cultural competence Clinical teachers’ perspectives on cultural competence in medical education Peih-Ying Lu,1 Jer-Chia Tsai2 & Scott Y H Tseng3

CONTEXT Globalisation and migration have inevitably shaped the objectives and content of medical education worldwide. Medical educators have responded to the consequent cultural diversity by advocating that future doctors should be culturally competent in caring for patients. As frontline clinical teachers play a key role in interpreting curriculum innovations and implementing both explicit and hidden curricula, this study investigated clinical teachers’ attitudes towards cultural competence training in terms of curriculum design, educational effectiveness and barriers to implementation. METHODS This study was based on interviews with clinical teachers from university-affiliated hospitals in Taiwan on the subject of cultural competence. The data were transcribed verbatim and translated into English. The interviews were analysed using grounded theory to identify and categorise key themes. RESULTS Five main themes emerged: (i) there was a clear consensus that students currently lack sufficient cultural competence; (ii) the

teachers agreed that increased exposure to cultural diversity improved students’ cultural understanding; (iii) present curriculum design was generally agreed to be inadequate, and it was argued that devoting space to developing cultural competence across the curriculum would be a worthwhile endeavour; (iv) different methods of performance assessment were proposed; and (v) the main obstacles to teaching and assessing cultural competence were perceived to be a lack of commonly agreed goals, the low priority accorded to it in an overloaded curriculum and the inadequacy of teachers’ cultural competence.

CONCLUSIONS Eliciting the viewpoints of the key providers is a first step in curriculum innovation and reform. This study demonstrates that clinical teachers acknowledge the need for explicit and implicit training in cultural competence, but there needs to be further debate about the overall goals of such training, the time allotted to it and how it should be assessed, as well as a faculty-wide development programme addressing pedagogical needs.

Medical Education 2014: 48: 204–214 doi: 10.1111/medu.12305 Discuss ideas arising from the article at ‘www.mededuc.com discuss’

1 Center for Language and Culture, College of Humanities and Social Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan 2 Department of Renal Care, College of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan 3 College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

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Correspondence: Dr. Peih-Ying Lu, Center for Language and Culture, College of Humanities and Social Sciences, Kaohsiung Medical University, 100 Shih-Chuan First Road, San-Ming District, Kaohsiung City 807, Taiwan. Tel: 00 886 093 330 2511; E-mail: [email protected]; [email protected]

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Clinical teachers’ perspectives on cultural competence

INTRODUCTION

In the age of globalisation and mass human migration, there has been a growing awareness that medical educators need to respond to cultural diversity by preparing future doctors to be competent in caring for patients regardless of their age, social, cultural or ethnic backgrounds.1–3 This trend has inevitably influenced and shaped the objectives and content of medical education worldwide. The US Association of American Medical Colleges1 and the UK General Medical Council,2 for example, have included cultural competence as one of the core competences that medical students have to develop. The current accreditation requirements as listed by the Liaison Committee on Medical Education3 demand medical institutions train students in the basic principles of cultural competence, give them experience of diversity and constantly evaluate their performance. The research on cultural competences in medical education, including curriculum, assessment, student outcomes and educator training, is extensive in the Western context.4–10 Currently, the literature largely focuses on neutralising the harmful effects of unclear communication or prejudicial assumptions based on socio-cultural differences and is specifically directed to addressing two discrete but related issues: the disparities in medical access between members of different cultures; and the promotion of shared decision making about treatment. A growing literature also delineates the impacts of socio-cultural factors, race and ethnicity on health and clinical care.11–14 As patients have different values, views and beliefs regarding health and wellbeing, doctors who are not prepared for cultural diversity may fail to take into account its impact on those patients.4 More importantly, past research suggests that the high incidences of failure among medical professionals from ethnic communities were not due to prejudice, but the result of candidates’ non-adherence to privileged discursive strategies. For example, in interview situations, questions eliciting professional views and attitudes can be misinterpreted as cues to divulge personal information.15 Furthermore, the pedagogical literature discussing the need to develop cultural competence in health care professionals is now extensive.8,16,17 Similarly, a substantial amount of medical literature on cultural competence emphasises the articulation of a set of appropriate attitudes, skills and knowledge.4,9,18

