‘Decolonising the Medical Curriculum‘: Humanising medicine through epistemic pluralism, cultural safety and critical consciousness

Introduction

Any curriculum must, by definition, exclude – the question is what is excluded and why, and whether the purpose of our education system should be to perpetuate existing power structures and norms, or equip students with the critical tools to question them. (Gebrial, 2020: 26)

The term ‘decolonising’ has lent itself to multiple definitions throughout history, but in its recent resurgence within higher education, it refers broadly to a movement to: (1) recognise how forces of colonialism, empire and racism (and other forms of discrimination, such as sexism, racism, heteronormativity and ableism) have shaped the systems in which we participate every day; and (2) offer alternative ways of thinking about the world, re-centring perspectives of populations historically oppressed and marginalised by these forces (Bhambra et al., 2018: 18). This is the framework we adopt in this article to consider what forms of knowledge and ways of knowing must be prioritised in efforts to decolonise the medical curriculum. The decolonial outlook sheds light on power imbalances within systems, institutions and interactions, and prompts exploration of how power can be redistributed to achieve intersectional equity. In the context of medicine, it may be used to examine how health systems that have inadvertently served to ostracise and even dehumanise segments of society can be reimagined, to cater to the needs of the whole patient population (Gishen and Lokugamage, 2019; Lokugamage et al., 2020a).

While the arts, humanities and social sciences have traditionally led the charge within the Decolonising the Curriculum movement globally, medical schools have been slow to embrace this approach, despite student feedback, growing activism and ground-up initiatives in recent years (for example, Clynch et al., 2020; Mukwende et al., 2020; Nazar et al., 2015). This inertia may be partly attributed to the hegemony of the biomedical perspective in contemporary medicine, based on a hierarchy of knowledge deeply entrenched in colonial history. Gaines and Davis-Floyd (2004: 96) write: ‘Like science, Western medicine was assumed to be acultural – beyond the influence of culture – while all other medical systems were assumed to be so culturally biased that they had little or no scientific relevance.’ Consideration of the anthropological, historical and philosophical underpinnings of Euro-American biomedicine may help to explain the marginalisation of alternative perspectives that are regarded as non-scientific or antithetical to its foundational premise. Any attempt to de-hierarchise systems of knowledge mounts a challenge to the historical power imbalances upon which the medical profession in Europe and America has rested for decades. Within the culture of medical research in the Global North, quantitative research is held to be more rigorous and prestigious than qualitative research. This has resulted in a neglect of subjectivised knowledge, such as lived experiences of illness or patient perceptions of treatment. An increasing requirement for patient and public involvement and engagement (PPIE) in research production, interpretation and application may have an important part to play in mitigating this bias (NIHR, 2015). From a global health perspective, however, patient voices from the Global South continue to be excluded within PPIE and remain under-represented in medical research, which has marshalled academic thinking towards improving knowledge democracy on a global scale (Openjuru et al., 2015).

By laying exclusive claims to labels such as ‘rational’, ‘modern’ and ‘objective’, Euro-American healthcare systems and institutions seek to absolve themselves from their role in perpetuating the systematic marginalisation of minority ethnic populations, alongside other groups that have been traditionally sidelined on the basis of disability, sexual orientation or gender identity. This has contributed to a higher rate of maternal mortality among ethnic minority women in the UK and the US (Anekwe, 2020; Knight et al., 2020; Lokugamage, 2019), reduced access to health services and care among older LGBT+ patients in the UK (Kneale et al., 2019; Westwood et al., 2015) and gender bias in medical science (Graham, 2016; Hanratty et al., 2000; Risberg et al., 2006).

To further deconstruct the process by which this occurs, we must consider why the concept of ‘evidence-based medicine’ (EBM), regarded as a ‘high altar’ of science or the closest approximation of scientific ‘truth’, is a fallible one. One area of fallibility lies in the failure of institutions to acknowledge and account for biases within ‘gold standard’ models of research production, evaluation and regulation. These biases stem not only from methodological flaws within individual studies, but also from the continuous entanglement of research production with institutional, political and commercial interests (Every-Palmer and Howick, 2014; Goldacre, 2014) – without the corresponding level of transparency necessary for institutions to remain accountable to the stakeholder groups they serve. For example, ambiguity surrounding the grade of evidence behind published clinical recommendations (NICE guidelines, for example) has come under fire, especially as an increasing number of studies reveal a surprising lack of high-quality evidence behind widely accepted and practised guidelines (Fanaroff et al., 2019; Ghui et al., 2016; Lee and Vielemeyer, 2011; Prusova et al., 2014; Wright, 2007). This defensive denial of bias by major scientific institutions has even led to the suppression of critical or dissenting voices, perhaps perceived as a threat to the established dominance of the evidence-based medicine paradigm in the health sciences (Holmes et al., 2006). In a 2018 scandal involving the Cochrane Collaboration, an organisation dedicated to independent systematic reviews of healthcare interventions, one of its original founders was expelled for his vocal criticism of biased reporting (Enserink, 2018; Gøtzsche, 2019). This event led to debate within academia about the ethical implications of using scientific censorship to preserve trust in public health institutions in the name of public interest (Demasi, 2018; Greenhalgh et al., 2019). The colonial undertones of this discourse, which functions to ‘(re)produce the exclusion of certain forms of knowledge production’ (Holmes et al., 2006: 185) to reinforce the stability of a hierarchical order, should not be overlooked.

