Sociocultural aspect of care is definitely part of the “problem”: Developing preclinical students’ cross-cultural care competence through problem-based learning

Introduction

The pandemic had highlighted existing sociocultural, diversity, and equity issues in medicine. Healthcare providers’ cultural competence and their roles in promoting quality care for diverse cultural groups are central to equity in health care (Flores, 2000; Seeleman et al., 2014). In the northern hemisphere where some countries have a high immigrant population and where diversity and inclusion are explicitly promoted, cross-cultural care competence (CCC) is regarded as one of the core competencies for future healthcare providers (AAMC, 2015; ACGME, 2022; GMC, 2018). Extensive literature, mostly based on western cultural contexts, suggests that CCC may improve physician-patient communication and collaboration, thereby improving clinical outcomes and reducing health disparities (Betancourt and Green, 2010; Green et al., 2017).

To respond to the need for health providers with CCC awareness, course guidelines were created (AAMC, 2015; Dogra et al., 2016) and ways to introduce diversity and enhance CCC in medical education programs implemented (Brottman et al., 2020). However, these still remain challenging to medical educators, particularly in countries where CCC topics are not prioritized in the packed medical curriculum (Lu P. Y. et al., 2014; Lu P.Y. et al., 2021). The authors’ previous study showed that there was a consensus on students’ lack of sufficient cultural competence as well as on the inadequacy of relevant training in the curriculum. In a larger scale, follow-up mixed-methods study, students’ self-perceived preparedness related to CCC was shown to be inadequate in the preclinical stage where curriculum is packed with training of medical knowledge and driven by licenser-exam (Lu P.Y. et al., 2021). These findings pose challenges that warrant educators to provide explicit and implicit training on cultural competence.

Studies about how CCC can be integrated into medical training is extensive (Ho M.J. et al., 2008; Lu P.Y. et al., 2021; Dogra et al., 2010). PBL that has been adopted more widely in medical programs provides opportunities for self-directed learning (Frambach et al., 2019; Trullàs et al., 2022). In the East Asian culture, PBL allow students to acquire experiences through more student-centered, interactive, and self-directed small-group learning pedagogical approach that depart from the cultural norm (Gwee, 2008) . Based on constructivism and cognitive learning theories, PBL emphasizes student learning through active participation rather than teacher instruction, the latter of which is more common in traditional East Asian pedagogies (Lam and Lam, 2009). PBL also allows students to construct and accumulate knowledge through participation, knowledge creation, and interactions with the environment. Drawing from Bloom’s Taxonomy (Krathwohl, 2002), which identified six levels of understanding (knowledge, comprehension, application, analysis, application, analysis, and synthesis), CCC-related knowledge can be levered to the individual application level by integrating various CCC issues into PBL sessions. In these sessions, students can build their knowledge of these topics using problem-focused, student-centered, and self-directed learning (Hmelo-Silver C.E., 2004), then apply these knowledge to help them navigate through similar situations in the future. Through a sociocultural learning process at the interpersonal level, students can also learn from one another through collaborative interactions during small group discussions to communicate, share their knowledge, and make joint decisions (Saqr et al., 2020; Hmelo-Silver C. E. and Eberbach, 2012). If group discussions are optimal, students would be more motivated to engage in more in-depth learning, drawing from their knowledge and intrinsic interests to work collaboratively (Dolmans and Schmidt, 2006). Further, these discussions can help students to work toward achieving adaptive expertise in the preclinical stage during which the skills and knowledge accumulated about CCC topics can be transferred and adapted to professional encounters in the clinical setting (Kua et al., 2021; Pusic et al., 2018). For instance, Shields et al. (2009) found that encouraging tutors to interweave discussions about alternative medicine, social economic issues, culture and diet in a gastrointestinal pathophysiology PBL course improved students’ perceptions of the frequency in which CCC was discussed. Through increased awareness and discussions of these topics, medical students can accumulate CCC-related knowledge and skills that would provide them with conceptual basis to explore biases and improve patient care in clinical practice. Taken together, PBL promotes a learning process carried forward through individual and interpersonal learning, and continual build-up of CCC-related knowledge and skills to care for the needs of diverse patient populations. We will further discuss this process in a later section.

Following the trend, most medical education programs in Taiwan adopted PBL at the turn of the 21^st century when it was introduced as an effective self-directed learning method (Lin, 2005; Lam and Lam, 2009). PBL is more often integrated into the preclinical stage where training mostly consists of medical and clinical science integrated modules (blocks hereafter). In order to balance the medical, science-based curriculum, the so-called humanities issues were recommended to be included in PBL sessions to provide the socio-psychological aspects of learning. However, these issues were mostly pertained to shared decision making based on disease prognosis or care relevant- medical ethics, often relegated to the last part of the case.

In this study, we integrated various CCC issues (i.e. LGBTQ gender stereotyping, complementary and alternative medicine, new immigrant spouses and medical advocate) into three blocks’ PBL sessions in order to investigate the effectiveness in developing students’ awareness and knowledge of CCC. To do this, we will first discuss the conscious competency framework of learning, which underlie how students’ knowledge and awareness of CCC issues can progress from unconscious incompetence toward conscious competence as they reflect on their learning experiences. We also identified obstacles encountered and discussed ways to improve CCC-integrated PBL curriculum design. Lastly, we proposed a potential curriculum guide for incorporating sociocultural and CCC issues into PBL.

