Emphasis is increasingly placed on cultural awareness in medical education. But Brenda Beagan argues that although it is important to understand what makes other people tick, we also need to understand ourselves

Most of us do not think about our own social locations. By social location I mean where we are situated in relation to members of other social groups. We live our lives day to day, experiencing the world around us in ways that we assume are more or less the same for everybody. We do not often recognise the ways in which our experiences, our understanding of the world, are shaped by who we are.^{1 2} We are blind to the ways that social group makes a difference ' especially when we are members of dominant social groups.

ZENA HOLLOWAY/REX

Take a good look at yourself

Dominant social groups are usually in the majority. But the dominance refers to the fact that they usually have greater social,political, and economic power. Their interests tend to be better represented in media, government, education, formal religions, and law. The interests and world views of dominant groups are considered the norm and the social world is structured to easily accommodate their needs.

Being considered the norm makes it harder to see ourselves as members of distinct social groups. We tend to see ourselves just as individuals.³ Those who are not the norm ' people from more marginalised social groups'are usually more aware of the impact of their own social location, and often much more aware of the existence of dominant social groups.

Medical students from middle class or upper class families tend to say their social class background makes no difference to their experiences of medical school or to their daily lives. In contrast, medical students who identify themselves as coming from working class or impoverished social backgrounds are likely to say their class background has had a negative impact in school and beyond.¹ Again, being middle class shapes your reality, experiences, and view of the world, just as much as does being working class.

So how does social location make a difference? For students, being from a middle to upper class background seems to help you fit in more easily in medical school.⁵ So does being of European heritage ' patients and staff more readily assume that a white man is a doctor than they do a person of African, Asian, or Aboriginal heritage. Female doctors and medical students are still often mistaken for nurses. The heightened sense of belonging enjoyed by students from dominant social groups is not a huge advantage, but constant subtle messages about not quite belonging can have a cumulative disheartening effect. Having to correct repeated assumptions that you are a cleaning person, because your skin is black, means you start interactions with patients at an initial disadvantage.It does not make it impossible to do your job, it just adds an unnecessary barrier.⁵

For patients, it is increasingly clear that who you are makes a difference to your health status as well as your health care.⁶ The social determinants of health have independent effects on health, although at the same time their effects interact. For example, although racism independently affects health, racism also affects education level which affects income which affects health. Populations with the poorest health are also least likely to use healthcare services, even when disparities in health insurance, transportation, and access to health care are taken into account. When patients from socially marginalised groups access health services, they may well experience different treatment. A patient's race, culture, sex, class, and so on influence doctors' attitudes. When patients receive what they perceive to be inferior treatment, prejudice, or bias, they may respond with mistrust and suspicion, becoming increasingly likely to refuse treatment or be non-compliant.⁶

So social location'who we are with respect to others'affects patients and doctors. Add to this the fact that social locations of doctors do not often mirror the social locations of their patients.⁷ Doctors are disproportionately from upper middle class social backgrounds. In Canada, people of Aboriginal and African heritage are significantly under-represented in medicine. Although there is nothing wrong with being a doctor from a well off white family, it does mean you have a particular world view that may not be shared by your patients.

Medicine has had a history of contributing to the oppression of some social groups, including people of colour, gay men and lesbians, people living in poverty, and women. The ways medicine has ill served such populations is not necessarily the result of bad intentions; rather it arises from the limitations of a particular world view coupled with the social power to unintentionally do damage. Recognising your own social location, your sources of power and privilege, does not make you a bad person. It does move you one step towards recognising the social location of others, clarifying that members of marginalised social groups are also not bad people who make poor lifestyle choices'rather they experience powerlessness and inequity in complex ways that result in poorer health and poorer health care. Recognising social power relations can guide doctors to ask the right kinds of questions and to work competently in the service of a diverse patient population.

Unfortunately the courses being developed in most medical schools intended to help graduates to better serve marginalised members of a society,⁶ tend to assume that social inequalities are formed and transformed by attitudes and awareness.⁸ They fail to address the sources of inequality; they fail to address power relations.¹ The first step towards understanding inequality is figuring out where we fit within social relations of power. It is critically important for medical students and educators to learn to examine our own social locations before we work out those of others.

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