So who's teaching whom?
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7230.323 (Published 29 January 2000) Cite this as: BMJ 2000;320:323All rapid responses
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EDITOR-Like Liz Smith1 I have worked in Africa. Like her I also am
the co-author of a training pack in race and cultural awareness2. But my
interest was triggered not by Africa but by being a patient in a foreign
land; a European country with an excellent and well resourced health
service whose staff knew a great deal about the "British way of life". I
still, however, found myself a square peg squeezing into round Swede-
shaped holes, cared for by kind, highly competent staff who made some very
incorrect assumptions about me.
I do not agree that information booklets about "the different needs of
Muslims Sikhs and Hindus" are what's needed. There are already far too
many resource packs, textbooks and training packs with this 'cookery book'
approach, with menus of cultural norms- What A eats, how B does her hair,
how C dies. Such an approach, in which the special features of "the Asian
family" or "the Afro-Caribbean child" are explored, with rigid and static
notions of culture, can worsen the care Black people receive as it leads
to pigeon-holing, victim blaming and stereotyping. In reality, people
often make surprising choices which may be totally at odds with their
cultural norms. Indeed the whole notion of "cultural norms" in a
multicultural society is questionable.
It arises from a simplistic and uni
-dimensional view of peoples' lives which "ignores the effects of host
cultures on minority ethnic communities, both collectively and at the
level of the individual. Members of minority ethnic communities live at
the intersection of two or even more cultures. At these intersections
reactions take place that no textbook can predict'' 3
Of course professionals need access to information about, for example,
Sikh naming systems, Hindu dietary norms etc. But in order to put such
information in context, and to apply it in an intelligent way to their
everyday practice, professionals need a structured opportunity to:
§ Explore their own attitudes
§ Recognise that they are not culturally neutral but a product of their
own cultural conditioning.
§ Understand how their own and others' attitudes towards race, colour and
religion interact with those towards class, age, gender, and disability.
Cultural competence is not about generalising on the contraceptive needs
of Roman Catholics, or about learning what Somali refugees eat for
breakfast on Thursdays. Becoming culturally competent firstly requires
learning a great deal about oneself.
Elspeth Webb
senior lecturer
Department of Child Health, University of Wales College of Medicine,
Cardiff CF4 4XN
1. Smith L. So who's teaching whom. BMJ 2000; 320:323.
2. Shah L, Thomas-Ramuset A, Webb E., Equal rights equal access -
improving the health care of disabled and chronically ill children from
minority ethnic communities : A training pack. Cardiff 1996. Department of
Child Health, UWCM.
3. Ingleby D. Psychosocial problems among children of migrants. In
Proceedings of the Annual Meeting of the European Society of Social
Paediatrics: Child Health Care for Migrants and Refugees. Rotterdam 1995;
Stichting Ouder en Kindzorg: 40-46
Competing interests: No competing interests
Congratulations to Liz Smith for an excellent article and showing the
way towards integration of and better treatment to the populace not only
in U.K. but wherever there are multicultural societies. The key words, in
the words of Ms. Liz Smith, are :"attitudes and understanding count at
every level of organisation" and "we are not all the same" to which I will
add,"and not too different in terms of needs, thoughts and beliefs".
Competing interests: No competing interests
Liz Smith's personal view reflecting on the need for health care
workers to develop cultural self awareness is timely(1). But as previous
work has shown there is a dearth of published literature describing
coherent programmes within undergraduate medical education in the UK that
effectively address these issues (2). It is vital that any future
programmes learn from other professional contexts and heed the lessons
from debates of the last 20 years that have taken place within primary and
secondary education. These have emphasised the inadequacy of purely
multiculturalist approaches that limit aims to learning about customs and
beliefs in cultures other than one's own. Also highlighted are the
deleterious effects of anti-racist 'race awareness training' that fails to
encourage participants to look at the wider social context and power
inequalities within society that lead to discrimination and so maintain
the disadvantage of those other than the ruling majority (3).
