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Critical Conversations in Health Professions Education

Medical Education to Enhance Critical Consciousness: Facilitators’ Experiences

Zaidi, Zareen MD; Vyas, Rashmi MD, MHPE; Verstegen, Danielle PhD; Morahan, Page PhD; Dornan, Tim PhD

Author Information
doi: 10.1097/ACM.0000000000001907
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[W]ith the question of the importance of telling the truth, knowing who is able to tell the truth, and knowing why we should tell the truth, we have the roots of what we could call the “critical” tradition in the West.

—Michel Foucault1

Present times have been described as “Globalization 3.0,” a technology-driven era with “flattening” of the globe.2–4 Increasing connectivity has led to new partnerships in health professions education between North America, Europe, and developing countries.5–7 In the article “International Medical Education and Future Directions: A Global Perspective,” Harden2 warns of the dangers of viewing international education in such partnerships through a narrow lens or as a form of colonialism. In the Association for Medical Education in Europe guide “Teaching Diversity to Medical Undergraduates: Curriculum Development, Delivery and Assessment,” Dogra et al8 note that many educational approaches are “rooted in the historical context of white domination of disadvantaged minorities and are very race or ethnicity focused.” This narrow focus, they propose, is attributable to positivist thinking. Belief in absolute objective truths discourages cultural or philosophical thinking and encourages pigeonholing of individuals. These authors advocate a social constructivist approach, which recognizes that different individuals “construct their own version of their culture dependent on the various social discourses of which they are aware or in which they participate.”

Social discourses about culture are constructed by groups in power who dictate assumptions which then serve as “common-sense understanding” for all.9 The “dominant discourses” of groups in power implicitly become the accepted way of looking or speaking about culture.10 Gramsci’s11 theory of “cultural hegemony” describes the power of a dominant class to present one authoritative definition of reality or view of culture. He also describes the concept of “subalternity,” which involves marginalization or a lack of autonomy among groups with alternative views.11 Subaltern social groups, which in modern times could be defined by identifying with gender, religion, or ethnicity, experience negation of their experiences and subsequent redefinition of their needs into activities promoted by those in power.11,12 Therefore, hegemony is usually not a declarative or aprioristically determined act; rather, it is an insidious process built into sociocultural landscapes. Other sociocultural theorists like Bakhtin,13 Freire,14 and Giroux15 link individual dialogue, language, and lived experiences of individuals to social projects with an emphasis on empowerment. Giroux15 proposes examining racism in society by “insurgent multiculturalism,” which focuses on unequal distribution of power rather than a deficit-based approach focusing on “subaltern” groups. This so-called “emancipatory pedagogy,” which builds on the works of Freire and Giroux, invites students and teachers to look critically for social inequity. Education, according to this theory, plays a fundamental role in creating a just and democratic society.16,17 Both students and educators take on new roles as “transformative intellectuals”18 and “cultural workers.”14

Over the past two decades there have been growing calls for medical education to develop “power awareness” and to “democratize.”19–21 It is not realistic to expect all stakeholders in medical education to become expert critical theorists, but they should, at least, be aware of different ways they theorize power.19 Wear22 suggests using Giroux’s theory of insurgent multiculturalism to help students and faculty examine their biases and recognize how power and privilege operate in medical education.

Deep cultural discussions about sensitive issues like race, gender, and power do not begin spontaneously.23 To the contrary, “educational cultural hegemony” discourages bringing in personal cultural context unless discussion leaders consciously encourage it.24 There are three main reasons why we need to counter these hegemonic trends, foster democratization of educational environments, and promote insurgent multiculturalism. First, training health professionals to take care of diverse populations is associated with improved patient satisfaction.25,26 Second, literature shows that “color-blind” institutional policies disadvantage minority groups. They impact recruitment, promotion, and retention27–29 and increase depression, anxiety, pain conditions, addiction, and hypertension.30–32 Third, prevailing ideologies about power privilege and disparities in society are fostered within the walls of our institutions. It is particularly important—in the wake of the Orlando gay nightclub shooting rampage, the Black Lives Matter movement, the refugee crisis, and innumerable terrorist attacks—for educators to create safe spaces to discuss these issues within their institutions.33–36 Though health professions educators do think it is important to discuss cultural backgrounds and prevent educational cultural hegemony, they lack skills to facilitate cultural discussions.37 This study explores how cultural discussions can be skillfully facilitated to help participants understand issues related to power, privilege, and critical consciousness. Emancipatory pedagogy is based on the concept that education should play a fundamental role in creating a just and democratic society by emphasizing critical consciousness, which is a reflective awareness of power and privilege.19 The theory of emancipatory pedagogy, which is itself within the critical theory paradigm, provides a conceptual framework. Our research questions are:

