Anna MacLeod

Measures of Cultural Competence: Examining Hidden Assumptions

Purpose The authors critically examined the quantitative measures of cultural competence most commonly used in medicine and in the health professions, to identify underlying assumptions about what constitutes competent practice across social and cultural diversity. Method A systematic review of approximately 20 years of literature listed in PubMed, the Cumulative Index of Nursing and Allied Health Literature, Social Services Abstracts, and the Educational Resources Information Center identified the most frequently used cultural competence measures, which were then thematically analyzed following a structured analytic guide. Results Fifty-four instruments were identified; the 10 most widely used were analyzed closely, identifying six prominent assumptions embedded in the measures. In general, these instruments equate culture with ethnicity and race and conceptualize culture as an attribute possessed by the ethnic or racialized Other. Cultural incompetence is presumed to arise from a lack of exposure to and knowledge of the Other, and also from individual biases, prejudices, and acts of discrimination. Many instruments assume that practitioners are white and Western and that greater confidence and comfort among practitioners signify increased cultural competence. Conclusions Existing measures embed highly problematic assumptions about what constitutes cultural competence. They ignore the power relations of social inequality and assume that individual knowledge and self-confidence are sufficient for change. Developing measures that assess cultural humility and/or assess actual practice are needed if educators in the health professions and health professionals are to move forward in efforts to understand, teach, practice, and evaluate cultural competence.

Making interprofessional education work: the strategic roles of the academy.

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Six ways problem-based learning cases can sabotage patient-centered medical education.

Purpose Problem-based learning (PBL) cases tell a story of a medical encounter; however, the version of the story is typically very biomedical in focus. The patient and her or his experience of the situation are rarely the focus of the case despite a prevalent discourse of patient-centeredness in contemporary medical education. This report describes a qualitative study that explored the question, “How does PBL teach medical students about what matters in medicine?” Method The qualitative study, culminating in 2008, involved three data collection strategies: (1) a discourse analysis of a set of PBL cases from 2005 to 2006, (2) observation of a PBL tutorial group, and (3) semistructured, in-depth, open-ended interviews with medical educators and medical students. Results In this report, using data gathered from 67 PBL cases, 26 hours of observation, and 14 interviews, the author describes six specific ways in which PBL cases—if not thoughtfully conceptualized and authored—can serve to overlook social considerations, thereby undermining a patient-centered approach. These comprise the detective case, the shape-shifting patient, the voiceless PBL person, the joke name, the disembodied PBL person, and the stereotypical PBL person. Conclusions PBL cases constitute an important component of undergraduate medical education. Thoughtful authoring of PBL cases has the potential to reinforce, rather than undermine, principles of patient-centeredness.

Ethnographies across Virtual and Physical Spaces: A Reflexive Commentary on a Live Canadian/UK Ethnography of Distributed Medical Education.

This article draws on an ongoing ethnography of distributed medical education (DME) provision in Canada in order to explore the methodological choices of the researchers as well as the wider pluralisation of ethnographic frameworks that is reflected within current research literature. The article begins with a consideration of the technologically mediated ways in which the researchers do their work, a way of work that is paralleled within the DME curriculum that forms the focus of the ethnography. The article goes on to problematise relationships amongst the researchers and between the researchers and the field of research, and to consider the ways in which methodological choices are mediated. In so doing, the article proposes an acceptance of methodological pluralism that is tempered by the need to acknowledge the sometimes-slight differences that distinguish ethnographic paradigms.

Patient-centredness in a context of increasing diversity: Location, location, location

The concept of ‘patient-centredness’ is increasingly central inmedical education curriculum (Richards & Inglehart 2006;Tsimtsiou et al. 2007); yet, it is also well-recognised that thepatients whom we serve are becoming increasingly diverse. Inthis edition, Gustafson and Reitmanova (2010) call ourattention to the fact that the Canadian population is becomingincreasingly diverse, and the make-up of that diversity hasshifted over the past decades. This shift has significantinfluence in terms of how medical education is conceptualised,planned and delivered. Therefore, our commentary beginswith a question for consideration: What does it mean to bepatient-centred in a context of increasing diversity?Patient-centred care (PCC) (Stewart et al. 1995; Tsimtsiouet al. 2007) is an approach that privileges the social aspects byacknowledging that a patient is more than her or his biology,symptoms, and/or body. It is often defined by what it is not:‘technology centred, doctor centred, hospital centred, diseasecentred’ (Stewart 2001, p 444) and occurs ‘when medicalmanagement comprises more than a single pill’ (Bauman et al.2003, p 253).Despite institutional attempts to apply a patient-centredapproach, these remain frequently uncritically, or superficially,realised in medical education (Tsimtsiou et al. 2007).A dualistic sorting of knowledge into two main categories:objective (disease, evidence-based, competence) and subjec-tive (illness, social, caring) (Good & Good 1993; Morris 2000)is common in medical education. Despite calls for patient-centredness, patients’ accounts of the illness experiencefrequently fall under the subjective, thus untrustworthy,domain. In contrast, medical tests and laboratory reports areconsidered ‘factual’ because of their presumed objectivity. Thisreinscribes traditional relations of power in the physician–patient relationship.One knows, the other feels; one prescribes, the othercomplies; one is paid, the other pays. Although thissharp division has begun to blur under the pressureof postmodern innovations such as the ubiquitousmalpractice suit, the old conceptual infrastructurethat sustained it is still, confusingly, in place. (Morris2000, pp 37–38)Traditionally, medical education has been constitutedthrough the study of disease, understanding sickness as abreakdown of the machine that is the body. Toombs (1993,1995) encouraged a shift calling for an approach that considersillness an interruption of participation in the social world. Ifengaged in educational settings, such an understanding hasthe potential to transform medical practice, making the patient,not the disease, the focus of diagnosis and treatment.However, such a shift would require thoughtfulness aboutthe patients, and their multiple complexities.