Methods

Conceptual framework: Conscious competency stages

This study applied the conscious competence stages to further understand the development of students’ CCC awareness and knowledge. Raising students’ awareness and sensitivity of CCC issues is a continuous process that entails students to progress from unconscious incompetence to conscious competence (Broadwell, 1969; Curtiss & Warren, 1973; Adams, 2022). In the first stage of unconscious incompetence, the student is unaware that their own knowledge or skill may be inadequate (Lane and Roberts, 2022). As they progress from the conscious incompetence stage to conscious competence, the student becomes aware that they are lacking some skill to carry out a task or have inadequate knowledge about certain topics, and then works to obtain the relevant knowledge and skills. In the last stage of unconscious competence, the expert or mastery level, the student is able to respond automatically that they have the ability to transfer and apply their existing knowledge and kills across multiple situations and tasks. As previously mentioned, our aim of integrating CCC issues into PBL sessions is to help students establish the foundations to progress from the unconscious or conscious incompetence stages to the later stages. Introducing different CCC issues in PBL sessions provide students opportunities to learn constructively and socially about diverse patient needs. Then, they can reflect on what they’ve learned, draw from, and transform these knowledge and skills to help them to develop adaptive expertise as they build up their learning experiences.

Study Design

Diversity issues students identified as being “less prepared for” from the authors’ previous study (Lu P.Y. et al., 2021) were incorporated into various block’s PBL scenarios at a Taiwanese medical school (see Table 1). In this study, sociocultural and CCC contents based on local Taiwanese contexts were embedded into the PBL sessions of three blocks (pediatrics and developmental medicine, renal and urinary system, and host responses and infectious diseases). Topics explored included issues pertaining to new immigrants, use of Complementary and Alternative Medicine (CAM), LGBT patients and gender stereotyping, and diverse socioeconomic classes. We used mixed methods to explore teachers’ and students’ perceptions of the outcomes and effectiveness of integrating CCC issues into PBL sessions.

Table 1. Cross-cultural issues integrated in blocks
Blocks	Cultural Issues	Scenarios	Patient Population
Host Response and Infection	Gender stereotyping (LGBTQ)	Young man who is suffering from abdominal pain and has HIV	LGBTQ
Cardiovascular System	People with different health belief, distrust of health care system, medical ethics, shared decision making	Middle-aged woman who has sudden chest pains	People with different health belief, distrust of health care system,
Respiratory System	Shared decision making	NA	NA
Renal and Urology System	Complementary and alternative medicine, gender differences in health care	Elderly grandma who has hematuria; Woman who has nausea and is vomiting	Elderly/using CAM
Endocrinology and Metabolism	Empathy and patient communication skill	NA	NA
Digestive System	Immigrant workers, communication, patient understanding of disease	NA	Immigrant workers
Musculoskeletal System	Distrust of medical professionals and the health care system	NA	Patient distrust of medical professionals and the health care system
Nervous System	physio-psychological disability, family medical decision	Woman who often faints	Patient with disabilities
Hematology and Neoplasia	Delivering bad news, holistic rehabilitation resources, socio-economic factors	Man who is suffering from dizziness and fatigue	Socio-economic classes
Reproduction Medicine	LGBTQ, medical advocate LGBTQ	NA	Sexual minority
Development and Pediatrics	Medical advocate, new immigrant (immigrant spouse), pediatric palliative care	Three-month old infant who experienced OHCA (out of hospital cardiac arrest); Newborn continuously throwing up, mother is a new immigrant from Vietnam	New immigrant/ spouses
Special Sense Organ	Indigenous, people with different health belief	NA	Indigenous individuals
Preventive Medicine, Community Medicine and Geriatric Medicine	Socioeconomical status, life style and cultural bias, social security, religious belief	Middle-aged man who has skin itchiness and suffering from nausea	individuals with diverse Socioeconomic status

Scenario writing: Integrating cross-cultural topics in PBL scenarios

In the institution of this study, PBL scenarios are generally written collaboratively by one basic sciences teacher and one clinical teacher. Each scenario includes six sections (i.e. chief complaints, patient history, physical examination, laboratory and image investigation, initial diagnosis and management, and clinical course). Previously, ‘humanities’ relevant issues usually appeared in the clinical course section to satisfy the requirements for ‘humanities’ integration by the medical education program. Starting from 2017, the aforementioned CCC topics were deliberately brought into PBL scenarios to create opportunities for students to discuss CCC and sociocultural issues. One of the researchers of this study who is a humanities faculty collaborated with clinical and basic sciences teachers to work on the scenarios.

The issues incorporated into patient history included descriptions related to patients’ ethnic backgrounds, religious beliefs, socioeconomic backgrounds, sexual orientation, and family contexts. Scenario writers were careful to provide only essential descriptions about the patients or their psychological and emotional state in order to induce students to develop cultural sensitivity and conduct further research. For instance, instead of directly saying ‘low-income labor’ to describe a patient’s job, a description of the patient’s working conditions was provided. Sociocultural or CCC issues such as the usage of CAM, different health belief other than western medicine, and new immigrant’s access to quality care were also integrated. The purpose of embedding these issues was for students to open up discussions in order to further their understanding of diverse patient groups and patients’ concerns. Aside from these, other CCC integrated topics can also include social and psychological support, financial support, resources and impact on recovery. Topics like these could help trigger student discussions on family and social resources that facilitate social advocacy.

