Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103

Black/African American Women's Woes: Women's Perspectives of Black/African American Maternal Mortality in the USA

BACKGROUND

Despite advances in perinatal care in the USA, maternal mortality is on the rise, and maternal death is higher than in any other high-income country. Maternal mortality in the USA is a persistent public health concern. This issue disproportionately affects Black/African American women, with their likelihood of pregnancy-related death being three times more likely compared to White women. This study aimed to explore the resources needed for Black/African American women to address the relatively higher maternal mortality rates recorded for them.

METHODS

An anonymous link with demographic and open-ended questions was sent to US women 18 years and older to participate in the study. A total of 140 participants responded to the survey. We retained a final sample of 118 responses after eliminating responses with missing data. Descriptive statistics are reported for closed-ended items. Open-ended responses were analyzed using content analysis procedures, where we coded and categorized the data into themes.

RESULTS

Six themes were identified from the study data: (1) Diversity, Equity, and Inclusion (DEI) training for health providers focused on racial bias and discrimination, (2) Advocacy, (3) Provider selection, (4) Researching doctors and delivery hospitals to inform women's birthing decision-making, (5) Women's care-seeking behaviors, and (6) Addressing the Social Determinants of Health.

CONCLUSION

Based on the study's findings, we recommend DEI training for healthcare professionals providing direct care to pregnant and postpartum women, advocacy and resource-awareness training for pregnant Black/African American women and their spouses/partners, or a family member, to assist them in their pregnancy and birthing journeys.

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Integrating Shared Decision-Making into Undergraduate Oncology Education: A Pedagogical Framework

The integration of shared decision-making (SDM) into undergraduate oncology education represents a critical evolution in medical pedagogy, reflecting the growing complexity and patient-centric focus of contemporary healthcare. This paper introduces a comprehensive pedagogical framework designed to embed SDM within the undergraduate medical curriculum, particularly in oncology, where the multiplicity of treatment options and their profound impact on patient life underscore the necessity of this approach. Grounded in a systematic literature review and aligned with established educational theories, this framework proposes twelve strategic approaches to cultivate future physicians proficient in both clinical acumen and patient-collaborative decision-making. The framework emphasizes real-world clinical experience, role-playing, case studies, and decision aids to deepen students' understanding of SDM. It advocates for the development of communication skills, ethical deliberation, and cultural competence, recognizing the multifaceted nature of patient care. The inclusion of patient narratives and evidence-based decision-making further enriches the curriculum, offering a holistic view of patient care. Additionally, the integration of digital tools within the SDM process acknowledges the evolving technological landscape in healthcare. The paper also addresses challenges in implementing this framework, such as curricular constraints and the need for educator training. It underscores the importance of continual evaluation and adaptation of these strategies to the dynamic field of medical education and practice. Overall, this comprehensive approach aims not only to enhance the quality of oncological care but also to prepare medical students for the complexities of modern medicine, where patient involvement in decision-making is both a necessity and an expectation.

Cultural topics with clinical implications needed in the dental curriculum to develop intercultural competence: A systematic review

OBJECTIVE

To identify cultural topics with clinical implications to be incorporated into the dentistry curriculum to develop Intercultural Competence.

METHODS

Systematic review with PRISMA criteria that exported 216 articles from the Web of Science, Scopus, and SciELO databases from 2012 to 2022, of which 40 were selected. The inclusion criteria were theoretical and empirical scientific articles, of quantitative, qualitative, or mixed methods nature, on cultural topics.

RESULTS

The data analysis allowed the organization of information into four cultural topics: Development of professional intercultural self-awareness, Individual, family, and cultural implications, Construction of intercultural therapeutic relationships, and Specific clinical aspects, each with particular contents to be developed in the dentistry curriculum. However, some clinical issues have yet to be explored in-depth, leaving research possibilities open to all disciplines in dentistry. Additionally, it is necessary to analyze the cultural bias in the discussion and conclusion of some reviewed articles, as they were conducted from an ethnocentric perspective. Thus, peer reviewers of scientific journals and researchers in these topics must have appropriate training in Intercultural Competence.

CONCLUSIONS

This review provides a guide and pedagogical sequence of the cultural topics that should be incorporated into the dentistry curriculum to achieve Intercultural Competence, it also highlights a wide range of relevant aspects to consider in establishing an adequate therapeutic relationship. Explicit accreditation criteria contribute to the establishment of Intercultural Competence in the curricula; however, in countries that lack regulations, there is a moral and ethical duty to incorporate the subject so that the future professional can manage and establish inclusive healthcare.

Problem-based learning curriculum disconnect on diversity, equitable representation, and inclusion

Diversity, equity, and inclusion (DEI) mission statements continue to be adopted by academic institutions in general, and by dental schools around the globe in particular. But DEI content seems to be under-developed in dental education. The objectives of this study were two-fold: to extract information from all the PBL cases at University of British Columbia's Faculty of Dentistry curriculum in terms of the diversity, equitable representation, and inclusion of patient and provider characteristics, context, and treatment outcomes; and; to compare these findings with the composition of the British Columbia census population, dental practice contextual factors, and the evidence on treatment outcomes within patient care. Information from all the 58 PBL cases was extracted between January and March 2023, focusing on patient and provider characteristics (e.g., age, gender, ethnicity), context (e.g., type of insurance), and treatment outcomes (e.g., successful/unsuccessful). This information was compared with the available literature. From all the 58 PBL cases, 0.4% included non-straight patients, while at least 4% of BC residents self-identify as non-straight; there were no cases involving First Nations patients although they make up 6% of the British Columbia population. Less than 10% of the cases involved older adults who make up almost 20% of the population. Only Treatments involving patients without a disability were 5.74 times more likely to be successful compared to those involving patients with a disability (p<0.05). The characteristics of the patients, practice context, and treatment outcomes portrayed in the existing PBL cases seem to differ from what is known about the composition of the British Columbia population, treatment outcome success, and practice context; a curriculum disconnect seems to exist. The PBL cases should be revised to better represent the population within which most students will practice.