These domains form an exhaustively detailed inventory and questionnaire for the assessment of cultural competence training in medical schools: Tool for Assessing Cultural Competence Training.1,19 The Tool for Assessing Cultural Competence Training contains some descriptions of competences that are specific to the medical profession that can help as a framework for how the general formulations of attitude, skill and knowledge might be adapted and extended to particular circumstances. Taiwan’s medical environment is also undergoing a series of changes and becoming more multicultural. Interracial marriage, an open foreign labour policy and global migration are causing an increase in the number of expatriates. In addition, differences in socio-economic class, gender and age often result in cultural barriers between medical practitioners and patients. The increased diversity of Taiwan has caused cultural competence to become a pressing issue in different domains, including the health professions. Nevertheless, the cultural competence of medical students and doctors has not yet received the attention it deserves. According to a study by Tsai et al.,20 cultural competence did not occur to the majority of medical educators surveyed as a core element of professionalism. Taiwanese medical schools offer 7-year programmes to high school graduates, starting with 2 years of mixed general education and pre-medical courses, followed by 2 years of pre-clinical courses, 2 years of clinical clerkships and a final year of internship.21 As with many Eastern countries, the adoption of Western ideas always brings up a valid question: do the assumptions of the Western model apply to our own circumstances? In the same vein, research into cultural competence in Taiwan began with forays into the applicability of Western-developed frameworks in Taiwanese settings.22,23 Although medical schools across Taiwan are encouraged to incorporate cultural competence into their curricula, there has been no unified strategy thus far for doing so. In medical settings, clinical teachers, who are both educators and practitioners, are formulating their own responses to this changing society and witnessing the students’ readiness for this transformation. The clinical teachers play a key role in implementing both explicit and hidden medical curricula in relation to the development of cultural competence and also in the provision of feedback that evaluates its educational effectiveness. Therefore, this study aims to investigate Taiwanese clinical teacher’s viewpoints on cultural competence in medical education and their observation and reflection upon

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P.-Y. Lu et al medical students’ cultural competence. These frontline clinical teachers’ perspectives provide insight into the design of effective courses and the obstacles facing the incorporation of cultural competence training into the medical education.

data to ensure anonymity of the clinicians, as well as obtaining their informed consent regarding the purpose of our study. We also provided a letter from a person other than our group to prove the aforementioned procedures were conducted. Data collection

METHODS

Participants and recruitment We recruited a purposive sample of 10 clinical teachers, who were either faculty members of a medical university in southern Taiwan or were working for its affiliated hospitals by invitation. The major university-affiliated hospital is a tertiary hospital with 1600 beds, located in the city centre. The municipal hospital affiliated with the university and the Christian hospital are district hospitals with around 500 beds each, located in a more industrialised area and suburban-rural area, respectively. We selected a group of clinical teachers, including both genders, from different specialties and dealing with patients of diversified socio-cultural backgrounds. Table 1 shows the characteristics of respondents. Ethical approval: Although no explicit Institutional Review Board (IRB) approval was sought due to the fact that it was not required for educational research in 2008 and our focus on clinicians rather than patients, we still sought to follow the general principles behind the Declaration of Helsinki by removing identifying information present in our

We conducted one-to-one semi-structured interviews in private rooms in the university hospitals during August 2008. The interviewers explained the procedures and goals of the study, including the confidentiality of responses, and obtained written consent. The interviewees also had a copy of written consent for their own reference. Seven questions were prepared (See Box 1 for an English translation of the questions, which were given in Chinese), but answers and follow-up questions were allowed to flow with smooth transitions designed to refocus after a while. The interviews lasted approximately 40–60 minutes. Data analysis The interviews were audio-taped and transcribed verbatim. We reviewed and discussed each transcript to reach a consensus on differences in coding. Ten interviews produced a great deal of transcribed data, which we analysed using grounded theory.24 We first reviewed the transcripts and identified recurring key points. We established codes for points that expressed broadly similar content and the collected data were sorted according to the codes. The codes were then

