Medically Related Cultural Issues Can Be Learned Outside the Classroom

I was greatly interested by the recent article by Flores et al.,¹ in which the authors reported the results of a telephone survey of 118 U.S. and 15 Canadian medical schools on the teaching of cultural issues in medical curricula. They were surprised to find that very few schools (U.S. = 8%, Canada = 0%) provided specific courses to address cultural issues, despite the important role culture plays in health care and the growing diversity in both countries. Based on their findings, Flores et al. concluded that most U.S. and Canadian medical schools provide inadequate instruction about cultural issues, especially cultural aspects of large minority groups.

While I believe that cultural issues are far more complicated than simply language and/or communication issues as the authors of this study have defined them, the study does raise important questions about how best to teach and learn about cultural issues. Is knowledge of cultural issues enough of a sustainable competency to justify a separate course in the already over-congested medical curriculum? How much should medical students be taught about cultural issues, and at what stage of their medical education? Are there cultural experiences that students can learn from outside the classroom?

Teaching cultural issues in medicine is like teaching American slang (itself a cultural issue) in foreign countries where no one speaks it. It is easier to learn slang where it is being used than in a course. Similarly, teaching a course about the Chinese art of healing (or other forms of alternative or complementary medicine, which are highly flavored by cultural issues) in a medical school that is loyal to the Flexner-report² model and that advocates curricular content that is factual, knowledge-based, and scientific may not be effective.

Thus it is that the culture of medical education itself affects what students learn about cultural issues. Flores et al. represent the perspective of traditional medical education, which emphasizes teaching rather than learning. For example, they report that cultural issues were taught in electives by 16% of U.S. schools and by no Canadian school, that Canadian schools were significantly more likely than were U.S. schools to “offer no instruction” on cultural issues, and that cultural issues were taught in the first two years by only 61% of U.S. and 27% of Canadian schools. The authors conclude, “It is not clear why most Canadian medical schools have lagged behind their American counterparts in teaching cultural issues,” (emphasis added) and they recommend that teaching cultural issues to future Canadian physicians should be a medical school priority. The problem here is twofold. First, their results reflect only a count of courses addressing cultural knowledge, not the ability of medical students to apply this knowledge to clinical reasoning. Second, >50% of the Canadian medical schools are adopting student-centered, problem-based, and self-directed learning (collectively called PBL), which is not often differentiated from problem-based teaching (bedside tutorial or case study). On the other hand, <25% of U.S. medical schools use PBL, relying instead on teacher-centered pedagogy. Thus, a major difference in U.S. and Canadian approaches to medical education may explain the reported findings.

In PBL, biomedical concepts, knowledge, and skills, be they biological, social or behavioral, or community or population perspectives, are integrated into the clinical problem as a trigger for learning in a student-centered and self-directed environment. During my 25-year academic life at McMaster University, where PBL in medical education originated,³ I have witnessed medical students deal with cultural issues such as communication, styles of living, religions and beliefs, special dietary habits, family values, community bonding, and health care accessibility throughout the entire curriculum, despite the fact that not a single course was specifically designed for teaching cultural issues. My students have taken electives in the Northern Territories of Canada, Indian reserves, and Chinese hospitals to experience the impact of culture on health care systems in the most practical manner. These students learned about cultural issues via hands-on, real-life experience, not via teachers in a lecture theater or in the form of a specifically designed course. If Flores et al. had studied students' learning of cultural issues in U.S. and Canadian medical schools, rather than the number of courses teaching cultural issues, the results could have been surprisingly different.