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Race, medical education and the overlooked role of pedagogical theory.

Tracey Collett and Cath Gristy


Hi everyone, I want to share in this blog post how pedagogical theory has helped me begin to address some of my issues and biases in teaching about race and ethnicity. Cath and I wrote this piece (below) at the beginning of the pandemic and at a time when people across the planet were starting to rise up against the ongoing oppression of non-majority populations driven in part by the Black Lives Matter Movement. Since writing this, I have begun to see how important it is that we are mindful of our philosophical / epistemological positions not just as individual educators, but as teams responsible for the overarching narratives of our (medical school) curricula.

TC


The issue

Despite 70 years of patient centred medical care and shifting from biomedical to biopsychosocial approaches, health professions education retains practices that emphasise the individual in relation to their health, rather than social determinants. Frequently with colleagues in BeSST we have discussed how this might be interpreted as promoting a blame narrative: ‘there is a suggestion that it is ultimately up to the patient to develop strategies to improve their lot’. Whilst there is growing political engagement from students (Kendall et al 2020) and some promising emerging ‘broader perspectives’ in medical education (for example the idea of structural competency or initiatives related to global and planetary health), some students have been slow to engage with ‘socio cultural’ understandings of health and illness.


My medical school provides opportunities for learning about the determinants of health via an integrated curriculum including a series of workshops. Within this context, sessions exploring race, ethnicity and medicine have been particularly problematic from my perspective as a lecturer. I frequently find myself questioning if and how I can ‘do justice’ to such a complex subject in two hours and in particular whether speaking as a white, middle aged, female lecturer in a western university, my messages about disadvantage and minority groups will be heard, accepted or taken seriously.


Towards a solution?

Cath Gristy (lecturer in education) and I met at an event hosted by the British Sociological Association Auto/biography Study Group. The Auto/Biography Study Group brings together people interested in the interrelations between biography, autobiography, text and lives, and the relationship between the differing genres of representing lives. The forward slash in auto/biography denotes the critical interrelationship between the self and the other, the private and public (British Sociological Association, 2021). I am very interested in auto/biography, particularly because as a lecturer, ‘what I say’, ‘how I look’, ‘how I act’ and ‘the ideas that I promote’ all contribute to the cultural construction of students’ knowledge. Reflexivity is key as I seek to ‘deliver’ in my role as an academic employed to facilitate students’ understandings of the social and cultural contexts of health and illness.

As part of our professional development, over a period of 3 years (pre Zoom), Cath and I decided to observe each other’s teaching. Many of our consequent discussions were about pedagogical theory and in particular, the dominance of teaching practices informed by perspectives that position students and teachers in hierarchical networks of power. Such practices, contrast with those informed by some philosophers who position learners as co-constructors.


Notably, within the critical pedagogical tradition, the idea of ‘Paulo Freire’s ‘cultural circles’ appeared to be particularly relevant to my sessions (Freire 1971). Cultural circles place the lived experiences of students at the centre of teaching and learning and in some schools of education are used in programmes seeking to address equity issues raised in diverse student groups. I think they resonate with (perhaps they are based on) the native American tradition of powwow circles, where, as Chairman of Chicago Indian Centre Powow, Ben Bearskin Junior (1987:1) states:

… we all sit in a circle because none of us is any better than the rest of us and a circle includes everybody,''


Taking new learning into account

In 2019 I took a new approach to my race and ethnicity workshop. Our year 1 and 2 cohorts are relatively small at approximately 160 students and I do 3 repeats of each of my workshops with approximately 50 – 60 students at a time. In 2019, I ensured my sessions were timetabled in appropriate rooms and as students came in I suggested they sit around the prearranged tables in groups of eight, ensuring as far as possible that the groups were diverse (particularly in terms of gender). I then deliberately introduced cultural circles.


Suggesting effective learning takes place when everyone contributes, I advised ‘go around, introduce yourselves- everyone gets to talk, do not miss anyone out’. I then asked the groups to discuss a topic: ‘care for the elderly’. The groups (multi-cultural, similar class background) had rich, engaged conversations. Many of the students had worked in care homes prior to attending university and their talk was suggestive of normalised, medicalised notions of older age as a period of inevitable decline. Yet some of the students had opposing cultural views: ‘the family cares for the older person, it is a time of repaying what has been given to them’. Some students (second and third generation Asian students for example), had mixed views – noting the gendered dimension of care and the economic imperative to work as possible reasons for care homes.