A complete list of the cross-cultural issues integrated is presented in Table 1 and an example of a case scenario is shown in Box 1. To facilitate tutors’ guidance, relevant supplementary materials were provided for the tutors’ reference, and faculty meeting for each block’s CCC-integrated PBL session included discussion and explanation sections.

Box 1. Example of CCC issues integrated into scenarios

Original script:

After a series of examination, Mr. Chan was diagnosed with…Mr. Chan’s attending physician, Dr. Wang, was planning to make an appointment with Mr. Chan and his family to explain his condition and treatment plan. Then, Mr. Chan’s son came to visit Dr. Wang early and asked that if Mr. Chan is diagnosed with cancer, can she not tell Mr. Chan?

Changed script:

After a series of examination, Mr. Chan was diagnosed with…Mr. Chan’s attending physician, Dr. Wang, was planning to make an appointment…Then, Mr. Chan’s son visited Dr. Wang before the scheduled appointment and he told Dr. Wang that his father, Mr. Chan, often does volunteer service at the temple so he deeply felt Holy Emperor Guan (a god in the local Taiwanese religion) would protect him. His (Mr. Chan’s) belief has been extremely helpful for calming his soul and supporting his spirits. Also, Mr. Chan’s son asked that if Mr. Chan is diagnosed with cancer, can the doctor not tell Mr. Chan to avoid giving Mr. Chan too much shock.

Participants

Pre-and post-questionnaires were administered to 365 third-and fourth-year undergraduate and second-year post-baccalaureate preclinical students enrolled in three blocks’ PBL. A total of 124 valid pre-PBL and 239 post-PBL responses were collected (Table 2). A pre-PBL tutors’ questionnaire was administered to 51 tutors of basic or clinical sciences and 24 responses were collected (33.3% basic sciences, 66.7% clinical sciences). After the PBL-sessions, eight students participated in focus groups and 12 tutors participated in semi-structured in-depth interviews. The medical school in which this study was conducted is the only medical school in Taiwan that has two programs respectively for undergraduate and graduate entry level. The comparable study level of the students is shown in Table 2.

Table 2. Student demographics (% of student respondents)
	Pre-PBL Questionnaire (N=124)	Post-PBL Questionnaire (N=239)
Program
Undergraduate 3^rd year	47.6%	51.9%
Undergraduate 4^th year	21.8%	28.5%
Post-Baccalaureate-2^nd year (comparable to undergraduate 4^th year)	30.6%	19.7%
Gender
Male	50.0%	NA
Female	50.0%	NA
Student status (Student Only)
Domestic students	91.13%	-
Overseas Chinese students and International Student	6.45%	-
other	2.42%	-
Note. Student respondents include 3^rd and 4^th year undergraduate and 2^nd year post-baccalaureate students enrolled in the pediatrics, infectious disease, and renal block PBL sessions. At the time of the study, this was the only medical school that had two programs respective for undergraduate and graduate entry level.

Data collection

We collected both quantitative and qualitative data to better comprehend both students’ and tutors’ perspectives. Quantitative data included responses from pre-PBL student and tutor questionnaires that were administered before PBL sessions and post-PBL student feedback questionnaires. Qualitative data included transcriptions from student focus groups and tutor interviews. The following sections summarize the data collection and analysis methods.

Quantitative data

Students voluntarily and anonymously completed pre-PBL questionnaires at the start of the first PBL session. This questionnaire consisted of ten questions, including items on student demographics, students’ preparedness to care for diverse patient groups, adequacy of curricular content on cross-cultural issues, and perceptions of the training environment related to CCC. At the last PBL session, students completed a post-PBL feedback questionnaire that included five items. Students rated the helpfulness of PBL participation for their interactions with diverse patient groups and in preparing them for clinical practice. Based on the CCC topics discussed in each respective block, students identified: 1) the most impactive CCC issues discussed; 2) needs of the particular cross-cultural patient group discussed, and 3) the most rewarding aspects they learned in these PBL sessions.

For tutors, a pre-PBL questionnaire was administered either at the tutor information session prior to the start of PBL or sometime before the first PBL session. Tutor questionnaires included items on demographics, perceptions of students’ preparedness to care for diverse patients, curricular content, and training environment related to CCC.

Qualitative data

Qualitative data were collected through semi-structured individual interviews with tutors and focus groups with students from the pediatrics and developmental medicine block. Students signed up for focus groups voluntarily through convenience and snowball sampling. Focus groups included four students per session and averaged 40 minutes each session. Due to the packed block curriculum, we opted to just recruit students from one block (n = 8) to explore students’ general perceptions of the CCC-integrated PBL course design and its effectiveness, and to cross-examine students’ and tutors’ perceptions.

For semi-structured tutor interviews, 12 PBL tutors (5 basic sciences, 7 clinical) from the three PBL courses were selected through purposive sampling and invited via email to participate.

Data Analysis

For quantitative analysis, we used SPSS to cross-examine students’ and tutors’ perceptions of students’ preparedness to care for diverse patients and the adequacy of CCC training. We conducted one-way ANOVA to determine whether differences existed between the two groups’ pre-questionnaire responses. Data from student post-questionnaires were analyzed using descriptive and content analyses to determine respondents’ learning and perspectives.

