2014, 36: 951–957
Cultural sensitivity or professional acculturation in early clinical experience? DAVID L. WHITFORD & AMAL REDHA HUBAIL Royal College of Surgeons in Ireland – Medical University of Bahrain, Kingdom of Bahrain
Abstract Aim: This study aimed to explore the early clinical experience of medical students following the adaptation of an Early Patient Contact curriculum from a European culture in Ireland to an Arab culture in Bahrain. Methods: Medical students in Bahrain took part in an Early Patient Contact module modelled on a similar module from a partner medical school in Ireland. We used a qualitative approach employing thematic analysis of 54 student reflective logbooks. Particular attention was placed on reflections of cultural influences of experience in the course. Results: Medical students undergoing this module received reported documented benefits of early clinical experience. However, students in Bahrain were exposed to cultural norms of the local Arab society including gender values, visiting the homes of strangers, language barriers and generous hospitality that led to additional challenges and learning for the medical students in acculturating to norms of the medical profession. Conclusion: Modules intended for curriculum adaptation between two cultures would be best served by a group of ‘‘core’’ learning outcomes with ‘‘secondary’’ outcomes culturally appropriate to each site. Within the context of the Arab culture, early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.
Introduction
Practice points
Early clinical experience within the medical curriculum has been shown to have benefits for medical students: motivating the students; improving confidence and self-awareness; improving communication and empathy with patients; and socializing the student towards their chosen profession, patients and society (Littlewood et al. 2005; Dornan et al. 2006; Dornan et al. 2007; Yardley et al. 2010, 2012). On the other hand, it may also generate feelings of inadequacy and fear, especially when students are underprepared (Smithson et al. 2010). Even when clear learning outcomes for early clinical experience are agreed, the attained learning may vary between individuals (Bell et al. 2009) and clinical settings (Wenrich et al. 2013). Cultural differences (values, attitudes and beliefs of a population) are known to determine some aspects of experience and learning in healthcare (Holtbrugge & Mohr 2010) and may be one factor in contributing towards variations in learning in early clinical experience. This can be particularly difficult to determine, particularly when other variables such as the module content may differ between medical schools. The globalization of higher education, including medical education, has continued to increase over the last decade (Harden 2006; Wildavsky 2010), making the assessment of cultural influences of learning more important. A new model in the international development of medical education has emerged fairly recently with the establishment of international
Adaptation of a curriculum for clinical modules from one culture to another can lead to additional challenges and learning for students Modules intended for adaptation between two cultures would be best served by a group of ‘core’ learning outcomes with ‘secondary’ outcomes culturally appropriate to each site The transfer of an early clinical experience module had the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures Integration of local and professional cultural norms should lead to improved professional acculturation in societies where the local culture may conflict with professional norms
campuses of existing medical schools. In this model, medical schools emphasize an international approach that involves mobility of teachers and students and the implementation of a curriculum that builds on exchanges between two or more countries (Harden 2006). The Royal College of Surgeons in Ireland – Medical University of Bahrain (RCSI Bahrain) was established in this way in 2004 and graduated its first cohort of doctors in 2010. RCSI Bahrain delivers the same curriculum
Correspondence: Professor David L. Whitford, Department of Family and Community Medicine, Royal College of Surgeons in Ireland – Medical University of Bahrain, PO Box 15503, Adliya, Kingdom of Bahrain. Tel: +973 17351450; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/110951–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.910296
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module learning outcomes as the RCSI medical school in Ireland, with the teaching adjusted for local circumstances. This has created the opportunity to investigate the impact of learning in different cultural and clinical settings. We set out to examine early clinical experience in a group of medical students in RCSI Bahrain after implementing an Early Patient Contact module in Bahrain. We took a particular interest in the challenges posed to the students’ experience by the implementation of this module developed in a European culture in Ireland and adjusted for an Arabic culture in Bahrain.
Methods The Royal College of Surgeons in Ireland has a long association with postgraduate health care education in Bahrain and in 2003 was invited by the Bahrain government to establish a new medical school in Bahrain. RCSI Bahrain was established in 2004 as a medical school based in Bahrain offering the same curriculum as the RCSI campus in Ireland, with adjustments made to suit local circumstances. The student intake to the university is international with 50% being from Bahrain and the remainder from over 30 different countries worldwide (Box 1). The Early Patient Contact module was incorporated into the RCSI curriculum as a response to increasing evidence of the value of early clinical experience. It is delivered in the first semester of the second year of the five year medical programme and is organized by the Department of Family & Community Medicine. The module coordinator in Bahrain had previously delivered the module in Ireland. The Early Patient Contact module consists of several components (Box 2). The module allows the students to work both independently and within a small group. The learning outcomes of the Early Patient Contact Module are to: Demonstrate an understanding of the importance of establishing a professional relationship with a family and the issues of confidentiality Demonstrate an understanding of social determinants of health, cultural influences on health and the impact of a new baby on family structure, function and dynamics Demonstrate an understanding of the impact of disease, disability and addiction on an individual
Demonstrate an understanding of the evidence base surrounding the importance of communication skills Demonstrate the skills of opening a consultation with a patient Both the components and learning outcomes for the module are shared between Ireland and Bahrain. However, adjustments have been made in Bahrain for local circumstances. For example, RCSI Bahrain delivers more communications skills teaching in view of the fact that there are more students whose first language is not English. Assessment of the module is through a reflective logbook. This seeks information from the students on aspects of confidentiality, social determinants of health, child development and vaccinations. The majority of the logbook is a reflection on the experience of the student during the family study and the Health Care Symposia. For the purpose of this study, we took the anonymized logbooks of 54 students who had completed the module. We carried out a qualitative thematic analysis of the reflections contained in the logbooks. The two researchers read through all the logbooks and familiarized themselves with the data. The first 12 logbooks were analyzed by the researchers to identify key themes and sub-themes. We looked particularly for themes that arose from reflections of cultural influences of the students’ experience of the module. The emerging themes were discussed and agreed by the two researchers and further data from all the logbooks organized around these themes using NVivo software. The study was approved by the Research Ethics Committee of RCSI Bahrain.