  1. How do facilitators encourage cultural discussions?
  2. How do facilitators and participants of those discussions co-construct an understanding about power and privilege in society?


Institutional review board approval was obtained through Foundation University, Pakistan.

Educational setting and participants

We selected two medical education training programs as the setting for the interviews. One, the Foundation for the Advancement of International Medical Education & Research (FAIMER), is a medical education fellowship program for international health professions educators from over 40 countries. The other, Maastricht University’s School of Health Science Education (SHE), offers master’s degrees and PhDs in health professions education to learners across the globe. Both programs have on-site learning components as well as distance learning. The FAIMER Institute, established in 2001,38–40 provides two-year part-time fellowships. These develop cohorts of 16 midcareer health professions faculty from Latin America, Africa, the Middle East, and Asia to act as educational research scholars and change agents within a global community of practice.41 The FAIMER Institute curriculum includes two (three- and three-week) residential sessions a year apart in Philadelphia and two 11-month e-learning periods conducted via listserv. During the total immersion residential sessions, fellows are encouraged to share information about their culture, particularly during structured “Learning Circle” activities,42 which foster interrelational groups that care about the development of each individual. The listserv is used for formal e-learning modules, for alumni-designed community conversations, and as an informal resource network and social support network for fellows.

The Maastricht SHE has more than 35 years of experience with education, research, and innovation. The school offers a wide range of courses in health professions education, from short courses and certificate courses to master of science and PhD degree programs. SHE reinforces internationalization through its research, education, and collaborations in health professions education.43 The Master of Health Professions Education (MHPE) program gives participants the knowledge and skills required for a career in health professions education and research. It is a two-year program taught in English. It is largely based on distance learning, with a maximum of three short periods in Maastricht. The MHPE attracts an international group of professionals from a variety of educational, professional, and cultural backgrounds who have acquired university degrees in one of the health professions in their native country (e.g., health sciences, medicine, nursing, physiotherapy, dentistry, pharmacy, speech therapy).43

These two programs were purposefully selected for this research because faculty have the experience of teaching in diverse multicultural settings. In 2015, we invited 16 faculty for interviews: 5 U.S. faculty from FAIMER, 5 Dutch faculty from SHE, and 6 FAIMER alumni with faculty appointments at FAIMER as Global Faculty Advisors. They are involved with FAIMER’s regional teaching institutes in India, Brazil, and China. We sampled purposefully, identifying faculty with the most experience in multicultural learning settings in their home countries as well as abroad as visiting health professions education faculty. As an example, FAIMER and SHE faculty teach in health professions education courses in the United States and Netherlands but also travel to Asia, the Middle East, Africa, and South America. We purposefully invited a sample of people who were heterogeneous for age, gender, country of origin, and qualifications—that is, clinician educators, basic scientists, master’s in health professions education, and doctorate (in medical education). Demographic characteristics of the interviewees are available in Table 1.

Table 1
Table 1:
Participant Demographics

Epistemology and methodology

Qualitative researchers consciously take an “epistemological stance.” This reflects the values and theory of knowledge that underpin their inquiry. The value underpinning this research was a quest to distribute power and opportunity equally within society. The underpinning theory of knowledge was that language, or discourse, both reflects and influences the distribution of power. This placed the research within the “critical” paradigm.44,45 There are many different critical discourse methodologies, from “microlinguistic” analysis of individual sentences to the identification of social discourses in huge textual archives. This research was guided by Fairclough’s contention that discourse is not limited to text; there is an interaction between people, which involves producing and interpreting text and results in social action.46,47 The purpose of this research was to enhance social justice, so the research team interacted with research participants and then analyzed the data from a critically reflexive position (see below).

