Virtual Mentor. August 2007, Volume 9, Number 8: 543-546.
Teaching Cultural Sensitivity through Literature and Reflective Writing
The Culture, Narrative, and Medicine course at Loyola University of Chicago's Stritch School of Medicine teaches cultural humility through literature and students' reflective writing.
Ruby Roy, MD
Teaching cultural competence to medical students in a meaningful way is challenging. Trying to teach cultural communication as a measurable skill oversimplifies both the complexities of culture, race, and ethnicity and their effect on the medical interaction. We want to embrace cultural understanding but avoid cultural stereotyping. To ask medical students to learn all the characteristics of a culture potentially categorizes future patients, thus denying them individual identity within the broader racial, ethnic, or cultural label we apply to them. For some, this approach has been denigrated as "political correctness," while, from the standpoint of the patient who is pre-judged by his or her label, it can seem racist.
"Cultural humility," a concept initially described by Drs. Tervalon and Murray-Garcia  is not only more respectful but also more pedagogically sound. Cultural humility asks physicians to understand their own culture(s) as well as that of the patient and view this understanding as a lifelong process of self-reflection and self-critique. If cultural humility is viewed thus, it may encourage the process of personal and professional growth.
Literature and reflective writing provide a natural tool to inspire questions and stimulate discussion on culture. Examining questions of culture, bias, and communication in a story or poem is emotionally safer than recounting personal experiences, but sharing of personal experiences and individual stories is also essential to apply the questions raised to one's own life and one's own medical practice.
We combined these techniques in teaching the Culture, Narrative, and Medicine elective at the Loyola University Chicago Stritch School of Medicine. We chose stories and poems by a variety of authors and two book-length narratives, There Are No Children Here by Alex Kotlowitz and The Spirit Catches You and You Fall Down by Anne Fadiman. This was not a literature class per se; the literary pieces were selected to inspire questions and discussion about cultural differences. We had four sessions: (1) the meaning of culture, (2) culture and discrimination: the nature of "otherness," (3) cross-cultural communication: how to build bridges, and (4) culture and medicine.
Students were required to bring a short reflective piece to refer to during discussion. This writing could be a topic of their own choosing or a response to the reading—and the students were given suggested questions in keeping with the theme of the day. The questions were selected to encourage personal reflection about the readings, for example: "How does your race, ethnicity, or cultural background affect the way you think about patients and their values?" or "Consider the nature of bias, differential care, and discrimination as depicted in this work. How have you experienced any of these?"
I asked the students to approach the reading as they would a patient who needed to be carefully evaluated: what can be learned from listening to the history, i.e., reading the story? We used literary analysis as an analogue to the physical exam: to evaluate the structure, language, diction, word choice, use of metaphor, and symbolism as we would evaluate physical signs.
The discussion followed a reflective listening technique taken from Rachel Naomi Remen's Healer's Art curriculum . This format presumes confidentiality and an expectation that students will not be competitive with each other in discussion—no arguing, no advice-giving, acceptance of opposing viewpoints, and generous listening. The participation evaluation for these sessions looked at oral and written participation equally, so that students who expressed themselves better in writing did not feel obligated to speak.
We took the last hour of the session to do a reflective writing assignment. This writing technique was inspired by Rita Charon's Narrative Medicine Workshop . Both faculty and students participated in the assignment and reading. The prompts, unknown to the students in advance, included such questions as "Describe a time when you felt out of place or that you didn't belong" and "Describe an interaction when you witnessed someone being affected by bias or prejudice." Although this exercise was foreign to all of the students and not greeted initially with enthusiasm, it was the richest part of the course for all involved. It stimulated intense personal discussion and reflection on the difficult themes of personal identity and bias. All of the students shared an appreciation for the value of spontaneous reflective writing and I learned anew that personal experience could be a strong teaching tool. (Three examples are included at the end of this article.)
Both teaching and practicing cultural humility is counter to our medical culture. Medical culture prides itself on being scientific, objective, and evidence based, but is often rigidly hierarchical and still quite paternalistic. For medical students who have spent four years working hard to fit themselves into medical culture mores, it is difficult to then admit that medical culture can, itself, be a problem. It's challenging to be humble in a culture that prizes expertise and knowledge. As one student wrote about one of the course readings, "Until I read this book, the ramifications of cultural humility had never really struck home. I had never considered myself to be culturally humble; as a matter of fact, I considered myself culturally proud."
In the same time, I began
To climb without a harness
Call the chaplain I was told
Compassion. Calm Clarity
Ruby Roy, MD, is a general academic pediatrician who recently joined the Neiswanger Institute for Bioethics and Health Policy and began teaching medical humanities at the Stritch School of Medicine, Loyola University Chicago.
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