For qualitative analysis, student focus groups and individual tutor interviews were recorded, transcribed verbatim, coded, and analyzed using inductive thematic analysis. Two researchers independently read and identified similar contents across transcripts, established codes to categorize recurring points, and sorted the data based on these codes. Codes were then grouped together and triangulated to produce four themes: (i) awareness raising- CCC topics in medical education, (ii) student engagement- reasons affecting participation, (iii) tutor concerns-competence in facilitation of CCC learning, and (iv) competition in the crowded curriculum. Bilingual researchers translated and verified the quotes from students and tutors and data from quantitative and qualitative analysis were triangulated and cross-examined.

Ethical considerations

Ethical approval for this study was obtained from the National Cheng Kung University Governance Framework for Human Research Ethics (Approval No.105-249).

Results

Quantitative results

Results from the pre-questionnaires were comparable to those presented in the authors’ previous study (Lu P.Y. et al., 2021). Both student and tutor respondents viewed students’ preparedness to care for culturally diverse patients as necessary (Students: 4.85\(\pm\)0.67; tutors: 4.82\(\pm\)1.01; 1= very unnecessary, 6= very necessary) and believed it is a serious problem when students receive inadequate cross-cultural training (Students: 3.13\(\pm\)1.02; tutors: 2.90\(\pm\)0.77; 1 = very problematic, 6 = very unproblematic).

Results from student post-questionnaire showed respondents generally agreed CCC-integrated PBL sessions were helpful or somewhat helpful in increasing their understanding of how to interact with diverse patient groups (overall mean = 2.87/4, std. dev.= 0.89) and in preparing them for clinical work (overall mean = 3.15/4, std. dev.= 0.76). Across the three blocks, 69.9% and 82.0% of students rated these sessions to be very helpful or helpful for these two items respectively. Depending on the scenarios used, students in the pediatrics, infectious diseases, and renal blocks identified issues dealing with “culture and opinions of patient advocates” (61.8%), “social resources needed during patients’ treatment” (57.9%), and “different generational cultures” (55.3%) to have the largest impact on their learning respectively. The patient needs and knowledge students indicated as having learned about are presented in Table 3.

Table 3

Student feedback questionnaire: impactive issues, understanding of patient needs, and knowledge gained from PBL sessions
	Pediatrics and developmental medicine (n = 68)	Renal and urinary system (n = 47)	Host responses and infectious diseases (n = 124)
Of the CCC or social issues listed, which issue perceived to be most impactive?	Family elders’ or members’ opinions (42)	Culture of different age cohorts or generations (26)	Social resources required during patients’ treatment (81)
* Which patient needs did you learn about through integration of CCC topics in scenarios?	• Respect for new immigrants and their beliefs (7) • importance of communication (6) • language barriers (5) • importance of psychological needs (5)	• Patients’ different health beliefs (7) • generation gaps in treatment acceptance (7) • empathy for patients (6)	• empathy and respect for LGBTQ patients (11) • patient privacy (11) • social support and medical resources (8) • ethics & law (8) • interpersonal relationships and psychological factors (6) • familial support (6)
*In these PBL sessions, what did you feel was the most rewarding or what did they gain?	• Preparation for issues we will encounter in the future (i.e. doctor-patient relationships, medical communication) (5) • Understanding of challenges, barriers to health care, and biases & stereotypes related to new immigrants (7) • Exposure to and increase understanding of diverse cultures and their influences on health care (4) • Medical related knowledge (2)	• Understanding of issues related to complementary and alternative medicine (CAM) (4) • Importance of considerations for different cultural contexts and the need to understand diverse patients’ perspectives (5) • medical communication & need to understand barriers to communication (3) • gender or sexual orientation concerns (2) • Problem-solving skills (2) • medical related knowledge (5)	Learning to conduct independent research on topics not taught in lectures and using information gathered to problem-solve (9) Connecting basic knowledge learned with clinical knowledge (10) Need to understand different facets, perspectives/ perspective-taking (12) Collaboration with team members (4) Importance of respect for patients of diverse cultural groups (2) Medical related knowledge (9) Other skills or knowledge (i.e. presentation, organization, problem-solve methods) (9)
* Number in parentheses indicate frequency in which these items were mentioned or rated

Qualitative

Aforementioned in the data analysis section, the qualitative data can be inducted into four themes. A summary of the themes and associated quotes is displayed in Table 4.