Data collection.

We recruited interviewees via an e-mail invitation, which explained the study and participants’ potential contribution to it. We reinforced that participation was purely voluntary before obtaining informed consent. Z.Z. and R.V. conducted in-depth, open-ended, semistructured interviews enquiring about participants’ experiences facilitating cultural discussions (see List 1). At the start of the interview, to sensitize participants and encourage open communication, we discussed cultural scenarios that we had personally encountered while facilitating discussions where culture was explicitly brought up. We also read out a definition of critical consciousness and asked participants to describe their experiences of highlighting power and privilege and how they interpreted their role while facilitating such discussions. Interviews, which lasted 30 to 45 minutes, were conducted face-to-face with U.S. faculty. All other interviews were conducted using Skype. We audio-recorded interviews, which a professional transcriptionist transcribed. We reviewed the transcripts for errors before proceeding to analysis.

List 1

The Guiding Questions for the Interviews

  1. When you come across a cultural discussion scenario like the samples we provided what do you tend to do and how do you react? (Additional probe (AP) #1,2,3)
  2. We are interested in the presence of ‘silence’. We have found that often when a cultural topic is brought up the discussion is very superficial or the comment does not generate any response, in other words there is ‘silence’. Why do you think this happens, what could the possible reasons be? And how do you handle that? (AP #4)
  3. A. Do you feel facilitators have a role in moving the cultural discussions from superficial to deeper level discussions (Going beyond just asking participants to give an example of their culture) e.g. there was a discourse about the Arab Springs. How could facilitators have used this as a learning moment for others to create awareness about the social and personal impact of a country transitioning from autocracy to democracy? Pause- Explain further by saying: B. How can facilitators help turn that discussion into creating an opportunity for development of an understanding of power relationships. And how can facilitators work to develop a sense of critical consciousness (i.e. understanding the role as an educator in helping create awareness about cultural and power issues)? What can facilitators say or do? (AP # 5)
Additional probes (APs)
  1. Looking at the scenarios provided do you recognize any patterns or have you personally encountered similar situations/discussions?
  2. What factors facilitate multicultural discourse (including factors that help provide a safe environment both for online and face-to-face sessions)?
  3. Thinking about your personal experiences what factors serve as barriers to multicultural discourse?
  4. Can you give us an example of when you encountered silence and how did you deal with it?
  5. Can you think of an instance/example where you felt that the discussion about culture could have been used as a learning moment for participants and yourself to generate a broader understanding about cultural issues, power relationships?

Critical reflexivity.

In keeping with critical research practice,45 we employed critical reflexivity to self-consciously explore our own positions on the data set. The first two authors are FAIMER fellows who have held academic positions in Pakistan and the United States (Z.Z.), and India and the United States (R.V.). D.V. and T.D. are faculty of Maastricht University who work with international students. T.D. has extensive experience in qualitative research and critical discourse analysis. P.M., the founding director of FAIMER, has extensive experience of academic leadership development involving gender and ethnic minority participants. To prevent implicit bias, we used Skype calls and e-mails to explore how our perspectives on culture had been shaped over years of interaction with learners from different backgrounds; we commented on documents and helped identify preconceptions that might have impacted data analysis.

Analytic procedures.

To organize and index the data set, two of us (Z.Z. and R.V.) initially coded the data using Braun and Clarke’s48 framework of latent thematic analysis. Following the six phases described by Braun and Clarke, we independently analyzed the data and identified themes, focusing on patterns and richness of responses rather than the number of responses, and assigned comments to themes. Once we had organized the coding into themes, we used a critical analytical approach to conduct the discourse analysis. Attention was paid to the genealogy or the evolution of discourse,49 studying how apparently “self-evident” discourses were linked to historic policies or practices. We read the transcripts, searching systematically for the “situated,” or contextual, meaning of words, identifying typical stories or figured worlds that invited readers or listeners to enter into the world of a social or cultural group, looking beyond what contributors were saying to identify what their discourse was “doing,” and exploring how metaphors were used. We worked independently of one another, highlighting material of interest and annotating it with marginal comments. We also exchanged and discussed comments to identify and explore areas of agreement and disagreement. Z.Z. kept notes on the discussions, archived them into a single data set, and maintained an audit trail back to the original data. She then wrote the narrative of results, proceeding from description to interpretation to explanation while constantly comparing these explanations against the original textual materials. The other authors contributed their reflexive reactions, critically examining and commenting on the emerging interpretation.