A cross-disciplinary approach to learning medical physiology and behavioral skills involving drama students performing as simulated patients

The early years of physiology education in medical curricula provide unique challenges. As well as inculcating concepts that are seen as difficult, modern curricula require that students learn in context in case-based learning courses. Additionally, regulating bodies stress that the soft skills of compassion, communication, and empathy are embedded throughout curricula. This has driven work in our organization involving drama and final-year medicine students during which they collaborate in realistic simulations of doctor/patient interactions. We adapted this transdisciplinary approach to second-year physiology tutorials. This emphasized the holistic importance of physiology to patient care, while also embedding "human factors" skills from the very earliest stages of the curriculum. After preparing by attending acting classes based on aspects of Konstantin Stanislavski's "System," the authors supervised tutorials in which drama students participated in a "physiology of hypofertility" session for second-year medical students, playing a 34-year-old woman with premature menopause (or their partner). Opinion (from all students) was evaluated by Likert questionnaires (which included open questions). A focus group of drama students was also interviewed, and the conversation was recorded for thematic analysis. Positive Likert scores were recorded for the authenticity of the tutorials, skills development, fostering empathy, and motivating students to improve. All participants evaluated the tutorial as highly enjoyable. These scores are reflected in positive open commentary on the questionnaires and in the focus group interviews. The results suggest that even basic science tutorials give opportunities for interdisciplinary study and enhancement of behavioral skills while gaining enthusiastic student acceptance.NEW & NOTEWORTHY This work details how physiology tutorials for early years medical students are transformed by taking the clinical case off the two-dimensional page and instead having the case scenario acted by drama students. This adds context and authenticity. The benefits are twofold: emphasizing the importance of physiology to the budding clinician and embedding empathy and compassion from the earliest points in a clinician's career.

A critical review of cultural competence frameworks and models in medical and health professional education: A meta-ethnographic synthesis: BEME Guide No. 79

BACKGROUND

Cultural competence resides at the core of undergraduate and postgraduate medical and health professional education. The evolution of studies on cultural competence has resulted in the existence of multiple theoretical frameworks and models, each emphasising certain elements of culturally appropriate care, but generally lacking in providing a coherent and systematic approach to teaching this subject.

METHODS

Following a meta-ethnographic approach, a systematic search of five databases was undertaken to identify relevant articles published between 1990 and 2022. After citation searching and abstract and full article screening, a consensus was reached on 59 articles for final inclusion. Key constructs and concepts of cultural competence were synthesised and presented as themes, using the lens of critical theory.

RESULTS

Three key themes were identified: competences; roles and identities; structural competency. Actionable concepts and themes were incorporated into a new transformative ACT cultural model that consists of three key domains: activate consciousness, connect relations, and transform to true cultural care.

CONCLUSION

This critical review provides an up-to-date synthesis of studies that conceptualise cultural competence frameworks and models in international medical and healthcare settings. The ACT cultural model provides a set of guiding principles for culturally appropriate care, to support high-quality educational interventions.

Diversity competence training for health professionals in Europe: a modified delphi study investigating relevant content for short or online courses

BACKGROUND

Diversity is a reality in our societies, requiring health professionals to adapt to the unique needs of all patients, including migrants and ethnic minorities. In order to enable health professionals to meet related challenges and reduce health disparities, long and demanding training courses have been developed. But due to busy schedules of professionals and often scarce resources, a need for shorter training courses exists. This study aims to investigate which topics and methods should be prioritised in designing basic diversity training courses that provide health professionals the opportunity to foster this competence.

METHODS

The study provided an expert panel of 31 academic and clinical migrant health experts with the content and methods of an existing diversity training course. The panel was asked to prioritise training topics and teaching methods in a two-stage process, using an adapted Delphi method. In the first stage, experts rated 96 predefined items, commented on those items, provided answers to eight open-ended questions and suggested additional content for a short course. In the second stage, they commented on the ratings from Round 1, and rated new suggested content. Consensus for training topics was set to 80% and for teaching methods 70%.

RESULTS

The entire panel deemed 'health effects of migration (pre-, during- and post-migration risk factors)' to be important or very important to include in a short/online, basic diversity training (100% consensus). Other high-scoring items and therefore topics to be included in trainings were 'social determinants of health' (97%) and 'discrimination within the healthcare sector' (also 97%). A general trend was to focus on reflective practice since almost all items regarding reflection reached consensus. 'Reflection on own stereotypes and prejudices' (97%) was the highest-rated reflection item. 'Opportunities and best practices in working with interpreters' was the highest-scoring skills item, both on consensus (96%) and mean value (5.77).

CONCLUSIONS

Experts' prioritizations of teaching content and methods for diversity training can help the design of short (online) trainings for health professionals and reduce unnecessary course content, thereby fostering professional development and enabling diversity competence trainings to be implemented also when time and/or financial resources are limited.

An ethnographic investigation of medical students' cultural competence development in clinical placements

As a result of an increased understanding of culture's impact on health and healthcare, cultural competence and diversity curricula have been incorporated into many medical programs. However, little is known about how students develop their cultural competence during their training. This ethnographic case study combined participant observation with interviews and focus group to understand students' views and experiences in developing their cultural competence during clinical placements. The results show that students' development of cultural competence is an individually varied process via four distinctive yet interrelated learning avenues. Immersion in a diverse healthcare environment contributes to students' development of cultural awareness and knowledge. Observation of culturally appropriate or inappropriate practices allows students to enhance their practical skills and critical reflection. Interaction with other clinical professionals, patients, and their family members, enables students' engagement within the busy clinical practice. Reflection helps students to actively think about culture's impact on health and internalize the importance of cultural competence. Students' learning via each avenue is interrelated and constantly interacting with their learning environment, which collectively contributes to their development. Integrating the results allowed the authors to generate a theoretical model that conceptualizes medical students' cultural competence development in clinical placements, which unearths students' cultural learning within the informal and hidden curriculum. This study provides a rare view of students' development of cultural competence in clinical placements, which may inform the pedagogic development of cultural competence and diversity education in medicine and healthcare.

Preparing Medical Students to Address Health Disparities Through Longitudinally Integrated Social Justice Curricula: A Systematic Review

PURPOSE

The education of health care professionals is a contributing factor to persistent health disparities. Although medical students are expected to understand racism, classism, and other social and structural drivers of health (SDH), standardization and best practices for teaching these concepts are lacking. Some medical schools are adopting social justice curricula (SJC) that prioritize health equity in teaching students to recognize SDH and preparing them to address the consequent health disparities. This systematic review sought to evaluate how these schools have integrated SJC into their core teaching; the criteria they have used to measure success and to what extent these criteria are met; and best practices in planning, implementing, and evaluating SJC.

METHOD

The authors searched 7 databases for English-language studies published between January 2000 and April 2020, reporting on longitudinally integrated SJC at U.S. medical schools intended for all students. Quantitative and qualitative outcomes were synthesized and summarized.

