analysis for this research study took into account the steps outlined by Miles & Huberman (1994). The thematic analysis was conducted by the author and then reviewed at a later date to consider whether the themes remained consistent in order to validate the assignment of data to the codes and themes Joffe & Yardley (2004). The themes identified were also reviewed by the project supervisor.

Findings

Direct quotes are presented in the findings to illustrate points made. Quotes are also integrated into the discussion to highlight themes identified through qualitative analysis. Where no difference between the different stakeholders’ perspectives is mentioned, the views were found across the range of stakeholders. In general, the findings showed no discernible pattern between sections of the sample.

Usefulness of guidelines

When asked whether it would be useful to have guidelines, 51 (5 communication teachers; 6 curricular heads; 13 diversity teachers; 13 policy-makers; 2 researchers; 5 students; 7 users) respondents felt that guidelines would be useful. Five (1 curricular head; 2 policy-makers; 2 students) respondents were unsure if guidelines would be helpful or not, and a policy-maker felt they were only for those who did not know the subject.

Four (1 communication teacher; 1 diversity teacher; 2 policy-makers) respondents felt that new guidelines would not be useful, as they already existed in some form. Both these policy-makers held senior positions with medical educational bodies.

I don’t really think that there should be anything more specific than an overall aim of why they should teach this. I think it should be left to individual medical schools to work out how they are going to serve that end. (R4: Communication teacher)

Format of guidelines

Seventeen of those who supported the development of guidelines (3 communication teachers; 5 curricular heads; 3 diversity teachers; 3 policy-makers; 1 researcher; 1 student; 1 user) of these explicitly stipulated that these would only be useful if they were not prescriptive and if they were applied flexibly. It was also important that any guidelines produced be practical. Four participants emphasized the need for any guidelines to be adapted to fit local circumstances.

Yes. Well I think they would need to be flexible, to take account of local conditions and the kinds of learning opportunities that the local environment presents. (R3: Communication teacher)

Some, but I think I would be more interested in how it might be taught …. I think it would depend on the nature of the advice …. It needs to be short, focused, realistic, in that it needs to be something that would show how this can be integrated into existing teaching, what its links are with all the teaching and if it also had ideas about how you might do it, practical suggestions and examples of practice. I think that alongside a few achievable objectives and learning outcomes would be really useful, but what I don’t want is a sort of 50 page document with pages of objectives and no real possibility of delivering. (R8: Curriculum head)

Only a student explicitly stated that guidelines should be prescriptive, as this was the only circumstance under which medical schools would take them seriously.

Yes, actually. I think the GMC have been very, very vague in its Tomorrows Doctors document. They wanted key learning outcomes. I certainly don’t remember them being terribly prescriptive and I think they should give examples of the key things to do with cultural diversity, the key areas like race, ethnicity, colour, disability. (R53: Student)

The role of guidelines

Although the question was phrased to ask if guidelines were needed with regard to what should be taught, participants were encouraged to raise whatever issues they felt were relevant. Earlier parts of the interview had discussed what should be taught regarding cultural diversity and also how it should be taught. Guidelines were considered to be potentially useful for several reasons, which included:

• Provide justification for teaching the subject (2: 1 communication teacher, 1 student).

• State what the contents of cultural diversity teaching might be (13: 3 communication teachers, 3 curriculum heads, 4 diversity teachers, 2 policy-makers 1 student, 1 service user).

• Help establish learning outcomes (8; 3 diversity teachers, 5 policy-makers).

• Set a standard (2 policy-makers and 1 student).

• Serve as a benchmark against which schools can compare themselves with one another (1 policy-maker).

• Improve standards (1 diversity teacher).

• Help those unfamiliar with the subject (1 policy-maker).

• Support those assigned with responsibility for developing such teaching (3: 1 curriculum lead, 2 diversity teachers).

• Provide course and curriculum designers with reassurance that cultural diversity has commonalities with other areas such as communication skills (2: 1 curriculum lead, 1 diversity teacher).

• Increase the credibility of the subject (3: all diversity teachers).

• Highlight good practice (5: 2 curriculum leads, 3 diversity teachers).