Results Individual students expressed a wide range of cultural influences affecting their experience of the early patient contact module in RCSI Bahrain. Box 2. Content of the RCSI Bahrain early patient contact module.
Components of the RCSI Bahrain Early Patient Contact Module Box 1. Age and origin of students taking early patient contact module.
Age and origin of students taking Early Patient Contact module (n ¼ 54) Age at medical school entry 17/18 years 19 years 20/22 years 25 years
22 21 9 2
Country of origin Bahrain Other Arab countries North america Europe Asia
28 5 11 5 5
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2 Introductory lectures: * Introduction to the Early Patient Contact Module * Introduction to the Calgary Cambridge communication skills method 4 small group (10 students) videoed communication skills sessions led by Bahraini Family Physicians 4 symposia with patients lasting one hour each. During these symposia, students have the opportunity to hear, discuss and reflect on the experiences of patients who have a disease, addiction or disability. 3 tutorials with Bahraini Family Physicians in health centres (8–9 students in each group). Students discuss issues of confidentiality, communication, patient centredness and pregnancy with the Family Physician A family study of a woman who is pregnant including two home visits, one antenatal and one postnatal (2–3 students in group). Students obtain demographic, social, health and developmental information as well as observing human behavior and family dynamics in the context of an Arab society.
Cultural sensitivity in early clinical experience
Language
Gender
Non-Arabic speaking students make up about 20% of the student population. Language emerged as an important theme for many students, both Arabic and non-Arabic speaking, suggesting that the learning experience of the students was sometimes compromised. For non-Arabic speaking students, this was their first realization that language might be a barrier in medical consultations:
Gender separation in the Arab culture was the most expected cultural challenge for the medical students. As a result, some students were surprised that some people are very welcoming and open minded about this issue.
‘‘My colleagues helped translate for me, it could have been better if we had an English speaking patient as all of us could have been able to follow the conversation’’ (St 10) However, language also posed difficulties for Arabic speaking students who either had to concentrate on translating: ‘‘The lady could not speak English and the foreign girl (student) could not speak Arabic. I tried to translate but it was difficult. I could not translate, ask questions and write notes at the same time’’ (St 23) or who have become accustomed to using English and use Arabic only occasionally in daily conversation and were therefore not conversant in ‘‘medical Arabic’’: ‘‘The first problem I faced is taking history in Arabic and not in English. It took a lot of effort trying to translate the routine questions into Arabic especially the symptoms and asking for specific disorders which she may carry or runs in the family.’’ (St 54) Moreover, some patients didn’t speak either English or Arabic, leading to a realization of the language difficulties posed in a multi-cultural society: ‘‘Firstly we tried to talk in English with her but apparently she could not understand us so we switched to Arabic and even her Arabic was weak because she is from India’’ (St 37) Students also struggled to gain depth in their consultations when the patient had a poor grasp of the language. This created a barrier in the range of expression of thoughts and feelings that could be explored: ‘‘There were a language barrier between us and the lady because she was Indian. The lady answers were too short, for most of the questions her answers were: yes, no or I don’t know.’’ (St 6)
‘‘I am a boy with two girls so can I come with them? She said that I am her son and I am welcome to come’’ (St 47) ‘‘The visit was arranged with the husband and he was fine to have a male student visit them as long as he was present during the visit. I was aware that this is part of the culture of the region’’ (St 21) However, this posed major problems for students when husbands were very strict about gender separation: ‘‘She finally agreed to the visit. She said she would ask her husband and call me back. When she didn’t call me back a couple days later, I called her again and asked her if we could meet up with her. She said she couldn’t meet with us because there were males in my group.’’ (St 15) Some students were just as surprised that perceived cultural values were not adhered to: ‘‘The fact that the husband left us alone with his wife was shocking. This is because we were not only females but also we had a male. In our culture, usually when there are male visitors there must be a male in the house (especially if the visitors are strangers).’’ (St 13) Attitudes towards gender separation influenced the consultation experience for some students, particularly males: ‘‘When I saw her, it was awkward at first because she just said hello to the female in our group, but this was expected’’ (St 40) ‘‘According to our society and cultural issues; some of the boys didn’t have the chance to ask the patient about some sensitive pregnancy questions.’’ (St 1) Even when male students were fully accepted, the knowledge that gender is an issue in the culture may have affected their learning experience:
For many students, however, language posed no problem: ‘‘Both the mother and the father spoke English fluently; therefore we did not have any problems with communication’’ (St 5)
‘‘I was truly worried and nervous about the family’s reaction when it comes to a male student asking some of the sensitive questions’’ (St 24)
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Home visiting Home visiting a stranger is not the cultural norm in Bahrain and led to some increased anxiety among students that were exposed to it for the first time: ‘‘Before I went with my partner to the family I had a feeling of dread and uncertainty, because I was going to a home of people that I don’t know’’ (St 22) But the benefits were often recognized in retrospect after the experience: ‘‘Before starting this course I thought it was inappropriate to enter patients’ houses . . . during the course I have realized that visiting them in their house was extremely important because it gives me a clear insight of their current condition and life style and understand the patient as a human being.’’ (St 54)
Hospitality For many of the Arab students, ‘‘empty-handed’’ is not the norm:
entering
a
home
‘‘We had brought traditional Bahraini sweets with us, as it’s a custom not to visit a family’s house empty handed.’’ (St 34) Similarly hospitality towards the students was the norm: ‘‘Both the husband and wife (pregnant one) were very welcoming and nice. This made me more comfortable. The maid brought out tea, dates and sweets for us, as is the custom.’’ (St 22)
Societal awareness Many of the students were ‘‘naı¨ve’’ at the way families lived in what they considered a very prosperous country: ‘‘it was absolutely shocking to see the neighbourhood we were about to enter. I have lived in the Gulf for 20 years, and only was exposed to the comfortable, wealthy lifestyle where each family had several cars, maids, and lived in massive villas. Never have I seen such poverty levels in the Gulf region, and this experience definitely opened up my eyes to the reality of the world I live in.’’ (St 49)