RESULTS

Searches identified 3,137 articles, of which 11 met inclusion criteria. Results demonstrated schools use a variety of teaching methods over a wide range of didactic hours to teach SJC concepts. Surveys and objective tests indicated students in SJC are generally satisfied and demonstrated improved knowledge and skills related to understanding and mitigating SDH, although findings related to changes in attitudes were equivocal. Evaluations at graduation and in residency demonstrated students who experience SJC are more prepared than their peers to work with patients who are underserved. Best practices in SJC included addressing the hidden curriculum, considering medical mistrust, and using tools like the Racial Justice Report Card and Tool for Assessing Cultural Competence Training.

CONCLUSIONS

These findings indicated SJC can prepare students to better address the root causes of health disparities. Future research should consider the long-term influences of these curricula on students, patients, and the community.

A discourse analysis of General Medical Council (GMC) guidelines for the inclusion of cultural diversity issues in medical education and practice

BACKGROUND

Several studies have highlighted the insufficient inclusion of cultural diversity in medical schools' curricula and the extent of health inequalities highlighted by the COVID-19 pandemic. This study aimed to critically review a range of GMC publications to identify the inclusion of cultural diversity topics in their guidelines, as according to recent studies, doctors are inadequately prepared to serve a diverse population.

METHODS

Twenty-four relevant GMC publications were analysed. An inductive thematic analysis was conducted to review the content of the guidelines; and discourse analysis was used to critically understand the linguistics used whilst also considering the cultural and social context.

RESULTS

The GMC publications primarily focused on discouraging discrimination and promoting equality. Themes around diversity in medical practice were less commonly covered. There was considerable internal inconsistency across the guidelines. Guidelines aimed at medical schools and medical students were more likely to consider cultural diversity issues compared to those intended for doctors.

CONCLUSIONS

Cultural diversity teaching can only be as effective as the policy that drives it. Despite the inclusion of cultural diversity issues in GMC guidelines, this study suggests considerable ambiguity in how these issues are represented and understood. The guidelines require careful revision and should be written to reduce the likelihood of variable interpretation, thereby promoting better cultural diversity inclusion in medical schools' curricula, and consequently better patient care.

The do's, don'ts and don't knows of redressing differential attainment related to race/ethnicity in medical schools

INTRODUCTION

Systematic and structural inequities in power and privilege create differential attainment whereby differences in average levels of performance are observed between students from different socio-demographic groups. This paper reviews the international evidence on differential attainment related to ethnicity/race in medical school, drawing together the key messages from research to date to provide guidance for educators to operationalize and enact change and identify areas for further research.

METHODS

Authors first identified areas of conceptual importance within differential attainment (learning, assessment, and systems/institutional factors) which were then the focus of a targeted review of the literature on differential attainment related to ethnicity/race in medical education and, where available and relevant, literature from higher education more generally. Each author then conducted a review of the literature and proposed guidelines based on their experience and research literature. The guidelines were iteratively reviewed and refined between all authors until we reached consensus on the Do's, Don'ts and Don't Knows.

RESULTS

We present 13 guidelines with a summary of the research evidence for each. Guidelines address assessment practices (assessment design, assessment formats, use of assessments and post-hoc analysis) and educational systems and cultures (student experience, learning environment, faculty diversity and diversity practices).

CONCLUSIONS

Differential attainment related to ethnicity/race is a complex, systemic problem reflective of unequal norms and practices within broader society and evident throughout assessment practices, the learning environment and student experiences at medical school. Currently, the strongest empirical evidence is around assessment processes themselves. There is emerging evidence of minoritized students facing discrimination and having different learning experiences in medical school, but more studies are needed. There is a pressing need for research on how to effectively redress systemic issues within our medical schools, particularly related to inequity in teaching and learning.

Exploring how physician educators approach politically charged topics with learners

CONTEXT

Medical educators hold and encounter different beliefs and values on politically charged health-related topics such as reproductive rights and immigration. Their views on these topics have implications for how they approach them with learners, yet little work has explored medical educators' views and pedagogical approaches. In this study, we used Hess's approaches to controversial topics (avoidance, denial, privilege, balance) as a guiding conceptual framework to explore physician educators' views on and approaches to politically charged topics. We used this understanding to provide guidance on how best to address politically charged issues within medical education.

METHOD

We used a constructivist qualitative approach to explore medical educators' approaches to politically charged topics. We interviewed 37 physician educators from two medical schools in different regions of the United States. In these semi-structured interviews, we presented participants with vignettes depicting politically charged topics arising in an educational setting. Participants described and explained their response to each vignette. Interviews were recorded, transcribed and analysed using constructivist-oriented thematic analysis.

RESULTS

Participants were thoughtful about preparing learners for participation in a professional community that holds certain responsibilities to a politically and culturally diverse society. Although some adopted clear approaches on politically charged topics and declared their stance on the topic to learners, others took a balanced approach, focused only on the medical aspects and withheld their views. The context and location of practice played a role in the approaches participants adopted. Additionally, they had varied views on which topics had a place in medical education.

CONCLUSION

Our findings provide insights that can help guide medical educators and training programmes in decisions about their role in facilitating conversations about politically charged, health-related topics and helping learners form their own perspectives and approaches to such topics.

A valid and reliable scale to assess cultural sensibility in nursing

BACKGROUND

Cultural sensibility is an important concept linked to the achievement of cultural competence. Health professionals must first improve their cultural sensibility to become culturally competent and to be able to offer competent care to culturally diverse populations. Aim To develop and psychometrically test the Cultural Sensibility Scale for Nursing (CUSNUR), a cultural sensibility scale that can be used in nursing for the achievement of competencies needed to care for culturally diverse populations.

DESIGN AND METHODS

The cross-sectional survey was conducted over two stages. The first stage involved the cross-cultural and discipline-specific adaptation of an existing scale addressing this concept in the field of law using the reverse translation method. Second, validation of the scale was carried out from October 2016-June 2017 by studying the psychometric properties of the questionnaire through an analysis of content acceptability and reliability and through exploratory factor analysis (EFA).

RESULTS

The questionnaire was designed to be clear, easy to understand, and of adequate length, and experts involved in content validation agreed that the scale meets these criteria. A total of 253 nursing students participated in the validation stage. Four factors were identified from the EFA: (1) patient and health professional behaviours, (2) self-assessments, (3) self-awareness, and (4) cultural influence. Two items were excluded. Factorial saturation is adequate for all factors (>0.30). The Cronbach alpha was measured as 0.75.