Addressing our first research question, participants spoke about practical behaviors that helped them facilitate discussions in multicultural settings. As these were based on actual experiences, we grouped them under a single theme: “The experiential lens and culture.” Key comments (selected on the basis of richness) and comments that captured the essence of the theme have been used as quotes. Participants also spoke in more abstract terms about influences on multicultural interactions such as power dynamics and racism, which we grouped into a second theme: “Discourses of power, race, and culture.”

The experiential lens and culture

Participants reflected on their past experiences of being facilitators of multicultural discussion groups. They made use of learners’ diverse heritages and allowed discussions to “arrive at a slightly different place from what might have been intended.” Asking the right question at the right time, understanding they have a “responsibility to latch on” to multicultural experiences, using an effective “trigger” to generate conversation, and building trust were at the core of facilitating multicultural discussions. This was noted to be difficult as facilitators had to challenge the groups to move out of their comfort zones for true learning to occur.

Participants attempted to create “emotional safe spaces,” where learners could feel safe discussing issues they may not have otherwise brought up; this was noted to be immensely important. In smaller group settings like Learning Circles in the FAIMER Institute program, facilitators noted that a climate of trust and ground rules such as never violating anonymity and privacy resulted in deep, reflective discussions:

I am always amazed at the level of intimacy that can occur and to see the level of intimacy that can occur between either one other person or small group of people when you have the power to set the climate for safety.

The context of multicultural discussions was important in both face-to-face and online settings. The inherently political nature of these discussions called for facilitators sometimes to step in and “speak up for victims.” Examples given were when groups discussed gender issues and men from male-dominated societies took the position that “I am the man and you are the woman and therefore I have more freedom and deserve more respect than you.” One study participant explained, “One majority comment or one judgmental comment by the people in your group or by the facilitator can kill that environment.”

Using silence

The participants commented that there were many reasons for learners to remain silent in multicultural discussions including understanding the need to handle political dimensions of group interactions and to keep a watchful eye on relationship building. For example, an “overarching norm among learners was that when they experience something that is disconcerting or potentially painful they resort to the ethical standards of ‘do no harm.’” So “if in doubt” or “fearful of showing ignorance” they chose to remain silent. Some may not know “quite how to engage in a way that will make positive difference.” Others may simply not participate because “the culture they grew up in encouraged respectful silence” or did not “empower them to speak out and have their voice heard.” If the “topic does not have relevance for learners in a group they may choose to remain silent.” Another example provided was that learners could be silent in situations where they may have experienced similar events:

There was actually a week where the topic for discussion was about “Rape and Abuse” because doctors have to handle rape survivors and victims of abuse and students had to learn what the correct way to do that is. But some of the students actually had experienced it themselves and they felt very uncomfortable in that environment and in some cases it brought back very traumatic feelings.

Discourses of power, race, and culture

Participants reflected on how they addressed racism, power, and multiculturalism in discussions they facilitated.

Blind spots and racism.

They expressed somewhat “monolithic” assumptions about contrasts between their own culture and other ones. Speaking of implicit bias, a participant noted the importance of “realizing that there are … ‘intrinsic assumptions’ (about) … our own cultures that we don’t necessarily recognize.” Another participant noted an “unconscious tendency to stereotype individuals.” Yet another voiced, “It’s a level of consciousness and awareness that can open up those blind spots.” Asking “why” and “how” questions expanded everyone’s understanding of the genealogy of their own cultures and “peeled away assumptions” about other cultures. Suspending one’s own assumptions and engaging in a discussion on banning of head scarves in France, for example, or asking why thousands of students decided to protest against a government, could bring contrasting assumptions into discussions. In the following examples, participants spoke of how a hidden curriculum in academia made faculty very conscious of hierarchy and careful about what they said, which impacted discussions about sensitive topics:

Some people may feel awkward at expressing an opinion because of the racism … you know, the extreme racism in our past. People might feel that something they say may be construed in a way, which is not understood by others in the group, and what they say may be construed as racist. So they don’t want to go into that territory, or they may be concerned of offending.

