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Insurgent Multiculturalism: Rethinking How and Why We Teach Culture in Medical Education

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Insurgent Multiculturalism: Rethinking How and Why We Teach Culture in Medical Education S PECIAL T HEME A RTICLE Insurgent Multiculturalism: Rethinking How and Why We Teach Culture in Medical Education Delese Wear, PhD ABSTRACT The author proposes a theoretical orientation for others to acquire and keep resources, including the cultural competency that reorganizes common curricular rituals, policies, attitudes, and protocols of medical responses to the study of culture in medical education. institutions. This approach includes not only the What has come to be known in medical education as doctor–patient relationship but also the social causes of cultural competency is theoretically truncated and may inequalities and dominance. Linked to professional actually work against what educators hope to achieve. development efforts, insurgent multiculturalism can Using Giroux’s concept of insurgent multiculturalism, she provide students with more opportunities to look at suggests that the critical study of culture might be their biases, challenge their assumptions, know people a bridge to certain aspects of professional development. beyond labels, confront the effects of power and Insurgent multiculturalism moves inquiry away from privilege, and develop a far greater capacity for a focus on nondominant groups to a study of how compassion and respect. unequal distributions of power allow some groups but not Acad. Med. 2003;78:549–554. Humility, and not so much the discrete mastery traditionally theoretically truncated and may actually work against what implied by the static notion of competence, captures most educators hope to achieve. I explicate Henry Giroux’s idea accurately what researchers need to model and hold pro- of insurgent multiculturalism as a more useful orientation to grams accountable for evaluating in trainees under the broad 1 cultural competency in medical education and then propose scope of multicultural training in medical education. it as a bridge to critical aspects of professional develop- ment.2 But first, I offer a critique of prevailing concepts of ultural competency, frequently addressed in cultural competency in medical education. many academic medicine publications and con- ference papers during the past decade, is Cperceived by medical educators and accrediting TEACHING CULTURE IN MEDICAL EDUCATION: bodies as deficient in the curriculum, and by extension, WHAT’S MISSING in medical students. In this article, I develop a theoretical orientation for cultural competency that reorganizes Cultural competency, agreed upon as a core value and common curricular responses to the study of culture in ostensibly modeled in clinical settings, has taken hold in medical education. In fact, I contend that what has come to curriculum decision making in medicine at all levels, from be known in medical education as cultural competency is medical school to residency to continuing medical educa- tion (CME). Cultural competency (sometimes known as cultural awareness, cultural sensitivity, or simply multicul- Dr. Wear is professor, Department of Behavioral Science, and associate turalism) usually has a definite curriculum component that director, Human Values in Medicine program, Northeastern Ohio is knowledge- or skill-based. It would probably surprise the Universities College of Medicine, Rootstown. ‘‘laity’’ to learn that this is a relatively new curricular project Correspondence should be addressed to Dr. Wear, Department of Behavioral because it seems commonsensical that the study of patients Sciences, Northeastern Ohio Universities College of Medicine, 4209 State Route 44, P.O. Box 95, Rootstown, OH 44272; telephone: (330) 325- in all their varieties would be found throughout the medical 6125; e-mail: [email protected]. Reprints are not available. curriculum: How does one take care of patients without A CADEMIC M EDICINE,VOL.78,NO .6/JUNE 2003 549 I NSURGENT M ULTICULTURALISM, CONTINUED knowing the social and cultural contexts from which they is a short overview of curricular strategies most commonly come or without knowing the complex interplay of patients’ used in health care curricula, such as cultural sensitivity/ values and beliefs with their conceptions of health and awareness approaches (focusing on attitudes), multicultural illness? approaches (focusing on knowledge), and cross-cultural Unfortunately, such patient-focused inquiry has not approaches (focusing on skills). These approaches revolve always been present in the medical curriculum. George around the development of respectful attitudes, accurate Engel’s now classic article in Science charged medicine with knowledge, and appropriate behaviors in care givers toward reducing humans to their smallest biological parts and diverse