‘naming ceremonies’ and the baby’s face being painted for the ceremony.’’ (St 38) ‘‘In Bahrain particularly, they believe that umbilical Hernia may be cured by placing a coin on the umbilicus for a period of time.’’ (St 10)
Anxiety Many of the students expressed considerable anxiety prior to their first visit: ‘‘I was feeling anxious to meet her and I have to say that I was feeling weird to be in this situation – meeting a strange lady in her own home and trying to break the ice’’ (St 42) Anxiety arose mostly because the students didn’t know what to expect: ‘‘We met the family - I was feeling anxious and a bit worried because I didn’t know what to expect, and when we were in their home at the beginning of the interview I was uncomfortable’’ (St 46) ‘‘I was very nervous and didn’t have a clue about how things would go.’’ (St 30) Anxiety also seemed to be greater in those who recognized the cultural norms: ‘‘To start with, this formed a concern for me, as I was not accustomed to discussing sensitive female issues around the opposite gender.’’ (St 3) ‘‘I think the reason behind my nervousness was that I am meeting new people from different culture, in strange and uncomfortable place’’ (St 10) But this soon settled, and by the second visit many of the students were feeling quite comfortable with their family: ‘‘After this second visit all of us felt comfortable with the family as if we knew them for a very long time’’ (St 35) The students recognized the impact this had on their communication and relationship with the patient: ‘‘By the end of the second visit, it was clear that we were very comfortable with each other and communicated well between ourselves’’ (St 44)
Health beliefs
Lack of confidence
The students came across some health beliefs that were new to them:
As this was a new experience for many of the students, they often expressed a lack of confidence in their ability:
‘‘The visits definitely gave us a great cultural experience as we were introduced to the concept of
‘‘All the negative thoughts are just popping up in my head, what if they weren’t comfortable with us? What
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if they didn’t like our questions? What if they refused to answer?’’ (St 5) ‘‘This was my first experience to meet a real patient. I was afraid about it. I kept saying what will I do? How will I react? What will they think of me? Can I ask the entire embarrassing questions about pregnancy?’’ (St 22)
Learning Overall, the experience was positively rated by the students and led to considerable learning (Box 3).
Discussion Analysis of the reflective logbooks from medical students undergoing the Early Patient Contact module at RCSI Bahrain suggest they undergo many of the benefits previously documented for early clinical experience (Littlewood et al. 2005) including reminding them of their vocation to be a doctor, increasing empathy with patients and family physicians, gaining confidence to carry out interviews, building selfawareness and responding to feelings of inadequacy, uncertainty and anxiety. However, delivering the Early Patient Contact module in Bahrain exposed the students to values, attitudes, beliefs and practices (i.e. the culture) of the local Arab society that led to challenges and learning for the medical students that were beyond the original learning outcomes. In particular, many students had to decide whether to challenge local cultural norms in order to learn and thereby acculturate to the norms of the medical profession. The study also raised implications for the adaptation of an Early Patient Contact module developed in one culture and delivered in another. The cultural issue that most challenged students experiencing the Early Patient Contact module was the societal attitude to gender. Women are often subordinate to men in Arab society (Mernissi 1987), and this is most pronounced in the Arabian Peninsula. Bahrain is more diverse than many of the surrounding countries in this regard, but this very diversity can pose a problem for medical students. In some households, gender equality is the norm and women occupy an equal place to the men. In other households, women are segregated and not encouraged to speak with, be in any form of physical contact with (e.g. handshake), or even be in the same room as men who are not family. This diversity led to some uncertainty and anxiety among male students prior to meeting the patient,
particularly as they might find out on arriving at the home that they could not gain access to the patient (although this had always been agreed in advance). Even if allowed access, a few male students were discouraged from speaking directly to a female patient or asking sensitive questions. Some students equally felt uncomfortable when their own cultural and social norms on gender were broken. A similar issue for many of the students was visiting the home of a person who is not known to them as this is considered culturally inappropriate within the society. A few students initially refused to carry out a home visit on the grounds that it was breaking their cultural norms. Others were very hesitant. Several students suggested changing the course such that male students would visit a male patient and female students a female patient and that all meetings with the patient would be restricted to health centers. This posed an interesting conflict in delivering the module. Should the medical school accede to the students’ request and redesign the early clinical experience to be more culturally sensitive to the students and society? Or should it encourage some cultural norms in society to be set aside in order to encourage the medical student to acculturate to their future professional role. The input from local Bahraini family physicians was invaluable in this respect. Clinical practice in Bahrain demands that doctors see patients of the opposite gender, ask sensitive questions, understand their family and social context, and clinically examine them. Professional acculturation is an important aspect of learning, and even more so when the local culture may militate against aspects of it. Strategies of acculturation have divided the ways in which individuals approach acculturation into four categories along two dimensions (Rudmin 2003). The first dimension concerns the retention or rejection of an individual’s native culture. The second dimension concerns the adoption or rejection of the host culture. From this, four acculturation strategies emerge (Berry 2008) (1) Assimilation occurs when individuals adopt the cultural norms of a dominant or host culture, over their original culture. (2) Separation occurs when individuals reject the dominant or host culture in favor of preserving their culture of origin. (3) Integration occurs when individuals are able to adopt the cultural norms of the dominant or host culture while maintaining their culture of origin. (4) Marginalization occurs when individuals reject both their culture of origin and the dominant host culture.
Box 3. Summary of learning experienced by students undertaking the RCSI bahrain early patient contact module.