Table 4

Themes, sub-themes, and quotation examples from tutor interviews and student focus groups.
Awareness raising- CCC topics in medical education
Preparing medical students to care for diverse CCC patient groups is important	“Medical communication is very important for doctor-patient and doctor-nurse relationships, so having empathy and good communication with diverse patients is very helpful for students’ future medical practice…” (Pediatrics, tutor PC-C)
Integrating CCC topics in PBL scenarios is helpful for students’ training	“I think more or less (helpful), by giving (students) multiple stimulation and increased exposure, they will become used to facing these issues and be used to interacting with these patients in the clinical setting. They will then apply some of their previous learning to look for information to enhance their understanding of these cultural groups. Learning these make a difference, they will improve, so I believe this (CCC-integrated PBL) is helpful.” (Infectious Diseases, tutor PC-F)
Raising students’ awareness of the existence of sociocultural aspects of learning	“In the discussion process, they will become aware that these things (related to CCC issues) exist in Taiwan…” (Infectious diseases, tutor PB-E)
Preparing students for future clinical practice before encounters with actual patients, awareness of bias and stereotypes	“I think at least (CCC-integrated cases) let students recognize that these issues exist. When they practice as doctors they will surely encounter families with issues related to new immigrants. For instance, bias against certain ethnic or racial groups, (these sessions) at least make them aware that this problem exists…” (Pediatrics, tutor PB-A) “We will encounter these (CCC issues) in the future, it’s impossible for us not to encounter as we will not only encounter Taiwanese patients in the future” (Pediatrics, student focus group A)
Recognizing importance of interprofessional team members	“Students can understand that some situations cannot be handled by clinical doctors themselves, they would need other team members. In other words, in terms of the CCC issues (discussed in the PBL sessions), it is ok if they don’t understand everything. They can just provide care…there are also nurses who can be attentive to many details that doctors are not aware of…and also psychologists and social workers…” (Pediatrics, tutor PC-A)
Students’ engagement in CCC issues- reasons for not participating
Inadequate student engagement or participation	“The biggest challenge is guiding them to discuss cultural or ethnic/racial issues. They (students) don’t want to discuss. I feel this is the biggest challenge. Everyone would briefly talk about it, but did not want to discuss this learning issue more in-depth, so I would provide them with hints…” (Pediatrics, tutor PB-B)
CCC has no “exact answers” or “guidelines”	“There are still some gaps in what was learned in class and reality. Students will still follow what they learned in class, whether it’s what doctors or teachers said or what was mentioned in the textbook. They will use these as models. However, in reality there will be gaps since actual patients’ situations would be influenced by background, socioeconomic, or educational level differences, they might not cooperate easily with doctors.” (Renal, tutor PB-D)
Difficulty in motivation—CCC contents “will not be tested on”	“I feel, some students’ responses are that (these issues) will not be tested on. This is also a problem. In other words, students feel that these humanities issues cannot be quantified or brought into OSCE… students still care more about grades and quantified outcomes” (Pediatrics, tutor PC-B)
Unfamiliarity with CCC topics and treating all patients equally	“The understanding of CCC of the group I facilitated is not very good. What I mean by not very good is that there is not a lot of opportunities for them to proactively discuss these aspects…their discussion is thus more dull and colder, I feel they are not familiar (with these topics) and information (on CCC) is not necessarily easy to find…” (Renal, tutor D) “I feel I will still prioritize standardized medical treatment because everyone’s cultural background is different… it’s impossible for me to have sufficient understanding of every patient’s culture…hence I will go along with typical medical procedures first…” (Pediatrics, student focus group B)
Lack relevant CCC knowledge and stereotypes or bias toward diverse patient groups they are unfamiliar with	“…so it might be their (students’) own stereotypes, they think these things are natural so that they won’t especially care and continue case discussing in the way they had originally planned. They did not think about more in-depth levels, they just think that using Chinese herbal medicine will bring forth some negative outcomes, so their preconceived notion is that Chinese herbal medicine will definitely have bad effects. Therefore, their stereotypes would lead them to not engage in more in-depth discussions of why (patients) use herbal medicine.” (Renal, tutor PB-D) “…aside from being from Vietnam, once the mother found her child to have odd symptoms, the mom took the child to receive some strange treatment using ashes- I was very surprised. Even when I think about immigrant spouses, I feel there are some sense of inequality, like I also have some bias. Even when we discuss now, we are more or less influenced.” (Pediatrics, student focus group B)
Difficult to understand without actual encounters or clinical interactions	“For them, it is difficult to understand the importance of these aspects. However much we tell them that they will encounter these issues in the future, they did not actually encounter real patients to understand the importance.” (Renal, tutor D)
Need additional guidance and directions to discuss CCC issues or topics	“We purposely asked the students to search for information, then they will discuss. This part requires tutors to design questions, then they will discuss. Otherwise, it is not really possible (for students) to carry on regular discussions” (Infectious diseases, tutor E)
Tutors’ concerns- competence in facilitation of CCC learning
Understanding of CCC	“…At that time when you mentioned cross-cultural topics, I thought, ‘hmm, that’s a good idea! We just translate the Chinese version to English version’… then afterwards, I realized what (CCC) meant was to discuss the different social and cultural background in the cases…” (Infectious diseases, tutor G)
Insufficient CCC knowledge or no previous training for CCC discussion	“Just like when we review the cases, because we do not have these sorts of experiences ourselves (guiding CCC-integrated discussions), we are unsure of how to guide this course…” (Pediatrics, tutor PB-A)
Basic & clinical science tutors’ perceptions and collaboration between basic and clinical science tutors	“For us tutors of basic sciences, we actually do not have experiences (related to medical communications) or even have basic knowledge of these… I feel the key is to pair with clinical doctors as clinical doctors would have more knowledge and experience to share (with students)” (Pediatrics, tutor PB-A) “Maybe us basic sciences tutors are not as convincing. Since clinical tutors probably have encounters (with these CCC issues), there will be better outcomes for them to discuss these with students” (Pediatrics, tutor PB-B)
Need for additional CCC training and more complete cases and guides	“As for tutors, I feel tutors need more training. I know it’s difficult, but having participated in some previous workshops, you know there are many of us guiding PBL sessions. If we don’t look closely at what’s in the cases, we just briefly go over so I don’t know how much do students gain, but just considering humanities aspects, it will be better to have a training for tutors.” (Renal, tutor PC-D)
Competing with space and time
Many topics within limited time	“If we are discussing biological or physiological aspects, we can quickly integrate these (into discussions). However, if we are talking about humanities, then I feel there’s not enough time… we would just briefly brush over as time do not permit us to discuss this much” (Infectious diseases, tutor G) “The biggest challenge is that there are too many issues (to discuss), and how to distribute time is a major problem…” (Pediatrics, tutor PC-C)

