We introduced a reflective practice curriculum within a clerkship to consolidate learning about diverse healthcare settings and patients and to raise consciousness about how health disparities may be associated with provider attitudes and behaviors. We concluded that our program was successful based on multiple outcomes. Our program builds on a similar curriculum for the obstetrics and gynecology clerkship addressing ethical conflicts19
in which students submitted essays followed by small group discussion. In that study our qualitative analysis of student narratives revealed that development of professional values was tied to personal values and strongly influenced by observed behaviors and dynamics of teaching faculty and residents. In this program our purpose was to discover whether written reflection followed by faculty-facilitated peer discussion led to nuanced approaches to addressing cross-cultural encounters and how unequal treatment or differential outcomes of care may result from physician behaviors. The thematic analysis of assignments led us to conclude that students indeed were learning critical concepts of cultural humility, mutuality and horizontality in the doctor–patient relationship, and about patient use of CAM, the influence of culture and self-awareness of one’s own attitudes, values, and assumptions as members of the “culture of medicine.” The results suggested that students may adopt behavior changes aimed at reducing health disparities in their own future practices.
Based on our analysis of the data, we developed a three-tiered theoretical framework for our RP model. The first essential tier is direct participant observation or experience, which occurs through student exposure to cross-cultural settings. Teaching and learning occur, but are limited by student multi-tasking, inattention, and in clinics, variability of the physician role-model as a medical educator. The second tier is individual reflection accomplished through the written assignment. This allows the student to better organize and consolidate jumbled impressions. The final tier, facilitated group reflection, provides the opportunity to confront other perspectives, have assumptions and expectations challenged, and deepen and extend learning .
Our study has several strengths. Two consecutive years of data are presented for a significant number of students. Our educational intervention was distinct in its structure and format and instructions to students were clearly presented. The evaluation data was complete with a high student response rate. We evaluated outcomes using multiple methods including written essays, in-class discussions and a pre-post knowledge test. We used a ‘triangulation’ approach to analyze qualitative data, combining interpretation from four different faculty with diverse teaching experiences and from different disciplines to reduce bias.
Our study is limited by the specificity of the patient cultural group (Latinos with diabetes) within our practice setting, and we cannot be certain if findings generalize to other cultural groups. However, there is no reason to believe that the techniques that we shared with students would not be effective in other cross-cultural settings. We did not analyze thematic responses by student demographics because the number of themes identified and class size did not permit such analysis (50% female, ethnic mix approximately 43% white, 40% Asian, 10% Hispanic, 1% African American). There is literature that suggests that providers’ own background and their cultural experiences impact their cross-cultural communication skills and their perceptions of their patients20–22
. Our evaluation tool was not validated because no validated tools for this purpose were available. Lastly, in asking students to rate their self-reported knowledge change about CAM and culture (questions 7 and 8, Fig. ), we did not explicitly define the difference between the two and our questions may not be sufficiently sensitive to differentiate knowledge gain in these two areas. However, the in-class discussions about CAM and culture suggested that most students were able to identify CAM as alternative approaches to Western medicine, while culture was consistently discussed in the context of differences in values, beliefs, practices and social norms among different groups.
Despite these study limitations, our findings reinforce existing literature about the power of the hidden curriculum15–17,23
. For example, although role-modeling was not identified as an explicit clerkship learning objective, it emerged as a powerful influence on learning, both negatively and positively. Similarly, the concept of the culture of medicine was not part of the clerkship’s formal objectives, yet it consistently appeared in students’ written and discussion comments. Without the addition of the RP components, these and other influential dimensions would have remained submerged.
We note that a few key ingredients are necessary to achieve desired goals. First, students benefit from having interdisciplinary faculty facilitate discussions. While physician faculty may add real-world credibility, “outsider” perspectives of faculty trained in the social sciences and philosophy expands their understanding of clinical issues. Second, the lack of evaluative function of participating faculty creates an environment of safety and openness. Third, we found an incremental approach of pedagogical value. Although our model runs the risk of being perceived as “repetitive” or “redundant”, circling back to clinical experiences through different modalities (written, oral) and in different settings (individual vs. facilitated group reflection) reduces the burden of multi-tasking, and encourages Socratic self-discovery. We believe that this approach is essential to stimulating critical thinking as opposed to rote regurgitation and adopting “politically correct” postures. This approach may allow students to develop practice styles that incorporate carefully considered ethical conclusions about interactions across cultures rather than simply imitating faculty or residents. We believe that this model of RP, woven into an existing curriculum, addresses the need for “critical consciousness”2
in the continuum of cultural competency training toward the development of self-awareness. However, because faculty themselves do not consistently practice RP at our institution, we are not certain if adoption of RP as a habit by physicians might enhance the effectiveness of our curriculum. Finally, as noted in the Program Description, facilitator skills needed to conduct the reflective practice sessions are easy to acquire and maintain and no specific training is necessary.
In summary, integration of a brief RP curriculum occupying only 2 hours of a required clerkship was feasible and highly acceptable to students, and associated with more complex and nuanced understanding and useful problem-solving of challenges frequently arising in cross-cultural encounters.
We speculate that this integrated model can be easily incorporated into most clerkships to promote critical thinking and consciousness about addressing health disparities through improved quality of cross-cultural encounters. The RP curriculum addresses content that is difficult to teach in stand-alone blocks. What remains to be discovered is what amount and quality of longitudinal exposure across clinical training is needed to foster and maintain the practice of self-reflection for lifelong learning.