Overall, the early clinical experience was positively rated by the students and led to considerable learning: ‘‘To begin with, and before the first visit, I had expected that the visits will not completely fulfil our purpose, since I had my mind fixed on the stereotype of our culture. I had expected that the couple might be secretive about declaring their personal information, and would be less open minded about discussing certain issues. However, by the third visit, their answers revealed that my expectations were completely false. I have come to realize that many people are more willing to share their experiences nowadays, and that they are more educated and well informed about medicine and science than they were before. This made me apprehend the fact that I should not jump into assumptions and formulate views about individuals in our society before getting to know them.’’ (St 34) ‘‘All three visits were an extraordinary experience. It helped me fine tune my communication skills. It has proven to me that a strong doctor-patient relationship can be irrefutably valuable. The adventure through the three sessions has helped me understand patient needs, emotions and physical fatigue during all three trimesters. It also allowed me to view the patient’s changing affection toward us.’’ (St 46)
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We would envisage that for medical students, the ideal is integration into the new culture of the host medical profession while maintaining their native Arab culture. The decision to encourage integration into the medical profession as an aspect of the early clinical experience was taken. In this way, the module would also prepare the students for some challenges that would inevitably be experienced later, e.g. male students needing to interact with female patients or students needing to ask questions about alcohol, drugs and sexual practices. The experiential learning of the early patient contact module provides the opportunity for some cultural differences to be discussed, adapted to by students and overcome in order to maximize learning and professional acculturation. Whereas some students perceived aspects of the local culture as interfering with their learning, most were able to reflect on the experience, determine how it was likely to influence their clinical experience in the future and develop means of overcoming these potential barriers. In doing so, it became clear that students in RCSI Bahrain experienced learning that went beyond that intended in the original learning outcomes. The anxieties experienced by students in Bahrain may have also exceeded those experienced in the same module in Ireland. It has been suggested that making expectations explicit reduces students’ fears (Ottenheijm et al. 2008) and as a result, the cultural learning and professional acculturation is now made explicit to students. The main language in Bahrain is Arabic but all medical school teaching is in English. Language barriers are therefore posed not only when patients struggle to communicate fluently in Arabic or English, but also when Arabic-speaking students are, for the first time, taking a medical history in Arabic that has been taught in English. The development of communication skills in a multicultural, multi-ethnic society in which half of the population is expatriate, largely from the Asian subcontinent, poses additional problems for students when language becomes a barrier. All such scenarios are not only bilingual but also bicultural (Haffner 1992). For some students their early clinical experience exposed them to the reality of their multinational society and the difficulties this will place when communicating with patients. It is difficult to exclude social desirability from these graded writing assignments. However, consideration of the local culture learning and issues of professional acculturation were not explicit requirements for the students in writing their assignments. In spite of this, these issues were a prominent theme throughout the student’s writing. Three intervention measures have been introduced in order to help the students overcome the challenges faced: (1) Making the cultural and language challenges more explicit to the students at the beginning of the module, in order that they are more prepared for these. Quotations from students in previous cohorts are extensively used and discussion of these encouraged. (2) Greater involvement of the Bahraini Family Physicians in encouraging the students into the local professional culture. Discussion of the challenges likely to be faced has been built into the learning outcomes for the Family Physician tutorials. 956
(3) A debrief session to discuss issues faced with the whole class. This builds confidence among the students in developing strategies for dealing with cultural issues in subsequent clinical experience.
Conclusion This study raises implications for both adaptation of curriculum into a different culture and professional acculturation in early clinical experience. Adapting an Early Patient Contact module developed in one culture into another culture can be a challenge and may lead to different ‘‘learning’’. Cultural norms should be taken into account in order to maximize learning outcomes and self-realization for all students. Modules intended for curriculum transfer would be best served by a group of ‘‘core’’ learning outcomes with ‘‘secondary’’ outcomes culturally appropriate to each site. Within the context of the Arab culture, this study suggests that early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.
Glossary Acculturation: A cultural learning process experienced by individuals who are exposed to a new culture or ethnic group. The psychology of ethnic groups in the United States. 2010. Chapter 4. San Francisco: Sage.
Notes on contributors DAVID WHITFORD, MD (Cantab), MA, MB BS, FRCGP, DRCOG, is a Professor of Family Medicine. He moved from Dublin to develop the community based teaching of a newly established RCSI Bahrain medical school. His research interests are in the fields of type 2 diabetes and the influence of family and peers on behavioural change. AMAL REDHA HUBAIL is a graduate of RCSI Bahrain and has now completed her internship in Bahrain. She was very research active as a medical student with 3 publications to date.
Acknowledgements We would like to thank the students who completed this course for their sincerity in their reflections. Declaration of interest: The authors report no declarations of interest.
References Bell K, Boshuizen HPA, Scherpbier A, Dornan T. 2009. When only the real thing will do: Junior medical students’ learning from real patients. Med Educ 43(11):1036–1043. Berry JW. 2008. Immigration, acculturation, and adaptation. Appl Psychol 46:5–34.
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Dornan T, Boshuizen H, King N, Scherpbier A. 2007. Experience-based learning: A model linking the processes and outcomes of medical students’ workplace learning. Med Educ 41(1):84–91. Dornan T, Littlewood S, Margolis SA, Scherpbier A, Spencer J, Ypinazar V. 2006. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. BEME Guide No 6. Med Teach 28(1):3–18. Haffner L. 1992. Translation is not enough: Interpreting in a medical setting. West J Med 157:255–259. Harden RM. 2006. International medical education and future directions: A global perspective. Acad Med 81:S22–S29. Holtbrugge D, Mohr AT. 2010. Cultural determinants of learning style preferences. Acad Manage Learn Educ 9(4):622–637, 9:622–637. Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. 2005. Early practical experience and the social responsiveness of clinical education: Systematic review. BMJ 331: 387–391. Mernissi F. 1987. Beyond the veil: Male-female dynamics in modern muslim society. Bloomington, IN: Indiana University Press.
