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Integrating Theory, Content, and Method to Foster Critical Consciousness in Medical Students: A Comprehensive Model for Cultural Competence Training

Dao, Diane K.; Goss, Adeline L.; Hoekzema, Andrew S.; Kelly, Lauren A., MS; Logan, Alexander A.; Mehta, Sanjiv D.; Sandesara, Utpal N.; Munyikwa, Michelle R.; DeLisser, Horace M., MD

doi: 10.1097/ACM.0000000000001390
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Many efforts to design introductory “cultural competence” courses for medical students rely on an information delivery (competence) paradigm, which can exoticize patients while obscuring social context, medical culture, and power structures. Other approaches foster a general open-minded orientation, which can remain nebulous without clear grounding principles. Medical educators are increasingly recognizing the limitations of both approaches and calling for strategies that reenvision cultural competence training. Successfully realizing such alternative strategies requires the development of comprehensive models that specify and integrate theoretical frameworks, content, and teaching principles.

In this article, the authors present one such model: Introduction to Medicine and Society (IMS), a required cultural competence course launched in 2013 for first-year medical students at the Perelman School of Medicine at the University of Pennsylvania. Building on critical pedagogy, IMS is centered on a novel specification of “critical consciousness” in clinical practice as an orientation to understanding and pragmatic action in three relational domains: internal, interpersonal, and structural. Instead of transmitting discrete “facts” about patient “types,” IMS content provokes students to engage with complex questions bridging the three domains. Learning takes place in a small-group space specifically designed to spur transformation toward critical consciousness. After discussing the three key components of the course design and describing a representative session, the authors discuss the IMS model’s implications, reception by students and faculty, and potential for expansion. Their early experience suggests the IMS model successfully engages students and prepares future physicians to critically examine experiences, manage interpersonal dynamics, and structurally contextualize patient encounters.

D.K. Dao is a fourth-year MD/MPH student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

A.L. Goss is a fourth-year medical student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

A.S. Hoekzema is a fourth-year medical student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

L.A. Kelly is a fourth-year MD/MPH student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

A.A. Logan is a fourth-year medical student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

S.D. Mehta is a fourth-year MD/MBE student, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

U.N. Sandesara is a seventh-year MD/PhD student, Perelman School of Medicine and Department of Anthropology, University of Pennsylvania, Philadelphia, Pennsylvania.

M.R. Munyikwa is a fifth-year MD/PhD student, Perelman School of Medicine and Department of Anthropology, University of Pennsylvania, Philadelphia, Pennsylvania.

H.M. DeLisser is associate professor of medicine and associate dean for diversity and inclusion, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

The authors have informed the journal that they agree that D.K. Dao, A.L. Goss, A.S. Hoekzema, L.A. Kelly, A.A. Logan, S.D. Mehta, and U.N. Sandesara contributed the intellectual and other effort associated with the first author.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A391.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Horace M. DeLisser, Perelman School of Medicine, University of Pennsylvania JMEC, Building 421, 6th Floor, 3400 Civic Center Blvd., Philadelphia, PA 19104-5162; telephone: (215) 898-4409; e-mail: delisser@mail.med.upenn.edu.

Medical educators face challenges in designing introductory cultural competence courses for preclinical medical students. Although an array of strategies exist1 , 2 for meeting national standards centered on knowledge, attitudes, and skills,3 , 4 there remains considerable disagreement among educators about how best to combine content from medicine with content from the social sciences and humanities to create an effective curriculum.

Many efforts follow the information delivery (competence) paradigm that prevails in the biosciences,5 incorporating “need-to-know” content from the intersection of medicine, social science, and the humanities (MeSSH) in modular form.6–8 Commentators have lamented the tendency, inherent in this approach, toward lists of attributes, or cultural “safaris,” that exoticize patients, ultimately obscuring social context, medical culture, and structures of power.9–17 This line of commentary recognizes the need to foster an orientation that equips students “to provide quality care to patients everywhere, from anywhere, with whatever differences in background.”10

However, in the absence of clear grounding principles, movement away from lists can easily lead to settling on a vague orientation of “open-mindedness,”18 fostering uncritical perspectives that ultimately overlook and may exacerbate social problems.16 , 19 To counteract this propensity, scholars have proposed incorporating rich ideas like “cultural humility,”20 “cultural sensibility,”21 “insurgent multiculturalism,”22 “narrative humility,”23 “elective affinity,”24 “phronesis,”5 and “structural competency”16 to ground a new learning approach. We believe that successful operationalization of such proposals requires specification of three key components of course design: the theoretical framework, the content, and the teaching principles.