Awareness raising - CCC topics in medical training

Consistent with our quantitative finding, qualitative results showed students and tutors perceived preparing medical students with knowledge and skills to care for diverse patient groups as important. Both groups also generally expressed integrating CCC topics into PBL scenarios to be helpful for students’ training.

Tutors indicated incorporating CCC issues can raise students’ awareness of the existence of sociocultural aspects of learning, some of which might be related to biases and stereotypes of oneself or of others. As a tutor mentioned, students might have some preconceived beliefs or biases about certain cultural groups before attending PBL sessions. Discussions with group members and research on topics related to diverse groups of patients in PBL sessions allowed these students to reconsider and adjust their own perceptions, especially when they realized their peers did not share their perspectives. Tutors also indicated these sessions provided students some preparation before they encounter diverse patients in the clinical setting and helped students to recognize the importance of other interprofessional team members.

Similar to what tutors conveyed, students acknowledged that they will encounter more CCC issues in the future, so CCC-integrated PBL sessions provided opportunities that prepare them for future clinical practice. They also indicated that they learned more about sociocultural aspects in these CCC-integrated PBL sessions compared to traditional PBL sessions, and felt PBL with CCC issues embedded were unique. As previously mentioned, students identified in the post-questionnaire cross-cultural or social issues they considered as impactive, along with needs of diverse patient groups based on the scenarios and cultural issues discussed in each block (see Table 3).

Students’ engagement in CCC issues- reasons affecting participation

Tutors’ and students’ qualitative data, however, showed students exhibited behaviors that did not align with students’ quantitative self-reported perspectives. Tutors reported some groups were not proactive in discussing CCC issues, while other groups only demonstrated some engagement and sensitivity toward CCC. These groups had brief discussions about the topic, but were missing more in-depth explorations. Reasons for variations in the depth and breadth of students’ engagement level in discussing CCC issues could be due to several factors including students’ understanding of the medical case, mentality and attitude, prior knowledge and unfamiliarity with CCC issues, and having inadequate motivation.

Traditionally, students seek to have more discussions related to biological knowledge as these aspects are more straightforward, and students are able to obtain “right” or “direct” answers. For instance, students expressed that in other PBL sessions, most research, discussions, and tutor guidance revolved around biological or medical principles such as how to diagnose or treat diseases. However, CCC issues often do not follow this pattern. In one focus group, respondents expressed it is “bothersome” to have to look for additional information, especially as CCC issues have “no scientific evidence” and have many disparate aspects on which to conduct in-depth research. There are no “exact answers” or “guidelines”, and each group member has different knowledge and attitudes toward different cultures. A few students further claimed psychosocial issues should be handled by others (such as social workers) rather than by doctors. Students’ responses were also somewhat echoed in tutor interviews. Tutors indicated it is difficult to motivate students to discuss CCC topics as students believe that CCC contents “will not be tested on” or “are not included in OSCE”.

In addition to students’ mentality and attitudes, tutors noted students might have difficulty in engaging in discussions as many students are unfamiliar with various CCC topics, especially the ones related to sociocultural issues. Tutors further observed that students had difficulty independently conducting additional self-directed research or diving into more extensive discussions, even with hints or deliberately designed questions from tutors. Several tutors further suggested it may be difficult for students to be aware of the importance of CCC without having actual encounters or clinical experiences with culturally diverse patient groups.

Consistent with tutors’ observations, students perceived themselves to lack relevant CCC knowledge and experience in interacting with various cultural groups. Thus, students indicated that they would treat all patients equally first as it is impossible to have sufficient comprehension of every culture. A few students also further acknowledged they may have some bias against some unfamiliar cultural groups. For example, a student mentioned being surprised by the actions that the new immigrant mother took toward treating her child’s symptoms. In their self-reflection, the student recognized they have some bias toward new immigrant spouses, which influenced their perceptions of the situation. Despite this acknowledgment, students still showed insufficient motivation to try to examine CCC topics more in-depth. As some students expressed, they would not push one another to engage in more extensive discussions of CCC topics unless tutors provide additional guidance to enhance engagement.

Tutors’ concerns- competence in facilitation of CCC learning

Tutors demonstrated some concerns regarding their own CCC knowledge. In order to guide student discussions, tutors need to possess a certain degree of CCC knowledge themselves. Although pre-PBL faculty training sessions were provided, many tutors still expressed discomfort with their own knowledge. As such, a tutor mentioned that he had initially misunderstood CCC as simply language issues in medical communication. Relatedly, several tutors felt they had insufficient knowledge and experiences to guide students effectively as they did not receive relevant training themselves. In sum, tutors emphasized the need for additional CCC training to enhance their knowledge and familiarity with CCC topics and suggested more complete cases and tutor guides are needed to help them prepare for CCC-integrated PBL sessions.

