Arno K. Kumagai

Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education

In response to the Liaison Committee on Medical Education mandate that medical education must address both the needs of an increasingly diverse society and disparities in health care, medical schools have implemented a wide variety of programs in cultural competency. The authors critically analyze the concept of cultural competency and propose that multicultural education must go beyond the traditional notions of “competency” (i.e., knowledge, skills, and attitudes). It must involve the fostering of a critical awareness—a critical consciousness—of the self, others, and the world and a commitment to addressing issues of societal relevance in health care. They describe critical consciousness and posit that it is different from, albeit complementary to, critical thinking, and suggest that both are essential in the training of physicians. The authors also propose that the object of knowledge involved in critical consciousness and in learning about areas of medicine with social relevance—multicultural education, professionalism, medical ethics, etc.—is fundamentally different from that acquired in the biomedical sciences. They discuss how aspects of multicultural education are addressed at the University of Michigan Medical School. Central to the fostering of critical consciousness are engaging dialogue in a safe environment, a change in the traditional relationship between teachers and students, faculty development, and critical assessment of individual development and programmatic goals. Such an orientation will lead to the training of physicians equally skilled in the biomedical aspects of medicine and in the role medicine plays in ensuring social justice and meeting human needs.

A qualitative exploration of how the conflict between the formal and informal curriculum influences student values and behaviors.

Purpose The third-year students at one medical school told the authors that values core to patient-centered care were impossible to practice in clerkships, in a culture where supervisors role modeled behaviors in direct conflict with patient-centered care. As they developed a new medical student curriculum, the authors designed the Family Centered Experience (FCE) to help students achieve developmental goals and understand the importance of and provide a foundation for patient-centered care. Method The authors solicited members of the first cohort to complete the FCE (the class of 2007) to participate in this focus-group-based study halfway through the third year. They explored the influence of the FCE on students’ experiences in the third-year clerkships, and how conflicts between the two learning experiences shaped these students’ values and behaviors. Results Students reported that during clerkships they experienced strong feelings of powerlessness and conflict between what they had learned about patient-centered care in the first two years and what they saw role modeled in the third year. Based on students’ comments, the authors categorized students into one of three groups: those whose patient-centered values were maintained, compromised, or transformed. Conclusions Students revealed that their conflict was connected to feelings of powerlessness, along with exacerbating factors including limited time, concerns about expectations for their behavior, and pessimism about change. Role modeling had a significant influence on consequences related to students’ patient-centered values.

Understanding the effects of short-term international service-learning trips on medical students.

Purpose The purpose of this qualitative study was to understand what meaning(s) preclinical students attributed to participation in one-week international service–learning trips (ISLTs) and what specific experiences during the trips accounted for such perspectives. Method Twenty-four first-year students who had participated in one-week ISLTs at the University of Michigan Medical School during February 2010 were invited to participate. Individual, semistructured interviews were conducted from March to August 2010 with 13 student participants. Using grounded theory analysis, several major themes were identified. Results Acquisition of clinical/language skills and knowledge of other health care systems were explicit benefits associated with student ISLT experiences. However, in-depth, reflective discussions revealed implicit insights and lessons, the most pervasive of which were student ambivalence concerning the value and effect of ISLTs on communities, issues of privilege and power, and ethical concerns when working with vulnerable populations. These implicit lessons stimulated new insights into future involvement in global health and emphasized the importance of reflection and discussion to enhance ISLT experiences. Conclusions The current study suggests that one-week ISLTs may engender implicit insights and lessons regarding ethical and societal issues involved with global health and may stimulate the development of critical reflection on current and future professional roles for student participants. Furthermore, these activities should allow time and space for dialogue and reflection to ensure that this implicit understanding can be put to constructive educational and service-oriented uses.

From competencies to human interests: ways of knowing and understanding in medical education.