Table 1 Summary of the demographics of the participants

Number

Specialty

Age range (years)

Gender

Academic rank*

Affiliated hospitals+

1

Paediatrics

50–60

Female

4

UH

2

Psychiatry

30–40

Female

3

UH

3

Urology

30–40

Female

1

MH

4

Neurology

50–60

Male

4

UH/MH

5

Otolaryngology

50–60

Male

4

UH

6

Nephrology

50–60

Male

4

UH/MH

7

Neurosurgery

40–50

Male

4

UH

8

General internal medicine

30–40

Male

1

UH

9

Obstetrics and gynaecology

40–50

Male

4

MH

10

Anaesthesia

40–50

Male

3

CH/UH

* 1 = attending physician; 2 = lecturer; 3 = assistant professor; 4 = associate professor; 5 = professor. + UH = university hospital; MH = municipal hospital; CH = Christian hospital.

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Clinical teachers’ perspectives on cultural competence grouped into concepts until the data were saturated. These concepts were then categorised into 13 categories, which were finally grouped into five elemental perspectives: (i) awareness of cultural diversity; (ii) performance of cultural competence in clinical practice; (iii) curriculum design; (iv) assessment of cultural competence; and (v) barriers in designing and teaching intercultural competence. Table 2 displays the summary of clinical teachers’ elemental perspectives on cultural competence in medical education, with the associated subthemes. The quotes were translated by the researchers (who are bilingual in Chinese and English).

Box 1 Interview Questions 1 In what ways do varying cultures and beliefs pose a challenge to medical professionals? Have you ever witnessed or experienced a medical miscommunication that was due to different cultural perspectives? 2 What is your opinion about the association between the current problems regarding health disparities across different cultural groups and cross-cultural communication? 3 Do you feel that medical students are capable of acknowledging their own stereotypes and bias when faced with patients from different cultural backgrounds? From your experience and understanding, would the students’ attitudes cause medical miscommunication or affect medical decision-making? 4 What sort of ‘cultural competence’ (including attitudes, knowledge, and skills) do you think a student should develop? 5 What sort of ‘cultural competence’ (including attitudes, knowledge, and skills) do you think a student should develop? 6 How can we assess ‘cultural competence’ in terms of these three aspects? 7 What are the greatest barriers to the successful planning, implementation, and evaluation of ‘cultural competence’ curriculum? How should we address these barriers?

RESULTS

Awareness of cultural diversity At the most basic levels, all respondents generally agreed that increased exposure to cultural diversity

results in improved cultural understanding, whether cultural competence is constructed in terms of national or other social factors. In regard to what defines awareness, most of the respondents considered recognising the existence of different cultures as the starting point. However, perspectives of awareness started to diverge beyond this point as some doctors emphasised the importance of not just understanding the culture, but being able to think as the ‘others’ would as well, whereas other respondents emphasised the importance of being able to use the right language to communicate effectively with the ‘others’. The respondents recognised that the influx of immigration has presented an unprecedented increase in cross-cultural interactions. They raised a few key issues in the area of communication. Language has complicated the issue of cultural differences. Domestically, students’ inadequacies in local languages such as Southern Min (min-nan), a spoken form of Chinese known as ‘Taiwanese’ in Taiwan, concerned some respondents, as they would have a problem communicating with elderly patients, particularly in southern Taiwan where the majority of the elderly are Taiwanese speakers. Internationally, some indicated that the language barrier resulted in ineffective communication. Although they used gestures or drawings to convey the meaning to the patient, the language barrier remained an unresolved problem to them. In short, their methods of dealing with this influx of immigrants were largely based on understanding that different cultures have different ways of dealing with unexpected situations. Performance of cultural competence With respect to student performance, there was a clear consensus on the students’ lack of sufficient cultural competence. The vast majority of respondents rated cultural competence among students as an average five out of a possible ten. A specific example raised was that many ‘sheltered’ Taiwanese medical students spent most of their time studying and, as a result, their attitudes were insufficiently sensitive when they were confronted by patients in real-time contexts. Some respondents indicated that the interns and junior doctors would not prioritise cultural competence as they had to master an enormous amount of clinical knowledge and had many other tasks to deal with. Many respondents raised the point that expectations about cultural competence were generally low for students just starting their clinical rotations, as the students were very