One problem facing medical educators is a lack of practical
suggestions in a medical context that can be used to stimulate training,
leading to inertia (4). A recently developed teaching resource offers a
start(5).
As part of a programme of education for diversity, sponsored by the
Department of Health, we are implementing a strand of teaching across the
undergraduate medical curriculum. The phased learning outcomes start with
students being expected to acquire an awareness of how their attitudes are
affected by issues such as gender, ethnic, cultural or social background,
sexual orientation and lifestyle and to recognise the potential for
prejudice in institutions and individuals. Later we intend to help
students to recognise their responsibility to practise in a manner that
avoids stereotypes and develop strategies to tackle prejudice within
themselves and others.
We look forward to further debate on the effective evaluation and
assessment of this and similar programmes of work.
Rhian Loudon, Clinical Research Fellow
Joe Kai, Senior Lecturer
on behalf of Birmingham Diversity in Medical Education group.
1. Smith L. So who's teaching whom? BMJ 2000; 320:323.
2. Loudon RF, Anderson PM, Gill PS, Greenfield SM. Educating medical
students for work in culturally diverse societies. JAMA 1999; 282:875-880.
3. Gill,D, Mayor, B and Blair, M. (Eds.) Racism and education - structures
and strategies London: Sage, The Open University, 1992.
4. Kai J, Spencer J, Wilkes M, Gill P. Learning to value ethnic diversity
- what, why and how?
Medical Education 1999; 33: 616 -623.
5. Kai J (Editor). Valuing Diversity - a resource for effective health
care of ethnically diverse communities
London: Royal College of General Practitioners, 1999.
Competing interests: No competing interests
Learning from each other
Editor- In her personal view “ So who’s teaching whom?” (1) Liz
Smith highlights some very pertinent issues. Working in other countries
can enhance knowledge and skills, and broaden one’s perspective
considerably.
Having begun life in India , I qualified in medicine in the UK , and then
spent several years preparing to return to rural India as an
ophthalmologist. Most regarded this choice as quaint, but there were
colleagues who showed genuine interest.
I worked for five years as an ophthalmologist in a Leprosy hospital
(providing eye services for the general population also) in Eastern India.
These have been the most challenging, interesting, (and exhausting !)
years of my career. There were times of feeling ill-equipped, ill-
informed, and totally inadequate for my responsibilities. I quickly had
to learn how to budget, to buy equipment, to write project proposals, to
train and manage staff, and to organise and teach on training courses and
workshops. My training in the UK had not afforded me these skills.
Clinically, I did my best to put into practice what I had learned in the
UK, and to give equivalent standards of care, despite caring for more
patients having less equipment , and there being no senior colleagues on
hand to give advice.
I am now back working as a specialist registrar in the UK, and enjoying
it. I have plenty of colleagues around to discuss topics of interest with,
plentiful equipment for every procedure and a wide range of treatments
available to prescribe. When I am on call, it is for ophthalmology alone.
I don’t have to set up drips on dehydrated infants, perform lumbar
punctures , manage pancreatitis, or deliver babies!
Is such experience in India and elsewhere, valued appropriately? I have
worked with scores of dedicated Indian colleagues who practise as I did,
with access to a tiny fraction of the budget we have here. Few have
European or American post-graduate training, but most have a wide range
of skills and abilities, and a comprehensive “world view” rarely found in
developed countries.
My experience has shown me that my UK training alone (albeit something I
appreciate) has given me a fraction of the knowledge and skills that I
regard as valuable, wherever I am working . Work opportunities in
developing countries broaden the mind and make one realise how much we
can learn from each other.
Kirsteen J Thompson ,
Specialist Registrar,
Tennent Institute of Ophthalmology,
Gartnavel General Hospital,
1053 Great Western Road,
Glasgow
G12OYN
1. Liz Smith. So who’s teaching whom? BMJ 2000;320:323.(29
January)
Competing interests: No competing interests