Participants struggled to free themselves from blind spots and stereotypes and help learners do the same, as the comments about banning headscarves in France and navigating hierarchy exemplify. Participants looked for ways of expressing opinions that did not express a dominant discourse that others might find offensive.

Power differential.

Participants tried to decrease the power distance between themselves, as facilitators, and learners. They traced power dynamics back to the language and social practices of group participants’ countries of origin. It was particularly difficult to teach learners from countries with authoritative regimes such as China, where learners had a “sort of blank stoicism”; from Malta, where learners are not used to active learning and communicating in class; and from Saudi Arabia, where educational hierarchy determined the rules governing curricula. These put barriers in the way of asking questions, whereas Western facilitators were used to environments where “asking questions was the norm” and critical thinking was encouraged. A participant commented that “in the Dutch culture, we really value critical reflection … which is very difficult for some of our international students who are not used to being critical.” Another said that “in an Eastern culture, people maintain hierarchy, while in the Western culture they are very open. Many times they are very open to asking questions, they are open to critique—which is not so in an Indian or the African setting and that is the first difference that needs to be understood.”

One participant noted that students from developing countries might find facilitators from the West condescending, which promoted a “superior–inferior kind of thinking.” Faculty setting course work or deadlines did not always take into account challenges in developing countries like power outages, or nonavailability of Internet. Western facilitators might be insensitive toward more subtle power issues that result in government-mandated top-down curriculum initiatives like a course called “Islamic Studies” in the Middle East, a block on military knowledge under repressive regimes, not everyone (in Singapore) having “the right to read the document describing the whole curriculum,” or people not speaking the dominant language being at a different “power level” from the ruling class. This contrasted with the West, where, for example, a student could walk into a dean’s office and have a lengthy discussion about the curriculum.

Facilitators used group discussions to construct relationships between themselves and “others” amidst the sometimes-conflicting norms of their own culture and those of their learners. To do so, they had to enter discourses of power and navigate cultural norms in their own culture as well as learners’ cultures.

Cultural lens.

“Developing a cultural lens” helped participants navigate cross-cultural discursive boundaries. This stemmed from personal interest in cultural topics (particularly social injustice), exposure through cultural interactions, and travel. They reported that “facile facilitators” were able to feel and attend to the “pain” that learners commonly experienced in multicultural settings. They focused their cultural lenses by being critically reflexive and having their sensitivity sharpened by experience. Facile facilitators dealt skillfully with gender issues and minority issues. In the interviews, such facilitators were noted to have a research interest in critical theory and dealing with social injustice issues. For example, one participant, a male facilitator from the United States, noted that he sometimes did not quite know how to respond to difficult situations and wondered if it was part of a “gender piece,” related to his Myers–Briggs orientation, or his (in)ability to attend to pain. The participant commented:

I think that, as a white man, I am often perhaps a little blind to what the need is, what the possibility is, what the judgment is that might be taking place. I think I am probably more aware than most white men but probably not as aware as I could be if I was a person that had some sort of minority status or status where I had been discriminated against for some reason, whether, it was a woman or person of color or whatever.


Principal findings and meaning

There are two main findings regarding how facilitators encourage cultural discussions and co-construct an understanding about power and privilege in society with participants. First, health professions educators working in multicultural settings encourage discussions around sensitive topics by creating a “safe space,” where these topics can be discussed and silence is respected. Second, during multicultural interactions they recognized and explicitly addressed issues related to power differentials, racism, implicit biases, and gender bias. They also noted the need to be better trained to be facile in attending to pain, racism, and power issues. Though the world is flattening secondary to technological advances, there are millions of disempowered people who live in the flat world without access to the tools or skill set to participate in a meaningful way.4 Emancipatory pedagogy invites both learners and educators to critically analyze political and social issues and the consequences of social inequity. The faculty interviewed in this study took us into the figured world of an international facilitator facing the challenges of emancipatory medical education. They owned the responsibility to address cultural issues and delve into deeper reflective discussions. They encountered power dynamics, which they noted were not just limited to individuals but could be traced up to institutional and government levels. They struggled with their own monolithic understanding of other cultures and tried to break free of stereotyping others, encouraging their learners to do the same.

