Diversity is not the exception, but the norm

The white heterosexual middle-aged man is implicitly the norm in medical education materials. But not for much longer, if Albertine Zanting has her way. As a PhD candidate, she studies the cultural diversity in medical education, and as a policy advisor, she translates her research findings into policies that embrace diversity as the norm in medical education.

Medical students learn during their studies by analysing patient cases, where they study descriptions of patients with specific health complaints to determine the underlying medical issue. Albertine Zanting examined the course materials of the medical bachelor's programmes in Maastricht and Rotterdam and investigated the meaning attributed to cultural differences without predefining them. She also examined the absence of any reference to culture. "Our research revealed that patients are routinely described as a man or woman of a certain age without addressing cultural differences, suggesting that age and gender are considered the primary factors in a medical problem, and culture is not deemed relevant.

The future doctor

Future doctors pursue their medical education within the Faculty of Health, Medicine, and Life Sciences, a part of Maastricht UMC+ and Maastricht University. After the initial three years of their education (bachelor), they engage in three years of clinical internships to gain practical experience and work alongside various medical specialists. This practical training takes place not only at Maastricht UMC+ but also in other Dutch and foreign healthcare institutions. Upon completing their studies, they become basic physicians and can apply for specialist medical training or gain experience as a basic physician (non-specialist resident physician, ANIOS) before pursuing specialisation. Some graduate physicians also choose to undertake doctoral research before embarking on specialist training

A unique field

However, medical education does address cultural diversity, albeit in separate courses or elective modules, primarily by referring to non-Dutch or non-Western nationalities or religions. And that's precisely the crux of the matter. By doing so, cultural differences are implicitly presented as deviations from an unconscious Dutch or Western norm patient, and thus problematised, according to Zanting. 'Suddenly, a patient is not just a 35-year-old woman but someone who grew up in Sudan. Subsequently, it is stated that Sudanese people experience pain differently than the Dutch, without delving deeper into individual differences within those groups or naming other groups.'

Furthermore, cultural characteristics are sometimes wrongly linked to a medical phenomenon. Zanting illustrates: 'For instance, a link is made between a genetic condition that occurs more frequently in Japanese or Ashkenazi Jews. However, it's not the nationality or religion that forms the underlying mechanism but rather their isolated way of life.'"

Normalise diversity

"This group thinking is quite understandable," explains Zanting, because research is typically conducted at group level. However, a physician treats individual patients and thus needs knowledge and skills to deal with individual differences. In her role as a policy advisor for diversity and internationalisation, she translates scientific insights into policies for medical education. "We aim to make diversity the norm without referencing those large groups based on nationalities or culture."

The advice to educators, therefore, is to integrate diversity into the learning objectives and content of the curriculum from day one and in all subjects, whether it's orthopedics, gastroenterology, or any other field. Then, present patients with a wide variety of differences in a non-stereotypical manner. Zanting asks, "Why can't we make patient names and images more diverse? Or describe a case of two mothers bringing their daughter to the emergency room because she happens to have appendicitis? And if someone's origin, be it Tunisia or the Netherlands or Germany, is relevant, it's important to know."

When teaching communication skills and medical procedures, it's crucial to expose students to diverse communication styles without resorting to stereotypes. In the Skills Lab, students practice medical consultations and physical examinations with simulated patients, volunteers who assume the role of patients. Zanting emphasizes, "How do you handle a patient who doesn't want to undress? Or one who speaks poor Dutch and brings someone along as a translator? To become a good doctor, it's essential for students to become aware of diversity, their own norms, and expectations, and to learn which characteristics are relevant in different situations.

From vision to action

Together with the programme coordinators at the Faculty of Health, Medicine, and Life Sciences, she developed an educational vision that emphasises the knowledge and skills students need to become competent physicians in a globalising society. However, it doesn't stop at just a vision. Along with her colleagues, she organises workshops and created a handout with concrete suggestions for educators on how to integrate diversity into their teaching. They have also compiled materials such as scientific articles and podcasts that teachers can use in their lessons. "It remains a work in progress to implement this vision in collaboration with all stakeholders."

She also collaborates with students. "A group of students noticed that they weren't learning enough about how to treat their own families adequately because, for instance, recognising skin conditions in darker skin isn't covered," Zanting explains. "They initiated a working group to address this issue. We share the same goals and, therefore, started working together. The students will be able to assess whether our recommendations are adequately integrated into practice."

Toward an inclusive healthcare system

In addition to her involvement in the medical programmes, Zanting also advises educators from other Maastricht programmes, such as Health Sciences and Biomedical Sciences. On a national level, she advocates for incorporating the recommendations from Maastricht into the national framework for medical education, which serves as the basis for all university medical programmes.

Her research doesn't stop at the course materials of the medical bachelor programmes. She continues by observing and interviewing master's students during their clinical internships to investigate if and how cultural differences are addressed in workplace interactions. "By systematically examining what works well and what can be improved, we can better align educational practices with scientific insights. This benefits not only medical education but ultimately the quality of healthcare as well."

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