Ottenheijm RPG, Zwietering PJ, Scherpbier AJJA, Metsemakers JFM. 2008. Early student-patient contacts in general practice: An approach based on educational principles. Med Teach 30:802–808. Rudmin FW. 2003. Critical history of the acculturation psychology of assimilation, separation, integration, and marginalization. Rev Gen Psychol 7:3–38. Smithson S, Hart J, Wass V. 2010. Students’ hopes and fears about early patient contact: Lessons to be learned about preparing and supporting students during the first year. Med Teach 32:e24–e30. Wenrich MD, Jackson MB, Wolfhagen I, Ramsey PG, Scherpbier AJ. 2013. What are the benefits of early patient contact? - A comparison of three preclinical patient contact settings. BMC Med Educ 13:80. Wildavsky B. 2010. The great brain race. Princeton: Princeton University Press. Yardley S, Littlewood S, Margolis SA, Scherpbier A, Spencer J, Ypinazar V, Dornan T. 2010. What has changed in the evidence for early experience? Update of a BEME systematic review. Med Teach 32(9): 740–746. Yardley S, Teunissen PW, Dornan T. 2012. Experiential learning: AMEE Guide No. 63. Med Teach 34:e102–e115.
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Cultural sensitivity or professional acculturation in early clinical experience? DAVID L. WHITFORD & AMAL REDHA HUBAIL Royal College of Surgeons in Ireland – Medical University of Bahrain, Kingdom of Bahrain
Abstract Aim: This study aimed to explore the early clinical experience of medical students following the adaptation of an Early Patient Contact curriculum from a European culture in Ireland to an Arab culture in Bahrain. Methods: Medical students in Bahrain took part in an Early Patient Contact module modelled on a similar module from a partner medical school in Ireland. We used a qualitative approach employing thematic analysis of 54 student reflective logbooks. Particular attention was placed on reflections of cultural influences of experience in the course. Results: Medical students undergoing this module received reported documented benefits of early clinical experience. However, students in Bahrain were exposed to cultural norms of the local Arab society including gender values, visiting the homes of strangers, language barriers and generous hospitality that led to additional challenges and learning for the medical students in acculturating to norms of the medical profession. Conclusion: Modules intended for curriculum adaptation between two cultures would be best served by a group of ‘‘core’’ learning outcomes with ‘‘secondary’’ outcomes culturally appropriate to each site. Within the context of the Arab culture, early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.
Introduction
Practice points
Early clinical experience within the medical curriculum has been shown to have benefits for medical students: motivating the students; improving confidence and self-awareness; improving communication and empathy with patients; and socializing the student towards their chosen profession, patients and society (Littlewood et al. 2005; Dornan et al. 2006; Dornan et al. 2007; Yardley et al. 2010, 2012). On the other hand, it may also generate feelings of inadequacy and fear, especially when students are underprepared (Smithson et al. 2010). Even when clear learning outcomes for early clinical experience are agreed, the attained learning may vary between individuals (Bell et al. 2009) and clinical settings (Wenrich et al. 2013). Cultural differences (values, attitudes and beliefs of a population) are known to determine some aspects of experience and learning in healthcare (Holtbrugge & Mohr 2010) and may be one factor in contributing towards variations in learning in early clinical experience. This can be particularly difficult to determine, particularly when other variables such as the module content may differ between medical schools. The globalization of higher education, including medical education, has continued to increase over the last decade (Harden 2006; Wildavsky 2010), making the assessment of cultural influences of learning more important. A new model in the international development of medical education has emerged fairly recently with the establishment of international
Adaptation of a curriculum for clinical modules from one culture to another can lead to additional challenges and learning for students Modules intended for adaptation between two cultures would be best served by a group of ‘core’ learning outcomes with ‘secondary’ outcomes culturally appropriate to each site The transfer of an early clinical experience module had the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures Integration of local and professional cultural norms should lead to improved professional acculturation in societies where the local culture may conflict with professional norms
campuses of existing medical schools. In this model, medical schools emphasize an international approach that involves mobility of teachers and students and the implementation of a curriculum that builds on exchanges between two or more countries (Harden 2006). The Royal College of Surgeons in Ireland – Medical University of Bahrain (RCSI Bahrain) was established in this way in 2004 and graduated its first cohort of doctors in 2010. RCSI Bahrain delivers the same curriculum
Correspondence: Professor David L. Whitford, Department of Family and Community Medicine, Royal College of Surgeons in Ireland – Medical University of Bahrain, PO Box 15503, Adliya, Kingdom of Bahrain. Tel: +973 17351450; E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/110951–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.910296
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module learning outcomes as the RCSI medical school in Ireland, with the teaching adjusted for local circumstances. This has created the opportunity to investigate the impact of learning in different cultural and clinical settings. We set out to examine early clinical experience in a group of medical students in RCSI Bahrain after implementing an Early Patient Contact module in Bahrain. We took a particular interest in the challenges posed to the students’ experience by the implementation of this module developed in a European culture in Ireland and adjusted for an Arabic culture in Bahrain.