In this article, we describe a new model of cultural competence training that combines theory, MeSSH content, and pedagogy to transcend the lists versus open-mindedness dilemma in sociomedical education. We take as our starting point the concept of critical consciousness, introduced to the medical education literature by Kumagai and colleagues.5 , 25–28 Building on critical pedagogy theory,29 we treat critical consciousness as a state of understanding how power and difference shape social structure and interaction (“reading the world”), coupled with an orientation toward pragmatic action. Critical consciousness-based learning, originally developed as a way to move beyond information delivery paradigms29 (i.e., lists), is well suited to resolve the current dilemma in sociomedical education: It simultaneously offers a specificity and orientation to action that are lacking in open-mindedness approaches.

Based on Introduction to Medicine and Society (IMS), a required introductory course introduced at the Perelman School of Medicine at the University of Pennsylvania (PSOM) in 2013, our model centers on a novel specification of critical consciousness in clinical practice as encompassing three relational domains: internal, interpersonal, and structural. After elucidating this theoretical foundation, we demonstrate how the IMS model gives rise to specific choices of MeSSH content and teaching methods. Additionally, we explain how the IMS model includes an approach to cyclical revision driven by longitudinal student engagement, and we discuss the model’s implications.

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The IMS Model

Curricular reform at PSOM

From 2008 to 2012, IMS’s predecessor course (The Doctor–Patient Relationship: Introduction to Communication and Culture) operated on a hierarchical, information delivery model, with lecturers and faculty small-group leaders delivering discrete content about sociocultural groups or specialized communication issues. In early 2013, in response to student feedback that the course was fragmented, essentializing, and simplistic, the PSOM administration convened a student working group (D.D., A.G., A.H., L.K., A.L., S.M., U.S.), which collaborated with the course director (H.D.) to develop and implement the IMS model described here. During the curricular reform process, the group drew inspiration from their diverse backgrounds, including experience with academic social medicine and medical anthropology,30 democratically structured workshops,31 public radio journalism, narrative medicine,32 and immigrant health.

IMS, which was implemented in fall 2013, is a required, semester-long introductory cultural competence course that enrolls 150 to 160 first-year students annually. IMS’s key learning spaces are small groups, in which the same 12 to 14 first-year students meet weekly with 3 to 5 faculty and near-peer (senior student) facilitators. The course’s total instructional time is 43 hours. Students and facilitators prepare for the two-hour small-group sessions by engaging with diverse multimedia assignments and attending an hourlong plenary presented by a leader in MeSSH. Sessions are run using a novel facilitation model that emphasizes relational communication, vulnerability, and personal transformation. Every element of the course structure is premised on our vision of critical consciousness, which serves as the model’s theoretical framework.

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Theoretical framework

The IMS model treats critical consciousness in medicine as the physician’s always-evolving orientation to navigating relationships in internal, interpersonal, and structural domains (Figure 1). The internal relationship to self is crucial for reflection and self-care; the effective physician cultivates an understanding of her biases, values, and previous experiences. Interpersonal relationships with patients and peers (physicians as well other providers in the clinical environment) require the physician to draw on relational communication skills, an appreciation of differing social positions, and a stance of humility and openness. Finally, the physician interacts with and is influenced by structural forces—that is, institutions, norms, and configurations of power—that ultimately shape patients’ lives and possibilities for care.16 , 33 This three-domain approach to critical consciousness organizes the practice of “reading the world”29 in a way that moves beyond a sole focus on the exoticized patient toward consideration of the self and of power relations.15 , 16 , 22 , 28 Moreover, unlike competency-based approaches that treat internal attitudes, interpersonal skills, and structural knowledge as end points, the IMS approach to critical consciousness prepares students for lifelong exploration of each domain.

