The Implications of Culture in the Education and Practice of Healthcare Professionals

1Judy McKimm & 2Hiroshi Nishigori

1Strategic Educational Development, Swansea University Medical School, Swansea University, United Kingdom; 2Center for Medical Education, Nagoya University Graduate School of Medicine, Japan


It has been a pleasure for us to act as guest editors for this themed issue on the Implications of Culture in the Education and Practice of Healthcare Professionals. We thank the TAPS Editorial team, our reviewers, and authors for all their hard work and patience and we hope you enjoy this varied issue with articles from around the region, and the world.

Original Articles

Exploring factors that motivate and influence medical students to attend medical school

Tari Stowers1, Mataroria P. Lyndon2,3, Marcus A. Henning2, Andrew G. Hill3,4& Melinda Webber5

1Faculty of Education, The University of Auckland, New Zealand; 2Centre for Medical and Health Sciences Education, The University of Auckland, New Zealand; 3Counties Manukau District Health Board, New Zealand; 4South Auckland Clinical Campus, The University of Auckland, New Zealand; 5Te Puna Wānanga/School of Māori and Indigenous Education, The University of Auckland, New Zealand


Introduction: This study explored motivation among a cohort of New Zealand medical students from The University of Auckland. The research questions were: 1) What motivates students to attend medical school? 2) What are the values, beliefs or cultural practices that influence students’ decisions to go to medical school? 3) How do students’ families influence their decisions to go to medical school?

Methods: Twenty medical students from The University of Auckland in Years Two and Five of a Bachelor of Medicine and Bachelor of Surgery (MBChB) degree participated in semi-structured focus group interviews. Two cohorts of medical students were involved, Māori and Pacific Admission Scheme students (MAPAS), and non-MAPAS students. An interpretive methodology was used, and data analysed using thematic analysis.

Findings: This study found both MAPAS and non-MAPAS students have intrinsic and extrinsic motivation to attend and continue medical school. However, the non-MAPAS students had more individualised motivations to study medicine whereas the MAPAS students were more motivated by collectivism. Family and cultural customs influenced MAPAS students’ motivation to study medicine. Non-MAPAS students were influenced by positive school experiences.

Common to both cohorts was the significant influence of family. Non-MAPAS students specified family members’ professions and educational support as influencing factors. In contrast, MAPAS students identified being motivated to study medicine to improve the financial and health situations of their families.

Conclusion: All students have different motivations for attending medical school which is influenced by their culture and environment. Culture encompasses the individual and their family, inclusive of ethnicity, beliefs, values and behaviours. Family plays a crucial role in motivating and influencing students to pursue medicine.

Keywords:         Motivation, Medical Students, Culture, Indigenous, Ethnic Minority

Integrating cultural awareness into busy residency training – What could work?

Cristelle Chow1, Raveen Shahdadpuri& Fred Stevens2

1KK Women’s and Children’s Hospital (KKH), Singapore; 2School of Health Professions Education, Maastricht University, The Netherlands


Introduction: Provision of culturally sensitive healthcare improves patient-clinician relationships and health outcomes. However, traditional cultural competence training may inadvertently reinforce racial and ethnic biases and can be challenging to implement into busy residency programs. This study aimed to contribute evidence-based recommendations for cultural awareness training to be integrated into existing residency programs, to promote holistic and longitudinal learning of cultural awareness.

Methodology: This was a qualitative study of healthcare staff and patient experiences within a culturally diverse population and cultural awareness issues that arise in a tertiary academic paediatric hospital. Nineteen participants (six residents, four faculty, four nurses and five caregivers) were purposefully sampled and underwent semi-structured individual interviews. Transcribed interviews were analysed for emerging themes.

Results: From a multi-faceted perspective, cultural awareness issues that emerged included: 1) addressing the tension between residents’ instrumental and expressive behaviour in patient care, 2) cultural and ethnic bias of caregivers towards doctors, 3) residents’ concerns about difficult patients, 4) understanding patients’ perspectives and 5) bias within inter-professional relationships. As expected, residents’ learning experiences about cultural awareness occurred through on-the-job learning rather than formal curricula.

Discussion: Resource-intensive cultural competency curricula may not always be feasibly integrated into busy residency programs. However, some practical methods to facilitate longitudinal workplace-based learning of cultural awareness include: 1) firm and transparent hospital policies against discrimination and engaging residents into developing such policies, 2) faculty development and leadership training on cultural sensitivity and supporting victims of discrimination, 3) incorporating cultural sensitive communication into assessment methods, 4) utilising patients as educators and 5) ensuring inter-professional team diversity.

