Reflecting on the Medical Curriculum: What would decolonisation look like?

In the wake of Black Lives Matter movement, universities are considering decolonising their curricula. Karina Chopra (5^th year Medical Student) and Sohinee Bhattacharya Senior Lecturer and course coordinator Global Health talk about what decolonising the medical curriculum means for students, staff and doctors.

As a medical graduate from India I felt as though I should have strong feelings about decolonising the medical curriculum but wasn’t quite sure what this involved. So when Karina proposed reviewing the literature on this topic as part of her medical elective, I said “Yes, please!”  The murder of George Floyd triggered a worldwide reaction and students across the world mobilised with campaigns such as ‘Why is my curriculum white?’ ¹ and ‘Rhodes must fall’.²   These movements aimed to challenge the issues of colonialist teaching within modern education.

What is meant by decolonisation? The concept of decolonising higher education has been extremely popular amongst the social sciences and humanities, paving the way for meaningful curricular change. However, within the medical and nursing field there has been a significant lag in this area.  Decolonisation can be defined as  “a way of thinking about the world which takes colonialism, empire and racism as its empirical and discursive objects of study… it purports to offer alternative ways of thinking about the world and alternative forms of political praxis’³ . Essentially, decolonisation aims to broaden individuals’ views beyond the Eurocentric perspective. This affects medical students at two levels – first by broadening their medical knowledge through inclusion of Global Health in their curriculum and second through their interpersonal exchange with patients and the public.

Is decolonisation of the medical curriculum essential? One may question whether there is a need to apply the concepts of decolonisation to medical education and whether this is essential. Why does a family doctor practising in rural Aberdeenshire need to know about exotic diseases that they will probably never see in their lifetime? One argument for including global health in the medical curriculum is that even the remotest parts of UK has recently seen much diversity in the population as a consequence of globalisation. An example of a situation where decolonisation would be beneficial is Dermatology where lack of knowledge of skin presentations in different skin tones may ultimately result in medical graduates misdiagnosing conditions in certain groups as they are not equipped to meet the needs of a diversifying population. Diagnosis of Lyme disease may be delayed as a result of medical professionals failing to recognise the characteristic rash in dark skin. Recognising this gap in teaching, a medical student at St George’s London recently published ‘Mind the Gap’, a pocket-book which aims to focus on diagnosing skin presentations in darker skin tones⁴.

What are we trying to achieve by decolonising the curriculum? There has been much research focusing on equality, diversity and inclusion (EDI) training to gain cultural competence⁵ – defined as a set of congruent behaviours, attitudes and policies that intersect within a system to allow healthcare professionals to treat patients from diverse backgrounds. This outcome is widely used but has been criticised for reinforcing stereotypes as it aims to attribute certain behaviours to individuals from particular background or race. The idea of cultural humility⁶ is a self-reflective process that examines the power imbalances between patients and clinicians. This reflective process raises the individual’s awareness of their own practices and beliefs, benefitting patient care. The British Medical Journal (BMJ) has dedicated a whole issue to this complex matter⁷. Cultural humility is the ideal that all clinical staff and students should aim for but cultural competence is the bare minimum that they need to achieve for good patient care.

How can we decolonise the medical curriculum? A search of the published literature identified 16 teaching interventions that had been shown to be moderately effective in reaching cultural competency. These ranged from discussion groups and lectures focussed on global health issues to case-based learning, simulation and vignettes incorporating clinical conditions that primarily affect people from ethnic minority backgrounds. Almost all included an element of reflective practice - individuals were asked to recount personal experiences where they had witnessed conscious or unconscious bias. There was support for creating a more inclusive curriculum especially addressing the issue of the ‘hidden curricula’ which relates to how students may be influenced by the biases held by professionals. Given the lack of uniformity and standardization in the outcome of interest (i.e. cultural competency/ humility), it is not surprising that none of the identified interventions laid claim to be the gold standard.

Conclusion: While globalising the medical curriculum may have modest gains we do feel that achieving cultural competence is mandatory to be a good healthcare professional. Alongside this there is a need to raise public awareness about diverse cultures as the doctor-patient interface is double sided and patients should have the same confidence and respect for a non-white healthcare professional as their white counterpart.

Karina Chopra is a final year medical student at the University of Aberdeen. Karina is involved with Students for Global Health Aberdeen, a society addressing issues pertaining to social justice.

Sohinee Bhattacharya is Senior Lecturer in Obstetric Epidemiology and course coordinator for Global Health and Global Health Humanities.

References:

1. University College London. Why is my curriculum white? - UCL - Dismantling the Master's House [Internet]. 2015 [cited 1 December 2020]. Available from: http://www.dtmh.ucl.ac.uk/videos/curriculum-white/
2. Mohdin A. Protesters rally in Oxford for removal of Cecil Rhodes statue. The Guardian [Internet]. 2020; Available from: https://www.theguardian.com/world/2020/jun/09/protesters-rally-in-oxford-for-removal-of-cecil-rhodes-statue
3. Bhambra GK, Gebrial D, Nisancioglu K. Decolonising the University. London: Pluto Press; 2018. 272 p.
4. Mukwende M. Mind the gap: A clinical handbook of signs and symptoms in black and brown skin. London; 2020. 33 p
5. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a culturally competent system of care. Washington DC; 1989.
6. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Heal Care Poor Underserved. 1998;9(2):117–25.
7. Adebowale V, Rao M. Racism in medicine: why equality matters to everyone. BMJ [Internet]. 2020;368(m530):2–3.