When considering the teaching and learning of topics of social relevance in medicine, such as professionalism, medical ethics, the doctor-patient relationship, and issues of diversity and social justice, one is tempted to ask, are the ways of knowing in these fields different from that in the biomedical and clinical sciences? Furthermore, given that the competency approach is dominant in medical education, one might also ask, is the competency model truly appropriate for all of the types of knowledge necessary to become a good physician? These questions are not merely academic, for they are at the core of how these subjects are taught, learned, and assessed.The goal of this article is threefold: first, to explore the nature of knowing and the educational goals in different areas of medicine and, in particular, those areas that have social relevance; second, to critically review the concept of competencies when applied to education in these areas; and third, to explore alternative strategies for teaching, learning, and assessment. This discussion reflects a view that the goal of education in areas of social relevance in medicine should be the enhancement of an understanding of-a deep and abiding connection with-the social responsibilities of the physician. Moving beyond competencies, this approach aspires toward the development of practical wisdom (phronesis) which, when embodied in the physician, links the knowledge and skills of the biomedical and clinical sciences with a moral orientation and call to action that addresses human interests in the practice of medicine.

Use of interactive theater for faculty development in multicultural medical education

Background: The development of critical consciousness, anchored in principles of social justice, is an essential component of medical education. Aim: In order to assist faculty instructors in facilitating small-group discussions on potentially contentious issues involving race, gender, sexual orientation, and socioeconomic class, a faculty development workshop was created. Methods: The workshop used ‘Forum Theater’ techniques in which the audience was directly involved in determining the course of a simulated classroom discussion and conflict. We assessed the workshops impact on the instructors’ attitudes regarding facilitation of small-group discussions through two surveys: one to gauge immediate impressions, and another, 9–15 months later, to assess impact over time. Results: Immediately after the workshop, participants reported that the topics covered in the sketch and in the discussion were highly relevant. In the follow-up survey, the instructors agreed that the workshop had raised their awareness of the classroom experiences of minorities and women and had offered strategies for addressing destructive classroom dynamics. 72% reported that the workshop led to changes in their behavior as facilitators. Differences in responses according to gender were observed. Conclusions: A workshop using interactive theater was effective in training faculty to facilitate small-group discussions about multicultural issues. This approach emphasizes and models the need to foster critical consciousness in medical education.

Remembering Freddie Gray: Medical Education for Social Justice

Recent attention to racial disparities in law enforcement, highlighted by the death of Freddie Gray, raises questions about whether medical education adequately prepares physicians to care for persons particularly affected by societal inequities and injustice who present to clinics, hospitals, and emergency rooms. In this Perspective, the authors propose that medical school curricula should address such concerns through an explicit pedagogical orientation. The authors detail two specific approaches—antiracist pedagogy and the concept of structural competency—to construct a curriculum oriented toward appropriate care for patients who are victimized by extremely challenging social and economic disadvantages and who present with health concerns that arise from these disadvantages. In memory of Freddie Gray, the authors describe a curriculum, outlining specific strategies for engaging learners and naming specific resources that can be brought to bear on these strategies. The fundamental aim of such a curriculum is to help trainees and faculty understand how equitable access to skilled and respectful health care is often denied; how we and the institutions where we learn, teach, and work can be complicit in this reality; and how we can work toward eliminating the societal injustices that interfere with the delivery of appropriate health care.

The impact of facilitation of small-group discussions of psychosocial topics in medicine on faculty growth and development.