Figure 1

Figure 1

Consider the case of a physician experiencing the death of a longtime patient. This scenario calls on the doctor to internally explore his or her feelings about the patient, his or her prior experiences with death and dying, and how these factors affect his or her relationship with the patient and orientation to the dying process. When interacting with the patient, the patient’s family, and other members of the care team, the physician traverses a complex web of interpersonal factors—emotional, communicational, and spiritual—to act effectively. Finally, the physician engages the structural facets of health care—historical, economic, political, and sociocultural factors including technological advances, the availability and acceptance of palliative care services, and the power dynamics of the doctor–patient relationship—that situate death in a social context, making some actions possible while precluding others.

Following the work of a number of scholars,5 , 25 , 34 , 35 we presume that attaining critical consciousness requires learning that is transformative in nature.36 , 37 Building on Kumagai and Naidu’s26 elaboration of dialogic spaces as sites for reflection in medical education, the IMS small group requires participants to bring their “whole selves”— their ideas, reactions, emotions, and experiences—into conversation with one another. The result is a process of dialogue, in which participants engage with alternative ways of seeing the world, enabled by the common ground provided by MeSSH content and a shared repertoire of relational communication skills. These intersubjective encounters, catalyzed by personal reflection, destabilize participants’ assumptions about themselves and the world,38–40 allowing for generation and integration of new perspectives. Over time, the repetition of this process generates cyclical transformation34–37 toward greater consciousness of social realities, how they are experienced differently based on social position, and their impact on the clinical encounter.

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Content

In the IMS model, choice of MeSSH content flows directly from the three-domain vision of critical consciousness and draws from diverse disciplines: medicine, to ground the course in clinical relevance; social sciences, to introduce rigorous social research and analytical frameworks; and humanities, to disrupt entrenched assumptions and introduce students to new emotional and experiential perspectives.27

The MeSSH content is organized into three blocks designed to provide an overview of critical issues that commonly arise in training and practice. The IMS course opens with the Foundations block, whose three sessions cover core principles of dialogic learning,25 , 26 , 28 focused on establishing a productive discussion space26; culture, cultural humility, and structural competency16 , 20 , 33 , 41 , 42; and the experience of suffering and illness.23 , 32 , 43 These initial sessions introduce fundamental sociomedical themes alongside core internal and interpersonal skills that help students engage with the course material and with peers. In the second block, Stratification, Privilege, and Disparity,44–46 students participate in four sessions on socioeconomic class,47 race,14 , 48–51 gender,52 , 53 and LGBTQ issues.54 This block helps students develop a repertoire of frameworks for understanding the effects of medical and social disparity across the three domains as they critically examine their own experiences and worldviews in relation to those of their peers and the patients they will serve. In the final block, Medical Culture and the Physician’s Role,11 , 17 students explore issues at the heart of their professional culture and experience as they participate in four sessions centered on risk behaviors and “compliance”55–58; anatomy lab and the medical gaze59–61; death, faith, and meaning62–64; and social ethics and advocacy.65 , 66 They also complete their own capstone project. In this block and through their capstone project, students prepare to critically analyze the norms and practices of being a physician as they seek to provide the best possible patient care.

The IMS model introduces course content in the form of preparatory materials and plenaries that provide initial provocation toward transformation. Students first review diverse MeSSH scholarship (e.g., statistical studies of disparities, conceptual frameworks for understanding inequality, personal narratives of underinsurance) and popular media materials (e.g., podcasts on questions of justice, essays addressing class disparity) related to the week’s topic. They then attend a plenary given by a leader in MeSSH—for example, for a session on risk behaviors, an anthropologist expert on drug use—or a panel of patients or medical professionals. The IMS plenaries and preparatory materials do not offer generalized “facts” about groups of people or instructions about how to approach a particular “kind” of patient; instead, they raise complex, exploratory animating questions that bridge the three domains of critical consciousness (for sample animating questions, see Chart 1 and Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A391). Both the plenaries and materials rely on data and frameworks that help orient students to the session topic; they also incorporate personal narratives and patient testimonials that add nuance and provoke emotional responses. Students’ initial explorations then feed into the small-group space, where specific teaching methods promote engagement and vulnerability.