Keywords:         Cultural Awareness, Professionalism, Postgraduate

A two-edged sword: Narrative inquiry into Japanese doctors’ intrinsic motivation

Hiroshi Nishigori1, Tomio Suzuki2, Tomoko Matsui3, Jamiu Busari& Tim Dornan5

1Centre for Medical Education, Nagoya University Graduate School of Medicine, Japan; 2Department of General Medicine, Osaka Medical College, Japan; 3Department of General Medicine, Nagoya University Graduate School of Medicine, Japan; 4Educational Development and Research Department, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands; 5Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, United Kingdom


Introduction: Although retaining a healthy and motivated medical workforce is becoming an intractable problem, the intrinsic motivation that keeps doctors working for patients remains under-investigated. The 2011 Tōhoku earthquake and tsunami provided a unique opportunity for culturally situated research into doctors’ intrinsic motivation. The purpose of this study was to answer the research question: what motivates doctors to work for patients above and beyond expectations?

Methods: This paper reports a qualitative inquiry informed by semi-structured individual interviews with 15 Japanese doctors who had joined disaster relief activities, which uses the Bushidovirtue code as a conceptual framework. The authors read transcripts repeatedly and conducted a cross-case analysis to identify final themes and illustrative narratives.

Results: A young doctor wanted to learn by testing out his capabilities. A senior doctor yearned to be of value to others. Other participants told how identifying with victims motivated them. There were negative as well as positive motivations, exemplified by a participant whose sense that well-educated people had a duty to help was coupled with a wish to avoid being blamed by others.

Discussion: Volunteering met participants’ needs for self-esteem by restoring their relationships with patients to ones in which they had some measure of control. But avoiding being blamed or losing Meiyo(Honour) also motivated physicians to volunteer. Reinforcing the satisfaction of a job well done may help offset the lack of control, guilt, and shame that too easily results from the relentless pressures of workload and external accountability in today’s healthcare systems.

Keywords:         Burnout, Bushido, Guilt, Intrinsic Motivation, Narrative Inquiry, Professionalism, Self-esteem

Teaching the generalisable skills of cultural competency: A new educational intervention in New Zealand

Katharine D. Thomas1& Susie Schofield2

1Department of Family Medicine, Sackler Faculty of Medicine, Tel Aviv University, Israel; 2Centre for Medical Education, University of Dundee, United Kingdom


Context: In the twentieth century “cultural” courses in medical education focused on imparting knowledge about ethnic and racial minorities. A new consensus has developed that emphasises a broader definition of culture: education should promote generalisable skills enabling effective interactions with all patients in our culturally complex world. In New Zealand, cultural competency is frequently taught within courses on the indigenous Māori people. This study evaluated whether a generalisable cultural competency intervention was acceptable and effective in this setting.

Methods: A generalisable cultural competency workshop was run for 17 general practitioners. A self-assessment questionnaire was completed by attendees and by a control group of 19 GPs. Participants provided feedback during the seminar and through standardised evaluation forms. Four medical education professionals were interviewed to explore their views on cultural competency education. The interviews were transcribed and thematically analysed.

Results: The questionnaires showed a non-significant, post-seminar increase in total cultural competency score by the seminar participants as compared with the control group (p= .33). Feedback was positive, with all respondents considering the seminar relevant to their needs. The interviewees supported generalisable cultural competency but lacked consensus around whether it should stand-alone or be embedded in ethnically-focused education.

Conclusions: This pilot study shows that participants found generalisable cultural competency education acceptable and that they perceived an improvement in their skills. Medical educators disputed the role of generalisable cultural competency. Further research is needed into how it can be utilised in New Zealand.

Keywords:         Medical Education, Cultural Competency, Physicians

Sinhala as the medium of instruction in medical education: Perception of medical students in Sri Lanka

Thilanka Seneviratne1, Kosala Somaratne2, Deelaka Bandara1, Vindya Alahakoon1, Dilan Bandara1, Randima Munasinghe1, Nabil Ilyas3, Thilini Subasingha4& P. V. R. Kumarasiri5

1Department of Pharmacology, Faculty of Medicine, University of Peradeniya, Sri Lanka; 2Base Hospital, Rikillagaskada, Sri Lanka; 3Teaching Hospital, Peradeniya, Sri Lanka; 4Lady Ridgeway Hospital, Colombo, Sri Lanka; 5Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka


Introduction: English is the medium of instruction in the medical faculties in Sri Lanka, although the majority of the students who admit to the medical faculties completed their secondary school education with Sinhala as their first language. This disparity presents a potential barrier to their assimilation of knowledge in medical education.