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Table 2

Clinical teachers’ perspectives on cultural competence in medical education

Themes/subthemes (total number of respondents who discussed each subtheme)

Illustrative quotes

Awareness of cultural diversity







The definition of awareness of cultural diversity (10) Key issues of language barriers and communication (6)





Performance on cultural



competence 

  

Evaluation of student’s performance rating on a 10-point scale 2–4 (4) 5–6 (4) 7–8 (2)

Curriculum design   

Core frameworks (8) Hidden curriculum (7) Difficulties (2)







 



Assessment    

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OSCE and mini-CEX (7) Observation (5) Reflective essay (3) Questionnaires (2)







I believe that in the current multicultural situation, especially with the so-called multiple ethnicity situations in Taiwan, his [the patient’s] intentions, his skin and his language may not be the same [as ours]. Perhaps due to the living environment or the different working class, he [the patient] presents a complete yet different way of living and thinking, and that is what I believe ‘cultural differences’ is defined. In the case of foreigners, like the new Vietnamese [immigrants]; I have some patients that are Whites, and they have a different perspective on disease. Whites tend to take more initiative [in the course of treatment]; they are more in-charge of their disease and they are less likely to accept the doctor’s viewpoint; they are very concerned with their quality of life and whether or not the side-effects can be eliminated and so on. Therefore, the medication I tend to prescribe for them is somewhat different compared to local Taiwanese. Even though he can speak Mandarin or whatnot, but even though it’s the same language, the understanding is different… Possibly 5 or 6, even though their awareness isn’t that strong, I can feel that the students are capable of using a more gentle and less direct attitude to see the patient or their conflict, partially because of a side of them that doesn’t want to create troubles, and partially due to a communication skill training problem. I’d think around 3 or 4 points, because when you have to communicate with a patient, language is a problem. Why the students never wanted to study that [language or its related culture] during the first 6 years? From my questioning, the large majority of the students said that they didn’t feel like this would be a problem [in the future]. Pretty high, maybe, 8 or 9 points if students have been reminded by the teacher or through patient feedback, or have been reminded by other people. Depends on what kind of environment you provide them [the students]. School is the same; medical school isn’t for doctors to teach medical students [medicine] only. Other related areas of medicine must be taught and practised. If you want to set foot in society, then interpersonal relationships and these kinds of things [cultural competence] you must have regularly practised. Through general education, this kind of basic and humanities-based courses, we can provide interesting material to arouse their [the students’] awareness and push forward. Medical students are from better-off socio-economic backgrounds, they need to learn diversities from service learning. Let students go to indigenous tribes in the summer break to provide volunteer work to expose them to disparities. I think that knowledge can let them fall into a vast cavern of cultural differences and end up smashing them [the students] into conflict head-on. From this shock [the students] will have to understand how to deal with and face people of different groups, how to accept the different groups, how to include them, and how to find a common point to talk about, to finally reach a consensual agreement. In reality this can be [done] through small group discussions. We can observe how they understand, of course, this kind of observation means that the teacher must have the time! I think we should use small groups as the basis for future plans and frameworks. We can let him [the student] and patient do a one-to-one communication and record it, sort of like our clinical bedside teaching. There is also a section where they meet patients, but I still feel that patient communication is still a weak point [for our students]! I feel that in terms of cultural competence evaluation, if it’s in the clinical section, then we can probably use a 360 degree [holistic] evaluation or perhaps something like the OSCE. But I feel that it is very difficult to use a one-to-one method to evaluate it [cultural competence], since its domains are broad, and unless we [the students] actually meet cultural conflict [during the examination], cultural competence would not manifest itself normally.

