Articles on the training of medical students and residents most often focus on cognitive approaches to teaching. A smaller literature addresses education on an emotional and experiential level (1) and on professional developmental issues. Even less frequent are discussions of the sociocultural aspects of learning. We are not referring to the teaching of content relating to sociocultural disciplines (a topic for a future editorial) but rather to the sociocultural process in teaching or, more broadly, a sociocultural approach to medical education.
Jerome Bruner articulated a role of culture in education over a decade ago. He wrote: “A system of education must help those growing up in a culture find an identity within that culture. Without it, they stumble in their effort after meaning. It is only in the narrative mode that one can construct an identity and find a place in one’s culture” (2).
Each sentence of this quotation alludes to a different part of Bruner’s expansive theory of education, to which we will not do justice in this brief editorial. Simplistically, the teaching of cognitive knowledge and facts falls short if the student is unable to go, in Bruner’s parlance, “beyond the information given” to a level of meaning. One of us (L.W.R.) wrote an essay nearly 20 years ago on one aspect of the experience of becoming a physician—the changed, dual nature of observing, interpreting, and understanding the world as both (still) a layperson and an (emerging) physician (3) (Appendix 1). Bruner claims that this meaning derives from a sense of identity within a culture, which is transmitted in a narrative mode among the members of the culture. In this sense, the sociocultural approach claims not only to pass on the attitudes, ethics, and professional standards of a community, but to be core to teaching the belief system of that community.
How might one apply this to the specific culture of medicine? Medical students and residents learn and apply the relevant knowledge and “facts” to clinical circumstances and manipulate this information in a process we call clinical reasoning. What meaning would Bruner say should be sought beyond this? As noted by Renee Fox (4),
Like other social roles, the role of the physician is defined and governed by a system of normative ideas and values. The physician is expected to orient his professional behavior to certain standards—to try to live up to them in the various situations and relationships with which he deals as a physician. Among the values and norms…[are that] the primary obligation of the physician is to do what he can to protect and further the welfare of the patient. In the “emotional aspects” of his relationship with the patient, the physician is expected … to be sufficiently detached or objective toward the patient … to exercise sound medical judgment and maintain his equanimity. He is also expected to be sufficiently concerned about the welfare of the patient to give him compassionate care. The physician is required to strike a comparable balance with respect to the scope of his relationship and involvement with the patient.
One must keep in mind that medical knowledge and “facts” are not monolithic entities. Not only do they change over time but at any point in time they are bound to the context of a particular medical culture that is defined geographically and historically. Frequently in the course of treating a patient, perhaps more often than not, the absence of absolutes necessitates the use of probabilities or intuition. Thus, learners need to understand the bounds and limitations of factual information in medicine, including what the local medical culture believes is relatively known and unknown. The practicing physician is expected to keep up with this evolving consensus and, at the very least, to practice not far from this community standard. An appreciation of the community standard of care is one level of meaning beyond the medical facts. An appreciation of the subtleties of managing the obligations, emotional aspects, and scope of the relationship with patients is several levels of meaning beyond the medical facts.
The trainee is faced with a challenge because textbooks generally don’t present the cultural norms, which are of an evolving and consensus nature. One cannot simply look up the community standard of care. It is instead transmitted between practitioners working together in a community and by the sharing of narratives (e.g., “I once saw a patient who …”). Charles L. Bosk (5) wrote eloquently about the surgeon’s competence as having two dimensions, one related to one’s clinical skill and judgment and the other related to one’s fidelity to a professional code of conduct:
Failure to perform competently as a professional means two different things. First, there is failure to apply correctly the body of theoretic knowledge on which professional action rests. Failures of this sort are errors in techniques. For surgeons, we have identified two varieties in this type of error—technical and judgmental. Second, there is failure to follow the code of conduct on which professional action rests. Failures of this sort are moral in nature … the profession subordinates technical performance to moral performance.
How is this communicated to trainees? The sociocultural model argues that enculturation of trainees into the medical community is essential to allow them to derive meaning in addition to knowledge. Without meaning, as defined here, the trainee does not make the transition from a memorizer of facts to a reasoning, practicing clinician. This is particularly true in those frequent clinical situations in which there is a lack of evidence.
This model suggests that medical education would be well advised to include sociocultural approaches to training, as we will illustrate below. This not only goes beyond inculcating ethical and professional standards of medicine, but it defines what we believe to be true about how medicine (Western, in our case) affects disease. It goes without saying that our culture is imperfect, biased, and parochial—as are all cultures. This is why we must constantly reassess our position in relation to evidence and to standard cultural practices. Learning an imperfect belief system has its drawbacks, but it may nevertheless be essential for a student to practice medicine meaningfully in accordance with what is known.