Objective: To assess the medical students’ perception of the medium of instruction in medical education.

Method: The medical students of the Faculty of Medicine, University of Peradeniya, Sri Lanka, enrolled from 2013 to 2017, whose first language is Sinhala were included in the study. Perceptions about the medium of instruction in medical education were assessed through an anonymous self-administered questionnaire, which used a five-point Likert scale for responses.

Results: From the total of 837 medical students, 665 (79.5%) participants had studied the General Certificate of Education – Ordinary Level (GCE O/L) in Sinhala and 172 (20.5%) in English. Eighty-eight percent (87.8%) had obtained an “A” grade for English Language in the GCE O/L examination. Over half (53.4%) of students responded that if medical textbooks were available in Sinhala, it would have increased their understanding of medical concepts. Nearly two-thirds (61%) responded that they perceived their performance in clinical examinations would have improved if those were carried out in Sinhala.

Conclusion: The findings reveal the positive perception of students towards using their first language in medical education. Specifically, students feel that concepts of medicine would be better understood if medical textbooks were available in Sinhala and that they could have performed better if examinations were done in Sinhala, their first language.

Keywords:         Mother Tongue, Native Language, First Language, Sinhala, English, Medical Education

Patients’ decision-making in the informed consent process in a hierarchical and communal culture

Astrid Pratidina Susilo1, Brahmaputra Marjadi2,3, Jan van Dalen4& Albert Scherpbier4

1Faculty of Medicine, University of Surabaya, Indonesia; 2Faculty of Medicine, Universitas Wijaya Kusuma Surabaya, Indonesia; 3School of Medicine, Western Sydney University, Australia; 4Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands


Objective: To investigate patients’ decision-making in the informed consent process in a hierarchical and communal culture.

Methods: This qualitative study took place in an Indonesian hospital and was conducted in line with the Grounded Theory approach. Fifteen patients and twelve family members were interviewed to understand the patients’ decision-making process and factors that contributed to this process. Interview transcripts were analysed using the constant comparison method.

Results: Patients used information to develop an explanation of their illness and treatment. They consented to a medical procedure if information from their physicians matched their own explanation. An increasing severity of the disease urged patients to decide, even when a satisfying explanation had not been developed. A hierarchical relationship between physicians and patients hampered patients’ discussing concerns or sharing emotions with their physicians. To maintain a harmonious relation with their physicians, patients accepted that some questions remained unanswered even after a decision had been made.

Conclusion: The strong hierarchical and communal context added to the complexity in the physician-patient relationship and consequently influenced patients’ decision-making. In addition to strengthening physicians’ communication skills, involving other health professionals as patient advocates or mediators is recommended to ensure patients make voluntary and informed decisions.

Keywords:         Decision-making, Informed Consent, Hierarchical Culture, Communal Culture, Grounded Theory

The hidden curriculum in peer-assisted learning: An exploration of case discussions and journal clubs at a Thai medical school

Amnuayporn Apiraksakorn& Stella Howden2

1Khon Kaen Medical Education Centre, Khon Kaen Hospital, Thailand; 2Centre for Medical Education (CME), School of Medicine, University of Dundee, United Kingdom


Peer-assisted learning (PAL) is a common feature of health professions education, characterised as learning from and teaching others who are from a similar background. Evaluations of PAL identify a range of positive outcomes for peer tutors/tutees but rarely address the hidden curriculum, which is a by-product of the learners’ educational experiences, shaped by wider organisational influences and culture. The aim of this case study was to explore the hidden curriculum associated with two modes of PAL used in the final year of an undergraduate medical programme in Thailand: Case Discussions and a Journal Club. A naturalistic evaluation approach, incorporating multiple data sources, was used to explore students’ perspectives on PAL (interviews), student and faculty behaviours during PAL (observation) and the school’s formal/written curriculum (document analysis). Three themes emerged from the thematic analysis of student interviews, triangulated with the observational data (reflecting positive and negative aspects of PAL): 1) developing self as a doctor; 2) learning through dialogue and feedback; and 3) barriers to learning. New insights were gained in relation to the influence of norms and social interactions i.e. recycling materials for Case Discussions and student difficulties with English language journals. Some of the barriers to learning are inherently connected to the study context and recommendations can be made locally for PAL review, however, revealing what is being learned, in the medical habitus, intended and unintended outcomes, highlights the importance of considering the hidden curriculum as an integral part of PAL planning, implementation and evaluation.

