Dr. Marta Moskal, Co-Investigator
A key purpose therefore is to encourage the study of languages and cultures in ways which can ultimately enrich practice. In this context, the series editors seek contributions to the series which reflect on the relationship between languages and intercultural communication and its implications for learning and teaching. First, PV and MM familiarized with the data. Second, they formulated labels both top-down and bottom-up which they systematically applied to the data indexing.
Third, they rearranged data according to themes that emerged from the data. We defined criteria for a diversity-responsive curriculum as the learning objectives that should be addressed in educational material in order for diversity to be fully integrated in the curriculum.
English in Medical Education An Intercultural Approach to Teaching Language and Values
The learning objectives were based on the outcomes of themes that emerged from the interviews in step 1 and the existing literature. A policy document containing 1 the preliminary learning objectives for a diversity-responsiveness curriculum and 2 information about the way in which the objectives were established was sent to VUmc SMS stakeholders, who were asked to give feedback.
After taking this feedback into account, the final learning objectives for diversity-responsiveness were established. The curriculum mapping was carried out as follows: From May to July , we collected preclinical and clinical education material i. Material was excluded from analysis when the objective was unrelated to learning about diversity. Within this material, we analysed each category for the presence of other intersecting categories.
For instance, we investigated whether a module i. The following three themes emerged from the interviews with stakeholders carried out in the exploratory phase: relevance of a diversity-responsiveness curriculum, essential diversity learning objectives, and implementation of diversity content in the curriculum.
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All stakeholders acknowledged the importance of a diversity-responsive curriculum. They mentioned both pragmatic and ethical arguments. From a social justice point of view, stakeholders felt that diversity responsiveness is important to target unequal access to professional opportunities for minority medical students, and that every patient has a right to receive tailored care from competent doctors. However, they mentioned that implementing diversity-responsive practices in the health care system should be efficient, i.
Stakeholders believed that medical curricula should provide opportunities to explore diversity-related themes both in-depth and broadly, and that teaching content should reflect contemporary issues in health care and society. No consensus existed as to whether cultural diversity should be operationalized by a broad or narrow use of culture. However, all considered it important that students have knowledge of sociocultural and demographic characteristics of social groups and minority groups in the Netherlands, including value systems, health beliefs and health practices, and the skills to optimize communication with patients from varying socio-cultural backgrounds.
They furthermore believed students should learn about social justice issues and socio-political concepts, such as oppression, stigma, exclusion and discrimination. Barriers to implementation of diversity content in the curriculum were perceived at a student, teacher and institutional level. For instance, stakeholders experienced that both students and teachers generally consider diversity-related topics uninteresting and irrelevant for medical practice. Furthermore, stakeholders mentioned that classes are taught by many different teachers and on many different locations, which impedes implementation.
Implementing diversity content was considered more challenging in the clinical program than in the preclinical program. A centralized approach to designing and editing course material, stakeholders suggested, is more likely to secure a high degree of implementation.
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Overall, stakeholders shared the opinion that diversity mainstreaming should not only take place in the preclinical and clinical programs, but across the organisation. They highlighted the importance of creating equal access to opportunities for students and the need for a focus on cultural competent patient care. All acknowledge the need for a sound evaluation of mainstreaming efforts. The process toward becoming a diversity-responsive physician involves the development of an orientation that recognizes dignity and autonomy of patients, and of a focus on providing high quality of care to a pluriform society across aspects such as culture, gender and class Kumagai and Lypson ; Verdonk and Abma Based on this notion, we formulated three primary, overarching learning objectives, which we considered essential to implement in order to achieve a diversity-responsive curriculum.
Objectives were related to the following areas of medical education: medical knowledge and skills, patient—physician communication, and reflexivity.
English in Medical Education: An Intercultural Approach to Teaching Language and Values
We aimed to formulate the objectives in such a way so as to discourage essentialist or fixed perceptions of social groups or categories and their value systems, health practices and health outcomes. First, students must be able to recognize and explain relevant differences between the five largest cultural groups in the Netherlands i.
Dutch, Dutch-Turkish, Dutch-Moroccan, Dutch-Surinamese and Dutch-Antilles with regards to epidemiology, aetiology, presentation, diagnostics and treatment of illness and disease, and have insight in determinants of health disparities and inequalities between these groups. Second, students must understand and explain the relationship between sex or gender and health behaviour and outcomes. By using the term sex as well as gender, we refer to differences between women and men that are both biomedical e.
Age, such as life-stages, and sexual orientation-related topics were listed under this objective. Third, students must have insight in present-day medical and social themes related to socioeconomic status and health, including class-based inequalities e. For instance, they must recognize the impact of language barriers and limited health literacy on outcomes of interactions, and develop competencies with regards to working with both professional and informal interpreters.
Through self-reflexivity training, students acquire the skills to take on a critical attitude towards oneself. Class issues were least often addressed. Diversity content included both biomedical and sociocultural aspects of health, which were most often addressed by means of single categories of difference i. When material did address multiple categories, intersections between categories of difference remained often unexplored. Most diversity topics were addressed in the preclinical program. Integration of the three categories of difference and their intersections in the clinical program were challenging to investigate: since most teaching takes place during rotations, written material is limited.
First, students learned about aetiology, pathology, physiology and epidemiology of specific diseases related to ethnicity and geographic location, such as communicable diseases and tropical infections e. A year-one preclinical module addressed complementary and alternative medicine CAM. Reading material included chapters of a textbook addressing the role of cultural and social factors in health and disease i. Helman C. In communication modules that took place throughout the preclinical program, students were trained to communicate with patients of diverse cultural backgrounds.