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Teaching methods

Collective dialogue that catalyzes transformation toward critical consciousness requires a learning space that is dynamic, open, and honest.25 , 26 , 28 To this end, every aspect of the IMS small-group design—from physical structure to content and activities—is designed to promote engagement and vulnerability. This design approach rests on five core teaching principles: intentional structuring, constant variation, built-in flexibility, IMS-specific facilitation, and relational communication.

Two acts of intentional structuring shape the small group as a separate space. First, the space is shaped by physical changes that include restricting electronic device use, placing bags in a corner of the room, and rotating assigned seats to promote interaction among all students. Second, during each small group’s first meeting, participants collectively author a “safe space contract,” outlining communication guidelines that foster openness and vulnerability (e.g., assume the best of others; speak for oneself, not for others). These practices shape an “intentional space”26 that is unique within students’ medical school experiences. They also cultivate a sense of student ownership and group identity, fostering deeper investment in the course.

Students enter the small-group space with initial provocation from the MeSSH preparatory materials and plenary. As a group, they participate in various exercises—also suffused with MeSSH content—that prompt them to examine their reactions, enter into dialogue with their peers, and explore structural connections (see Table 1). Constant variation in activities creates multiple avenues for student engagement, thereby addressing participants’ diverse backgrounds, learning styles, communication habits, and reactions to preparatory material. Each session guide for facilitators contains varied discussion formats—partnered, small (3–4 students), medium (6–7), and large (12–15) groups—and an assortment of exercises. (The facilitator guides for two sessions are provided in Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A391). Although some activities and discussion prompts are required, facilitators maintain flexibility to adapt to group dynamics and to adjust direction to capture productive moments of dialogue. By incorporating both variation and flexibility, the design of IMS small-group sessions enables facilitators to stimulate rich exploration of a topic across the three domains while meeting students where they are.

Table 1

Table 1

IMS’s fostering of critical consciousness also relies on a novel facilitation model founded on skill building in which near-peer facilitators (fourth-year medical students) play a central role. Each small group is assigned three near-peer facilitators and two faculty facilitators; at least two of these students and one of these faculty members are present for each session to facilitate the discussions. Before the IMS course begins, all facilitators attend a skills-based training workshop where they participate in simulated group discussions, with direct coaching, to practice specific facilitation strategies for managing the small-group space and prioritizing student voices (e.g., using silence, reflecting questions back to students, ensuring no participant dominates the discussion, supporting relational communication). Near-peer facilitators, rather than faculty, are empowered to serve as the primary managers of group dynamics. Shifting responsibility for managing the space from faculty to peers provides two key benefits. First, as previously shown,67–69 near-peer facilitation enhances discussion by bridging experience gaps between physicians and medical students while also building students’ facilitation capacity. Second, faculty facilitators, freed from juggling multiple tasks, can concentrate on engaging in the dialogic process as equal participants, modeling vulnerability and openness. By flattening the usual medical school hierarchy, this facilitation model opens up new modes of communication and actively cultivates student vulnerability.

Because the IMS model aims at transformation through self-reflection and dialogue, it requires personal sharing and empathic listening; these actions depend on teaching and reinforcing the practice of relational communication. Before entering the IMS dialogic space, first-year students attend a training session in which they learn and practice relational communication skills (Table 2); these skills are reinforced by facilitators in every small-group session. Relational communication fulfills three important functions. First, it provides a foundation for the more advanced communication skills that are vital to clinical practice (e.g., delivering bad news, discussing goals of care, motivational interviewing) and prepares students to effectively manage interpersonal power dynamics within the clinical setting.70–72 Second, by strengthening students’ practice of personal sharing, relational communication enables vulnerability among a group of individuals with diverse backgrounds, identities and experiences. Third, developing effective communication skills empowers students to manage interpersonal tension within the small group instead of escalating or avoiding it, creating an ideal environment for productive dialogue.

