The conceit of curriculumCynthia Whitehead, Ayelet Kuper & Fiona Webster

Prescriptions for curricular reformabound in the medical educationliterature. As a community of edu-cators, we delight in dialogue andreflection on our curricular exper-iments. This makes good sense, forif we can find more interesting,efficient or relevant ways to helpour trainees to develop into com-petent professionals, we obviouslywant to do so. The author of thearticle ‘Improving cultural compe-tence education: the utility of anintersectional framework’,1 pub-lished in this edition of the journal,contributes to robust curriculumdevelopment with her recognitionof the need for theoreticallyderived curricula in the area ofcultural competence. Powell Sears1

examines the introduction of cul-tural competence education in USmedical schools. She notes thatstudies of cultural competenceprogrammes have as yet demon-strated little positive impact. Lim-ited success to date, she suggests,relates to the use of overly simplisticapproaches to culture. She pro-poses that the failure to recogniserace as but one of many possiblesocially constructed aspects ofidentity contributes to the repro-duction of stereotypes. PowellSears1 advocates the use of theintersectional framework to provide

medical trainees with a moresophisticated understanding ofhow patients occupy various sociallocations.

Studies of cultural competence pro-grammes have as yet demonstrated little

positive impact

The use of theory in this article1 isto be lauded and reflects growingrecognition of the importance oftheory-informed curricula.2–4 Inparticular, this article1 addressesintersectionality, which is generallyregarded as both a theory and aresearch method.5,6 Historically,the recognition that we all holdmultiple social locations served tocontest the essentialism thatunderpinned many radical andliberal feminist theories of women’soppression.7 Use of the intersec-tional framework has the potentialto add richness to medical trainingin the area of cultural competenceto provide a sense of the nuancesand complexities of identity. Wewould only add to Powell Sears’argument1 a caution against inad-vertently creating a hierarchy ofoppression whereby someone’smembership of multiple margina-lised groups might be added up inan almost linear way to elucidatethe limits of any individual’s lifechances. Instead, it is important toemphasise that complexities ofidentity are neither static nor tem-porally fixed. Moreover, under-standing the features of a patient’smultiple identities will not in itselfconfer understanding of thatpatient’s experiences or risks, norimprove health outcomes.

The use of theory reflects growingrecognition of the importance of

theory-informed curricula

We find it interesting that evenauthors who embrace a socialscience-derived theoreticalapproach to curriculum designuse the language of change in theoutcomes of health systems as ameasure of the curricular interven-tion. To us, this resonates with thedegree to which the medicaleducation community, perhapsunthinkingly, adopts clinicallanguage and standards in its edu-cational work. As we all know, it iscommonplace in the medical edu-cation literature to find assertions(or, at least, statements of hope)that a new curricular model or ideawill make a significant difference tohealth outcomes. However, we mustput curriculum, particularly formalcurricular innovations, into properperspective. Exactly how much canwe expect our new approaches toaffect how our trainees practise andthink? And how much can we hopethat these curricular interventionsin and of themselves will bringabout improvements in healthoutcomes?

The medical education community,perhaps unthinkingly, adopts clinical

language and standards in itseducational work

Recently, some researchers havestarted to question and analysesuch educational claims. Monrouxeand Rees,8 for example, most

commentaries

Toronto, Ontario, Canada

Correspondence: Cynthia Whitehead,Department of Family and CommunityMedicine, Faculty of Medicine, University ofToronto, Room 510, 263 McCaul Street,Toronto, Ontario, M5T 1W7, Canada.Tel: 00 1 416 978 0710; Fax: 00 1 416978 3912; E-mail: cynthia.whitehead@utoronto.ca

doi: 10.1111/j.1365-2923.2012.04245.x

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appropriately have taken the med-ical education community to taskfor trying to fit medical educationresearch into a biomedical re-search paradigm (which expectspractical patient care outcomes)rather than embracing a socialscience approach, commentingthat although the attempted linksto ‘hard’ medical science areunderstandable in a world of cli-nicians, the biomedical model isalso taken up as a rhetorical posi-tioning device in an attempt toclaim legitimacy in the medicalenvironment. Monrouxe and Rees8

cogently argue that this position-ing actually constrains medicaleducation research as it leads to afocus on practical individual andlocal interventions and limitsattention to theory-driven, socialscience approaches.