Diversity teachers in particular saw guidelines as serving a supportive function and highlighting good practice.

Yes. I think ultimately what needs to happen is that medical schools as a whole need to get together … at the moment it is so disparate. I think it is also very reliant on individuals and as one of those individuals, I find it's a constant sticking your neck out. When it's the flavour of the month then it's safe to stick your neck out and other times it is very, very wearing. (R26: Diversity teacher)

Others saw guidelines increasing the credibility of this area and enabling the curriculum to be more coherent.

I can see that sometimes topics we choose may seem kind of random. Maybe more getting together of module leaders to look at the whole curriculum and how it works because I think one thing students do think about is repetition. Some of that is poor planning but also because maybe they don’t understand that sometimes something like chronic illness you don’t just do once. There isn’t enough co-ordination across the curriculum. (R14: Diversity teacher)

Developing the guidelines

When the question was asked about who should be involved in the development of guidelines, just over one-half of respondents (32: 4 communication teachers; 3 curricular heads; 7 diversity teachers; 7 policy-makers; 1 researcher; 5 students; 5 users) felt that a range of individuals needed to contribute. There was a view that guidelines should be developed through consensus and a recognition that those involved with developing guidelines would need to be aware of their own biases by individuals being from different groups. One curriculum head suggested that someone who was too involved might not necessarily be constructive. No one mentioned evidence-based medicine and the use of guidelines to highlight support for different approaches.

I think people who are interested [should develop them]. I think what we need to do is to be aware of the people with a bee in their bonnet. There are people who come with baggage and I think we need to have people who are taking an overview about this, not, you know, I went to somewhere and they were awful to me, we want to get away from that. (R12: Curriculum head)

A communication teacher expressed the view that someone with expertise in several areas, e.g. clinical practice and sociology, should lead the development of guidelines as this might help achieve a better balance.

I think that one way that you can achieve this is by a group of people who are very committed and who are involved in this teaching, could advise the GMC on putting together guidelines, so it's consistent. (R15: Diversity teacher)

It would have to be collaboration between medical students and medical academics and bodies that represent different cultures and patients associations …. (R49: Student)

The Royal Society of Medicine (RSM) model that was used for the development of guidelines for communication teaching was suggested as applicable to ‘cultural diversity’.

We use the RSM just because they have a forum on communication, which is already up and running and there are lots of people from different universities who are all involved in that. Now I originally took on the role with my colleagues in A about trying to coordinate development of a curriculum, so we took the lead on it to begin with and so we just went to all the medical schools and said what are you kind of teaching, and what do you think you should be teaching? (R19: Diversity teacher)

Three respondents suggested specific organizations to take the lead including the British Sociological Association (1 diversity teacher with a sociology background), the Commission for Racial Equality (a user) and the General Medical Council (a user). Two policy-makers were not sure which organization might be appropriate. A further two felt that doctors should lead the development and another suggested local initiatives but was unsure how this might progress. The responses perhaps confirm the uncertainty about what medical schools are doing, and also anxieties about a top-down approach by the development of a national curriculum.

Discussion

In summary there was support for the development of guidelines if they were developed through a multidisciplinary forum involving a range of stakeholders, as long as they were flexible. They were viewed as one way in which teaching in ‘cultural diversity’ might gain some credibility. No one commented on the possibility that too much variety in teaching programmes might be disadvantageous. Not only does too much variety suggest that there may be inconsistency in learning outcomes but it may also suggest that there is a lack of clarity about what should be taught and perhaps also the teaching methods required. The majority of respondents felt that a multidisciplinary consensus was required, although four participants mentioned interested teachers as potential leads.

It is useful to consider the implication of reservations concerning guidelines in an area with little track record of quality teaching. It is possible that, if there were guidelines, more programmes might be shown to be somewhat lacking and that this would further undermine the already weak positions of many teachers in this field. There was a fear that guidelines would reduce innovation so that, for example, if a particular programme were highlighted, then new programmes or developments would be deemed unnecessary. However, this is a rather static view of education. Coles (in Lowry1993) stated that education is an evolutionary process: even quality programmes need to be developed continually especially in fields like diversity that are subject to constant change. The existence of a few programmes that set the benchmark may be a useful step forward; schools unable to meet the basic standards would have opportunities to consider the limitations to their progress. Teachers may also feel that guidelines would serve to undermine their already unclear value.

