Invoking culture in medical education research: A critical review and metaphor analysis

Abstract

Introduction: 'Culture' is a word frequently invoked within medical education literature to explain challenges faced by learners in practice. While social settings and practices are widely acknowledged as critical influences on medical education, there is vast variability in how the term 'culture' is employed. This may lead to confusion, resulting in assumptions and oversights.Objective: This critical literature review aims to characterise how the term 'culture' is explicitly and implicitly conceptualised in medical education research.Methods: Four leading English language journals in the medical education field were searched in a twelve-month period for research papers or reviews that mentioned culture in title or abstract in a substantive way. A content analysis was undertaken of extracted definitions. In addition, metaphor analysis was used to identify conceptual metaphors, which were subsequently clustered thematically.Results: Our search yielded 26 papers, 8 of which contained definitions, mostly from the organisational literature. We interpreted nine conceptual metaphors related to how the term culture was employed (terroir, divider, dominant force, toxic force, obstacle, microclimate, object, brand and holdall) in four categories (unchanging, powerful, can adapt around, can be used).Discussion: This critical review reveals that medical education as a field: 1) draws most explicitly from the organisational literature; 2) invokes culture in multiple means but in ways that privilege either acontextual human agency or all-powerful social forces; and 3) regards culture as a negative or neutral force but rarely a positive one.There is a notable absence around conceptualisations of 'culture' that allow educator, student and administrator agency but at the same time acknowledge the deep forces that various social settings and practices exert. Other literatures investigating learning cultures and cultural reflexivity focus on this nexus and may provide possible means to advance considerations of culture within medical education research.

Widening how we see the impact of culture on learning, practice and identity development in clinical environments

“…They found that there is a 'notable absence around conceptualisations of culture that allow educators, students and administrators agency' but at the same time acknowledge the influence of social settings and practices. 19 Watling et al offer a framework that recognises three perspectives on culture: organisational, identity and practice. 9 The organisational perspective highlights the shared assumptions and values that bind individuals within an organisation.…”

“…What is now emerging is an interest in the impact of the wider organisation in which a trainee and a supervisor are situated, how this impacts on learning and how this varies across health services, cities, regions and countries. As part of exploring these institutional factors, a critical review by Bearman et al is timely in its invitation to medical educators to ‘invoke culture’ 19 . Their work revealed that medical educators comment on culture frequently but usually negatively or from a neutral stance.…”

“…Their work revealed that medical educators comment on culture frequently but usually negatively or from a neutral stance. They found that there is a ‘notable absence around conceptualisations of culture that allow educators, students and administrators agency’ but at the same time acknowledge the influence of social settings and practices 19 …”

Values, culture, narrative and medical education: The case for a renewed focus

“…1 Recent literature, including Bearman et al's contribution in this issue, underscores the imperative by exploring the relationship between culture, values, narrative and medical education. [2][3][4][5] Culture is a contested concept, but it influences pedagogy, teaching and learning, 2,3,5 so there is a compelling case for further research and theory development to bring about a better understanding of culture with its concomitant values and narratives both in medical education and healthcare writ large. Justice, prudence and fortitude or courage are thought to be chief among the values that enable people to flourish, experience joy and find fulfilment.…”

“…There are gaps in medical education that have been subject to little or no critical scrutiny 1 . Recent literature, including Bearman et al’s contribution in this issue, underscores the imperative by exploring the relationship between culture, values, narrative and medical education 2‐5 . Culture is a contested concept, but it influences pedagogy, teaching and learning, 2,3,5 so there is a compelling case for further research and theory development to bring about a better understanding of culture with its concomitant values and narratives both in medical education and healthcare writ large.…”