Reflective Practice Enriches Clerkship Students' Cross-Cultural Experiences

UCI - Department of Family Medicine, University of California, Irvine, School of Medicine, Orange, CA 92868, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 05/2010; 25 Suppl 2(S2):S119-25. DOI: 10.1007/s11606-009-1205-4
Source: PubMed


To describe a curriculum incorporating written reflection followed by reflective discussion with the goal of enhancing students' recognition and handling of cross-cultural and health disparity issues in different healthcare delivery settings. PROGRAM AND SETTING: This required curriculum was implemented within a 4-week family medicine clerkship (n = 188 students, 6 to 12 per rotation) in 23 successive rotations over 2 years. Electronic submission of a written assignment in response to structured questions was followed by in-class discussion in week 4.
Outcomes were students' session evaluations, thematic analysis of student responses, and analysis of faculty facilitators' reflections about discussion sessions. Students' cultural knowledge about their patients' health beliefs around diabetes was assessed using multiple choice questions at the beginning and end of the clerkship.
One hundred percent of students submitted narratives. Student evaluations demonstrated high acceptance, appreciation of sessions and faculty. Analyses of written assignments and in-class discussions identified recurring themes. Students achieved greater synthesis and more nuanced understanding of cross-cultural encounters after discussion. Self-rating of confidence in addressing cultural issues after the curriculum was high at 3.17 +/- SD 0.57 (1-4). Cultural knowledge scores improved significantly. Core components for success were clerkship director support, required participation, experienced faculty facilitators without evaluative roles, a structured assignment and formal forum for trigger question discussion.
Written reflection followed by facilitated peer discussion adds value to simple 'exposure' to cross-cultural clinical experiences for medical students.


Available from: Désirée Lie
Reflective Practice Enriches Clerkship Students Cross-Cultural
Desiree Lie, MD, MSED
, Johanna Shapiro, PhD
, Felicia Cohn, PhD
, and Wadie Najm, MD, MSED
UCI - Department of Family Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA;
UCI - Department of Internal
Medicine, University of California, Irvine, School of Medicine, Orange, CA, USA.
AIM: To describe a curriculum incorporating written
reflection followed by reflective discussion with the goal
of enhancing students recognition and handling of
cross-cultural and health disparity issues in different
healthcare delivery settings.
PROGRAM AND SETTING: This required curriculum
was implemented within a 4-week family medicine
clerkship (n=188 students, 6 to 12 per rotation) in 23
successive rotations over 2 years. Electronic submis-
sion of a written assignment in response to structured
questions was followed by in-class discussion in week
PROGRAM EVALUATION: Outcomes were students
session evaluations, thematic analysis of student
responses, and analysis of faculty facilitators reflec-
tions about discussion sessions. Students cultural
knowledge about their patients health beliefs around
diabetes was assessed using multiple choice questions
at the beginning and end of the clerkship.
RESULTS: One hundred percent of students submitted
narratives. Student evaluations demonstrated high
acceptance, appreciation of sessions and faculty. Anal-
yses of written assignments and in-class discussions
identified recurring themes. Students achieved greater
synthesis and more nuanced understanding of cross-
cultural encounters after discussion. Self-rating of
confidence in addressing cultural issues after the
curriculum was high at 3.17±SD 0.57 (14). Cultural
knowledge scores improved significantly. Core compo-
nents for success were clerkship director support,
required participation, experienced faculty facilitators
without evaluative roles, a structured assignment and
formal forum for trigger question discussion
DISCUSSION: Written reflection followed by facilitated
peer discussion adds value to simple exposure to
cross-cultural clinical experiences for medical students.
KEY WORDS: reflection; cross-cultural; RP curriculum.
J Gen Intern Med 25(Suppl 2):11925
DOI: 10.1007/s11606-009-1205-4
© Society of General Internal Medicine 2009
Training future physicians to work with culturally diverse
patients in different communities is essential for the develop-
ment of good clinical practice and to reduce health dispa-
1 3
. Creative curricular approaches
have been
described to integrate cultural competency into existing
courses. New content
should take into account student
attitudes, prior exposure and developmental stage.