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Clinical teachers’ perspectives on cultural competence

Table 2

(Continued)

Themes/subthemes (total number of respondents who discussed each subtheme)

Barriers in teaching and assessing intercultural competence

Illustrative quotes 

We [teachers and students] have cultural stereotypes and bias …. if students could try to put down what their bias is like when encountering patients…put down this kind of self-reflection and hand it to me.



I feel that the biggest barrier regarding this is that this kind of cultural background is really very hard to put into actual text. The hardest part… would be that those responsible for writing out the framework for the curriculum don’t feel that this is necessary, this is the biggest barrier. Students definitely don’t [practise/learn], because this isn’t tested!

 

  

No common goals (3) Low priority (4) Lack of awareness of cultural diversity (teacher’s) (6)

OSCE = objective structured clinical examination; min-CEX = mini-clinical evaluation exercise.

much used to a sequential training of thought and often valued objective truth over subjective truth. Another key point touched upon was that not every doctor or teacher included cultural competency teaching; the respondents agreed that a student’s cultural competence was unlikely to improve in this case, especially if the student’s attitudes and beliefs brought him or her into direct conflict with the patient’s. Each respondent expressed a strong belief that if cultural competence could be either taught or embedded in teaching, there would be a positive effect on the students’ awareness and behaviour in situations of conflict. Curriculum design Most of the respondents indicated that current curriculum design was generally insufficient and that devoting space in the curriculum to developing cultural competence would be a worthwhile endeavour. Elements described as desired aspects of ‘cultural competence’ include critical thinking, empathy, awareness of cultural differences, understanding beliefs and values, an openness and willingness to learn and communicative skills. Although there were many other points raised, the general ideas suggested were not all that different from the definition of cultural competence in the Western context alluded to above.

Regarding the actual content of the curriculum, the respondents also offered much advice, both specific and general. Starting from the more general advice, most respondents suggested a combination of reflections on actual patient encounters and guided lessons. The effective methods to achieve this competence varied between doctors. The majority, however, favoured a ‘hidden curriculum’ approach to provide learning opportunities: some pointed out the limited effectiveness of lecturing about dynamic situations, others talked about how students learned just as well from each other as from their teachers when they were actively involved in a given situation. In addition, respondents unanimously agreed that the first step was making the student aware of cultural differences. Beyond that, perspectives diverged. One respondent believed that as long as the basics were covered, students would naturally ‘pick up on’ the cultural competence through clinical courses and experience. Expanding on this philosophy, this doctor suggested that reflection on specific cases with actual patients from different cultures allows for maximum efficiency compared with lectures about general principles. Experiential learning in the undergraduate years was regarded as a good opportunity to expose students to different cultures. One respondent indi-

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P.-Y. Lu et al cated that as most medical students were from better-off socio-economic backgrounds, they needed to learn about diversity through service learning. Another respondent pointed out that providing students with opportunities to participate in cultural activities in rural areas was a good way to enable them to understand different values and beliefs. He also indicated that students who volunteered over their summer vacation to work with indigenous tribes were exposed to disparities. Such exposure also even brought them to understand how small cultures can have an impact on health issues, such as betel nut consumption. The difficulties in the implementation of a curriculum that seeks to address cultural competence were recognised: they include a lack of consensus among leaders, teachers and learners, a lack of universal core contents and standards, and competition in a currently overloaded curriculum. Opinions also varied on the effectiveness of the timing of the training. Some respondents thought it should start as early as pre-medical (first and second year) and be integrated into the pre-clinical curriculum through problem-based learning (PBL), for example. Some respondents thought that real-patient encounters in clinical years would have more impact. In addition to service learning, early exposure to cultural diversity through role modelling and a humanities course in general education was suggested. Assessment of cultural competence The objectivity and feasibility of the direct assessment of cultural competence were still of major concern. Most of the respondents did not indicate any specific measures to assess cultural competence. None of the respondents mentioned developing an evaluation tool. Direct observation of learners’ performance and multi-source feedback were suggested. These multiple sources included written feedback, such as reflective essays during the early clinical years. One of the respondents suggested letting patients give students feedback, whereas another was of the opinion that the respondents’ evaluations were more reliable. The objective structured clinical examination (OSCE) and the mini-clinical evaluation exercise were suggested as ways to evaluate cultural competence explicitly. Some suggested understanding students’ learning outcomes could happen in some unofficial settings, such as at dinners or coffee breaks. It was generally agreed that self-reflection