Keywords:         Peer-assisted Learning, Peer Teaching, Hidden Curriculum, Medical Students, Medical Education

Transnational clinical teacher training: Lessons learned and cross-cultural implications

Ardi Findyartini1, Justin Bilszta2, Jayne Lysk2& Diantha Soemantri1

1Faculty of Medicine, Universitas Indonesia, Indonesia; 2Melbourne Medical School, University of Melbourne, Australia


Introduction: Transnational faculty development initiatives (FDIs) constitute a strategy to improve the quality of the teaching staff in medical schools. This study evaluates feedback from participants of an FDI designed as part of a collaborative transnational partnership between researchers of an Australian and an Indonesian medical school.

Methods: The FDI was a three-day program that explored four major topics: effective clinical teaching, methods of teaching and supervising in clinical settings, assessment of clinical learners and clinical education in practice. These topics were identified through comprehensive needs analysis and curriculum blueprinting exercises. Each participant (n= 27) submitted one piece of reflective writing and one critical appraisal or teaching/assessment assignment on each topic. Using a thematic analysis approach, two researchers independently reviewed each participant’s written assignments to identify emerging themes.

Results: Five core themes were identified. Most revolved around the benefits of the training, especially the learning issues that the participants identified during the FDI and how they could be applied to their local contexts. Additional themes covered participants’ views on the delivery of the FDI and cross-cultural implications. Peer observation of teaching, qualitative assessment and feedback provision were also significant issues raised by the participants.

Conclusions: This study presents important lessons for cross-cultural adaptation of best practices in the development and delivery of transnational FDIs.

Keywords:         Faculty Development, Transnational, Collaboration, Cross-cultural, Clinical Teacher

Characterisations of Māori in health professional education programmes

Caitlin Harrison1, Rhys Jones& Marcus A. Henning3

1The University of Auckland, Aotearoa, New Zealand; 2Te Kupenga Hauora Māori, The University of Auckland, Aotearoa, New Zealand; 3Centre for Medical and Health Sciences Education, The University of Auckland, Aotearoa, New Zealand


Formal Indigenous health curricula often exist in institutional contexts that tacitly condone racist discourses that are at odds with the goal of developing culturally safe health professionals. Recognition of the impact of informal and hidden curricula on learners has increased, yet few studies have provided empirical evidence about this aspect of health professional education. This study sought to examine characterisations of Māori (Indigenous New Zealanders) in learning environments at the University of Auckland’s Faculty of Medical and Health Sciences. A cross-sectional study design based on the Stereotype Content Model elicited student perceptions (n = 444) of stereotype content in undergraduate nursing, pharmacy and medical programmes. The Stereotype Content Model identifies interpersonal and intergroup perceptions in relation to warmth and competence. These perceptions are considered fundamental and universal to the impressions people form when meeting one another. Stereotyping is associated with distinct affective and behavioural responses that can lead to discrimination. In this study, students rated perceived warmth and competence characterisations pertaining to four target ethnic groups (Māori, Pacific Nations, Asian and Pākehā/European). Characterisations of Māori warmth were rated lower than Pacific Nations peoples, comparable to Pākehā/European and higher than characterisations of Asian peoples. In reference to competence characterisations, Māori were rated equal to Pacific Nations peoples and lower than both Asian and Pākehā/European peoples. This study’s results highlight a degree of incongruence between the University of Auckland’s formal Māori Health curricula and messages conveyed in the broader institutional context, with implications for educational outcomes and students’ future clinical practice.

Keywords:         Indigenous Health, Health Professional Education, Stereotype Content Model, Informal/Hidden Curriculum

Personal View

Doctors as objects of worship: Reconsidering doctors’ competency based on cultural context

Mariko Morishita& Hiroshi Nishigori1,2

1Medical Education Center, Graduate School of Medicine, Kyoto University, Japan; 2Center for Medical Education, Graduate School of Medicine, Nagoya University, Japan


Doctors’ competency is one of the central themes of medical education, which has focused on the knowledge, skills, and morals of doctors. However, as doctors in Japan, we often wonder how we are perceived by patients and located in their belief systems. How we should be as doctors, which is often defined by lists of competencies produced by medical associations in various countries (including Japan), is not the same as what patients want us to be. This notion came to mind from anecdotes and the first author’s experience, as described below.