One challenging domain to address is self-reflection and
culture of medicine , described in the Association of American
Medical Colleges revised Tool for Assessing Cultural Compe-
tency Training
.Students unconscious or unexplored
assumptions about patients from diverse backgrounds may
affect the the rapeutic relationship
; and assumptions
about the patients health literacy and beliefs are a potential
source of health disparities
. Student learning may be
influenced by the hidden curriculum of corridor conversa-
tions and behaviors (as opposed to verbal injunctions) of role
rather than formal instruction. This learning is not
easily captured by traditional evaluations. Focus groups
and other qualitative methods provide an additional lens to
examine these influences. Reflective practice (RP), variously
defined, is at once a method of self-reflection for practitioners,
a teaching strategy for engaging learners and a means of
assessing teaching and practice
We implemented and evaluated a new RP curriculum to
complement clerkship activities that addressed cultural diversity,
aimed at promotin g and fostering cri tical thinking and behaviors
that reduce health disparities. We hypothesized that reflective
writing followed by faculty-facilitated peer discussion would be
acceptable to students; increase students awareness of their own
values; and help them to identify strategies to recognize and
improve outcomes of cross-cultura l clinical encounters.
The RP curriculum was introduced to two consecutive classes
of 188 (n=98 for 20072008, n=90 for 20082009) third-year
medical students (50% male, average age 23 years, 40% white,
40% Asian, 10% Latino, 1% black) from one medical school
in 23 successive clerkship rotations (6 to 10 students per
rotation). The 4-week family medicine clerkship consisted of
apprenticeship to a preceptor supplemented by small group
teaching. Students were evaluated by direct observation, end-
of-clerkship O bjective Structured Clinical Examination
(OSCE), attendance and written assignments. In outpatient
settings, 25 to 75% of patients were Latino. A half-day group
Page 1
medical visit (GMV) with Latino diabetic patients and a walking
tour of community botanicas (shops that sells herbs, charms,
and spiritual items, especially marketed to Latinos) were added
in the prior year to enhance cultural competency training.
Reflective practice was introduced in 2007 to foster reflection
as part of a longitudinal teaching theme in medical humanities
and bioethics, and to gauge learning from different settings.
The goal of reflection was for students to examine and share
views of cross-cultural encounters. The university institutional
review board approved the study.
The RP assignment was explained on day 1 of the clerkship
and instructions sent out by email, with a reminder emailed
the week before discussion. The written assignment was due
2 days before the 2-hour face-to-face teaching session con-
ducted by two faculty (JS, FC), directors of the medical
humanities and bioethics programs; physician faculty (DL,
WN) taught when available. The session took place in the final
week, after the OSCE and group medical visit. Faculty read all
student assignments, summarized themes and prepared dis-
cussion questions.
Written Assignment (Fig. 1). Students were required to write
about experiences from two different models of healthcare
during the clerkship. Experiences were chosen f rom the
following: a) Outpatient clinic; b) Visit to botanicas; c) Home
visits; d) The group medical visit. They were asked to reflect on
how cultural differences could enhance or complicate the
encounter, lessons learned about practicing across cultures,
and physician role-models treating diverse patients (Questions
1 to 6). Descriptive responses were expected. In project year 2,
two questions (7 and 8) were added asking students to self-rate
learning about complementary and alternative medicine (CAM)
and cross-cultural medicine (Fig. 1) with Likert scale
responses of 1=not, 2=somewhat, 3=moderately and 4=
definitely enhanced.
Discussion sessions. Since students did not read each others
assignments, the discussion session provided the only formal
opportunity to compare and contrast students views. The
facilitators elucidated and gui ded expl oration of such
similarities and differences. For example, a session might
begin with the faculty probing the students understanding of
culture by stating: Some of you wrote about culture as
characterized by race and ethnicity. Others wrote about the
culture of medicine. How might these differ? Or Some of you
Figure 1. Student written assignment instructions for reflective practice curriculum, University of California, Irvine School of Medicine, 2009.
S120 Lie et al.: Reflective Practice for Cross-cultural Encounters JGIM
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want patients to take responsibility for their health; others
emphasize the effect of culture on how patients construe
illness and health. What are the benefits and pitfalls of each
position? Facilitators ensured that discussions did not merely
reiterate assignments, but deepened and extended them. Group
discussions emphasized exploring different ways of addressing
cross-cultural encounters that students perceived to be
frustrating and resulting in barriers to optimal healthcare
(language differences, time constraints, stereotyping by faculty
or residents).