Methods The Royal College of Surgeons in Ireland has a long association with postgraduate health care education in Bahrain and in 2003 was invited by the Bahrain government to establish a new medical school in Bahrain. RCSI Bahrain was established in 2004 as a medical school based in Bahrain offering the same curriculum as the RCSI campus in Ireland, with adjustments made to suit local circumstances. The student intake to the university is international with 50% being from Bahrain and the remainder from over 30 different countries worldwide (Box 1). The Early Patient Contact module was incorporated into the RCSI curriculum as a response to increasing evidence of the value of early clinical experience. It is delivered in the first semester of the second year of the five year medical programme and is organized by the Department of Family & Community Medicine. The module coordinator in Bahrain had previously delivered the module in Ireland. The Early Patient Contact module consists of several components (Box 2). The module allows the students to work both independently and within a small group. The learning outcomes of the Early Patient Contact Module are to: Demonstrate an understanding of the importance of establishing a professional relationship with a family and the issues of confidentiality Demonstrate an understanding of social determinants of health, cultural influences on health and the impact of a new baby on family structure, function and dynamics Demonstrate an understanding of the impact of disease, disability and addiction on an individual
Demonstrate an understanding of the evidence base surrounding the importance of communication skills Demonstrate the skills of opening a consultation with a patient Both the components and learning outcomes for the module are shared between Ireland and Bahrain. However, adjustments have been made in Bahrain for local circumstances. For example, RCSI Bahrain delivers more communications skills teaching in view of the fact that there are more students whose first language is not English. Assessment of the module is through a reflective logbook. This seeks information from the students on aspects of confidentiality, social determinants of health, child development and vaccinations. The majority of the logbook is a reflection on the experience of the student during the family study and the Health Care Symposia. For the purpose of this study, we took the anonymized logbooks of 54 students who had completed the module. We carried out a qualitative thematic analysis of the reflections contained in the logbooks. The two researchers read through all the logbooks and familiarized themselves with the data. The first 12 logbooks were analyzed by the researchers to identify key themes and sub-themes. We looked particularly for themes that arose from reflections of cultural influences of the students’ experience of the module. The emerging themes were discussed and agreed by the two researchers and further data from all the logbooks organized around these themes using NVivo software. The study was approved by the Research Ethics Committee of RCSI Bahrain.
Results Individual students expressed a wide range of cultural influences affecting their experience of the early patient contact module in RCSI Bahrain. Box 2. Content of the RCSI Bahrain early patient contact module.
Components of the RCSI Bahrain Early Patient Contact Module Box 1. Age and origin of students taking early patient contact module.
Age and origin of students taking Early Patient Contact module (n ¼ 54) Age at medical school entry 17/18 years 19 years 20/22 years 25 years
22 21 9 2
Country of origin Bahrain Other Arab countries North america Europe Asia
28 5 11 5 5
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2 Introductory lectures: * Introduction to the Early Patient Contact Module * Introduction to the Calgary Cambridge communication skills method 4 small group (10 students) videoed communication skills sessions led by Bahraini Family Physicians 4 symposia with patients lasting one hour each. During these symposia, students have the opportunity to hear, discuss and reflect on the experiences of patients who have a disease, addiction or disability. 3 tutorials with Bahraini Family Physicians in health centres (8–9 students in each group). Students discuss issues of confidentiality, communication, patient centredness and pregnancy with the Family Physician A family study of a woman who is pregnant including two home visits, one antenatal and one postnatal (2–3 students in group). Students obtain demographic, social, health and developmental information as well as observing human behavior and family dynamics in the context of an Arab society.
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Language
Gender
Non-Arabic speaking students make up about 20% of the student population. Language emerged as an important theme for many students, both Arabic and non-Arabic speaking, suggesting that the learning experience of the students was sometimes compromised. For non-Arabic speaking students, this was their first realization that language might be a barrier in medical consultations:
Gender separation in the Arab culture was the most expected cultural challenge for the medical students. As a result, some students were surprised that some people are very welcoming and open minded about this issue.
‘‘My colleagues helped translate for me, it could have been better if we had an English speaking patient as all of us could have been able to follow the conversation’’ (St 10) However, language also posed difficulties for Arabic speaking students who either had to concentrate on translating: ‘‘The lady could not speak English and the foreign girl (student) could not speak Arabic. I tried to translate but it was difficult. I could not translate, ask questions and write notes at the same time’’ (St 23) or who have become accustomed to using English and use Arabic only occasionally in daily conversation and were therefore not conversant in ‘‘medical Arabic’’: ‘‘The first problem I faced is taking history in Arabic and not in English. It took a lot of effort trying to translate the routine questions into Arabic especially the symptoms and asking for specific disorders which she may carry or runs in the family.’’ (St 54) Moreover, some patients didn’t speak either English or Arabic, leading to a realization of the language difficulties posed in a multi-cultural society: ‘‘Firstly we tried to talk in English with her but apparently she could not understand us so we switched to Arabic and even her Arabic was weak because she is from India’’ (St 37) Students also struggled to gain depth in their consultations when the patient had a poor grasp of the language. This created a barrier in the range of expression of thoughts and feelings that could be explored: ‘‘There were a language barrier between us and the lady because she was Indian. The lady answers were too short, for most of the questions her answers were: yes, no or I don’t know.’’ (St 6)
‘‘I am a boy with two girls so can I come with them? She said that I am her son and I am welcome to come’’ (St 47) ‘‘The visit was arranged with the husband and he was fine to have a male student visit them as long as he was present during the visit. I was aware that this is part of the culture of the region’’ (St 21) However, this posed major problems for students when husbands were very strict about gender separation: ‘‘She finally agreed to the visit. She said she would ask her husband and call me back. When she didn’t call me back a couple days later, I called her again and asked her if we could meet up with her. She said she couldn’t meet with us because there were males in my group.’’ (St 15) Some students were just as surprised that perceived cultural values were not adhered to: ‘‘The fact that the husband left us alone with his wife was shocking. This is because we were not only females but also we had a male. In our culture, usually when there are male visitors there must be a male in the house (especially if the visitors are strangers).’’ (St 13) Attitudes towards gender separation influenced the consultation experience for some students, particularly males: ‘‘When I saw her, it was awkward at first because she just said hello to the female in our group, but this was expected’’ (St 40) ‘‘According to our society and cultural issues; some of the boys didn’t have the chance to ask the patient about some sensitive pregnancy questions.’’ (St 1) Even when male students were fully accepted, the knowledge that gender is an issue in the culture may have affected their learning experience:
For many students, however, language posed no problem: ‘‘Both the mother and the father spoke English fluently; therefore we did not have any problems with communication’’ (St 5)