CONCLUSIONS

This study presents the first version of the CUSNUR and demonstrates that the scale is valid and reliable.

Pharmacy graduates' perceptions of competency, integration, and social accountability in the undergraduate curriculum of pharmacy schools in Nigeria

INTRODUCTION

An integrated, competency-based curriculum that fosters social accountability including cultural sensitivity among graduates is an educational strategy towards producing practice-ready professionals. This study aimed to evaluate pharmacy graduates' perceptions of competency, integration, and social accountability in the undergraduate curriculum of Nigerian schools of pharmacy.

METHODS

A cross-sectional online survey consisting of a 42-item questionnaire was administered to 467 purposively selected pharmacy graduates who completed their undergraduate training between January 2012 and February 2020 from 20 accredited Nigerian pharmacy schools. Mann-Whitney U test was used to determine the differences in the participants' responses on a Likert scale.

RESULTS

Of 467 participants, 54.4% felt that the Nigerian undergraduate pharmacy curriculum was not adequate in content, while 54.2% felt the courses in the curriculum were not well integrated to facilitate easy learning by students. About half (50.6%) strongly agreed or agreed that "the basic pharmacy courses are well synchronized with the clinical components" but 28.9% strongly disagreed or disagreed. The majority (88%), with no significant difference between gender (z = -1.615, P = .11), strongly agreed or agreed that they apply knowledge of clients' culture and disparity to deliver pharmaceutical services.

CONCLUSIONS

Marginally above half of the graduates perceived the Nigerian undergraduate pharmacy curriculum to be deficient in course content. There is evidence of limited integration and social accountability in the curriculum. Cultural sensitivity appears to be a component of the curriculum but this needs to be properly structured. The pedagogy strategy for learning cultural sensitivity should be further interrogated.

Contending with Our Racial Past in Medical Education: A Foucauldian Perspective

Practices of systemic and structural racism that advantage some groups over others are embedded in American society. Institutions of higher learning are increasingly being pressured to develop strategies that effectively address these inequities. This article examines medical education's diversity reforms and inclusion practices, arguing that many reify preexisting social hierarchies that privilege white individuals over those who are minoritized because of their race/ethnicity. Evidence: Drawing on the work of French theorist Michel Foucault, we argue that medical education's curricular and institutional practices reinforce asymmetrical power differences and authority in ways that disadvantage minoritized individuals. Practices, such as medical education's reliance on biomedical approaches, cultural competency, and standardized testing reinforce a racist system in ways congruent with the Foucauldian concept of "normalization." Through medical education's creation of subjects and its ability to normalize dominant forms of knowledge, trainees are shaped and socialized into ways of thinking, being, and acting that continue to support racial violence against minoritized groups. The systems, structures, and practices of medical education need to change to combat the pervasive forces that continue to shape racist institutional patterns. Individual medical educators will also need to employ critical approaches to their work and develop strategies that counteract institutional systems of racial violence. Implications: A Foucauldian approach that exposes the structural racism inherent in medical education enables both thoughtful criticism of status-quo diversity practices and practical, theory-driven solutions to address racial inequities. Using Foucault's work to interrogate questions of power, knowledge, and subjectivity can expand the horizon of racial justice reforms in medicine by attending to the specific, pervasive ways racial violence is performed, both intra- and extra-institutionally. Such an intervention promises to take seriously the importance of anti-racist methodology in medicine.

Assessing Asian Medical Students' Readiness for Diversity: Localizing Measures of Cross-Cultural Care Competence

Phenomenon: There is now broad acceptance that the development of cross-cultural competence (CCC) supports the delivery of appropriate care to diverse groups and is an essential component in medical education worldwide. CCC training in East Asian contexts has been constrained by the fact that "cultural diversity" training globally has focused primarily on the needs of racial and ethnic communities, to the relative neglect of other groups. The present study explores Taiwanese students' perceptions of CCC provision to identify gaps in local medical education and thus facilitate a more systematic delivery of CCC. Approach: Using an adapted and translated version of the Cross-Cultural Care Survey developed by Harvard Medical School, we collected 1567 student responses from four geographically-distributed Taiwanese medical schools between 2015 and 2017. In addition to student responses, we also collected 122 clinical teacher responses from two of the four medical schools that were surveyed to cross-examine the students' self-perceived competence. The data were analyzed with SPSS and ANOVA was employed with student data to compare the differences among different stages. The analysis focuses on CCC in 4 stages of training: general education, basic pre-clinical and integrated clinical sciences, clerkship, and internship. Findings: The findings show that students felt unprepared to deal with health disparities and the needs of diverse groups and there was no evidence of an increased sense of preparedness in the development of relevant skills in the analyses of the pre-clinical to clinical stages of the curriculum. Similarly, teachers also perceived students across the different stages of training to be unprepared in dealing with the health disparities and needs of diverse groups. However, although findings from teachers' responses parallel those from students, teachers tend to perceive students to be even more unprepared than they perceive themselves to be. The training for CCC appeared inadequate from both set of data and students perceive CCC training to be less explicitly evident in the medical program as it advances from the foundation stage to the pre-clinical stage. Insights: The study raises some crucial issues in terms of diversity and CCC training in medical education programs. The fact that increased awareness of health disparities and the needs of diverse groups fails to be aligned with a sense of preparedness and skillfulness confirms that CCC has not been explicitly and sufficiently addressed in the medical curriculum, particularly in the pre-clinical stage when the focus is on acquiring scientific and technical knowledge. This study shows how a questionnaire designed by and for an American medical institution situated in a highly diverse society can be adapted so that its findings serve as a baseline for medical education programs in Taiwan, and perhaps in other countries that are beginning to acknowledge hitherto "hidden" diversity. This study also has implications which indicate that CCC is crucial in the delivery of appropriate care by members of the medical profession to diverse patients.

Virtual patients reflecting the clinical reality of primary care - a useful tool to improve cultural competence

BACKGROUND

Virtual patients are educational tools that may be described as case-based interactive computer simulations of clinical scenarios. In terms of learning outcomes, improved clinical reasoning skills and knowledge acquisition have been shown. For further exploring the role of virtual patients in medical education, a greater focus on context-specific cases, combined with suitable educational activities, has been suggested. A knowledge gap has been identified in cultural competence in primary care. As primary care physicians are often the main medical providers for patients with refugee backgrounds, they would probably benefit from improved training focusing on how to apply cultural competence in everyday work. Using virtual patient cases, as a complement to clinical training, may be one way forward. The aim of this study was therefore to explore a learner perspective on the educational use of a virtual patient system designed to contribute to training in cultural competence in a primary care context.