The faculty facilitators did not receive any special training
for conducting the sessions. Their preparation consisted of a
careful reading of students essays. Facilitators followed a
question route based on the main topics of the essays,
specifically employing the following questions: a) What do we
mean by culture? (probe: Is Medicine a culture?) b) What are
examples of ways working across culture enhanced your
patient encounters? (probe: patient as physicians teacher) c)
What were some of the difficulties you encountered working
across culture? How did you ameliorate them? d) There is a lot
of agreement about examples of negative role-modeling. What
do you think are some of the factors that influence physicians
to behave in these ways? What will prevent you from behaving
in these ways? e) What is the most important lesson about
working across cultures that you learned on this clerkship?
In conducting these sessions, facilitators employed basic
group facilitation skills, including showing positive regard for
all participants; expressing respect for participant opinions;
creating an atmosphere of openness and nonjudgmentalness;
guiding discussion, but doing more listening than talking;
employing a Socratic approach based on asking questions and
follow-up probes; encouraging participation of all members,
including quiet ones; and emphasizing the value of differences
of opinion. Facilitators also tried to challenge conventional
thinking, encouraged students to adopt alternative perspec-
tives, and consider assum ptions, stereotypes, and biases.
Neophyte facilitators can be easily trained in 12 hrs.
We examined session evaluations to assess the perceived value
of the RP sessions. Students were asked to rate the value of the
session for reflecting on CAM and culturally-relevant experi-
ences and to prepare for practice in a diverse environment; the
importance of cultural competency training; and faculty facil-
itators skill, on a scale with 1 = outstanding/high and 5 =
poor/low. During year 2, self-ratings of learning in CAM and
cross-cultural medicine (questions 7 and 8 of assignment) were
also assessed. Descriptive analysis consisted of calculating
percentage responses, means and standard deviations (SDs).
We also conducted qualitative thematic analyses of the written
assignment and discussion sessions
. Two levels of analysis
occurred for the written assignment (Fig. 2). First, one faculty (JS)
reviewed all assignments and compiled verbatim summaries (i.e.,
using exact student language) from each groups assignments,
eliminating only redundancies, repetitions, and extensive exam-
ples. Second, these summaries were reviewed by three faculty
(JS, FC, DL) who independently extracted themes. Extracted
themes were collated and then compared for agreement and
disagreement. Through group discussion, consensus was
achieved on major recurring themes across all 23 rotations
For the discussion sessions, JS, WN and FC independently
summarized their impressions of sessions in writing, and
common themes were extracted by consensus.
In year 2 of the program, we administered five cultural
knowledge questions to evaluate students knowledge of their
Latino patients health belief and practices. Responses were
analyzed based on the number of correct answers given pre-
and post-participation in the clerkship.
Results. All students participated and completed assignments.
Most students reported spending about 30 minutes on the
written assignment. Overall student ratings (response rate
156/188=83%) of sessions showed predominantly positive
responses. A rating of 1 or 2 (outstanding or excellent) was
given by 80.5% of students for value for reflecting on CAM and
culturally-relevant experiences; 70.5% for value to prepare
for medical practice in a diverse environment; 84.9% for
importance of cultural competency training during medical
school; and 87.6% for teaching s kills of f acilitators.In
particular, students explicitly expressed appreciation in their
written com ments for faculty summaries of th eir written
assignments. In year 2, student mean rating of self-
confidence in addressing CAM was 2.75±SD 0.68 (n=83/90):
confidence for addressing cultural issues was greater at 3.17±
SD 0.57 (n=83/90) out of 4 for questions 7 and 8 (Fig. 1)
Thematic analysis of student assignments (Table 1) sug-
gested 7 predominant themes: 1) Cross-cultural encounters
provide mutual learning opportunities for physician and
patient. Students shifted from describing the medical encoun-
ter as a top-down transmission from doctor to patient to a
more horizontal, mutual process of learning about and
appreciation for the other. 2) Medicine is a culture in and of
itself. Students commented on particular ways of thinking
(logico-deductive), evaluating evidence (EBM), speaking (med-
icalese), appearing (white coats), and behaving (professional
objectivity) that defined Medicine as a culture with specific
beliefs and assumptions. 3) Language barriers significantly
complicate the doctorpatient relationship, and strategies
for addressing them are essential. Students repeatedly
expressed frustration at not sharing a common language with
patients, and felt that this inhibited rapport. They recognized
the important role of a well-trained interpreter; and also
expressed the intention t o learn Spanish and attend to
nonverbal cues. 4) Cultural beliefs can negatively affect
patient compliance, while expressing interest in the
patients views builds trust. Students described penetrating
be low the surface of a patients noncompliance only to
discover culturally-based misunderstandings, fears, or beliefs.