Teaching without a blackboard and chalk: conflicting attitudes towards using ICTs in higher education teaching and learning

ABSTRACT This article, derived from a three-year ethnography of distributed medical education provision in a Canadian university, explores the ways in which information and communication technologies are used by teachers and students in their everyday work within technologically rich teaching environments. The environments being researched are two university campuses: a campus at the main university site and a satellite campus in a neighbouring province. The article seeks to contrast dominant, institutional discourses of technology use in higher education teaching with the everyday practices of staff and students. The article concludes that there is a gap between policy and practice in distributed education and that the teaching and learning experience and context of staff and students in different sites need to be analysed in depth, in terms of: whether the experience of learning across sites can be positioned as being comparable; the extent to which technology ameliorates learning and teaching; and understanding the work done by staff.

The hidden curriculum: Is it time to re-consider the concept?

The concept of ‘‘the hidden curriculum’’ has become a part of the everyday discourse of medical education. With roots in the broader field of education, the concept has had a significant influence on medical education since Hafferty & Franks brought it to our attention (1994). Twenty years later, this personal view paper problematizes the concept and discusses whether ‘‘the hidden curriculum’’ is a concept that has run its course. Reflecting on my experience at a recent medical education conference, I realize that perhaps the most striking learning experience for me was, as they often are, an informal one. Time and time again, I heard conference delegates use phrases like: What can you do? It’s the hidden curriculum in action. Oh, it’s probably because of the hidden curriculum. That’s bad! Talk about hidden curriculum! ‘‘The hidden curriculum’’ rolled off the tongues of medical educators from across the country: established and emerging, clinical and non-clinical. It was referred to in plenary sessions as well as in countless oral and poster presentations. The hidden curriculum was such a prevalent discourse of my conference experience that I found myself thinking about it conceptually. As a recent convert to the power of social media for

Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School

Abstract Phenomenon: Homelessness is a major public health concern. Given that homeless individuals have high rates of mortality and morbidity, are more likely to be users of the healthcare system, and often report unmet health needs, it is important to examine how homelessness is addressed in medical education. We wanted to examine content and framing of issues related to homelessness in the case-based learning (CBL) curriculum and provide insights about whether medical students are being adequately trained to meet the health needs of homeless individuals through CBL. Approach: CBL content at a Canadian medical school that featured content related to homelessness was analyzed. Data were extracted from cases for the following variables: curriculum unit (e.g., professionalism/ethics curriculum or biomedical/clinical curriculum), patient characteristics (e.g., age, sex), and medical and social conditions. A thematic analysis was performed on cases related to homelessness. Discrepancies in analysis were resolved by consensus. Findings: Homelessness was mentioned in five (2.6%) of 191 CBL cases in the medical curriculum. Homelessness was significantly more likely to be featured in professionalism/ethics cases than in biomedical/clinical cases (p = .03). Homeless patients were portrayed as socially disadvantaged individuals, and medical learners were prompted to discuss ethical issues related to homeless patients in cases. However, homeless individuals were largely voiceless in cases. Homelessness was associated with serious physical and mental health concerns, but students were rarely prompted to address these concerns. Insights: The health and social needs of homeless individuals are often overlooked in CBL cases in the medical curriculum. Moreover, stereotypes of homelessness may be reinforced through medical training. There are opportunities for growth in addressing the needs of homeless individuals through medical education.

Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process.

Background: Dalhousie Universitys MD Programme faced a one-year timeline for renewal of its undergraduate curriculum. Aim: Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century. Methods: We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as ‘deliberative curriculum inquiry’. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units. Results: The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme. Conclusion: The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Interprofessional education for faculty and staff – A review of the Changing Worlds: Diversity and Health Care Project

The medical community is giving increasing attention to issues of social class, gender, race, ethnicity, culture and other areas of difference in interprofessional education and patient care. The Changing Worlds: Diversity and Health Care Project, an interprofessional diversity education initiative, was designed with the aim of exploring social issues in the medical professions. This project brought together the Faculties of Medicine, Dentistry and Health Professions at Dalhousie University in an effort to address issues of difference related to multiplicities of races, ethnicities, cultures, languages, sexualities and religions. The findings of this paper include methods for the project implementation and future direction for education initiatives aimed at issues of social justice and equity in health care.