‘‘I was truly worried and nervous about the family’s reaction when it comes to a male student asking some of the sensitive questions’’ (St 24)
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Home visiting Home visiting a stranger is not the cultural norm in Bahrain and led to some increased anxiety among students that were exposed to it for the first time: ‘‘Before I went with my partner to the family I had a feeling of dread and uncertainty, because I was going to a home of people that I don’t know’’ (St 22) But the benefits were often recognized in retrospect after the experience: ‘‘Before starting this course I thought it was inappropriate to enter patients’ houses . . . during the course I have realized that visiting them in their house was extremely important because it gives me a clear insight of their current condition and life style and understand the patient as a human being.’’ (St 54)
Hospitality For many of the Arab students, ‘‘empty-handed’’ is not the norm:
entering
a
home
‘‘We had brought traditional Bahraini sweets with us, as it’s a custom not to visit a family’s house empty handed.’’ (St 34) Similarly hospitality towards the students was the norm: ‘‘Both the husband and wife (pregnant one) were very welcoming and nice. This made me more comfortable. The maid brought out tea, dates and sweets for us, as is the custom.’’ (St 22)
Societal awareness Many of the students were ‘‘naı¨ve’’ at the way families lived in what they considered a very prosperous country: ‘‘it was absolutely shocking to see the neighbourhood we were about to enter. I have lived in the Gulf for 20 years, and only was exposed to the comfortable, wealthy lifestyle where each family had several cars, maids, and lived in massive villas. Never have I seen such poverty levels in the Gulf region, and this experience definitely opened up my eyes to the reality of the world I live in.’’ (St 49)
‘naming ceremonies’ and the baby’s face being painted for the ceremony.’’ (St 38) ‘‘In Bahrain particularly, they believe that umbilical Hernia may be cured by placing a coin on the umbilicus for a period of time.’’ (St 10)
Anxiety Many of the students expressed considerable anxiety prior to their first visit: ‘‘I was feeling anxious to meet her and I have to say that I was feeling weird to be in this situation – meeting a strange lady in her own home and trying to break the ice’’ (St 42) Anxiety arose mostly because the students didn’t know what to expect: ‘‘We met the family - I was feeling anxious and a bit worried because I didn’t know what to expect, and when we were in their home at the beginning of the interview I was uncomfortable’’ (St 46) ‘‘I was very nervous and didn’t have a clue about how things would go.’’ (St 30) Anxiety also seemed to be greater in those who recognized the cultural norms: ‘‘To start with, this formed a concern for me, as I was not accustomed to discussing sensitive female issues around the opposite gender.’’ (St 3) ‘‘I think the reason behind my nervousness was that I am meeting new people from different culture, in strange and uncomfortable place’’ (St 10) But this soon settled, and by the second visit many of the students were feeling quite comfortable with their family: ‘‘After this second visit all of us felt comfortable with the family as if we knew them for a very long time’’ (St 35) The students recognized the impact this had on their communication and relationship with the patient: ‘‘By the end of the second visit, it was clear that we were very comfortable with each other and communicated well between ourselves’’ (St 44)
Health beliefs
Lack of confidence
The students came across some health beliefs that were new to them:
As this was a new experience for many of the students, they often expressed a lack of confidence in their ability:
‘‘The visits definitely gave us a great cultural experience as we were introduced to the concept of
‘‘All the negative thoughts are just popping up in my head, what if they weren’t comfortable with us? What
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if they didn’t like our questions? What if they refused to answer?’’ (St 5) ‘‘This was my first experience to meet a real patient. I was afraid about it. I kept saying what will I do? How will I react? What will they think of me? Can I ask the entire embarrassing questions about pregnancy?’’ (St 22)
Learning Overall, the experience was positively rated by the students and led to considerable learning (Box 3).
Discussion Analysis of the reflective logbooks from medical students undergoing the Early Patient Contact module at RCSI Bahrain suggest they undergo many of the benefits previously documented for early clinical experience (Littlewood et al. 2005) including reminding them of their vocation to be a doctor, increasing empathy with patients and family physicians, gaining confidence to carry out interviews, building selfawareness and responding to feelings of inadequacy, uncertainty and anxiety. However, delivering the Early Patient Contact module in Bahrain exposed the students to values, attitudes, beliefs and practices (i.e. the culture) of the local Arab society that led to challenges and learning for the medical students that were beyond the original learning outcomes. In particular, many students had to decide whether to challenge local cultural norms in order to learn and thereby acculturate to the norms of the medical profession. The study also raised implications for the adaptation of an Early Patient Contact module developed in one culture and delivered in another. The cultural issue that most challenged students experiencing the Early Patient Contact module was the societal attitude to gender. Women are often subordinate to men in Arab society (Mernissi 1987), and this is most pronounced in the Arabian Peninsula. Bahrain is more diverse than many of the surrounding countries in this regard, but this very diversity can pose a problem for medical students. In some households, gender equality is the norm and women occupy an equal place to the men. In other households, women are segregated and not encouraged to speak with, be in any form of physical contact with (e.g. handshake), or even be in the same room as men who are not family. This diversity led to some uncertainty and anxiety among male students prior to meeting the patient,
particularly as they might find out on arriving at the home that they could not gain access to the patient (although this had always been agreed in advance). Even if allowed access, a few male students were discouraged from speaking directly to a female patient or asking sensitive questions. Some students equally felt uncomfortable when their own cultural and social norms on gender were broken. A similar issue for many of the students was visiting the home of a person who is not known to them as this is considered culturally inappropriate within the society. A few students initially refused to carry out a home visit on the grounds that it was breaking their cultural norms. Others were very hesitant. Several students suggested changing the course such that male students would visit a male patient and female students a female patient and that all meetings with the patient would be restricted to health centers. This posed an interesting conflict in delivering the module. Should the medical school accede to the students’ request and redesign the early clinical experience to be more culturally sensitive to the students and society? Or should it encourage some cultural norms in society to be set aside in order to encourage the medical student to acculturate to their future professional role. The input from local Bahraini family physicians was invaluable in this respect. Clinical practice in Bahrain demands that doctors see patients of the opposite gender, ask sensitive questions, understand their family and social context, and clinically examine them. Professional acculturation is an important aspect of learning, and even more so when the local culture may militate against aspects of it. Strategies of acculturation have divided the ways in which individuals approach acculturation into four categories along two dimensions (Rudmin 2003). The first dimension concerns the retention or rejection of an individual’s native culture. The second dimension concerns the adoption or rejection of the host culture. From this, four acculturation strategies emerge (Berry 2008) (1) Assimilation occurs when individuals adopt the cultural norms of a dominant or host culture, over their original culture. (2) Separation occurs when individuals reject the dominant or host culture in favor of preserving their culture of origin. (3) Integration occurs when individuals are able to adopt the cultural norms of the dominant or host culture while maintaining their culture of origin. (4) Marginalization occurs when individuals reject both their culture of origin and the dominant host culture.