Relationship to other publications

Monrouxe and others have highlighted the need for narrative, interactional safe space or pedagogical space for sociocultural discussions.50–52 Learning circles,42 wisdom circles,53 conversation circles,54 and simple conversations55 are examples of pedagogical safe space approaches that stem from a clear recognition that participants in any long-term activity or group benefit from intentional conversations to process human feelings and develop relationships. We have previously described the use of “Identity Text” by health professions educators, which engages learners by asking them to describe the influence of culture on their identity through creative writing or other multimodal forms of cultural production.24 Our study showed that creating a safe space and being facile to pain are key to encourage cultural discussion and create an understanding about power and privilege in society.

Recently, Kumagai et al33 have advocated for the need to purposefully introduce cognitive disequilibrium or a situation/conflict where the learners are forced to critically reflect on their past experiences and current positions on the topic for transformative learning experience to occur. Drawing on the Foucauldian idea of “parrhesia”—that is, speaking boldly and fearlessly1—we do find descriptions in the literature voicing the need for learners and teachers to have the courage to speak up and critique institutions and individuals who control power, knowledge, or technology.33,56 In our research, facilitators discussed situations when they role modeled such “parrhesia”—for example, “speaking up for the victims” or “breaking away from dominant discourse” and “asking learners to explore their underlying assumptions regarding banning headscarves in France.” Their descriptions corroborated other literature emphasizing the need to let go of objectivity and to acquire skills to “make the invisible visible.”57 They also agreed that a lack of skills and training to facilitate cultural discussions could have an adverse effect.58

Limitations and strengths

Since we invited faculty who had expertise in facilitating cultural conversations, they had an understanding of critical theory, critical consciousness, and awareness about the role of educators in promoting social justice. Their background in education and conversations with educators over the years may have made them more attentive to critical consciousness. It is possible that facilitators who do not have such experience may have provided different and perhaps not very reflective responses. However, for the purpose of our study, as it is the first to directly inquire whether facilitators are able to address critical consciousness, our sample served well.

Our purposeful sampling of facilitators for the interviews aimed to include faculty who had experience in face-to-face and online cultural interaction, but we did not delve into differences between the two modalities during the interviews. It is likely that facilitations in both areas have their own set of challenges. Though the faculty facilitators we interviewed are well traveled and used to teaching internationally, it would have been interesting to have asked them for critical reflexive statements regarding their own backgrounds and positions on multicultural discussions. We were limited by facilitators’ availability for the interviews and therefore were not able to balance gender and background qualifications (our sample had more women and fewer clinical faculty with advanced medical education training). On the other hand, our sample may be representative of typical health professions education programs with more PhD-trained faculty and less clinically trained faculty with additional degrees. The strengths of the study include sampling of faculty facilitators involved in international medical education from two institutional leaders in the field—that is, FAIMER and SHE. Our sample size is not large, but we did not consider this to be a limitation as the faculty interviewed have facilitated conversations in developing as well as developed countries and gave us thoughtful detailed responses to the questions, which should be generalizable to other international health professions educators. The deliberate inclusion of American (North and South) and European facilitators as well as facilitators from the developing world provided us with a range of different views.

Implications for future research

In this era of internationalization of education where we have moved “from a curriculum taught by local teachers to local students, to a model where there is greater mobility and either international students or international teachers, the future lies in a transnational curriculum with international teachers and international students.”2 In this context, the focus of the curriculum needs to be on globally agreed learning outcomes with carefully planned learning experiences. The characteristics and skills needed to be a transnational teacher will need to be mapped out. How many training sessions are required and in what skills will they need to be proficient are questions that require further research. The transnational teacher plays a unique role in the process of transformative learning experiences by discussing with others the “reasons presented in support of competing interpretations, by critically examining evidence, arguments, and alternative points of view.”59 Altering the frame of reference, which is composed of “points of view” and “habits of mind,” is an important educational achievement.60 Habits of mind or ethnocentrism are hard to change, but points of view can change with critical reflection.59 Our research paves the way for others looking to explore how to counter educational cultural hegemony and promote transformative learning and emancipatory pedagogy.


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