Following this activity, we discussed how having a diversity of voices and multiple perspectives ‘at the table’ helps ensure breadth of understanding. I offered students information about ‘definitions’ (race, ethnicity and culture); ‘information about the ethnic make-up of the UK – (in terms of standard census classifications)’; ‘the meaning of minority’ and reiterated the problem of representation ‘in all spheres of society’. Following some exploration of historical and contemporary examples of discrimination (in education, employment, medicine) we practiced cultural circles again, focussing on ‘discrimination experiences’. This led to a lively large group discussion with opportunities to discuss institutional discrimination, racism, ethnocentricity and micro aggression. We concluded by re-emphasising that having ‘everyone at the table’ ensures breadth of understanding and extrapolated this idea to ‘the board room’, ‘the policy group’, ‘the think tank’, ‘governments’.


Reflection

Students had not fully engaged with my race and ethnicity sessions previously, despite developments including collaboration with local community organisations and the University’s equality and diversity group. I realised that my past interventions focused on changing my pedagogical approach without interrogating the underpinning pedagogical theory. Moving away from positioning myself uncritically as the expert and adapting sessions so that ‘everyone had a voice’, gave students joint ownership, they engaged and I could contribute on my own terms, as an invested party, sharing my knowledge.


I have been running these sessions for three years and have now adapted all my workshops similarly. Attendance has been good, I have received positive feedback. Students have asked to champion sociology in the school and presented a proposal to jointly review representation of ethnic diversity across the whole curriculum.


More recently and I think, encouraged by wider social events and the decolonisation agenda, colleagues and I have come across the same students elsewhere in the curriculum. We have noticed that they are using phrases that I have not heard before such as ‘… in my culture’ and ‘.. I feel uncomfortable with the way that has been presented’. The conversations have been broader and richer, more consciously linking, in the words of C. Wright Mills, (1959), private and public issues, or individual issues to structural / cultural issues.


Crucially and as suggested at the beginning of this piece I am beginning to work out (and admittedly I think I am a little slow to the party here), the value of critically interrogating not just our own practice as individuals but our own practice as groups. I have been influenced by some of Alan Bleakley et al’s ideas about curriculum. Bleakley argues that we often assume that the curriculum itself is an immovable thing (if we consider it at all). Drawing on others (for example, Pinar and Reynolds, 1992) Bleakley suggests that it is perhaps more useful to think of the curriculum as a text (Bleakley et al 2006, Bleakley et al, 2011). Taken in this way, we are encouraged to take responsibility ‘as authors of the text’. As such, making instrumental changes is not enough, rather we need to think about our underlying philosophical positions and measure our actions against this. Currently as a school we are seeking to rewrite our educational principles. I am pleased that as part of this there has been an open commitment to critical pedagogies, social constructionism and collaborative approaches.

I know that in the grand scheme of things my workshop is a small piece in the jigsaw of change, if anyone else has any thoughts / experiences on the subject of theory and change please share!


Acknowledgement: With thanks to Professor Gayle Letherby Honorary Professor (Sociology), Plymouth University and Visiting Professor, University of Greenwich, for helping me think sociologically about sociology in medical education.


References


British Sociological Association Auto/Biography Study Group https://www.britsoc.co.uk/groups/study-groups/autobiography-study-group [accessed 08/06/21]


Ben Bearskin Junior (1987) cited in News report, Chicago Tribune

https://www.chicagotribune.com/news/ct-xpm-1987-11-06-8703230867-story.html#:~:text=''Indians%20sit%20in%20a,includes%20everybody%2C''%20says%20Bearskin.&text=In%20the%20powwow%20circle%20we [accessed 08/06/21]


Bleakley, A. Bligh, J. Brown, J. (2011) Medical Education for the future: identity power and location Springer Dordrecht Heidelberg London, New York.


Bleakley, A. Marshall, R and Bromer, R. (2006) Toward an Aesthetic Medicine: Developing a Core Medical Humanities Undergraduate Curriculum Journal of Medical Humanities, 27, pages197–213

Freire, P. (1971) To the coordinator of a cultural circle. Convergence; Toronto Vol. 4 (1). Preview available from

https://www.proquest.com/openview/773ee8ee4307ee38ddb821e485568f2e/1?pq-origsite=gscholar&cbl=2030445


Kendall, K. Harden, J. Collett, T. Kelly, M. and DeIongh, A. (2020) Does Covid 19 offer opportunities for medical students to apply sociology to clinical Practice BMJ Opinion, October 23. https://blogs.bmj.com/bmj/2020/10/23/does-covid-19-offer-opportunities-for-medical-students-to-apply-sociology-to-clinical-practice/


Pinar, W. Reynolds, W. (1992) Understanding Curriculum as Phenomenological and Deconstructed Text (Critical Issues in Curriculum) Teachers' College Press.

Wright Mills, C (1959) The Sociological Imagination, Oxford University Inc New York.


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