Box 3. Summary of learning experienced by students undertaking the RCSI bahrain early patient contact module.
Overall, the early clinical experience was positively rated by the students and led to considerable learning: ‘‘To begin with, and before the first visit, I had expected that the visits will not completely fulfil our purpose, since I had my mind fixed on the stereotype of our culture. I had expected that the couple might be secretive about declaring their personal information, and would be less open minded about discussing certain issues. However, by the third visit, their answers revealed that my expectations were completely false. I have come to realize that many people are more willing to share their experiences nowadays, and that they are more educated and well informed about medicine and science than they were before. This made me apprehend the fact that I should not jump into assumptions and formulate views about individuals in our society before getting to know them.’’ (St 34) ‘‘All three visits were an extraordinary experience. It helped me fine tune my communication skills. It has proven to me that a strong doctor-patient relationship can be irrefutably valuable. The adventure through the three sessions has helped me understand patient needs, emotions and physical fatigue during all three trimesters. It also allowed me to view the patient’s changing affection toward us.’’ (St 46)
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We would envisage that for medical students, the ideal is integration into the new culture of the host medical profession while maintaining their native Arab culture. The decision to encourage integration into the medical profession as an aspect of the early clinical experience was taken. In this way, the module would also prepare the students for some challenges that would inevitably be experienced later, e.g. male students needing to interact with female patients or students needing to ask questions about alcohol, drugs and sexual practices. The experiential learning of the early patient contact module provides the opportunity for some cultural differences to be discussed, adapted to by students and overcome in order to maximize learning and professional acculturation. Whereas some students perceived aspects of the local culture as interfering with their learning, most were able to reflect on the experience, determine how it was likely to influence their clinical experience in the future and develop means of overcoming these potential barriers. In doing so, it became clear that students in RCSI Bahrain experienced learning that went beyond that intended in the original learning outcomes. The anxieties experienced by students in Bahrain may have also exceeded those experienced in the same module in Ireland. It has been suggested that making expectations explicit reduces students’ fears (Ottenheijm et al. 2008) and as a result, the cultural learning and professional acculturation is now made explicit to students. The main language in Bahrain is Arabic but all medical school teaching is in English. Language barriers are therefore posed not only when patients struggle to communicate fluently in Arabic or English, but also when Arabic-speaking students are, for the first time, taking a medical history in Arabic that has been taught in English. The development of communication skills in a multicultural, multi-ethnic society in which half of the population is expatriate, largely from the Asian subcontinent, poses additional problems for students when language becomes a barrier. All such scenarios are not only bilingual but also bicultural (Haffner 1992). For some students their early clinical experience exposed them to the reality of their multinational society and the difficulties this will place when communicating with patients. It is difficult to exclude social desirability from these graded writing assignments. However, consideration of the local culture learning and issues of professional acculturation were not explicit requirements for the students in writing their assignments. In spite of this, these issues were a prominent theme throughout the student’s writing. Three intervention measures have been introduced in order to help the students overcome the challenges faced: (1) Making the cultural and language challenges more explicit to the students at the beginning of the module, in order that they are more prepared for these. Quotations from students in previous cohorts are extensively used and discussion of these encouraged. (2) Greater involvement of the Bahraini Family Physicians in encouraging the students into the local professional culture. Discussion of the challenges likely to be faced has been built into the learning outcomes for the Family Physician tutorials. 956
(3) A debrief session to discuss issues faced with the whole class. This builds confidence among the students in developing strategies for dealing with cultural issues in subsequent clinical experience.
Conclusion This study raises implications for both adaptation of curriculum into a different culture and professional acculturation in early clinical experience. Adapting an Early Patient Contact module developed in one culture into another culture can be a challenge and may lead to different ‘‘learning’’. Cultural norms should be taken into account in order to maximize learning outcomes and self-realization for all students. Modules intended for curriculum transfer would be best served by a group of ‘‘core’’ learning outcomes with ‘‘secondary’’ outcomes culturally appropriate to each site. Within the context of the Arab culture, this study suggests that early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.
Glossary Acculturation: A cultural learning process experienced by individuals who are exposed to a new culture or ethnic group. The psychology of ethnic groups in the United States. 2010. Chapter 4. San Francisco: Sage.
Notes on contributors DAVID WHITFORD, MD (Cantab), MA, MB BS, FRCGP, DRCOG, is a Professor of Family Medicine. He moved from Dublin to develop the community based teaching of a newly established RCSI Bahrain medical school. His research interests are in the fields of type 2 diabetes and the influence of family and peers on behavioural change. AMAL REDHA HUBAIL is a graduate of RCSI Bahrain and has now completed her internship in Bahrain. She was very research active as a medical student with 3 publications to date.
Acknowledgements We would like to thank the students who completed this course for their sincerity in their reflections. Declaration of interest: The authors report no declarations of interest.
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