Cultural identity and representing culture in medical education. Who does it?

Abstract

There are few places in the world where the delivery of health care takes place in mono-cultural contexts. Thus the ‘teaching’ of cultural diversity, development of cultural ‘awareness’ or gaining of cultural ‘safety’ is a ubiquitous priority in medical education. Yet it has not been adequately addressed. For example, in Australia there was a call in 1989 for medical and health professional courses to include ‘compulsory’ study of Australian Aboriginal culture and health which would be conducted by Aboriginal people.1 It is only very recently that a coordinated approach to this at a national level has been mooted for medical schools. The two articles by Dogra2 and Dowell3 in this issue set out two important approaches to addressing this priority. One sets out the approach to teaching cultural diversity in a British medical school. The other describes a cultural immersion experience in a New Zealand medical school. Both report success through positive student feedback. But there is an important question underlying both studies. How is culture represented and who gets to represent it? The importance of this question is readily seen in the British paper by Dogra in the conflation of the concepts of ‘culture’ and ‘race’ and the labelling applied to so-called racial groups. Some of the students labelled as part of the ‘white’ race had some difficulty with the term and at least two of them wanted subcategories of North American, Australian and European. What is important is ‘cultural identity’ or in Dogra’s words an ‘individual’s perception of their cultural background. This, we argue, is derived from a complex of cultural, gender, social, economic, religious and political affiliations not from the individual’s supposed biological inheritance. We would not be surprised if those labelled as ‘Asian’, ‘Mixed’, ‘Black African’ or ‘Black Other’ races in the British example raised concerns about their labels as well. It is an individual’s cultural identity that affects interactions with the health system and influences health status. Thus teaching cultural diversity and developing cultural awareness in medical education means learning to respect and value differing cultural identities as a starting point to understanding health needs and delivering excellent health care. The cultural immersion experience described in New Zealand would appear to be an excellent way of gaining this. What’s more, cultural identity is learned first hand. It is taught or ‘represented’ to the students by those who genuinely possess it. But there was one problem raised by the authors of the New Zealand article. Students who had been extended the hospitality of the local communities found it difficult to be critical of certain lifestyle issues in health or to make critical comments about the providers of health care who had been their hosts during the experience. For this, students need to be able to understand the strengths and weaknesses of their own cultures and cultural identity. Critical comment comes unstuck when it comes from a perspective that one culture is normal, dominant, strong or superior and the other is not. On the words of Kai et al.4 Valuing ethnic (cultural) diversity embraces acknowledging an individual’s culture in its broadest dynamic sense, for example a patient’s ethnicity, education, socio-economic background, religion, prior health experiences and values. It requires a heightened awareness of our own attitudes and sensitivity to issues of stereotyping, prejudice and racism. We found this out to our detriment at a cultural awareness camp for first year students at our own medical school when we failed to provide opportunity for some of our North American international students to affirm their own cultural identity. There would appear to be at least three key elements in teaching cultural diversity, developing cultural awareness or fostering cultural safety in medical schools. Students should have opportunities to discuss and reflect upon their own cultural identities. They should interact with others who will represent and explain their own differing cultural identities. Finally they should be prepared for delivery of health services in a manner which values, respects and enhances the cultural identities of those under their care. Some useful sites relating to cultural diversity in medical education: http://www.xculture.org/ http://www.diversityRx.org/ http://healthlinks.washington.edu/clinical/ethnomed/