They identified a direct link b etween understanding the
patients perspective, developing trust, and formulating cul-
turally appropriate and acceptable treatment plans. 5) The
family-centric orientation of many cultures means that
physicians should be prepared to acknowledge the role of
the family in patient care. This theme included observations
about involving f amily members in treatme nt plans; and
identifying the real
decision-maker in the family (not neces-
sarily the patient). 6) A larger number of patients than
expected are frequent users of CAM. Students were often
surprised at the prevalence of CAM practices in the commu-
nity, and at patients preference to use CAM over western
medicine. Students wrote that unless they specifically inquired
S121Lie et al.: Reflective Practice for Cross-cultural EncountersJGIM
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about CAM practices, patients would not necessarily disclose
them. 7) Positive physician attitudes and behaviors in
cross-cultural encounters are essential, and include listen-
ing, being open-minded and avoiding stereotyping. Students
commented on both negative and positive physicia n role-
models and highlighted the importance of positive interactions
in a therapeutic relationship.
Analysis of the discussion sessions by 3 faculty suggested
added value of these peer interactions. The written exercise
allowed students to describe concerns in a secure and candid
fashion. The discussion enhanced the written exercise by
enabling students to reco gnize shared concerns, deepen
understanding, and problem-solve with peers and faculty. Of
note, students also reflected on parallel experiences about
cross-cultural encounters from prior clerkships.
Eighty nine of 90 students in year 2 provided answers to the
five cultural knowledge questions. Students answered a mean
of 2.73 questions correctly on the first day of clerkship and a
mean of 4.02 questions correctly at the completion of the
clerkship. The paired difference was 1.29 (SD 1.76), 95%
confidence interval 0.92, 1.66 (P<0.0001) for a significant
We introduced a reflective practice curriculum within a
clerkship to consolidate learning about dive rse healthcare
settings and patients and to raise consciousness about how
health disparities may be associated with provider attitudes
Three faculty independently coded summaries from 23 groups, compiled from 188 essays. Every
summary was coded by 2 faculty members. Top themes were identified by each faculty. The
themes identified by all 3 were collated for a final list of 7 common themes, by group consensus.
7 themes (identified from written reflections on cross-cultural encounters):
1. Physician and patient can find common ground through negotiation and balance of power
2. Practice of medicine is itself a culture that has to be negotiated
3. Language barriers contribute to challenge of cross-cultural encounters
4. Cultural stereotyping and assumptions can adversely affect trust, adherence and treatment plans
5. Family plays important role in health and illness and cross-cultural encounters
6. Importance of showing interest in, developing understanding of culture and use of CAM
7. Positive role models listen, are open, tolerant of CAM use, and nonjudgmental
Abbreviations: CAM = Complementar
and Alternative Medicine, GMV = Group Medical Visits
188 students (23
groups) submitted
essays 2007-9
23 summaries compiled
by JS
Main themes identified
independently by 3
JS coded 23
Patient-doctor power balance
Horizontal and vertical learning
Language barriers
Positive role model behaviors
Medicine is a culture
Avoid stereotypes/assumptions
Role of family in illness
Learn about culture/CAM
Self-reflection important
Group vs individual differences
DL coded 12
Common ground/negotiate
Language barriers important
Positive role model behaviors
Culture of medicine
Include listening and being non-
Avoid stereotyping
Family is part of the cultural
FC coded 11
Mutual learning (patient-doctor)
Language a key barrier
Positive role model behaviors
Medicine is a culture itself
Avoid assumptions/stereotypes
Family important role in care
Understanding culture/CAM
Figure 2 . Flow of thematic analysis of student written assignments by faculty, University of California, Irvine School of Medicine, 2009.