groups and cultures. However, these approaches provided a biopsychosocial model of medicine, a heuristic often lapse into the familiar, reductionistic, add-a-lecture- based on complex interaction among the organizational test-for-knowledge curricular response, what Fox calls levels (i.e., the biological, social, and cultural dimensions) ‘‘biologizing’’ the cultural aspects of health, illness, and of human beings.3 Medical education rose to this challenge medicine.7 and responded in several ways, devising new programs that Unfortunately, medical education rarely looks outside its brought students to patients in more natural settings out- own literature to examine how culture is conceived and side hospitals and urging more collaborative relationships taught in other domains. The discourses conceived in with other health care providers such as nurses and social cultural, curriculum, feminist, and postcolonial studies are workers. People have social dimensions, young doctors-in- critical and complex and provide alternative ways of thinking training were told, and attention should be paid to these about teaching culture relevant to medical education. The areas as significant determinants of health and illness. Now cultural sensitivity/awareness approach, for example, has been such pronouncements sound oddly dated, self-evident, like criticized for over a decade for its naive emphasis on the role old wine in new bottles. But they have appeared again in of individual attitudes in the formation of and trans- the medical education literature under the guise of cultural formation of racism (i.e., if educators just talk about it and competency, as though diversity in race, ethnicity, cultural ‘‘expose’’ students to different cultures, they will become identity, religious belief, and sexual identity suddenly ap- more sensitive, understanding, and respectful). Of course, peared in medical settings! this approach (like many others) assumes that the locus of Very few academic medical educators would deny the normalcy is white, Western culture—that ‘‘difference’’ need for students to understand and respect differences means nonwhite, non-Western, non-heterosexual, non– among people based on gender, race, ethnicity, social class, English-speaking, and most recently, non-Christian—how physical or intellectual abilities, sexual identity, or religious they are different from us. But this difference can not be too beliefs. Yet, racial disparities in health have been docu- great; the proponents of cultural awareness/sensitivity also mented throughout history, and socioeconomic status hope to convince students that we’re all part of the human remains a ‘‘persistent and pervasive predictor of variations family and that our differences make our own democratic in health outcomes.’’4 The recent Institute of Medicine’s culture rich—leading to what Cameron McCarthy calls (IOM) study, ‘‘Understanding and Eliminating Racial and a ‘‘Disneyfied’’ culture with harmony among all groups.8 Ethnic Disparities in Health Care,’’5 is a direct confronta- The cultural competency approach (which includes the tion of injustices in medical care in the United States based IOM’s multicultural and cross-cultural approaches) has its on providers’ attitudes, lack of knowledge, and lack of skills. own set of problems in addition to the ones cited above. Thomas Inui, one of the committee members, reported that The approach looks more directly at the language and committee members were ‘‘stunned’’ by the evidence of customs of particular nondominant groups, especially their the roles that ‘‘bias, stereotyping, prejudice, and clinical beliefs and behaviors surrounding health, illness, and health uncertainty on the part of health care providers play in care providers and institutions. The thinking here is that perpetuating health care disparities.’’6 In fact, the commit- doctors—mostly white, well educated, and middle-class or tee found that ‘‘when sociocultural differences between higher—don’t know enough about the range of people they patient and provider aren’t appreciated, explored, under- will be caring for (be they people of color; people from stood, or communicated in the medical encounter, the result nondominant racial, ethnic, or religious groups; people who is patient dissatisfaction, poor adherence, poorer health out- are economically disadvantaged; people who are disabled; comes, and racial/ethnic disparities in care.’’5 people who do not speak English; or people who are not The IOM’s report is one of the most direct and searing heterosexual). When medical students learn characteristics looks at the damage brought to patients because of pro- of these groups, they can provide better health care because viders’ cultural biases and ignorance. Identifying current they will no longer hold ignorant or biased beliefs about efforts in teaching cultural issues to medical students,
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