Adding to our BMERG Journal Club series, this month Dr Claire Hudson reflects on the discussion from our January journal club focussing on Cultural Competency.
Liu, J., K. Miles, and S. Li, Cultural competence education for undergraduate medical students: An ethnographic study. Frontiers in Education, 2022. 7. https://www.frontiersin.org/articles/10.3389/feduc.2022.980633/full
This paper was chosen by my colleague, Assoc. Prof Liang-Fong Wong, who has a combined interest in cultural competency and medical education, being Year 4 co-lead for our undergraduate MBChB programme and Associate Pro Vice-Chancellor for Internationalisation. Both Liang and I are keen to develop our qualitative research skills, and at first glance, this paper seemed like an excellent example of a qualitative study.
What is ‘Cultural Competency’?
Liu et al suggest culturally competent healthcare professionals should “communicate effectively and care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, gender and other sociocultural relevant biases in healthcare delivery”; others have defined attributes of culture competency including “cultural awareness, cultural knowledge, cultural skill, cultural sensitivity, cultural interaction, and cultural understanding”. These concepts were explained effectively at the start of the paper; I felt the authors provided me with context for my subsequent reading.
What was the research?
The authors perceived that teaching of cultural competency is inconsistent across medical schools, and there is a paucity of evidence for how effective the teaching is, and how students actually develop their cultural competency throughout their training. They aimed to describe students’ experiences of learning and developing cultural competency, using an ethnographic approach. They carried out student observations, interviews and focus groups; recruiting participants from a central London medical school.
What were the findings?
There is a wealth of qualitative data and discussion presented in the paper, so perhaps the authors could summarise their overall findings in a clearer way. They suggest that students develop cultural competency in stages; in the pre-clinical years they have formal teaching opportunities, and as their clinical exposure increases, the culture content becomes embedded and derived from other learning experiences, including intercalation and placements. They highlight the importance of learning from patients’ lived experiences, from peers and from other (non-medical) student communities.
What did we think?
- Clear descriptions: I come from a quantitative, scientific background, therefore I find reading qualitative papers quite challenging; the terminology used is noticeably different and somewhat out of my ‘comfort zone’! Having said that, the authors very clearly explained the basis of ethnography and reflexivity, which really helped us understand the rationale for them adopting these approaches. Data collection and analysis were explained in detail which reassured us that these were robust and valid. However, thorough descriptions mean a long paper; and it could be more concise in places.
- Awareness of limitations: A strength of this research was the authors’ transparency about some of its limitations. For example, they acknowledged a potential bias in participant recruitment due to the main author’s own cultural background, but described ways to mitigate this. We found it really interesting that the authors observed different dynamics in the interviews and focus groups depending on the facilitator. In those conducted by a PhD student, a rapport was built such that the students were relaxed and open with their communication, allowing them to be critical about the cultural competency teaching they had received. Conversely, in those conducted by a medical school academic, students were more reserved and tended to be positive about the teaching, highlighting an obvious teacher-student power dynamic. Importantly, this was acknowledged, and adjustments were made. Our biggest take-home message: Carefully consider who facilitates interviews and focus groups so there are no conflicts of interest, and trust is fostered between participants and researchers. Otherwise, students may just tell you what you want to hear!
- Evaluation to recommendations: We also remarked that the authors have been clever in the way they present this study for publication. Essentially, they have carried out an internal evaluation of cultural competency teaching in their own medical school, but they have externalised this by making a series of recommendations. They benefit from a very diverse student population, and showcase some really good practice in cultural competency teaching which could be adopted by medical schools.
Overall reflections
Reading this paper made us reflect on non-clinical teaching on other programmes; it is important to remember that diverse student populations increase cultural awareness in all settings. Widening participation schemes and overseas students are important for this. During group work, I try to make the groups as diverse as possible, and I believe this is a positive experience.
The study highlighted different levels of engagement from students with cultural competency teaching, some thought it was ‘pointless’ as they were already culturally competent, or they thought the skills were ‘soft’ and would rather be learning facts, other found it really valuable. This is familiar when teaching other skills in other disciplines; the constant battle getting ‘buy-in’ from students, highlighting the need to always explain ‘Why’ certain teaching is important.
This study is a good showcase for qualitative research, and I made a mental note to refer back to this paper when developing my own qualitative research in the future; which must be a good sign!
Read our previous Journal club review on Self-regulated learning here: https://bmerg.blogs.bristol.ac.uk/2023/11/24/journal_club_publication_review1/