Table 2

Table 2

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IMS Model in Practice

To provide a practical example of how the IMS model integrates theory, content, and teaching methods, we will describe how these components come together in the 10th IMS session, Death, Faith, and Meaning. By this point in the IMS curriculum, students have explored topics such as illness experiences and medical culture, and they have cultivated vulnerability and developed relational communication skills in their small groups.

One week before the session, students receive via e-mail animating questions that highlight key aspects of death and dying, as well as learning objectives that ground these questions in specific learning and communication practices (see Chart 1). The preparatory materials feature voices of physicians, MeSSH scholars, and dying patients. One piece is required, and students choose a second piece from four options (one video, one audio, two text), resulting in a variety of intellectual and emotional responses. Students send one-page reflections on the media/topic to one of the student or faculty facilitators for comment, seeding dialogue for the small group.

The plenary features an interdisciplinary panel of palliative care specialists, moderated by a physician. The panel’s discussion is largely driven by students’ questions and engages with the animating questions by connecting personal experiences to interpersonal and structural dynamics.

From the plenary, students move into their small groups, where they participate in several activities (see Chart 1 and Table 1). Facilitators are prepared to validate a diversity of perspectives and strong emotions, to avoid tokenizing students with specific cultural viewpoints, and to defer discussions of narrow medicolegal issues. The small group begins with a go-around during which students briefly reflect on their reactions to the plenary or readings. Next, students and facilitators write short “popcorn” responses to the prompt, “In what ways do you find meaning?” The written responses are redistributed anonymously, and each is read aloud. Because facilitators preface this activity by asking students to remain open in defining “meaning,” there is likely to be a mix of religious/spiritual and other responses, which will plant the seeds for further discussion.

Participants then return to internal exploration by writing reflectively on “a time you were near death” and debriefing the writing in subgroups, further prompted by the question “What qualifies as a ‘good death’ to me?” Students are encouraged to practice relational communication (e.g., validation of different perspectives) to foster interpersonal sharing and vulnerability and to notice how their internal experiences and meaning frameworks affect their ability to communicate around this topic.

Turning toward the structural domain, the final discussion revisits the notion of “a good death” in the context of prevailing values of Western medical culture. After viewing a documentary clip about medicalized dying, the small group explores themes such as illness as “battle,” the goal of prolonging life, and hospice as “withdrawal of care.” The discussion emphasizes students’ personal experiences and gives them a sense of how structural dynamics manifest in interpersonal interactions around dying. The session closes with a go-around that allows students to identify their emotional state, offer final reflections, and express any concerns.

Although students arrive at the 10th session with their own orientations, collectively working through these activities generates a partially shared body of new knowledge around death and dying. What is cultivated is not merely an accrual of perspectives but also a fundamental transformation of the student’s relationship to the internal, interpersonal, and structural aspects of these issues as well as a new understanding of the interplay between these domains. The exercises help students develop a personalized tool set for processing, understanding, and communicating around death and meaning that they can apply and expand in subsequent humanism courses, clerkships, residency, and beyond.

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Iterative Revision of the IMS Curriculum

The continued vitality of the IMS model depends on iterative course revision driven by facilitator debriefings and continuous student involvement. Each year, following the conclusion of the course, several students are selected to form a group that evaluates, revises, and implements the next iteration of the course in conjunction with the course director. The students and course director review feedback from the just-completed course and make adjustments to the course while ensuring that the changes are grounded in the IMS model. During the course, there are facilitator debriefings after each session, led by the students working with the course director, that provide feedback for immediate changes in upcoming sessions or for next year’s course. The IMS model thus incorporates institutional transformation—an ever-advancing spiral of implementation, reflection, negotiation, realignment, and reimplementation—in a student-driven form that ensures the course remains responsive to learners’ needs.