METHODS

Three virtual patient cases portraying patients with refugee backgrounds were developed. The cases addressed various issues and symptoms common in primary care consultations, while also incorporating intercultural aspects. The system also provided the informants with individualized feedback. Primary care physicians and medical students were invited to test the cases and participate in an interview about their experience. Data was analyzed using qualitative content analysis.

RESULTS

The analysis generated the theme Virtual patients might help improve cultural competence in physicians and medical students by complementing knowledge gained through the informal curriculum. Informants at different educational levels found it suitable as a tool for introducing the topic and for reflecting on one's own consultations. It could also compensate for the predominant informal manner of learning cultural competence, described by the informants.

CONCLUSIONS

Virtual patients could be useful for gaining cultural competence in a primary care context. Advantages that could benefit learners at both pre- and post-graduate levels are decreased dependence on the informal curriculum and being presented with an illustrative way of how cultural competence may be applied in the consultation.

Diversity and inclusion in simulation: addressing ethical and psychological safety concerns when working with simulated participants

Healthcare learners can gain necessary experience working with diverse and priority communities through human simulation. In this context, simulated participants (SPs) may be recruited for specific roles because of their appearance, lived experience or identity. Although one of the benefits of simulation is providing learners with practice where the risk of causing harm to patients in the clinical setting is reduced, simulation shifts the potential harm from real patients to SPs. Negative effects of tokenism, misrepresentation, stereotyping or microaggressions may be amplified when SPs are recruited for personal characteristics or lived experience. Educators have an ethical obligation to promote diversity and inclusion; however, we are also obliged to mitigate harm to SPs. The goals of simulation (fulfilling learning objectives safely, authentically and effectively) and curricular obligations to address diverse and priority communities can be in tension with one another; valuing educational benefits might cause educators to deprioritise safety concerns. We explore this tension using a framework of diversity practices, ethics and values and simulation standards of best practice. Through the lens of healthcare ethics, we draw on the ways clinical research can provide a model for how ethical concerns can be approached in simulation, and suggest strategies to uphold authenticity and safety while representing diverse and priority communities. Our objective is not to provide a conclusive statement about how values should be weighed relative to each other, but to offer a framework to guide the complex process of weighing potential risks and benefits when working with diverse and priority communities.

Educating on Sexuality to Promote Health: Applied Experiences Mainstreaming the Gender and Human Rights Approach

In the articulation between research and health intervention, we see the need to situate comprehensive sexuality education in the triangle formed by the salutogenic approach, the mainstreaming of gender and human rights, and the development of competencies in health promotion. For this purpose, we present a set of investigations carried out in Ecuador and Spain through a qualitative methodology with the respective health interventions that seek to obtain significant results of the teaching-learning process on sexuality. The field work contemplates situations of violence as a health problem, orienting the intervention in health empowerment toward pleasure. The health education experiences implemented allow us to conclude that comprehensive sexuality education reinforces the competencies of health personnel to attend to diversity. These findings, and the results expected in ongoing research, allow us to form a competency framework aimed at specifically improving medical education so that medical professionals can generate health processes with a cross-cutting approach to gender and human rights.

Start the Way You Want to Finish: An Intensive Diversity, Equity, Inclusion Orientation Curriculum in Undergraduate Medical Education

PROBLEM

Medical students often feel unprepared to care for patients whose cultural backgrounds differ from their own. Programs in medical schools have begun to address health: inequities; however, interventions vary in intensity, effectiveness, and student experience.

INTERVENTION

The authors describe an intensive 2-day diversity, equity, and inclusion curriculum for medical students in their orientation week prior to starting formal classes. Rather than using solely a knowledge-based "cultural competence" or a reflective "cultural humility" approach, an experiential curriculum was employed that links directly to fundamental communication skills vital to interactions with patients and teams, and critically important to addressing interpersonal disparities. Specifically, personal narratives were incorporated to promote individuation and decrease implicit bias, relationship-centered skills practice to improve communication across differences, and mindfulness skills to help respond to bias when it occurs. Brief didactics highlighting student and faculty narratives of difference were followed by small group sessions run by faculty trained to facilitate sessions on equity and inclusion.

CONTEXT

Orientation week for matriculating first-year students at a US medical school.

IMPACT

Matriculating students highly regarded an innovative 2-day diversity, equity, and inclusion orientation curriculum that emphasized significant relationship-building with peers, in addition to core concepts and skills in diversity, equity, and inclusion.

LESSONS LEARNED

This orientation represented an important primer to concepts, skills, and literature that reinforce the necessity of training in diversity, equity, and inclusion. The design team found that intensive faculty development and incorporating diversity concepts into fundamental communication skills training were necessary to perpetuate this learning. Two areas of further work emerged: (1) the emphasis on addressing racism and racial equity as paradigmatic belies further essential understanding of intersectionality, and (2) uncomfortable conversations about privilege and marginalization arose, requiring expert facilitation.

Opportunity for change: Undergraduate training in family medicine

The coronavirus disease 2019 (COVID-19) pandemic has changed the world as we knew it, and medical education is not an exception. Walter Sisulu University (WSU) has a distributed model of clinical training for the Bachelor of Medicine and Bachelor of Surgery (MBChB) programme. To address the challenges occasioned by the pandemic, the Department of Family Medicine and Rural Health undertook a modification of its MBChB VI programme. The changes aim to ensure the protection of all stakeholders and maintain the integrity of the programme, including the assessment. Changes were made in the delivery of the programme and in the way people interact with one another. Continuous assessment was modified, and the oral portfolio examination was introduced as the summative assessment tool. Although COVID-19 threatened the traditional way of teaching and learning, it however provided us with the opportunity to refocus and reposition our undergraduate medical programme.