The concern regarding limiting innovation perhaps reflects the same concern that has been identified with clinicians who consistently expressed concerns about cookbook medicine (e.g. Grilli et al.1996; Gattellari et al.2001). There is also concern that the production of national guidelines would not necessarily take into account local issues. The way in which guidelines are developed may mitigate these concerns.

It is of note that no one mentioned evidence-based medicine and the use of guidelines to highlight support for different approaches. This may be because cultural diversity is a relatively new subject within medical curricula and the evidence base has yet to be developed. However, it may also reflect a lack of awareness of the literature that does exist. Another important issue that was not apparent from the responses was the lack of effective leadership in this area because it is not the professional or academic territory of any one group or discipline, which no one felt it should be. However, the views that guidelines needed consensus suggest that there is recognition that no single body is well placed to address the subject.

Other than Tomorrow's Doctors GMC (1993, 2003), there are no national policies in place regarding the place of ‘cultural diversity’ teaching within medical education. There are some NHS initiatives, although these are lacking in substantive educational theory or philosophy (e.g. Department of Health 2003). Guidelines for cultural diversity could frame the issue more educationally and move the teaching of ‘cultural diversity’ from a political to an educational framework. What is politically expedient may not be educationally coherent. Given the concerns raised by the participants in the study, it may be most useful to develop guidelines and consult widely with all stakeholders. It would, therefore, be important for stakeholder representatives to consult widely within their group to ensure that as many perspectives as possible are sought. Although this may initially be labour intensive, it has the advantage of being inclusive and, thereby, it is more likely that the outcomes will be deemed relevant and implemented successfully. Hayward et al.(1997) argued that respected organizations and opinion leaders should be involved in the development of guidelines and that the acceptability of any proposed format and medium for guidelines presentation should be pre-tested.

Any guidelines produced need to give examples of ‘good practice’. They should not suggest that there is only one way of teaching diversity and also need to refer to some educational theory to frame them in an educationally coherent way. Any endorsement for a particular model needs to be clear about the evaluation that the model has undergone.

Renvoize et al.(1997) found that many of the methods used to validate guidelines locally were inadequate. They argued that evidence-based clinical guidelines should be developed nationally, leaving hospitals to focus their energies on local adaptation, dissemination, implementation and evaluation of such guidelines. It is arguable that this is equally applicable in complex areas such as cultural diversity.

Flores et al.(2000) found that common reasons for use of practice guidelines were standardization of care and helpfulness. Much more likely to be cited were problems with guidelines including failure to allow for clinical judgement, use in litigation and limitation of autonomy. They felt that practice guidelines were more likely to be followed if they were simple, flexible, rigorously tested, not used punitively and motivated by desires to improve quality, not reduce costs. The indication from this study is that the same would apply to educational outcomes.

Conclusion

The participants were, in general, positive abut the place of guidelines but did express reservations about how they might be developed and used. The findings suggest that guidelines set by a credible group made up of various stakeholders would be well received and implemented. The attitudes towards educational guidelines appear to reflect a similar picture to attitudes towards clinical practice guidelines. In developing educational guidelines, educators may find the experience of clinicians who have developed clinical guidelines invaluable.

Acknowledgements

The author acknowledges the support of the University of Leicester through a semester's sabbatical to complete her PhD, and her supervisor Nick Jewson. Thanks are offered to Ruth Edwards and Khalid Karim for reading earlier drafts

Conflict of interest: None.

Additional information

Notes on contributors

Nisha Dogra

NISHA DOGRA, BM DCH MRCPsych MA PHD, is senior lecturer and honorary consultant in child and adolescent psychiatry at the University of Leicester. This paper comes from her PhD thesis. She is involved in educational research in cultural diversity and psychiatric education and in issues of cultural competence in healthcare.