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Conclusion

The IMS model is a novel, comprehensive approach—integrating theory, content, and method—for implementing critical consciousness-based cultural competence education in medical schools. We believe it provides a generalizable strategy for preparing future clinicians to manage the internal, interpersonal, and structural aspects of clinical encounters. By bringing together MeSSH provocation and engaged students in a dialogic space that relies on intentional structuring, constant variation, flexibility, relational communication, and near-peer facilitation, the IMS model helps bridge the gaps between clinical practice, MeSSH scholarship, and medical student experience. Moreover, it represents an example of curricular reform driven and sustained in large part by medical students.

As of this writing in spring 2016, the IMS course has been offered three times, and the early experience has been promising. The results of standard PSOM course evaluations have demonstrated statistically significant improvements each year for the three years the course has been in existence in nearly every category, including overall course quality (Figure 2). This improvement took place even as students were asked to engage in deeper reading, writing, reflection, and dialogue.

Figure 2

Figure 2

While rigorous measurement and description of outcomes remain for future study, we note six preliminary trends for the first three years of the course. First, rates of completion of preparatory assignments and attendance at plenaries have risen markedly. Second, the recasting of the small-group space according to the IMS model has transformed discussions; in the student-led IMS debriefings, many facilitators have observed that students are noticeably more open and vulnerable, actively challenging their own assumptions and demonstrating humility while engaging with other worldviews. Third, productive dialogue across difference has been enhanced by extensive practice of relational communication skills—skills that numerous students have reported beginning to use outside this course. Fourth, on the postcourse student evaluation that addresses all aspects of the course, many students have cited the effectiveness of near-peer facilitators in cultivating dialogue.

Fifth, echoing findings of previous research,73 faculty facilitators have identified the course as transformational for them, citing positive effects on their awareness of sociomedical issues, their doctoring practice, and their enthusiasm and pride in teaching medical students. Sixth, student involvement in iterative revisions has generated significant innovations and yielded a course that is continuously adapted to be accessible, compelling, and relevant to each new group of students taking the course, yet stays true to its theoretical framework. We believe this iterative approach, with ongoing student involvement, is essential to sustaining the effectiveness of the IMS model over time and to implementing it successfully at other institutions.

We recognize that sociomedical learning requires longitudinal approaches to reinforcement and retention that go beyond single-semester courses.74 , 75 Indeed, we feel that the IMS model has great potential for longitudinal application, especially in community-based and clinical courses where dynamic cycling between a dialogic space and action in the world can foster long-term, consolidated transformation. At PSOM, based on the IMS model’s successful application in a stand-alone course, the administration is seeking to expand the model across the entire longitudinal sociomedical curriculum, from the preclinical through clinical years. This decision demonstrates both the promise and potential of a longitudinal IMS model. The IMS model also provides an innovative way to fulfill cultural competence training expectations, as outlined by the Association of American Medical Colleges in its Tool for Assessing Cultural Competence Teaching3 (TACCT; for the mapping of IMS course sessions to the knowledge, skills, and attitudes included in the TACCT questionnaire, see Supplemental Digital Appendix 3 at http://links.lww.com/ACADMED/A391).

However, the IMS model’s most transformative work occurs in an ongoing process—the spiral of provocation, disorientation, dialogue, heightened consciousness, and reprovocation that students collectively undertake. It therefore lays the foundation for students to become and remain lifelong, critically conscious sociomedical learners who are able to assimilate new understandings—whether knowledge of specific sociocultural circumstances, attitudes toward previously unencountered situations, or skills in advanced clinical communication—throughout their clinical careers. The outcome is a process of learning that transcends both list-based and open-mindedness approaches, creating new possibilities for the formation of empathic, thoughtful, and effective future physicians.

Acknowledgments: The authors are extremely grateful for the advice, support, and encouragement provided by Gail Morrison, MD (vice dean for education), Stan Goldfarb, MD (associate dean for curriculum), Paul Lanken, MD (associate dean for professionalism and humanism), and Anna Delaney, MBA (chief administrative officer and director, Curriculum Office) from the Academic Programs Office at the Perelman School of Medicine at the University of Pennsylvania. The authors acknowledge their appreciation for the collaboration of Eran Magen, PhD (scientific director of the Center for Supportive Relationships) on more recent stages of IMS’s relational communication skills materials and instruction. They would also like to thank Eilann Santo for her contributions to this project.

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