Prevalence and curriculum of sexual and gender minority education in Japanese medical school and future direction

Background: In Japan, sexual and gender minorities (SGM) remain stigmatized, provoking hospital access barriers and health disparities from judgmental care. Japan's Western-influenced introduction of SGM course content into medical education for future physicians addresses these disparities, although often perfunctorily and inconsistently.Objective: To examine the prevalence and characteristics of medical education curriculum with respect to SGM patients, we surveyed medical schools.Methods: A medical education faculty member from each of 80 Japanese medical schools received double postcards to identify relevant SGM coursework. Upon acknowledgement, 43 schools received seven-item anonymous questionnaires in March 2018. Survey results were analyzed from the perspective of three of the qualities and abilities required of a physician - Patient Care, Knowledge for Practice, and Professionalism from Japan's Medical Core Curriculum - to develop recommendations for outcomes-based SGM curriculum through the lens of Van Melle's medical education framework.Results: The response rate was 46%, with 22 schools providing SGM lectures mostly to first- and third-year students. Obstetrics and Gynecology, Neuropsychiatry, and Introduction to Medicine lectures were the top three subjects offering SGM lectures, primarily consisting of basic knowledge of SGM and Differences in Sex Development. Several lectures addressed the health challenges of SGM. Primary reasons for not offering SGM lectures were lack of suitable instructors or no school policies.Conclusions: Students can best experience the humanity of SGM patients and employ more appropriate diagnostic practices and modes of treatment with targeted curriculum to address SGM health disparities and inclusion of SGM patients in clinical practice training. To disseminate SGM education in Japanese medical schools, development of qualified instructors and policies is essential, employing currently active experts. The Van Melle reforms framework can guide in the development of recommended tailored learning experiences and lectures for improved and expanded SGM education, integrating appropriate coursework within current medical core curriculum structure.

Preferred teaching styles of medical faculty: an international multi-center study

BACKGROUND

In the current wave of educational reforms, understanding teaching styles of medical faculty can help modify instructional strategies for effective teaching. Few studies have probed distinctive teaching styles of medical faculty. We compared preferred teaching styles of faculty from seven medical schools in United Arab Emirates, the Netherlands, Saudi Arabia, Malaysia, Pakistan, and Sudan.

METHODS

The validated Grasha-Riechmann teaching style inventory was administered online for data collection and used SPSS version 20.0 for statistical analysis.

RESULTS

Of the 460 invitees, 248 responded (response rate; 54%). Delegator teaching style was most common with a highest median and mean of 2.38 and 2.45, respectively. There was a significant correlation between expert and authority teaching styles, correlation coefficient 0.62. Similarly, we found a significant correlation between authority teaching style and nature of curriculum, correlation coefficient 0.30. Multiple regression analysis showed that only authority teaching style and male gender had significant correlation. Interestingly, 117 (47%) teachers disagreed with the teaching philosophy of delivering course contents by strictly following learning outcomes. Female teachers (114/248) were more willing to negotiate with their students regarding how and what to teach in their course, while male teachers tended to allow more autonomy by allowing students to set their learning agenda.

CONCLUSIONS

This study showed that the medical teachers preferred delegator teacher style that promotes students' collaboration and peer-to-peer learning. Most teachers are conscious of their teaching styles to motivate students for scientific curiosity. These findings can help medical educators to modify their teaching styles for effective learning.

Revisiting cultural competence

BACKGROUND

Although the importance of developing health care trainees and trainers' cultural competence is widely acknowledged, limited information is available on what elements of cultural competence should be taught. A lack of theoretical clarity and consensus over what constitutes the competence attributes is a key hurdle in faculty development (FD). This results in patchy cultural education across health schools globally. Based on a literature review, we propose a new framework that may inform clinical cultural education and the development of clinical educators in this area.

METHODS

A critical interpretive synthesis was carried out on articles extracted from Medline, CINAHL and Web of Science. Sixty-nine articles were included for analysis, through which we engaged with the reconceptualisation of cultural competence in order to provide theoretical clarity and pedagogical guidance for FD in clinical cultural education.

RESULTS

The synthesis illustrates that an ecological system is required to achieve comprehensive cultural competence development. We therefore composed a discursive multi-level framework to highlight the needs of achieving cultural competence at the individual, team, organisational and systemic levels. Affective, cognitive and behavioural domains are to be achieved at the individual level. Leadership skills training is a key component in achieving higher level competences. Successful FD needs to cover these developmental areas.

DISCUSSION

This review offers a multi-level approach to developing cultural competence, which can be useful for clinical educators to improve their clinical practice and education in diverse cultural contexts. More research is needed to evaluate the effectiveness of the proposed framework and the methods.

Barriers to obtaining reliable results from evaluations of teaching quality in undergraduate medical education

BACKGROUND

Medical education is characterized by numerous features that are different from other higher education programmes, and evaluations of teaching quality are an integral part of medical education. Although scholars have made extensive efforts to enhance the quality of teaching, various issues unrelated to teaching that interfere with the accuracy of evaluation results remain. The purpose of this study is to identify the barriers that prevent objective and reliable results from being obtained during the evaluation process.

METHODS

This study used mixed methods (3 data sources) to collect opinions from different stakeholders. Based on purposive sampling, 16 experts familiar with teaching management and 12 s- and third-year students were invited to participate in interviews and discussions, respectively. Additionally, based on systematic random sampling, 74 teachers were invited to complete a questionnaire survey. All qualitative data were imported into NVivo software and analysed using thematic analysis in chronological order and based on grounded theory. Statistical analyses of the questionnaire results were conducted using SPSS software.

RESULTS

Sixty-nine valid questionnaires (93.24%) were recovered. A total of 29 open codes were extracted, and 14 axial codes were summarized and divided into four selective codes: evaluation preparation, the index system, the operation process, and the consequences of evaluation. The main barriers to obtaining reliable evaluation results included inadequate attention, unreasonable weighting, poor teaching facilities, an index without pertinence and appropriate descriptions, bad time-points, incomplete information on the system, lagged feedback, and disappointing result application. Almost all participants suggested lowering the weight of students as subjects, with a weight of 50-60% being appropriate. Students showed dissatisfaction with evaluation software, and the participants disagreed over the definition of good teaching and the management of student attendance.

CONCLUSIONS

This study reveals the difficulties and problems in current evaluations of teaching in medical education. Collecting data from multiple stakeholders helps in better understanding the evaluation process. Educators need to be aware of various issues that may affect the final results when designing the evaluation system and interpreting the results. More research on solutions to these problems and the development of a reasonable evaluation system is warranted.

The 'exotic other' in medical curricula: Rethinking cultural diversity in course manuals

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.

