1. CULTURAL ISSUES DR LIZ SPENCER

2. CONSIDER SOMEONE YOU KNOW WELL FROM ANOTHER BACKGROUND Family brothers / sister - are they youngest / oldest rich / poor – if rich earned or inherited education – what sort of school, normal, usual attainment Career Why are they medic, are family medics, choice or expectation What are their drivers – money, status, prestige, personal Culture What does she think about your culture What annoys her / is her culture ahead of yours – in what way What is cultural synergy – does she believe in cultural synergy

3. CROSS-CULTURAL COMMUNICATION NANCY ADLER Communication is any behaviour that another human perceives and interprets. Verbal & non-verbal Complex multilayered dynamic process through which we exchange meaning sender receiver

4. CROSS-CULTURAL MISPERCEPTION Perception is selective Perception is learned Perception is culturally determined Perception tends to remain constant We see things that do not exist We do not see things that do exist

5. DEFINING CULTURE “learned patterns of thinking, feeling and acting” “the way we do things around here” “acquired knowledge that people use to interpret experience and generate social behaviour. This knowledge forms values, creates attitudes and influences behaviour

6. 4-6 Priorities of Cultural Values

7. ETHNICITY Ethnicity implies one or more of Shared origins or social background Shared culture and traditions that lead to sense of identity/group A common language or religious tradition Ethnic minority – a group of people differentiated from the rest of the community by racial origins or cultural background and usually claiming or enjoying official recognition of their group identity OED Races are difficult to define and there are no objective rules for deciding what constitutes a race or to what race a person belongs Malik

8. ASME SEMINAR – 22 NOV 2010 The role of cultural issues in medical education

9. UK CENSUS White Mixed Asian Black Chinese Other All non-white categories into single minority ethnic (ME) category

10. PROPORTION OF ME MEDICAL STUDENTS 32% acceptances in medicine & dentistry 20% in other undergraduate courses Varies between medical schoolsUCAS 2009 Meta-analysis between ethnicity & performance 15 studies from 10 English medical schools ME significantly underperformed in UG exams Significant difference in machine-marked tests as well as face to face Woolf Potts McManus in press BMJ

11. POSSIBLE FACTORS ME applicants had lower UCAS score & lower A level grades Social – parents occupation & education, english as first language, living at home, school attended Psychological – study habits, personality, motivation, stress Dr Katherine Woolf, Lecturer in Medical Education UCL Questionnaire study for PhD

12. Summary of questionnaire study Exam scores psychological and demographic factors ethnicity ?

13. STEREOTYPES Categorisation that organises our experience Never describes individual behaviour Helpful as allows people to understand & act appropriately to new situations Consciously held – group norm NOT individual Descriptive not evaluative – not good or bad Accurate & best guess – for group Modified – with experience Effective managers alter their stereotypes to fit actual people

14. Stereotype threat (Steele & Aronson, 1995)  Pervasive negative stereotypes of particular groups exist (e.g. black people are less intelligent; women are bad at maths)  Group members worry that if they perform poorly in tests they will confirm stereotype  Results in psychological ‘threat’  If too severe, threat can undermine performance Joshua Aronson Claude M Steele

15. Most ME medical students are Asian  Do negative stereotypes exist about this group?

16. Yes. Negative stereotyping of Asian medical students exists (Woolf, Cave, Greenhalgh, Dacre, 2008)

17. Stereotypical Asian medical student perceived by many teachers and students as:  Pushed into medicine by parents  Over-reliant on book learning  Poor at communicating with patients  Too quiet in class  Stereotype threat feasible

18. HOFSTEDE’S CULTURAL DIMENSIONS 1.Power distance 2.Uncertainty avoidance 3.Individualism/collectivism 4.Masculinity/femininity

19. HOFSTEDE’S CULTURAL DIMENSIONS Power distance: Less powerful members accept that power is distributed unequally High power distance countries: people blindly obey superiors; centralized, tall structures (e.g., Mexico, South Korea, India) Low power distance countries: flatter, decentralized structures, smaller ratio of supervisor to employee (e.g., Austria, Finland, Ireland)

20. HOFSTEDE’S CULTURAL DIMENSIONS Uncertainty avoidance: people feel threatened by ambiguous situations; create beliefs/institutions to avoid such situations High uncertainty avoidance countries: high need for security, strong belief in experts and their knowledge; structure organizational activities, more written rules, less managerial risk taking (e.g., Germany, Japan, Spain) Low uncertainty avoidance countries: people more willing to accept risks of the unknown, less structured organizational activities, fewer written rules, more managerial risk taking, higher employee turnover, more ambitious employees (e.g., Denmark and Great Britain)

21. HOFSTEDE’S CULTURAL DIMENSIONS Individualism: People look after selves and immediate family only High individualism countries: wealthier, protestant work ethic, greater individual initiative, promotions based on market value (e.g., U.S., Canada, Sweden) High collectivism countries: poorer, less support of Protestant work ethic, less individual initiative, promotions based on seniority (e.g., Indonesia, Pakistan)

22. HOFSTEDE’S CULTURAL DIMENSIONS Masculinity: dominant social values are success, money, and things High masculine countries: stress earnings, recognition, advancement, challenge, wealth; high job stress (e.g., Germanic countries) High feminine countries: emphasize caring for others and quality of life; cooperation, friendly atmosphere., employment security, group decision making; low job stress (e.g., Norway)

23. Iran The first time my American professor told me “I don’t know the answer” I asked myself “why is he teaching me?” In my country a professor would give the wrong answer rather than admit ignorance.

24. Trainee was receiving poor evaluations on her ability to make decisions in a clinical setting. Her poor performance was not due to lack of knowledge but the result of her discomfort in offering her opinion to a more senior physician

25. A foundation trainee failed to arrange or attend any appraisal meetings with her educational supervisor. After 6 months he contacted the FP Director. She had not met with her educational supervisor because it would be inappropriate for her to be alone in a place with a male that was not her husband.

26. Cultural Issues in Medical Learner Evaluation Michael Fitzgerald Open Medical Education Journal 2009;2:57-63 Increase awareness in medical teachers Ensure learner clearly understands what is expected of them & how performance will be evaluated Regular review of evaluation systems to look for differences in learners with different cultural beliefs