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was a critical process, but despite there being various reliable means of using self-reflection as an assessment tool, it was still not commonly performed and encouraged. The main barriers Most of the respondents generally agreed that there were multiple barriers to the successful planning, execution and evaluation of ‘cultural competence’ in the medical curriculum. Accordingly, the main obstacles identified by the respondents were: (i) a lack of the common goals for cultural competence education among educators and learners; (ii) a lack of awareness and self-reflection about cultural diversity among members of the general public and medical professionals in particular; (iii) the low priority accorded to cultural competence education; (iv) a lack of a systematic way to combine factual knowledge and communication skills and professional attitudes in teaching; and (v) a lack of consensus and collaboration among medical educators in integrating the curriculum design and assessment methods. The respondents in this regard generally expected these problems should be strategically dealt with in the future.

DISCUSSION

So far, this paper has put forward a set of judgements, articulated by informed practitioners, about the place of cultural competence training in medical education in Taiwan. We now consider the implications of these judgements from three aspects: curricular content, assessment and clinical teachers’ cultural competence. Cultural competence curriculum design The findings showed that most of the respondents were concerned about medical students’ awareness of cultural diversity and performance of cultural competence. However, they were positive that, with proper teaching, students would progress significantly. The data produced a wide spectrum of suggestions regarding curriculum, demonstrating that respondents, with their wealth of experiences, recognised the inadequacy of current provision and had insights into a variety of possible ways of including cultural competence in a broader curriculum. From the point of view of the respondents, there was a consistent focus on increasing the duration of learning as the segmented curriculum divided learning into pre-medical, pre-clinical years and clinical

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Clinical teachers’ perspectives on cultural competence years. This probably bears some relation to the low expectations the respondents currently have for students. The beliefs held by the respondents reflected a general trend among medical professionals in Taiwan to promote better linkage between the several phases of medical programmes in Taiwan. This attitude towards integration was best reflected in the suggestions that cultural competence is taught in different stages. For example, the ‘hidden curriculum’ format was suggested as service learning traditionally took place in the freshman or sophomore pre-medical years. Including cultural elements into PBL was also suggested for the pre-clinical stage. However, apart from one respondent’s suggestion of using ‘reflective writing’ to train the clinical students, most of the respondents tended to think that cultural competence could be developed ‘naturally’ in contact with or from observation in the clinical settings. In addition, as with other countries, one of the barriers for the implementation of cultural competence in medical education has been the mindset of medical educators and learners.25 As stated above, in the Taiwanese context, the development of cultural competence has not yet been considered a high priority.20 The respondents’ insights help to identify the professional, educational and social ‘needs’ that a systematic programme for the development of cultural competence must address. When we are writing cultural competence into the current curricular syllabus, we have to consider: (i) the learners’ prior cultural competence and (ii) the amount of time available for developing cultural competence in the curriculum. Although generalisations are always to be treated with some scepticism, Taiwanese students, compared with their international peers, come from a more rigid exam-oriented high school education.21,26 This may lead to them being relatively weak in reflection and in the depth and breadth of their general knowledge. As the data show, the clinical teachers had similar concerns. In this regard, the training in cultural competence should start as early as the pre-medical years, that is, in the freshman and sophomore years of a general education programme, to develop the students’ general knowledge of cultural diversities through integrated courses and experiential learning with learning objectives designed to broaden cultural perspectives. The teaching of cultural competence can also be incorporated into individual courses. For example, language issues in intercultural medical communication can be more explicitly introduced to courses in English for Medical Purposes27 or Taiwanese for Medical Purposes. The integration