S122 Lie et al.: Reflective Practice for Cross-cultural Encounters JGIM
Page 4
and behaviors. We concluded that our program was successful
based on multiple outcomes. Our program builds on a similar
curriculum for the obstetrics and gynecology clerkship addres-
sing ethical conflicts
in which students submitted essays
followed by small group discussion. In that study our qualitative
analysis of student narratives revealed that development of
professional values was tied to personal values and strongly
influenced by observed behaviors and dynamics of teaching
faculty and residents. In this program our purpose was to
discover whether written reflection followed by faculty-facilitated
peer discussion led to nuanced approaches to addressing cross-
cultural encounters and how unequal treatment or differential
outcomes of care may result from physician behaviors. The
thematic analysis of assignments led us to conclude that
students indeed were learning critical concepts of cultural
humility, mutuality and horizontality in the doctorpa tient
relationship, and about patient use of CAM, the influence
of culture and self-awareness of ones own at titudes, values ,
and assumptions as members o f the culture of medicine .
The results suggested that students may adopt behavior
changes aimed at redu cing health disparities in their own
future practices.
Based on our analysis of the data, we developed a three-
tiered theoretical framework for our RP model. The first
essential tier is direct participant observation or experience,
which occurs through student exposure to cross-cultural
settings. Teaching and learning occur, but are limited by
student multi-tasking, inattention, and in clinics, variability
of the physician role-model as a medical educator. The second
tier is individual reflection accomplished through the written
assignment. This allows the student to better organize and
consolidate jumbled impressions. The final tier, facilitat ed
group reflection, provides the opportunity to confront other
perspectives, have assumptions and expectations challenged,
and deepen and extend learning .
Our study has several strengths. Two consecutive years of
data are presented for a significant number of students. Our
educational intervention was distinct in its structure and
format and instructions to students were clearly presented.
The evaluation data was complete with a high student
response rate. We evaluated outcomes using multiple methods
including written essays, in-class discussions and a pre-post
knowledge test. We used a triangulation approach to analyze
qualitative data, combining interpretation from four different
faculty with diverse teaching experiences and from different
disciplines to reduce bias.
Our study is limited by the specificity of the patient cultural
group (Latinos with diabetes) within our practice setting, and
we cannot be certain if findings generalize to other cultural
groups. However, there is no reason to believe that the
techniques that we shared with students would not be effective
in other cross-cultural settings. We did not analyze thematic
responses by student demographics because the number of
themes identified and class size did not permit such analysis
(50% female, ethnic mix approximately 43% white, 40% Asian,
10% Hispanic, 1% African American). There is literature that
suggests that providers own background and their cultural
experiences impact their cross-cultural communication skills
and their perceptions of their patients
. Our evaluation tool
was not validated because no validated tools for this purpose
were available. Lastly, in asking students to rate their self-
reported knowledge change about CAM and culture (questions
7 and 8, Fig. 1), we did not explicitly define the difference
between the two and our questions may not be sufficiently
sensitive to differentiate knowledge gain in these two areas.