Does diversity go beyond sex and gender? Gender as social category of diversity training in health profession education - a scoping review

Background: Sex and gender are social categories of diversity. Diversity can be perceived with an intersectional framework as it demonstrates the intersecting categories that might contribute to oppression, inequality, power and privilege. This article focused on what aspects were considered in diversity training programmes for health professions and the role of sex/gender in this context. Method: This scoping review focuses on the social categories mentioned in diversity education of health professionals. Articles on diversity training for health professionals were searched for in the Web of Science database using the keywords gender, diversity, training, education and health professions. Twelve articles were finally included in this review. Thematic analysis was employed to summarise information deduced from articles. Findings: Gaps in the aspects included in diversity training were identified. Findings show that culture was mostly discussed, whereas sex/gender and lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) were focused on only to a minor extent. Cultural diversity training includes self-reflection on one's own culture, whereas a comparable tool for sex/gender and LGBTQI is missing. Additionally, other social categories of diversity, such as disability or age, are largely absent. Conclusion: Diversity should be incorporated in its full breadth in health profession education and not fragmented. Additionally, other social categories such as gender might benefit from including self-reflection on these categories in addition to reflecting on the role of power and privilege in order to increase self-awareness for diversity. In this way, othering of the population might be prevented and healthcare can be improved for all.

Assessment of third-year medical students' comfort and preparedness for navigating challenging clinical scenarios with patients, peers, and supervisors

BACKGROUND

Medical training focuses heavily on clinical skills but lacks in training for navigating challenging clinical scenarios especially with regard to diversity issues. Our objective was to assess third-year medical students' preparedness to navigate such scenarios.

METHODS

A 24-item survey was administered electronically to third-year medical students describing a range of specific interactions with patients, peers, and "upper-levels" or superiors including residents and attendings, spanning subjects including gender, race/ethnicity, politics, age, sexual orientation/identity, disability, and religion. Students rated their level of comfort via a 5-point Likert scale ranging from 1 ("Very Uncomfortable") to 5 ("Very Comfortable"). Basic demographics were collected and data were summarized for trends.

RESULTS

Data were analyzed from 120 students (67% response rate, 54.2% female, 60.8% non-Hispanic white). Students reported lower comfort with peer and superiors compared to patient interactions (p < 0.0001). Students reported the highest comfort with sexual orientation/identity- and religion-related interactions (median (IQR): 3.3 (1.3) and 3.4 (10.0), respectively) and the lowest comfort with gender-, race/ethnicity-, and disability- related interactions (median (IQR): 2.3 (1.3), 2.0 (1.0), 2.5 (1.5), respectively). Males reported significantly higher median comfort levels for scenarios with upper-level, gender, and religion related interactions. Males were more likely to be completely comfortable versus females across the 24 scenarios, although multiple male response patterns showed evidence of a bimodal distribution.

CONCLUSIONS

Third-year medical students report generally inadequate comfort with navigating complex clinical scenarios, particularly with peers and supervisors and relating to gender-, race/ethnicity-, and disability-specific conflicts. There are differences across gender with regards to median comfort and distribution of scores suggesting that there is a subgroup of males report high/very high comfort with challenging clinical scenarios. Students may benefit from enhanced training modules and personalized toolkits for navigating these scenarios.

An exploratory study on microaggressions in medical school: What are they and why should we care?

INTRODUCTION

Microaggressions and their impact have been documented in minority college students; however, little is known about the experience of medical students. This study reports the prevalence and understanding of microaggressions among medical students at the University of Florida College of Medicine (UFCOM), while gaining insights into experiences of medical students dealing with microaggressions.

METHOD

A nine-question survey was sent out to all medical students at the UFCOM in the spring of 2017 to understand their experiences with microaggressions. The authors used simple statistics and chi-test to analyze the demographic data and an inductive thematic qualitative analysis was performed on the open-ended responses to study medical students' understanding of the term, experiences, and impact of microaggressions.

RESULTS

The response rate was 64% (n = 351/545). Fifty-four percent reported experiencing microaggressions, of those the majority were female students (73% compared with 51% among male students, p = 0.0003); for female students from minority backgrounds this was 68% and for white female students 76% (p = 0.2606). Microaggressions are more common in the second year of medical school (30%), followed by the third year (23%). Most students were able to recognize and identify microaggressions, but some denied the concept existed, attributing concerns about microaggressions to a culture promoting oversensitivity and political correctness. Students described microaggressions related to sexism; religion; skin colour; and ethnicity. Students described indifference, emotional reactions and denial of the event as coping mechanisms.

CONCLUSION

Microaggressions are prevalent on a day-to-day basis among medical students with female students from a minority background as well as white female students experiencing more microaggressions. Further research is needed to explore interventions to counter microaggressions in order to ensure a healthy learning environment.

Perspectives of Patients With Mental Illness on How to Better Teach and Evaluate Diversity Education in the National Health Service

INTRODUCTION

Diversity education is a mandatory requirement for all mental-health practitioners and health care professionals in the UK National Health Service. Wide variability exists in the development, delivery, and evaluation of diversity education across health care settings, with limited evidence to suggest the optimal approach for teaching this subject. This study aimed to explore the perspectives of patients with mental illness on how to better teach and evaluate diversity education in the National Health Service.

METHODS

A participatory research approach was used with five mental-health patient organizations. Forty-two patients with mental illness took part in three participatory workshops. Data were analyzed through template analysis.

RESULTS

The findings indicated that a focus on the nuances and dynamics of clinical relationships would be beneficial. Specifically, the relationship considered most important to examine with respect to diversity education was the "practitioner-self" relationship.

DISCUSSION

Reconstructing the relationship-centered care model with the addition of the practitioner-self relationship may be better suited to theoretically informing future developments in diversity education. Further research is needed to understand what educational approaches contribute toward a relationship-centered care outlook and how relationship building behaviors, particularly those relevant to the practitioner-self relationship are best developed in diverse settings.

Consensus statement on an updated core communication curriculum for UK undergraduate medical education

OBJECTIVES

Clinical communication is a core component of undergraduate medical training. A consensus statement on the essential elements of the communication curriculum was co-produced in 2008 by the communication leads of UK medical schools. This paper discusses the relational, contextual and technological changes which have affected clinical communication since then and presents an updated curriculum for communication in undergraduate medicine.

METHOD

The consensus was developed through an iterative consultation process with the communication leads who represent their medical schools on the UK Council of Clinical Communication in Undergraduate Medical Education.

RESULTS

The updated curriculum defines the underpinning values, core components and skills required within the context of contemporary medical care. It incorporates the evolving relational issues associated with the more prominent role of the patient in the consultation, reflected through legal precedent and changing societal expectations. The impact on clinical communication of the increased focus on patient safety, the professional duty of candour and digital medicine are discussed.