of formal and hidden curricula requires further collaboration among clinical teachers and their colleagues in the humanities and social sciences faculties. The pre-clinical years, where PBL is hybridised into the curriculum, can explicitly involve more cultural issues in discussion and scenario writing28 to develop cultural competence. Taken together, these steps should prepare students for stepping into the clinical settings, whereas reflective writing and observation can facilitate the iterative development from knowledge into practice. Assessment Regarding the evaluation of learning outcomes, most of the respondents proposed different methods. Some respondents suggested that students’ cultural knowledge can be assessed through OSCEs. This seemingly echoed some of North American medical educators’ studies, which showed that a cultural competence OSCE could be effectively integrated into the medical curricula to teach cultural competence.29,30 In Taiwan, Ho et al.’s research23 further supported the use of OSCE as a measure of cultural competence improvements after a short course on patient-centred approaches to cultural competence. However, they also found the benefit seemed to degrade over time in a follow-up study. In addition, a discrepancy was found between the students’ self-assessment of competence and their observed competence as demonstrated by OSCE scores.31 Skelton32 cast doubts on OSCEs as a tool, cautioning that it can descend into formulaic, checklist learning. A concern was also raised over what ‘intercultural competence’ versus good interpersonal interviewing skills in OSCEs were termed.33 Despite such findings, the respondents in this study appeared not to have looked critically into tools for evaluation. For example, a wide spectrum of evaluation instruments for cultural competence, presently used in standardised assessments, such as the American Liaison Committee on Medical Education, did not occur to them. How authentic performance of attitude, skills and knowledge can be transferrable from one stage to the other was also absent from data. Although self-reflection was brought up, how it could be built into a formal curriculum and then assessed remained a challenge. One possible reason is that as stated in obstacle 2, the clinical knowledge, skills and tasks required of the medical students are perceived as far more important than cultural issues. Shapiro et al.34 also observed this phenomenon in their study. The other reason, as revealed in some responses, is that doctors

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P.-Y. Lu et al themselves are overloaded and it is difficult for them to find time and energy to design more feasible methods for assessments. Clinical teachers’ cultural competence In Taiwan, although cultural competence has been more recently included as a major element in developing medical professionalism,35 whether teachers are prepared for teaching cultural competence still remains in question. In this regard, an important concern was also raised from the data: whether the doctors themselves are culturally competent enough to teach students. Typically, the doctors learned cultural competence not through training, but from their own experiences. As such, the doctors tended to drift towards a ‘working’ definition of cultural competence that stresses effective communication with patients regardless of language or culture. As such, this might be regarded as a highly subjective and personal ‘hit or miss’ methodology to the development of self-understanding lacking any systematic integration. As mentioned previously, the doctors did not express a more comprehensive set of characteristics that might be included in a better-defined cultural competence inventory such as the American Tool for Assessing Cultural Competence Training.19 This is perhaps due to a singular focus on the attitude that one should try to solve the ‘communication problem that is due to culture’ that prevails among Taiwanese doctors. This explains why over half of the respondents indicated that language issues might be a problem that prevented effective understanding of patients’ cultural backgrounds. This problem is further compounded by the fact that their suggestions to improve student cultural competence typically favour cultural exposure. These suggestions tended to focus around ‘learning to communicate through experiences’ as opposed to ‘learning to understand’. It is also noted that most of the respondents’ understanding of ‘intercultural competence’ is largely related to interactions between ethnic groups, although some talked about different age groups and social classes. From their responses, cultural essentialism was evident from time to time. Cultural beliefs and behaviours that are attributed to a particular group can lead to stereotyping and oversimplification of a culture, rather than respect for its complexity. It is noted that some respondents also working in a university-affiliated hospital located in a region with a high working-class population were able to see how different social classes affected doctor–patient communication and the negotiation of