However, the in-class discussions about CAM and culture
Table 1. Major Themes, Elaborations, and Examples, from Student Essays, University of California, Irvine, 20079
Theme Elaboration Example
1. Cross-cultural encounters provide
mutual learning opportunities for
physician and patient
This theme highlights the bidirectional learning
between patient and physician that students
discovered in cross-cultural interactions
Cultural differences can provide two different
perspectives to the patient-doctor relationship,
and given that both parties maintain an open
mind, may elucidate new avenues to treatment
Male (M), 3/09
2. Medicine is a culture Students recognized that medicine was a
culture like any other culture that promoted
specific beliefs, assumptions, and priorities
images and RCTs. These arent the same as the
values of patients from other cultures M, 4/09
3. Str ategies for addressing language
barriers are essential
Language differences emerge as a consistent
frustration limiting the quality of the doctor/
patient encounter; and students examined
various solutions
Always always always utilize a translator in the
case of a language barrier to avoid
misunderstandings between the patient and the
doctor Female (F), 12/08
4. Issues of culture can affect patient
compliance, while expressing interest in
the patients culture b uilds trust and
leads to culturally appropriate treatment
This theme indicates students awareness of the
link between communicating interest/
understanding of culture; establishing trust;
and improving patient buy-in and compliance
The doctors genuine interest and desire to learn
about the patients culture helps the patient see
that the doctor is taking the patients culture into
consideration when forming a treatment plan. F,
5. Because of the family-centric orientation
of many cultures, physicians should
address the role of the family in patient
This theme emphasizes the importance of family
within various cultures in successfully
addressing patient care issues
Individuals from Latino and other backgrounds
may be family-oriented and it is important to
involve the entire family in important medical
decisions. M, 2/09
6. Patients frequently use Complementary
and Alternative Medicine (CAM)
This theme reflects student lack of awareness of
the prevalence of CAM practices in the patient
Botanicas are widely used in many cultures; and
many patients will not tell you that they use
botanicas, unless you ask them. F, 11/08
7. Positive physician attitudes and
behaviors in cross-cultural encounters
This theme represents qualities noted in
describing positive role-models: listening,
open-minded, not judgmental, and avoiding
Listens to patient attentively and addresses them
thoroughly; respects patients health beliefs and
encourages patient to share thoughts. F, 12/08
S123Lie et al.: Reflective Practice for Cross-cultural EncountersJGIM
Page 5
suggested that most students were able to identify CAM as
alternative approaches to Western medicine, while culture was
consistently discussed in the context of differences in values,
beliefs, practices and social norms among different groups.
Despite these study limitations, our findings reinfo rce
existing literature about the power of the hidden curricu-
. For example, although role-modeling was not iden-
tified as an explicit clerkship learning objective, it emerged as a
powerful influence on learning, both negatively and positively.
Similarly, the concept of the culture of medicine was not part of
the clerkships formal objectives, yet it consistently appeared in
students written and discussion comments. Without the addi-
tion of the RP components, these and other influential dimen-
sions would have remained submerged.
We note that a few key ingredients are necessary to achieve
desired goals. First, students benefit from having interdisci-
plinary faculty facilitate discussions. While physician faculty
may add real-world credibility, outsider pers pect ives of
faculty trained in the social sciences and philosophy expands
their understanding of clinical issues. Second, the lack of
evaluative function of participating faculty creates an environ-
ment of safety and openness. Third, we found an incremental
approach of pedagogical value. Although our model runs the
risk of being perceived as repetitive or redundant, circling
back to clinical experiences through different modalities
(written, oral) and in different settings (individual vs. facilitated
group reflection) reduces the burden of multi-tasking, and
encourages Socratic self-discovery. We believe that this
approach is essential to stimulating critical thinking as
opposed to rote regurgitation and adopting politically correct
postures. This approach may allow students to develop practice
styles that incorporate carefully considered ethical conclusions
about interactions across cultures rather than simply imitating
faculty or residents. We believe that this model of RP, woven into
an existing curriculum, addresses the need for critical con-
in the continuum of cultural competency training
toward the development of self-awareness. However, because
faculty themselves do not consistently practice RP at our
institution, we are not certain if adoption of RP as a habit by
physicians might enhance the effectiveness of our curriculum.
Finally, as noted in the Program Description, facilitator skills
needed to conduct the reflective practice sessions are easy to
acquire and maintain and no specific training is necessary.
In summary, integration of a brief RP curriculum occupying
only 2 hours of a required clerkship was feasible and highly
acceptable to students, and associated with more complex and
nuanced understanding and useful problem-solving of chal-
lenges frequently arising in cross-cultural encounters.
We speculate that this integrated model can be easily
incorporated into most clerkships to promote critical thinking
and consciousness about addressing health disparities
through improved quality of cross-cultural encounters. The
RP curriculum addresses content that is difficult to teach in
stand-alone blocks. What remains to be discovered is what
amount and quality of longitudinal exposure across clinical
training is needed to foster and maintain the practice of self-
reflection for lifelong learning.
Acknowledgements: This project was supported by a grant from the
National Institutes of Health (NIH), National Heart, Lung and Blood
Institute, award# K07 HL079256-01 An Integrative, Evidence-based
Model of Cultural Competency Training in Latino Health across the
Continuum of Medical Education (20049) and from the Association of
American Medical Colleges (AAMC) grant initiative Enhancing Cultur-
al Competence in Medica l Schools (2 0058) supported by the
California Endowment. The contents are solely the responsibility of
the authors and do not necessarily represent the official views of the
NIH or AAMC. The authors gratefully acknowledge the invaluable
contributions of Loretta Garcia and Jennifer Encinas for data collection
and management, and the support of clerkship director David
Morohashi, MD.