CONCLUSION

Changes in the way medicine is practised should lead rapidly to adjustments to the content of curricula.

PRACTICE IMPLICATIONS

The updated curriculum provides a model of best practice to help medical schools develop their teaching and argue for resources.

Circling the undefined-A grounded theory study of intercultural consultations in Swedish primary care

Well-functioning physician-patient communication is central to primary care consultations. An increasing demand on primary care in many countries to manage a culturally diverse population has highlighted the need for improved communication skills in intercultural consultations. In previous studies, intercultural consultations in primary care have often been described as complex for various reasons, but studies exploring physician-patient interactions contributing to the understanding of why they are complex are lacking. Therefore, the aim of this study was to explore intercultural physician-patient communication in primary care consultations, generating a conceptual model of the interpersonal interactions as described by both the patients and the physicians. Using grounded theory methodology, 15 residents in family medicine and 30 foreign-born patients, the latter with Arabic and Somali as native languages, were interviewed. The analysis generated a conceptual model named circling the undefined, where a silent agreement on issues fundamental to the core of the consultation was inadequately presumed and the communicative behaviors used did not contribute to clarity. This could be a possible contributory cause of the perceived complexity of intercultural consultations. Identifying what takes place on an interpersonal level in intercultural consultations might be a first step towards building a common ground for increased mutual understanding, thereby bringing us one step closer to sharing, rather than circling the undefined.

Medical students interact with multicultural patients to learn cultural diversity

PURPOSE

The aim was to present our experiences implementing a cultural diversity (CD) education program.

METHODS

The authors held a 4-hour CD class for third-year medical students. The aim of the class was to facilitate students to realize and reflect on the importance of CD on healthcare delivery in Korea. The class was comprised of an orientation about CD in Korea, physicians and multicultural guests sharing their experiences with students, small group discussion, and Q&amp;A panel with multicultural guests. Students provided written feedback for program evaluation. Authors classified their comments qualitatively.

RESULTS

Students mostly responded positively to the class with a significant focus on interacting with the multicultural guests. Students realized the significance of CD in healthcare and reflected deeply on their discussion with the multicultural patients. Students needed more time to interact with multicultural guests from a greater range of cultures represented in Korea. Most did not need English interpretation.

CONCLUSION

The aim of the class was achieved. Medical students' interaction with multicultural patients may promote the students' understanding and reflection about CD in health care.

Medical Education to Enhance Critical Consciousness: Facilitators' Experiences

PURPOSE

To analyze educators' experiences of facilitating cultural discussions in two global health professions education programs and what these experiences had taught them about critical consciousness.

METHOD

A multicultural research team conducted in-depth interviews with 16 faculty who had extensive experience facilitating cultural discussions. They analyzed transcripts of the interviews thematically, drawing sensitizing insights from Gramsci's theory of cultural hegemony. Collaboration and conversation helped the team self-consciously examine their positions toward the data set and be critically reflexive.

RESULTS

Participant faculty used their prior experience facilitating cultural discussions to create a "safe space" in which learners could develop critical consciousness. During multicultural interactions they recognized and explicitly addressed issues related to power differentials, racism, implicit bias, and gender bias. They noted the need to be "facile in attending to pain" as learners brought up traumatic experiences and other sensitive issues including racism and the impact of power dynamics. They built relationships with learners by juxtaposing and exploring the sometimes-conflicting norms of different cultures. Participants were reflective about their own understanding and tendency to be biased. They aimed to break free of such biases while role modeling how to have the courage to speak up.

CONCLUSIONS

Experience had given facilitators in multicultural programs an understanding of their responsibility to promote critical consciousness and social justice. How faculty without prior experience or expertise could develop those values and skills is a topic for future research.

Australian medical students have fewer opportunities to do physical examination of peers of the opposite gender

PURPOSE

Peer physical examination (PPE), by which junior medical students learn physical examination skills before practicing on patients, is a widely implemented and accepted part of medical curricula. However, the ethical implications of PPE have been debated, since issues including student gender impact on its acceptability. Research has previously demonstrated the phenomenon of 'attitude-behavior inconsistency' showing that students' predictions about their participation in PPE differ from what they actually do in practice. This study asks whether gender and student self-ratings of outlook affect engagement in PPE.

METHODS

This study gathered data from students who had completed PPE with the objective of determining what factors have the greatest impact on the actual practice of PPE by students. Data were used to derive the number of opportunities students had to examine a peer, for various body parts. Respondent gender and self-ratings of outlook were recorded.

RESULTS

Responses from 130 students were analysed: 74 female (57%) and 56 male (43%). Students have fewer opportunities to examine peers of the opposite gender; this is statistically significant for all body parts when male students examine female peers.

CONCLUSION

Gender is the factor of overriding importance on whether these peer interactions actually occur, such that students have fewer opportunities to examine peers of the opposite gender, particularly male students examining female peers. Student outlook has little impact. We speculate that the more acceptable PPE is to participants, paradoxically, the more complicated these interactions become, possibly with implications for future practice.

Identity text: an educational intervention to foster cultural interaction

BACKGROUND

Sociocultural theories state that learning results from people participating in contexts where social interaction is facilitated. There is a need to create such facilitated pedagogical spaces where participants can share their ways of knowing and doing. The aim of this exploratory study was to introduce pedagogical space for sociocultural interaction using 'Identity Text'.

METHODS

Identity Texts are sociocultural artifacts produced by participants, which can be written, spoken, visual, musical, or multimodal. In 2013, participants of an international medical education fellowship program were asked to create their own Identity Texts to promote discussion about participants' cultural backgrounds. Thematic analysis was used to make the analysis relevant to studying the pedagogical utility of the intervention.

RESULT

The Identity Text intervention created two spaces: a 'reflective space', which helped participants reflect on sensitive topics such as institutional environments, roles in interdisciplinary teams, and gender discrimination, and a 'narrative space', which allowed participants to tell powerful stories that provided cultural insights and challenged cultural hegemony; they described the conscious and subconscious transformation in identity that evolved secondary to struggles with local power dynamics and social demands involving the impact of family, peers, and country of origin.

CONCLUSION

While the impact of providing pedagogical space using Identity Text on cognitive engagement and enhanced learning requires further research, the findings of this study suggest that it is a useful pedagogical strategy to support cross-cultural education.