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Optimising doctor-patient communication and ensuring that all people receive quality health care requires that doctors understand the influence of social contexts and cultural back-grounds on patients’ health beliefs and behaviours. Cross-cultural curricula have often taken a categorical and potentially stereotypical approach to cultural awareness, one that embeds patients within static ‘cultures.’ Although the notion that members of discrete groups uniformly behave in distinctive ways is an unproductive and potentially dangerous oversimplification, an understanding of the range of variations in cultural beliefs can be helpful in the clinical encounter. Rather than memorising social or cultural ‘facts,’ students should be aware of the points of variance across a spectrum of socio-cultural contexts.
Conventional evaluation methods, such as multiple-choice examination questions, are poorly suited to the kinds of generative thinking and knowledge framework construction that are important in preparing for diverse medical encounters. To assess the evolution of students’ knowledge frameworks regarding socio-cultural health care issues, we piloted the use of concept maps, which are visual representations of the cognitive analysis of a case that display both relevant concepts and links between them.
The pilot study was conducted over two quarters (autumn of 2006 and 2007) and included two cohorts of Year 4 students who enrolled in an elective course on socio-cultural issues in health care. The full-time, 2-week course included seminars and experiential exercises led by faculty members in medical anthropology and internal medicine. At the beginning of each course, students received brief training in the process of concept mapping, which included identifying discrete ideas, ranking them by importance and establishing hierarchical relations among them. The students were then presented with a short, written case scenario (which included elements related to socio-cultural contexts, health care ethics and culturally responsive health care) and asked to construct a (pre-instruction) concept map. The identical scenario was presented at the end of the course and students constructed a post-instruction concept map.
Twenty concept maps (10 pre- and 10 post-instruction) were analysed independently by two raters who were blinded to both the identity of the student and the temporal order of the map pairs. All maps were correctly categorised as either pre- or post-instruction. Although these students had self-selected to participate in an advanced-level elective on socio-cultural issues in health care, their concept maps revealed evolution in terms of both complexity and depth, indicating that the degree of potential change in the general medical student population may be even greater. This finding was corroborated by the students’ self-assessments that the course furthered their understanding of the ‘inter-relationships among health, illness, culture and health disparities’ (mean = 5, using a 5-point scale where 5 indicates ‘strongly agree’) and the ‘influence of personal, cultural, ethnic and spiritual identities and beliefs on the experience of health and illness’ (mean = 5). Concept mapping holds promise as a method of assessing ‘meaningful’ knowledge, specifically in terms of the expected changes and differences in the knowledge frameworks of medical students after instruction in socio-cultural issues in health care.