Conflict of Interest Statement: None disclosed.
Corresponding Author: Desiree Lie, MD, MSED; UCI - Department
of Family Medicine, University of California, Irvine, School of
Medicine, 101 The City Dr South, Bldg 200, Rm 512, Orange, CA
92868, USA (e-mail:
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S125Lie et al.: Reflective Practice for Cross-cultural EncountersJGIM
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    • "While extremely important for the practice of healthcare, cultural competency training provides little direction for the identification and resolution of cross-cultural ethical dilemmas. The competency training approach is not sufficient for understanding and managing the complex ways in which culture shapes healthcare decision-making (Kumagai and Monica 2009; Dharamsi 2011; Butler et al. 2011; Chang, Simon, and Dong 2012; Lie et al. 2010; Vogt 2011; Hester 2012; Gregg and Saha 2006). Critics of medical education strategies that focus on cultural competencies through skills training Bioethical Inquiry "
    [Show abstract] [Hide abstract] ABSTRACT: This paper presents a pedagogical framework for teaching cross-cultural clinical ethics. The approach, offered at the intersection of anthropology and bioethics, is innovative in that it takes on the "social sciences versus bioethics" debate that has been ongoing in North America for three decades. The argument is made that this debate is flawed on both sides and, moreover, that the application of cross-cultural thinking to clinical ethics requires using the tools of the social sciences (such as the critique of the universality of the Euro-American construct of "autonomy") within (rather than in opposition to) a principles-based framework for clinical ethics. This paper introduces the curriculum and provides guidelines for how to teach cross-cultural clinical ethics. The learning points that are introduced emphasize culture in its relation to power and underscore the importance of viewing both biomedicine and bioethics as culturally constructed.
    Full-text · Article · Jan 2016 · Journal of Bioethical Inquiry
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    • "Reflection is used as a means of promoting the professional development of both student and practice nurses (Paget, 2001). Reflection assists student nurses to: develop skills in dealing with personal emotions that occur during clinical practice (O&apos;sullivan et al., 2012), better understand and increase their ability to solve problems in the clinical setting (Lie et al., 2010), and develop critical thinking analysis skills (Asselin, 2011). Reflective practice also provides a framework for designing graduate nursing curricula (Horton-Deutsch et al., 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: This paper addresses the importance of considering cultural characteristics prior to implementing reflective practice into nursing courses. Reflective practice implementation in Eastern countries raises challenges related to differences in the cultural characteristics between Eastern and Western countries. This paper will use Hofstede’s framework to explore and identify the influence of culture on reflective practice in Western and Eastern nursing education and the implications this has for the future implementation of reflective practice in Eastern nursing education.
    Full-text · Article · Aug 2014 · Nurse Education Today
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    • "It is a powerful method for students to express their emotions based on good and bad experiences during practice [2,3]. Furthermore, students are prompted to share their learning moments through writing, discovering themselves deeply by looking through their own written reflections [4]. In writing reflective diaries, the students pick up self-reflective assessment skills during their clinical posting to develop their critical thinking by identifying their own limitations, reflecting upon learning incidents, and thereby creating changes among themselves [5]. "
    [Show abstract] [Hide abstract] ABSTRACT: Learning contracts and reflective diaries are educational tools that have been recently introduced to physiotherapy students from Malaysia during clinical education. It is unclear how students perceive the experience of using a learning contract and reflective diary. This study explores the learning pathways of the students after using a learning contract and a reflective diary for the first time in their clinical placement. A total of 26 final-year physiotherapy students completed a learning contract and a reflective diary during clinical placements. Two researchers explored the data qualitatively by the thematic content analysis method using NVivo. A total of four and six main learning themes were identified from the data of the students through a learning contract and reflective diary. These learning themes reflected the views of the students about what they have considered to be important learning pathways during their clinical placements. They give valuable insights into the experiences and opinions of students during their clinical education process, which should be useful for enhancing teaching and learning methods in physiotherapy education.
    Full-text · Article · Jul 2013 · Journal of Educational Evaluation for Health Professions
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