Competition in a crowded curriculum

Most tutors and students raised challenges and obstacles to effectively integrate CCC topics into PBL sessions due to packed curriculum and time shortage. Tutors generally agreed there are already many topics to cover within the PBL sessions (i.e. biological and medical knowledge). Tutors felt discussions usually start with aspects such as physiology and pathology, then CCC issues usually end up being just briefly touched upon due to insufficient time. They also mentioned that with too many topics to discuss, students can become confused and their focus diverted. Students then end up focusing on issues and information they can easily seek out.

Discussion

In this study, we integrated CCC issues into the scenarios of three block’s PBL sessions to foster students’ awareness and learning of these CCC topics in the preclinical curriculum through the lens of the conscious competence framework. We then examined quantitatively and qualitatively the effectiveness of including these sociocultural elements through students’ and tutors’ perspectives. Thus far, this paper has laid out quantitative and qualitative findings from medical students and PBL tutors. We now triangulate both sets of results and consider the implications from four aspects: (i) effectiveness of PBL in raising awareness of the impact of diversity on healthcare, (ii) gap in students’ CCC learning experiences, (iii) tutors’ competence in guidance, and (iv) integration of proper CCC issues into PBL.

Effectiveness of PBL in raising awareness of the impact of diversity on healthcare

The findings showed that CCC-integrated PBL allowed students to be more aware of diverse cultural groups’ healthcare needs and prepared them for clinical learning. Although students had some difficulty engaging in in-depth discussions of CCC issues and some tutors raised the concern that it was challenging for students to do so without patient encounters, this integration nevertheless offered opportunities for preclinical students to be introduced to some CCC topics they are unfamiliar with. Placed within the conscious competency framework, students can acquire relevant knowledge and skills that enable them to transfer and respond to similar CCC situations as they become more situated through individual and collaborative learning. As learning and development of adaptive expertise are gradual processes (Lajoie and Gube, 2018), Whether students were able to reach the higher competency levels might not be clear in our study. However, students’ identification of impactive issues and patient needs post-session demonstrated that they were able to establish some foundational knowledge and awareness of CCC. Having systematic and repeated learning of CCC topics would also allow them to accumulate necessary knowledge and skills they can transform, adapt, and apply to different situations in the clinical environment (Mylopoulos and Regehr, 2009; Kua et al., 2021).

As posited in cognitive learning theories (Hmelo-Silver C. E. and Eberbach, 2012), CCC-integrated PBL sessions provided space for students to reflect on their own thinking through metacognition, and recognize their own perceptions, biases and stereotypes of diverse cultural groups. This reflection is especially important as biases and stereotypes held by healthcare providers likely have negative consequences on care quality, healthcare equities, physician-patient communication, and treatment of patients from diverse cultural groups (Hall et al., 2015; FitzGerald and Hurst, 2017). In our study, students’ recognition of their own biases and observation of peers’ responses further demonstrated the value of incorporating CCC issues into PBL sessions as they were able to increase their awareness of sociocultural issues discussed.

Varying from traditional PBL sessions or lectures, CCC-integrated PBL sessions provided students explorative learning environment that enable them to draw from their own knowledge of and experiences with diverse cultural groups, to learn interactively with peers and tutors, and to readjust their own perceptions and values. Medical students’ abilities to engage in these steps are critical as encounters with culturally diverse patients are inevitable in future clinical practice.

In short, our findings showed CCC-integrated PBL sessions were still relatively effective in helping students to strengthen their cultural awareness, be more conscious of biases and stereotypes associated with diverse cultural groups, and in improving students’ development of competence and adaptive expertise. Despite the effectiveness in raising students’ awareness, we were aware, however, that several issues emerged and questions remain about how CCC topics can be better integrated. In the following sections, we discuss some concerns that need to be addressed in future course design.

Gap identified in students’ CCC learning experiences

The quantitative data showed students and tutors generally agreed that some CCC elements have been included, albeit sparsely and inadequately, in the medical curriculum. Tutor and students, however, raised different viewpoints regarding students’ CCC preparedness and learning experiences in PBL sessions. Firstly, tutors showed their hesitation about students’ preparedness in the quantitative data, which resonated with the results from previous studies (Lu P. Y. et al., 2014; Lu P.Y. et al., 2021) and the qualitative data. Qualitative analysis revealed that although students were generally able to identify CCC-related patient care issues (i.e. decision-making pattern, bias, language, and gender issues) from the scenarios and exhibit some awareness and sensitivity to these issues, some tutors still believed there is a gap to bridge as most students considered CCC solely meant equal treatment without any differentiation. This is comparable with findings from previous studies (Worden and Ait-Daoud Tiouririne, 2018; Lu P. Y. et al., 2022; Verdonk et al., 2009) in which students were unaware of patients’ sociocultural background or felt treating all patients equally regardless of culture or background would help doctors avoid holding preconceived bias and negative stereotypes against certain patient groups. In these instances, students would unlikely notice or even risk aggravating cultural barriers that contribute to health disparities.