Self-reflexivity related to culture was addressed in a module about the culture of Western medicine. Sex differences in heart disease were addressed in preclinical year 3, and gender was a focus in preclinical modules that addressed sexual harassment and sexual abuse, including child abuse. Class-related health inequalities were addressed in preclinical year 1 and 2 through modules on SES and education level-based differences in life expectancy, health literacy, and working conditions. Diversity aspects were also incorporated in preclinical and clinical internship programs.
Good practices were a preclinical reflection assignment about cultural diversity, and intervision sessions for year-two clinical students where, among other topics, experiences with culture-related aspects of diversity were addressed.
Finally, we identified a few modules that took an intersectional approach to analysing and explaining health outcomes. In preclinical year two, for instance, a module on malnutrition addressed the intersections of ethnicity and poverty in relation to vitamin D-deficiency in children who receive long-term breastfeeding. Another preclinical module about health care for undocumented migrants addressed the intersections of migrant status, being undocumented and gender, and their relation to health outcomes and access to health care.
Several learning objectives were absent or only marginally addressed. For instance, we found few material that explicitly dealt with diversity in relation to lifestyle issues, self-management and determinants of chronic disease. Communication and reflexivity were only marginally addressed from a diversity perspective. Furthermore, sex and gender differences related to diseases of non-sexed organ systems or chronic conditions including auto-immune diseases received little attention, and pharmacological sex differences were discussed only in reference to teratogenicity.
Partner violence was not addressed at all. Moreover, sex was presented as a stable category, and gender was used as a fixed binary. Communication-related content did not address gender differences relevant for the patient—physician communication, as was the case with reflexivity-related content.
Finally, there was a limited focus on class-related determinants of health outcomes; class-related factors such as health literacy were not mentioned in relation to physician—patient communication, and class was not included in reflexivity assignments.
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We found no written material on diversity among ageing populations and the ageing process. In this paper, we reported the outcomes of a multiple method study that took place at an Amsterdam, the Netherlands-based medical school, VUmc SMS. We explored local ideas about diversity-responsive medical education, outlined diversity-responsive learning objectives for preclinical and clinical medical education, and mapped the VUmc SMS curriculum for diversity-responsive material using an intersectionality-based approach.
Outcomes of the curriculum mapping expose that, despite several good practices, diversity-responsiveness of the curriculum could be improved. For instance, most content referred to a narrow definition of culture i. Class remained the least pronounced aspect of diversity despite its strong association with life style and life expectancy Mackenbach et al. Kumagai and Lypson describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking. Acquiring critical thinking and critical consciousness skills can help students learn to reflect on their own norms, values and position; when possessed by physicians, such skills may contribute to more health equity Verdonk and Abma Largely lacking from the curriculum was content that explored determinants of health and patient experiences based on the unique biosocial and sociocultural locations of patients.
Instead, the role of biosocial and sociocultural factors in health outcomes was addressed by means of single categories of difference. This suggests a unitary or multiple approach to diversity teaching Hankivsky Along these lines, adopting a methodology that uses either an intercategorical approach to difference analyses between groups , an intracategorical approach to difference analyses within groups or both can document the degree to which marginalized or minority patient groups receive attention in educational content McCall However, as mentioned in the Methods section of this paper, we believe that all categorical approaches to human health identity will inevitably struggle to grasp the complexity of lived patient experiences and the social and biosocial processes that produce and produce them, let alone succeed to provide the information to translate this complexity to medical know-how.
Fixing the institutions requires that medical schools should aim to establish compositional diversity i. The aim for an inclusive learning climate also demands an effort towards interactional diversity, which refers to the stimulation of positive interactions between students with diverse backgrounds Saha et al. As fixing the numbers, fixing the institutions, and fixing the knowledge are interdependent and complementary, they cannot be seen as isolated domains of institutional reform.
For example, sociocultural issues are more likely to be integrated into the curriculum by a medical school with a larger cultural diversity among their student body Van Wieringen et al. However, the transformative potential of fixing the knowledge, institution and numbers is largely mediated by the acceptance of cultural diversity issues as legitimate medical knowledge. Hierarchical notions of knowledge can hinder effective implementation of diversity issues, as outcomes of interviews in Phase 1 support.
This study has several strengths and limitations. First, by analyzing content at the level of knowledge, communication and reflexivity, we took into account the three approaches to diversity teaching i.
However, as Dogra mentions, the different outcomes of these approaches have consequences for assessment. We experienced that mapping the written curriculum did not suffice to evaluate the degree of implementation of cultural sensibility or critical thinking Fook and Askeland ; Dogra Other study designs and methods are needed to provide such insight. Instead, such factors were categorized under one of the aforementioned three categories. We suggest that future efforts to take an intersectionality-based approach to curriculum mapping aim to include other categories of difference as separate, equally important patient identities or groups.
An evaluation of the representation of these identities is particularly necessary since they are often underrepresented or absent in medical curricula. For instance, research has shown that time spent on LGBT-issues was small across curricula in the US, Canada and South-Africa, and that the quality, quality and content of educational material varied Muller ; Obedin-Maliver et al. To increase quality of care for patients at intersections of less visible or marginalized categories, future research in this area should focus on exploring whether and how their issues are addressed in medical curricula.
The authors of the paper reported that students with a minority background experienced a lack of respect in the way they were treated by peers and teachers for instance during modules on physical examination , and that these students felt that patient cases used to teach about specific health issues of minority groups were stigmatising and stereotypical Tjitra et al. As this provided us with insight in the student perspective, we chose not to interview students as part of this study.