Medicine in a multicultural society

A Muslim woman entered the consultation room. The doctor stood, greeted her, and then proffered his hand expectantly in his usual cordial manner. His actions were met with a frosty stare, which surprised the doctor. His other patients would visibly relax at this otherwise welcoming gesture. A few days later, he was relating the story to a colleague. She laughed and then said, “Didn't you realise? She was probably a strict Muslim. Her bare hands cannot make any contact with yours.”He smiled feebly. “Oh,” he said. “I don't know very much about other cultures.” The doctor was, at his own admission, a “well meaning blunderer.”

This story, related during a workshop entitled “Multicultural aspects of medical education” at the Association for the Study of Medical Education (ASME) conference in July, highlighted the problem facing healthcare professionals working in Britain today. Britain is undoubtedly a multicultural society. Doctors and medical students will interact with different ethnic and cultural groups daily, so students need to learn the significance of culture and ethnicity and their role in effective communication. The General Medical Council recognises this fact. It advises that the medical curriculum should provide medical students with “the opportunity to develop and hone the range of skills and techniques that are necessary to communicate clearly, sensitively and effectively with patients and their relatives, and colleagues.”¹ While the majority of medical students are able to reel off precise epidemiological statistics and the probabilities of certain ethnic groups succumbing to a given disease, many are unsure how to behave appropriately when meeting someone from a cultural background that is different from their own. The workshop started with the notion that everybody's cultural knowledge and behaviour could be fitted on to a Cartesian graph. Cultural competence, knowledge of the theory behind other cultures, is plotted along the x axis against cultural humility, awareness of how to behave in the presence of other cultures, along the y axis (see figure).

While improving knowledge of cultural issues needs to be brought to the forefront of medical education, it is essential that patients do not become victims of cultural stereotypes imposed on them by the medical profession. Knowledge without humility is insufficient. As depicted on the graph, the ideal is cultural safety. Those who are culturally safe, not only have sound knowledge, but also are able to both respect and value differences in culture.²

It is clear that culture does not only impact on disease statistics, but also plays a important part in health and illness behaviours and beliefs, bedside etiquette, and perceptions of doctors.³ If medical students are made aware of the impact culture has on an individual's health and wellbeing then it would seem that they would be able to interact with patients and care for their health more successfully.

This then begs the question: “How do you gain cultural knowledge?” The workshop agreed that a textbook or a checklist, documenting the latent messages of all the winks, nods, and handshakes that are codes of communication in different cultures, was not the answer. Lists are inflexible, provide little detailed insight into how certain beliefs arise, and potentially prompt pigeonholing. You can never reliably predict that a member of any given cultural group is going to think x, believe y, and do z, and thereby presume their actions and behaviours. Everyone is an individual in his or her own right.

If crib sheets delineating every perceived cultural idiosyncrasy are not the solution to the quandary it would seem that learning by experience is the only effective approach to developing cultural safety in medical students.

Medical school should provide a good environment for students to learn about different cultures. The current intake of students into most medical schools includes individuals from different cultural backgrounds with diverse religious beliefs. The structure of the medical curriculum in most schools provides opportunities for the discussion of pertinent cultural issues. In a seminar or tutor group setting, students can respectfully raise questions of their peers who may be able to share their own cultural knowledge and understanding in a controlled environment. Speaking with peers allows students to appreciate the nuances that may exist within a culture, acquiring insight while simultaneously challenging their own prejudices and stereotypes. This should encourage students to consciously consider the following key questions without being blinded by personal misconceptions:

• What is the cultural, ethnic and religious background of this patient?
• How will this affect the way I will interact with this patient?
• How will this affect the management of my patient?

Members of the workshop also thought that “simulated” patients were an excellent way for students to evaluate their comfort and ability to work with people of different cultures. These are real patients or actors who are trained to present particular problems in a typical style and to respond in a standard manner to various stimuli. In this way, students can fine tune their ability in asking key questions and interpreting relevant cues to gain a fuller understanding of the patient. Furthermore, by obtaining feedback from the standardised patient and peers observing the interaction, students can learn to apply their knowledge about a culture to an individual in a sensitive manner. On this note, much to the chagrin of the students in the group, the objective structured clinical examinations (OSCEs) were touted as a chance to formally examine cultural issues. Examinations aim to evaluate the basic competence of medical students ensuring that they may be fit to practise in accordance with the standards outlined by the General Medical Council. There are many facets to medical competence, one of which is the ability to treat the whole patient. As such, doctors may be expected to show that they have taken into account the cultural expectations of that individual and more importantly the individual's definition of wellbeing and lifestyle. Thus, the knowledge and understanding of cultural, ethnic, and religious issues provide a solid foundation on which a medical student can learn to establish a good patient and doctor relationship for the future. By incorporating cultural issues into the medical curriculum, the doctors of tomorrow may be better equipped with the skills necessary to effectively meet the needs of a diverse and evolving society.

Deborah Cohen, fourth year medical student, University of Manchester
Email: debsicohen@hotmail.com

Mitesh Desai, fourth year medical student, University of Manchester
Email: miteshdesai@compuserve.com

Professor Sam Leinster, dean, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich


studentBMJ 2001;09:357-398 October ISSN 0966-6494

1. General Medical Council. Draft recommendations on undergraduate medical education, July 2001.www.gmc­uk.org
2. Prideaux D, Edmondson W. Cultural identity and representing culture in medical education. Who does it? Medical Education 2001;35:186­7.
3. Hillier S. The health and health care of ethnic minority groups. In: Scram­ bler G, ed. Sociology as applied to medicine.London:WB Saunders, 1997.