How much can we expect our newapproaches to affect how our trainees

practise and think?

Even in areas in which outcomemeasures are deemed possible, thespecific effects of educationalendeavours can be extremely hardto ascertain. Wong et al.,9 forexample, performed a systematicreview of the literature on qualityimprovement (QI) and patientsafety curricula. They concluded:‘…improving patient outcomes asa result of educational efforts rep-resents a particularly dauntingtask, given that intensive, large-scale QI efforts often fail to dem-onstrate improvements in healthoutcomes.’9 If it is daunting todemonstrate this effect in thecontext of QI, which focuses onidentifying and measuring desiredpractice changes, how much moredifficult will it be to do so in areassuch as cultural competence,which defies easy definition andmeasurement?

Improving patient outcomes as a result ofeducational efforts represents a particu-

larly daunting task

Monrouxe and Rees’8 2009 articleprovides one compelling argumentfor our tendency to use high-stakesoutcomes language in promotingnew curricula. We propose thatthere are several other possiblecontributors. Because much workby doctors is performed within abiomedical framework, it is com-fortable to fit curricula into suchtaken-for-granted ways of thinking.The need to ‘sell’ curricula alsoresonates in a health care systemthat increasingly embraces businessmodels and emphasises the need toappear ‘accountable’ to govern-ment funders and medical faculties.Further, we should not ignore thepossibility that hubris may, in part,lead us to make such claims. Arro-gance about our potential to shapeour trainees and health systemsthrough our curriculum contentand design will not serve us well as acommunity of educators. This con-ceit seems to be particularly pre-valent in medical education. Legaleducators, for example, do notclaim that curricular reforms in lawschool will create more just socie-ties. However, even if curricularclaims stem from a desire to ‘mea-sure up’ to clinical standards, thesuggestion that medical educationcan fix society diverts attentionfrom structural societal inequities.

Arrogance about our potential to shapeour health systems through our curricula

will not serve us well

If tinkering with curriculum will dothe trick, there is no need toactually attend to serious socialconcerns. For example, in Canada,where we live, we know compas-

sionate and caring doctors whoprovide medical care on indige-nous Canadian reserves. Somemake regular trips from theirhomes in large cities to spendweeks each year working in suchunderserved areas. If we were toteach cultural competence usingthe intersectional framework, thesedoctors might communicate betterwith aboriginal patients and havebetter insight into the array offactors that add to their life chal-lenges. Although this type ofunderstanding is extremely impor-tant, the intersectional framework,just like any other curricularenhancement, will do little to ad-dress issues of poverty, addiction,lack of running water and inade-quate housing that infuse the fabricof reserve life and surely cannot befixed by compassionate care. Norwould it correct the structuralinequities that make it nearlyimpossible for the residents ofthose reserves to become doctorsthemselves and advocate for thehealth needs of their own commu-nities.

The suggestion that medical educationcan fix society diverts attention from

structural societal inequities

What claims can we then reasonablymake for curricula? We certainly donot think that curricular contentand curricular design are irrele-vant. Anatomy lectures and cadaverdissection give trainees insight intothe structure of the human body.A curricular focus on the socialdeterminants of health will ensuretrainee awareness of these factors.Specific skills training may makeindividual doctors better commu-nicators or advocates. These are allhighly desirable aspects of medicallearning. However, no matter howmuch we are able to instil particularknowledge, skills and values in

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individual trainees, these dedicatedyoung practitioners go out to trainand then work in institutions thatare shaped and governed by polit-ical, social and economic forces.Curriculum may be able to makeindividuals more aware of some ofthe forces at play; it cannot, how-ever, shift inequities that are sys-temic. As medical educators, weneed to be aware of the types ofinstitutional change that are actu-ally required to achieve the im-proved health outcomes we claimto be trying to accomplish throughour curricular innovations. Wemust take care not to suggest thatthe ills of society can be cured bymedical curricula. Our curricularreforms will be more appropriateand more honest if we only expect

of them what they can actuallyaccomplish.

