letters to the editor Dealing with diversity: stepping backwards to see the whole picture Karen M Stegers-Jager1 & Axel P N Themmen1,2 Editor – As the authors of ‘Dealing with diversity in medical education’,1 we thank Mohammad Ali and Mohammed Halim2 for their recent contribution to the debate on diversity in this journal.

centredness in our students, it will be necessary to take the diversity of the student body into account as ethnic differences in student attitudes regarding patient-centredness have been found.4

Ali and Halim2 argue that, irrespective of the diverse backgrounds of students and patients, medical schools should not make ‘wholesale institutional change to accommodate minority students in terms of course content and assessment methods nor abandon a patient-centred approach’.

Ali and Halim2 also argue that a universal method of assessment and examination cannot be avoided, but we wonder what the reference standard would be given that even within Western Europe, differences exist in doctor–patient communication.5 Furthermore, our own research has shown that Western minority students (originating from Belgium, Germany, the UK, the USA, etc.) also achieve lower clinical grades than their Dutch counterparts.6 We don’t think this is because their communication skills are worse; we think it is because they just use different communication styles. We expect that Dutch students might similarly perform less well in other Western countries!

We agree that the aim should be to train patient-centred doctors. In our opinion, and that of others, this does not mean that one must, as a doctor, share all information and all decisions with the patient.3 Patient-centredness is actually about taking into account the needs, beliefs and cultures of individual patients. Therefore, we would like to stress again that there is a need for all students to develop a wider repertoire of communication styles in order to meet the needs of a diverse patient population. In the training of this patient1 Institute of Medical Education Research Rotterdam (IMERR), Erasmus MC, Rotterdam, The Netherlands 2 Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands

Correspondence: Karen M Stegers-Jager, Institute of Medical Education Research Rotterdam, Erasmus MC, Room AE-241, PO Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 10 7038123; E-mail: [email protected] doi: 10.1111/medu.12610

According to Ali and Halim,2 the aim should be a healthy process of integration, and we cannot but agree with them. In line with a recent paper by Tienda, we would like to stress that in order to promote integration, medical schools will have to organise ‘meaningful social and academic interactions among students who differ in their experiences, views and traits’.7 Put differently, it is not enough to have a diverse student population; we must help students to ‘inhibit their natural tendencies to sort into homogeneous niches’7 and not to

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retreat to ‘islands of comfortable consensus’.8 Only then will it be possible to achieve the broader social goal of inclusion and to reap the educational benefits of a diverse student population in preparing our future doctors for an increasingly diverse patient population.

REFERENCES 1 Stegers-Jager K, Themmen A. Dealing with diversity in medical education. Med Educ 2013;47:752–4. 2 Ali MA, Halim MU. Recent ideas on ethnic diversity in medical education: one step forward, two steps back? Med Educ 2014;48:451. 3 Stewart M. Towards a global definition of patient centred care. BMJ 2001;322 (7284):444–5. 4 Hauer KE, Boscardin C, Gesundheit N, Nevins A, Srinivasan M, Fernandez A. Impact of student ethnicity and patientcentredness on communication skills performance. Med Educ 2010;44:653–61. 5 van den Brink-Muinen A, Verhaak PFM, Bensing JM et al. Communication in general practice: differences between European countries. Fam Pract 2003;20 (4):478–85. 6 Stegers-Jager KM, Steyerberg EW, Cohen-Schotanus J, Themmen APN. Ethnic disparities in undergraduate pre-clinical and clinical performance. Med Educ 2012;46:575–85. 7 Tienda M. Diversity not equal inclusion: promoting integration in higher education. Educ Res 2013;42:467–75. 8 Haring-Smith T. Broadening our definition of diversity. Liberal Educ 2012;98:6–13.

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