Every time a medical student or resident walks into an inpatient service to start a new rotation, we have an opportunity to teach from a sociocultural perspective. To what degree do we take advantage of this? Indeed, a medical student takes a big step when he or she dons the “white coat” and has the privilege of immersion on the medical wards and of engaging patients. Have we been optimizing their engagement and negotiation of the medical culture? Traditionally, trainees on inpatient rounds have flocked behind and learned at the feet of one faculty member at a time. When time permits, the attending will query students in turn about medical facts in a process traditionally called “pimping.” Students who fail to provide the answer sought are shamed into reading more that evening. If lucky, students have been taken aside by the faculty member or senior resident for a minilecture or to demonstrate a physical finding. Most antithetical to a sociocultural approach has been sending students off on their own to see a patient, collect laboratory results, write up the history, and return hours later to put an “H & P” into the chart—to be reviewed and countersigned by the resident. This mode of teaching, though perhaps useful for training cognition and skills, does not champion a sociocultural approach. It does not take advantage of the community but instead tends to segregate the student. Even when attempting to engage him or her in the team’s division of labor, the student is often sent off alone on some lowly task, like drawing blood cultures.
Some clinical exercises do currently make use of a sociocultural approach, for example, morbidity and mortality (“M&M”) conferences and tumor boards. In these forums, trainees are in the midst of multiple faculty members, often from different disciplines (e.g., surgery, oncology, pathology, radiology), thinking through a case. These venues have been identified as transmitting important cultural messages within medicine. In describing how practitioners of medicine may improve their skills and, specifically, prevent mistakes and “failure,” Bosk (5) wrote of the importance of systematic, structured social efforts that give emphasis or pressure (what he calls “social controls”) to certain values (e.g., being skillful, avoiding errors) in medical training and clinical activities. He stated:
First, there must be some hierarchy, or a functional equivalent, that permits question-answer sequences, what we call the competence quizzes of rounds, about the appropriateness of different treatment modalities. Second, some face-to-face interaction is necessary. Physicians need to feel part of the same community and [be] answerable to one another. Third, there must be some public forums for discussing problems and allocating blame. Such forums create as well as sustain a community by giving members a sense of their shared identity. Fourth, the community needs some control of the sanctions.
These sociocultural training venues are extremely important to the curriculum as well as to what has been characterized as the “hidden curriculum” (6) in medical training.
Psychiatry tends to have fewer clinical conferences with multiple faculty members. At the University of California, San Francisco (UCSF), one of us (A.K.L.) designed a seminar with the intent of maximizing the above described transmission of medical culture. The seminar focused on cases seen in an anxiety and affect of disorders clinic, where patients presented for second opinions. After a resident and attending interviewed a patient and reviewed the records, the case was subsequently presented during the seminar to a group of faculty in the psychiatry department. This panel consisted of seven faculty members, including psychiatrists, a neuropsychologist, and a psychiatric pharmacist. The orientation of these clinicians ranged from biological to psychodynamic but all practiced an integrated biopsychosocial model of care. Other faculty often attended, as did a wide range of trainees, including medical students and psychiatry residents.
Lively discussions of the case always ensued, highlighting areas of agreement and disagreement. Trainees observed the faculty debate and defended their points of view. Coming to a consensus as to what to recommend in the form of a second opinion was not always a simple task. On some points most everyone agreed, which served to define a community standard for this local culture. The feedback from residents was that they infrequently had an opportunity to watch the thinking processes of a group of faculty members. They were often surprised by how the faculty could be so united about some clinical issues and be so divided on others. They already knew that faculty members had varying practices but they had never seen these differences applied to the same case and then debated. In our view, of greatest importance was that over time most residents and a few medical students gradually and progressively felt comfortable with expressing their views and partaking in the debate. This “coming to the table” suggested that the learner was actively engaging and negotiating the medical culture.
Rogoff (7), a developmental psychologist, notes that a sociocultural approach to education is distinct from the common and assumed model of primary education in the United States:
Assumptions and practices regarding learning … are heavily influenced by the centrality of particular school formats that became prevalent when mass, compulsory schooling became widespread, about a century ago. School-based assembly line instruction was explicitly modeled on the organization of factories, with learners (and teachers too, often) treated as part of a mechanism designed by administrators or consultants for bureaucratic efficiency. This tradition is based on a mechanical metaphor, with experts inserting information into children, as raw materials, and sorting them in terms of their quality and the extent to which they have received the information (7).
A common procedure in this model is for the expert teacher to call on students in turn and ask each student a question with a known answer, sorting out the ones who successfully “guess what the teacher is thinking.” This seems reminiscent of the above described “pimping” on medical rounds.
