Competency-based medical education (CBME) has become a core pedagogical paradigm to ensure that the graduates have developed the competencies required to be responsive to the needs of the communities they will serve[1,2,3]. Competency-based frameworks for medical education define competencies to be achieved, promoting transparency in education[4,5]. This allows training organizations to confirm whether an educational program successfully produces graduates with the competencies needed for practice[6,7].
However, there are also concerns in the implementation of CBME. The definition of CBME is subject to inconsistency because the term “competency” describes a rather broad concept. As the competencies, even though including broad abilities, must be incorporated CBME into their curricula, teachers must break down a competency into a number of objectives with concrete, specific and behavioral expressions; this is called the technological approach. In this approach, the learning strategies and materials are systematically planned in accordance with the targeted objectives. Assessments for the objectives also need to be set according to detailed objectives[9,10,11]. While long lists of learning objectives across the curriculum can guide students’ learning, it becomes difficult to support individual learning needs through flexible learning plans.3 The technological approach may not allow teachers to fully capitalize on the comprehensive nature of CBME or to encourage learners’ flexible thinking and diverse values.
The field of social medicine seeks to provide social care by understanding how social and economic conditions affect health and illness, and foster the conditions that lead to a healthier society.12 The social determinants of health (SDOH), to which increased attention is now being paid in medical education, are a complex array of political, economic, environmental, and cultural factors that strongly influence health status and equity[12,13,14]. This means that modern healthcare providers need to understand that the care is not universal for all patients. Incorporating information on the SDOH into health professions curricula is challenging for teachers because the content of SDOH differs among the individuals or communities. Developing effective ways of teaching variable knowledge that can adapt to the change is needed[16,17].
Previous studies have emphasized the importance of diversity in teaching medicine, particularly in the field of primary care. Physicians must respect the diversity of patient values and societal needs. Even in cases of an established diagnosis, patient care varies depending on the SDOH surrounding the patient. Healthcare providers must have a high degree of competency to comprehensively understand and solve problems for each patient. As such, we must consider ways to teach the multidimensional themes of diversity and individuality in medicine. This is a limitation of the present technological approach in CBME.
There is a need to develop a new pedagogical approach to teaching the multifaceted, multi-valued themes of diversity in medicine in society. Therefore, we developed an educational program of social medicine that employs the Rashomon approach, which stresses the importance of learner subjectivity and of inductively assessing student learning through observing interactions among students, teachers, and educational resources. This study aimed to investigate how the Rashomon approach shapes medical students’ education on diversity in medicine.
The Rashomon approach
Atkin clarified the differences between the Rashomon approach and the technological approach. (see Table 1)[20,21,22]. In the technological approach, educational content is organized based on the teacher’s intentional educational plan. A general educational goal (Competency), which is defined as a comprehensive expression of the goals to be educated, is set first and then classified into sub-goals, which are further divided into specific objectives. To achieve these goals, teachers must plan, select and employ appropriate teaching strategies. In the technological approach, assessment requires objectivity, relevance, and credibility, making it necessary to define a generalized concept as well as certain criteria for the course evaluation.
Like the technological approach, the Rashomon approach begins with setting general goals. However, without classifying these into specific sub-goals or small objectives, teachers then generate a variety of creative teaching and learning activities on general goals, making use of their experience as experts. All events triggered by these learning activities—not only those related to the originally set general goals—should be observed and recorded. This approach multifaceted observations of all events are incorporated into the evaluation. The effects are fed back through creative teaching and learning activities which can be achieved in an infinite number of ways.
The Rashomon approach was named after the 1950 film, Rashomon. In this film, a single event, a homicide is described from the different perspectives of the characters. In the Rashomon approach, teachers, like film directors, need to fully understand the big pictures so that they can engage characters = students in creative learning activities which relates to the general goals. Having a deep understanding of goals allows teachers to offer the learning activities based on their own experience and technical expertise, which is a key tenet in the Rashomon approach. In the film, flashbacks and flash-forwards were used extensively and this technique can be used to reinforce information and to stress different aspects as required[24,25]. In the Rashomon approach, it is expected that diverse learning can be facilitated when teachers add different ideas and improvised activities to learning based on their experiences. The Rashomon approach also functions as an evaluation method for various learning of students from the activities and comprehensively assessing learners’ understanding. It is important in terms of the educational impact that unintended achievements are also emphasized in the Rashomon approach[26,27] Therefore, in this approach, teachers must have the ability to create activities that are appropriate for the learning situation and to comprehensively assess learners.
In this respect, Rashomon's approach is unique because it encompasses both aspects of learner-centered and teacher-led education. In addition, in this approach, students learn an educational goal that includes unplanned insight from a variety of perspectives through creative learning activities with teachers.