REFERENCES

1 Powell Sears K. Improving culturalcompetence education: the utility ofan intersectional framework. MedEduc 2012;46:545–51.

2 Hodges BD, Kuper A. Theory andpractice in the design and conductof graduate medical education. AcadMed 2012;87 (1):25–33.

3 Eva KW, Lingard L. What’s next?A guiding question for educa-tors engaged in educationalresearch. Med Educ 2008;42(8):752–4.

4 Albert M, Hodges B, Regehr G.Research in medical education:balancing service and science. AdvHealth Sci Educ Theory Pract 2007;12(1):103–15.

5 Tsouroufli M, Rees CE, MonrouxeLV, Sundaram V. Gender, identitiesand intersectionality in medicaleducation research. Med Educ2011;45 (3):213–6.

6 Morris M, Bunjun B. Using Intersec-tional Feminist Frameworks in Research.Ottawa, ON: Canadian ResearchInstitute for the Advancement ofWomen 2007;1–9.

7 Chantal M. Feminism, citizenship, andradical democratic politics. In: LindaJN, Steve S, eds. Social Post-modernism: Beyond Identity Poli-tics, UK: Cambridge University Press1995;315–29.

8 Monrouxe LV, Rees CE. Picking upthe gauntlet: constructing medicaleducation as a social science. MedEduc 2009;43 (3):196–8.

9 Wong BM, Etchells EE, Kuper A,Levinson W, Shojania KG. Teachingquality improvement and patientsafety to trainees: a systematic review.Acad Med 2010;85 (9):1425–39.

Broadening our perceptions of diversity in medicaleducation: using multifocal lensesMichelle McLean

Monday, 5 December 2011, 08.30 hoursBrisbane local time. My first day at anew university, jet-lagged from a 14-hour flight from the Middle East2 days earlier. To ensure that I hitthe ground running, Outlook Ex-press was up and operating. Apartfrom the usual backlog of universitycommuniques, an e-mail from KevinEva inviting me to submit a com-mentary to Medical Education was oneof the first messages to arrive. Anarticle entitled ‘Improving cultural

competence education: the utility ofan intersectional framework’ fol-lowed shortly.1 As I am not involvedin health care research per se, thisframework was new to me. As I readthe article, which provided exam-ples of how the inter-relatedness ofmany variables such as sexuality,race and socio-economic status canimpact on health and illness, itbecame apparent that this frame-work has potential in the teachingand learning context.

Intersectionality, as a perspective,concept, lens, theory, paradigm orframework,2 has been described as:‘the entanglement of identity cate-gories that make up an individual,the different attributions of powerthat result from such variedconfigurations, and the need to

view intersectional beingsholistically rather than try to teaseapart different strands of identity.’3

Arising from post-colonialfeminism and other criticaltheories, intersectionality repre-sents a paradigm shift in the waypeople should be viewed. Instead ofperceiving social locations such asrace and gender as separate enti-ties, intersectionality examines theinter-relatedness of social relations,incorporating many constructedidentities such as sexuality, socio-economic status and ‘ableness’.2

Being ‘intersectionally competent’would therefore require doctors(and teachers, in the educationalcontext) to understand the inter-action of the broad social catego-ries (often related to power) thathave a patterned impact on the

Brisbane, Queensland, Australia

Correspondence: Michelle McLean, Faculty ofHealth Sciences & Medicine, BondUniversity, Gold Coast, 4229, Queensland,Australia. Tel: 00 61 7 5595 1584; Fax: 00 61 75595 4122; E-mail: mimclean@bond.edu.au

doi: 10.1111/j.1365-2923.2012.04215.x

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commentaries