Purpose To use qualitative analysis of interview transcripts with clinician–educators who facilitate small-group discussions on psychosocial themes—including doctoring—to answer the question, “What impact does facilitating small-group discussions of the patient’s experience with chronic illness, the doctor–patient relationship, and doctoring have on faculty instructors’ attitudes regarding their roles as clinicians and teachers?” Method In 2006, in-depth, face-to-face interviews using an open-ended question format were conducted with individual faculty small-group instructors teaching in the Family Centered Experience and Longitudinal Case Studies courses at the University of Michigan Medical School. Interview transcripts were analyzed using grounded theory methodology to identify emerging themes. Accuracy of interpretations and saturation of themes was confirmed by repeated contextual reading of the transcripts. Results Several major thematic codes emerged from the data. Facilitation of small-group discussions of psychosocial topics and doctoring fostered reflective approaches to patient care and teaching; enhanced interpersonal relationships between facilitators and their students, colleagues, and patients; and acted as a source of fulfillment and renewal among faculty facilitators. Conclusions Small-group teaching of the art of doctoring may stimulate personal and professional growth among faculty facilitators and renewed interest in teaching and patient care.

Reflection, dialogue, and the possibilities of space.

To educate physicians who are capable of delivering ethical, socially responsible, patient-centered care, there have been calls for identifying curricular space for reflection on the human and societal dimensions of medicine. These appeals, however, beg the question: What does it mean to devote space in an otherwise busy curriculum for these types of reflection? This Perspective is an attempt to understand the nature of this educational space in terms of its purpose, uses, dynamics, and limitations, and the underlying components that allow reflection and transformation to occur. Reflections on psychosocial themes often take the form of dialogues, which differ from the discussions commonly encountered in clinical settings because they require the engagement of the participants’ whole selves—life experiences, backgrounds, personal values, beliefs, and perspectives—in the exchanges. Dialogues allow for the inclusion of affective and experiential dimensions in addition to intellectual/cognitive domains in learning, and for an emphasis on discovering new perspectives, insights, and questions instead of limiting participants solely to an instrumental search for solutions. Although these reflections may vary greatly in their form and settings, the reflective space requires three qualities: safety and confidentiality, an intentional designation of a time apart from the distractions of daily life for reflection and dialogue, and an awareness of the transitional nature—the liminality—of a critically important period of professional identity development. In this open space of reflection and dialogue, one’s identity as a humanistic physician takes form.

Troubling muddy waters: Problematizing reflective practice in global medical education

The idea of exporting the concept of reflective practice for a global medical education audience is growing. However, the uncritical export and adoption of Western concepts of reflection may be inappropriate in non-Western societies. The emphasis in Western medical education on the use of reflection for a specific end—that is, the improvement of individual clinical practice—tends to ignore the range of reflective practice, concentrating on reflection alone while overlooking critical reflection and reflexivity. This Perspective places the concept of reflective practice under a critical lens to explore a broader view for its application in medical education outside the West. The authors suggest that ideas about reflection in medicine and medical education may not be as easily transferable from Western to non-Western contexts as concepts from biomedical science are. The authors pose the question, When “exporting” Western medical education strategies and principles, how often do Western-trained educators authentically open up to the possibility that there are alternative ways of seeing and knowing that may be valuable in educating Western physicians? One answer lies in the assertion that educators should aspire to turn exportation of educational theory into a truly bidirectional, collaborative exchange in which culturally conscious views of reflective practice contribute to humanistic, equitable patient care. This discussion engages in troubling the already-muddy waters of reflective practice by exploring the global applicability of reflective practice as it is currently applied in medical education. The globalization of medical education demands critical reflection on reflection itself.

On the Way to Reflection: A Conversation on a Country Path

Ways of exploring the related acts of thinking and reflection are not just confined to expository prose. Following Heidegger’s (1966) model of a conversation that gradually reveals deeper meanings of the concept of thinking, the following is a record of a conversation during a walk in the country on a summer’s evening. Three individuals, a Doctor, a Philosopher, and a Poet, revisit the topic of reflection from a variety of different perspectives in hopes of understanding its place in the practice of medicine. In particular, they explore an area of reflection where medicine is often silent: during times of great suffering and loss. Along this country path, as night gradually falls, they attempt to capture the complex meanings of reflection that culminate in that intimate “open space” where medicine is practiced and where fundamentally important human events occur.