Rogoff described a contrasting model that she termed learning by “intent community participation.” This harkens back to children learning at home while participating in activities with adults in a community setting. Rogoff notes, under the awareness of the teacher, the student learns by intent observing and eventually helping:
When learners become involved in activities in the intent community participation tradition, engagement with more experienced community members is coordinated in a reciprocal (though usually asymmetrical) manner, with mutual responsibility and respect for each other’s contributions. They are expected to contribute as they are able and tend not [to] be micromanaged in specific actions. People (including newcomers to an activity) are expected to contribute and coordinate around shared family and community endeavors like members of an orchestra (7).
Such a model in medical training would put more emphasis on both nurturing and assessing this process of engagement. This engagement is likely to require time to deepen and is not encouraged by a clinical curriculum, which moves the learner from place to place every 4 to 6 weeks, as typical of rotating clerkships, and with faculty members who have less and less time to spend with students (8). Perhaps one of the virtues of the now piloted, year-long clerkships in the third year of medical school will be the extended time for medical students to be engaged by a faculty preceptor (9). Most of these longitudinal clerkships have students engage several faculty members, in different specialties on different days of the week, in parallel over the year, thus putting them in longitudinal contact with a community of providers. Here, the model of intent community participation is created, albeit somewhat artificially. The more the students may observe these faculty members interact, in sharing patients across disciplines, the greater the fidelity to the model.
In sum, a sociocultural approach to training encourages any teaching technique that makes the belief systems of the community more accessible and transparent to the trainees. This may involve more trainee observation of faculty member interaction, be that in clinical work (as described above), didactics (e.g., journal clubs), or administration (e.g., committees). This calls for more observation of faculty in action, in the context of faculty peers. The resulting transparency may be at times daunting for faculty members, especially if points of disagreements with colleagues are highlighted before an audience of trainees.
Making the belief systems of the community more accessible is one strategy for identifying component assumptions or messages of the hidden curriculum. These cultural premises are powerful influences on behavior (6) and can be detrimental to clinical practice and learning. One example is an assumption that hierarchy is necessary, or that the judgment of more senior doctors should not be questioned (6). Such an assumption also happens to be antithetical to the practice of evidence-based medicine (10). Identifying the cultural premises that underlie the hidden curriculum is surely necessary, therefore, to improving the culture for learning (6).
Bruner suggested that meaning was derived by growing up in a culture and finding an identity within that culture. Perhaps, then, we should not talk just about engaging the learner with the medical culture, but also about the learner’s task of finding an identity in that culture. A few steps will be required to trace the connection between engaging the culture and identity, as follows. In the process of grasping the community standard, the learner develops a context for what he or she experiences—the student begins to understand what he or she knows in the context of what the community knows. Bruner writes that students learn “how people come to know what others have in mind” and develop an “intersubjectivity” (2). In other words, socialization involves developing a sense of one’s mind in reference to the cultural mind—a social constructivist, postmodern view.
A person’s perspective is presumably a product of that person’s experiences or narrative. The culture of medicine provides a set of knowledge and guidelines held to be true by the community, and in the context of this, the individual practices and accumulates a unique clinical experience. The culture provides a reference point for the interpretation of this experience and gives it meaning. The individual practitioner’s narrative, commonly introduced by “in my clinical experience” or “in my hands,” becomes the basis for professional identity. Perhaps students would benefit, with an increased sense of purpose, from the metacognition that they are right now laying the foundations for their clinical experience, expertise, and identity, and that the soundness of this foundation will depend on their seeking exposure to pathology in quality and quantity, tracking down the outcomes of interventions, and comparing their experience to the evidence base in their community and beyond.
The development of professional identity need not be limited to the accumulation of clinical experience but should be extended to the range of professional work in medicine, including research, education, and administration. Engaging residents in the culture of management and helping them to assume the identity of an administrator is addressed in part by the article in this issue on training chief residents (11).
This editorial hopes to provide a preliminary framework for thinking about the sociocultural aspects of medical education and to suggest more careful consideration of its importance to this enterprise. We submit that a sociocultural approach may be vital not only to the transmission of attitudes and ethics but also to the development of clinical knowledge, community standards, and professional identity. Verification of this will entail future research. Such research may find that the sociocultural approach presents challenges because it involves teaching more often on an implicit level than an explicit one. Implicit lessons may require longer periods of reiterative exposure of the trainee to material, only afforded by longer-term and continuous exposure to each patient and to each educator. Additionally, they may necessitate greater transparency of the thoughts, feelings, and practices of the educator—and of the institution’s hidden curriculum.