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efficient treatment. Some respondents also touched upon cultural difference in gender and age by using examples of some elderly women who still resisted having procedures that they consider intrusive, such as pap tests. The data also implied that medical educators’ cultural awareness is one of the most important factors in educating future medical professionals. Explicit modelling of proper attitudes and sharing of cultural understanding is essential to students learning in this regard. As students normally perceive attending physicians as role models, how to help doctors to raise their awareness and recognise the significance of developing medical students’ cultural competence is important. In summary, these results shed light on the need to re-evaluate the role that cultural competence plays in medical professionalism and therefore reconsider the teaching and assessment of cultural competence for both pre-clinical and clinical students. The findings of this study imply that the development of students’ cultural competence should start from as early as the medical or general education years. Through humanities courses or experiential learning, cultural awareness can be highlighted and cultural competence can be developed. It is also hoped that proper assessment tools compatible with our local socio-cultural context can be developed for better results. These can also be integrated into PBL and included as elements in the OSCE in order to prepare students for their clinical years. The characteristics that define a ‘culturally competent’ individual must be identified and clearly delineated so that future students have a chance to prepare for and achieve the standards required. Therefore, we suggest that an effective faculty development programme for pedagogy needs to be provided. Limitation Like many other studies, this study has its limitations in terms of its representativeness. We interviewed clinical teachers at a single medical school and its affiliated hospitals, which may limit the generalisability of our findings. In addition, respondents were not randomly selected; it is possible that doctors who hold different views or have more knowledge about cultural competence did not participate. However, we have some reasons to be confident that the views expressed by the respondents in our institution are typical of those held by members of different institutions in our country. First, the uniform selection criteria employed by medical schools across Taiwan may limit the diversity of the respondents in our study, but at the same

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Clinical teachers’ perspectives on cultural competence time, they make these perspectives more generalised to others in the profession. Second, the affiliation of all medical schools in Taiwan with an urban medical centre and the fact that under the National Insurance Plan most doctors work in similar medical contexts, increase the representativeness of our sample nationally, especially in the primary centres of care. In addition, as the study has tried to include clinical teachers with different specialties and characteristics, we believe that it highlights and exemplifies the diverse experiences of teaching cultural competence, which might shed light on future studies.

CONCLUSION

There will be an inevitable increase in the ways in which people migrate across cultural boundaries and encounter difference. Culturally competent medical students should be trained to be aware of how interaction with people from different cultural background unfolds, to be sensitive to the possibility of cultural assumptions prejudicing their behaviour and to be prepared to use this knowledge to act and adapt where necessary. We have highlighted an aspect that is currently underappreciated in cultural competence research: the opinions and observations of clinical teachers of cultural competence in medical education in the Taiwanese context. By understanding their experiences, concerns and suggestions, this qualitative data can help create a better picture of the possible ways to enhance cultural competence in medical education. Furthermore, the suggestions have relevance across medical schools with combined undergraduate and medical programmes in some other countries with regards to implementing their own local version of cultural competence, especially in cases where a direct adaptation from Western systems is employed. It also implies that there would be considerable value in undertaking a further large national quantitative research on clinical teachers’ understanding of cultural competence in medical education and on medical students’ perspectives to identify comprehensive goals in this regard. The findings of this study can help to establish a baseline for such further researches.

Contributors: P-YL designed the study, conducted the interviews, supervising data processing, analysed the data, and drafted and revised the paper. J-CT contributed to designing the study, conducting the interviews and critically revising the manuscript. ST contributed to data translat-

ing and analysing. All authors gave final approval of the version to be published. Acknowledgements: the authors wish to thank the ten clinical teachers who generously and enthusiastically spent time on providing their opinions. The authors are very grateful to Professor John Corbett who kindly read and commented on an earlier version of this paper. Funding: none. Conflicts of interest: none. Ethical approval: although no explicit IRB approval was sought due to the fact that it was not required for educational research in 2008, ethical consideration was given by a qualified professional outside the research team involved. The general principles behind the Declaration of Helsinki were followed, identifying information in the data were removed to ensure anonymity and informed consent was given by the participants.

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