Secondly, tutors and students identified different challenges they encountered. While tutors indicated limited time to discuss CCC topics or packed curriculum to be reasons for students’ lack of proactive discussions, students mentioned about not having enough content to discuss due to insufficient knowledge and prior training. Placed within the conscious competency framework, these students are demonstrating their conscious incompetence in acknowledging that they have insufficient knowledge, but were unsure of how to respond effectively (Lane and Roberts, 2022). Moreover, since PBL’s student-centered approach deviates from the predominantly teacher-centered, lectured-based pedagogy observed in East Asian countries (Shimizu et al., 2019), having to frame switch to other learning modes might partially explain why students had difficulty in engaging in ongoing discussions of CCC topics. Findings from various research also implicated the need to consider how Asian communication styles and cultural factors shape PBL processes in Asian countries (Frambach et al., 2019; Gwee, 2008). As some previous research suggested, Asian students tend to be rote and passive learners who are more concerned with absorbing knowledge (Tavakol and Dennick, 2010). Thus, the level of effectiveness and the extent in which students can actively participate in the more explorative structured CC-integrated PBL sessions will require further consideration. These insights are helpful for tutors to determine effective approaches to facilitate student discussions and remind medical educators to consider both tutors’ and students’ underlying concerns when developing appropriate course designs that maximize students’ learning of CCC. Apart from concerns about students’ participation in CCC discussion, the tutors’ abilities to guide student discussions also plays a crucial role.

Competence in guiding CCC issues in PBL

Influenced by the development of medical professionalism in North America (AAMC, 2011), Taiwan’s medical education began to recognize the need to prepare students to provide quality care to diverse patient groups roughly a decade ago. Developing students’ cultural competence in medical education was seen as an important element for medical education (Ho Ming-Jung et al., 2011) and was included in the standards for medical school accreditation (TMAC, 2013, 2020). However, findings from this study revealed concerns about whether tutors themselves are ready to guide discussions on cultural competence. For instance, a tutor in our study had misunderstood the meaning of CCC, but based on the authors’ previous research findings, this confusion is not uncommon among faculty members (Lu P. Y. et al., 2014). Previous research also found medical teachers reported having limited previous training in cultural competence and insufficient knowledge and skills in teaching cultural competence (Hordijk et al., 2019). Facilitation of CCC discussion appeared challenging for some tutors who might not be familiar with the CCC issues discussed. This raises the issue of who should facilitate discussions if tutors themselves report having inadequate knowledge and experience. Nevertheless, students still benefit by having both tutors of basic and clinical sciences facilitate discussions as tutors’ diverse backgrounds provided more holistic perspectives from different disciplines. However, the effectiveness of this facilitation pairing will require further investigation in future studies. To provide more effective facilitation of student discussions, these tutors would benefit from having more self-learning or training opportunities as CCC issues are sometimes complex for the teachers themselves.

In our institution, before PBL sessions begin, tutors usually attended a pre-PBL training session in which they reviewed the cases with tutor guides. These sessions, however, were not observed to be attended by every tutor who facilitated group discussions and were often conducted very close to the start of PBL sessions, leaving tutors little turnaround time for preparation. Since most tutors did not receive training on CCC themselves and typically pull their knowledge of these topics from their own experiences, tutors’ varying experiences would lead them to adopt different definitions and subjective approaches that contribute to students’ level of participation or engagement. As such, findings from Shields et al. (2009) showed tutors’ participation in a faculty development program that encourage the discussion of CCC topics in a clinical course was effective in improving students’ awareness of these topics. Hence, encouraging or requiring tutors to attend pre-PBL CCC training sessions can improve guidance to facilitate students’ discussion while also allowing them to complement the other tutor’s expertise. Moreover, using tools such as the Tool for Assessing Cultural Competence Training (TACCT) (Lie et al., 2006) can help tutors identify specific competencies and construct frameworks that can be extended to their facilitation of particular CCC issues.

Integrating proper CCC issues into PBL

Concerns raised previously indicate much effort is needed to construct clearer guidelines for integrating proper CCC issues into PBL scenarios. As local, cultural contexts likely trigger varying perspectives from students and tutors, especially when the issues discussed deal with CCC, the need for clearer guidelines that align with these local contexts is essential.

Some steps can be considered when constructing PBL scenarios. First, appropriate social or cultural topics for different blocks need to be identified. Second, good PBL cases were shown to integrate elements of basic and clinical sciences, professionalism, psychosocial components, empathy, and shared decision making (Azer et al., 2012). In scenario writing, teachers are advised to identify learning topics discussed, incorporate elements associated with psychosocial components, adapt scenarios to fit local sociocultural contexts, and avoid stereotypes or biases. Third, as teachers of clinical sciences, basic sciences, and humanities have expertise in different areas, collaboration will provide more holistic perspectives on how CCC topics with more clinical relevance can be better designed and integrated into PBL scenarios. Fourth, medical education programs can consider developing handbooks or guidelines to provide teachers with fundamental guidelines on how to incorporate CCC contents into scenarios.

Limitations

Several limitations in terms of representativeness should be recognized. The study was conducted in a single medical school, which may limit the generalizability of our results. However, we have reasons to believe perspectives conveyed by respondents in our institution still align with those held by other Taiwanese medical school students and tutors. Since Taiwanese medical schools use uniform selection criteria in student acceptance, the perspectives presented by students and tutors may be generalizable to those from individuals at other schools. In addition, both tutors of basic and clinical sciences were included in our quantitative and qualitative data to provide a better summation of the diverse experiences of their views on integrating CCC issues, which might highlight points that need further consideration in future studies.

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