The first step of decolonisation, as stated in the opening of this article, is to ‘recognise’ – to identify the biases within medicine that arise from medical education and training. It is only by first acknowledging that institutionalised forms of coloniality exist in our society today that we can begin to imagine what a postcolonial or decolonial reality may look like in a medical curriculum. Critiquing the unquestioned dominance of ‘Western’ epistemology within our spheres of knowledge through this lens can allow the ‘reconstruction and the restitution of silenced histories, repressed subjectivities, subalternised knowledges and languages’ (Mignolo, 2007: 451). In medicine, these ‘silenced histories’ constitute the exploitation of minority and indigenous populations in the name of science. These ‘repressed subjectivities’ are the perspectives of marginalised populations buried under the weight of medical paternalism. These ‘subalternised knowledges and languages’ are the healing traditions that have been displaced by the standardisation of a Eurocentric rhetoric about what constitutes medicine. In this article, we discuss our ongoing work with decolonising the medical curriculum at UCL Medical School (UCLMS), evaluate the need for a shift from diversity to decoloniality in medical education and propose a framework for this change. We suggest that to decolonise medicine is to humanise medicine – to allow counter-colonial narratives that accurately represent our patient population to emerge, and to begin to broaden our collective understanding of what constitutes health, illness and healing.

From diversifying to decolonising the UCLMS curriculum

There is a strong case to be made for a more diverse medical curriculum. Diversity-related teaching has been shown to increase medical students’ confidence in handling communication barriers in clinical practice, with the potential for lasting attitudinal shifts (Cocksedge et al., 2014). It may also reduce prejudice and negative stereotyping (Hill and Augoustinos, 2001), behaviours which deter patients from minoritised and marginalised groups from seeking medical care (Phelan et al., 2015). However, the misappropriation of the term ‘diversity’ to promote tokenism (see Niemann, 2016) in many institutions has led the Decolonising the Curriculum movement to call for ‘decolonising, not diversity’, in a bid for more extensive reform – to ensure that radical restructuring is not substituted by comfortable rebranding. We are also conscious of Tuck and Yang (2012) who reminded us that decolonisation is ‘not a metaphor’ that can be employed to a variety of ends without bearing witness to the historical and present realities of settler colonialism, which has led to the displacement of indigenous people, knowledge and traditions in space and time (Richardson, 2020). Neither is decolonisation interchangeable with words such as ‘diversification’ or ‘liberation’, which we adopted at the beginning of our work. Bearing this in mind, we describe our process in moving from diversifying to decolonising the medical curriculum at UCLMS and the journey that remains.

At UCLMS, medicine is taught in a six-year undergraduate curriculum (MBBS: Bachelor of Medicine, Bachelor of Surgery). The first two years focus on the scientific fundamentals of clinical medicine, with limited patient contact, the third year is spent completing an integrated bachelor of sciences (iBSc), while the final three years focus on clinical placements alongside teaching. Diversity teaching is largely delivered via the Clinical and Professional Practice (CPP) ‘vertical’ modules, which are taught throughout the six-year spiral curriculum. Overall, the aims of the diversity curriculum at UCLMS are: (1) to emphasise the perspectives of minoritised groups, particularly pertaining to their experiences within healthcare; and (2) to engage students to think critically about how these experiences may be improved and to participate actively in their learning. CPP learning is designed to show medical students how sharing power promotes deeper trust within the doctor–patient relationship (Skirbekk et al., 2011) and facilitates more meaningful patient-centred interactions, including through reflection (Morgan, 2018). Teaching takes the form of lectures complemented by tutor-facilitated small group work tutorials, which regularly involve role play where students, patients or actors take on different characters within a given clinical scenario. Students are provided with feedback on their clinical communication skills and are given the opportunity to reflect on how they felt within each role.

The original working group began as a project entitled Liberating the Curriculum, a UCL-wide initiative that started in 2016. This group was set up by two faculty members and a medical student. In the pioneering phase, we focused on performing a gap analysis of diversity teaching, to pave the way for deeper inquiry into why these gaps exist. Inspired by Inclusive Curriculum Health Check (UCL, 2018), we began our project with a student-led curriculum mapping exercise to formally assess the coverage of diversity-related topics and their integration into the curriculum (Chow et al., 2020). We classified formal teaching sessions in the UCL CPP curriculum for Years 1 to 6, with Year 3 excluded as there is no MBBS teaching in the iBSc year. The sessions were classified according to 12 diversity-related themes chosen following consultation with a faculty–student group: social class, race/ethnicity, discrimination, gender, challenging power hierarchies, sexuality, ethics/human rights, disability, diversity, marginalised groups, stigmatised groups and patient experience. To account for extra-curricular teaching, we asked UCLMS academic year leads to provide a list of relevant diversity-related activities that had not been formally programmed and relevant scholarly activity produced by the department.

The mapping results are represented using a wind rose diagram (see Figure 1) to provide visualisation of the relative coverage of topics across five years. For a single teaching session, a score of 0 was awarded if a theme was not mentioned, 0.5 if a theme was mentioned but not in depth (‘included’) and 1 if a theme was central to the session (‘key’). For each year, the total scores were then added up for each theme; the distance of each data point from the centre is proportional to the score allocated to each theme in each year. Overall, the results showed that each theme was covered at least once, with patient experience consistently having the highest representation in the curriculum across the years. This reflects a push for a patient-centred approach within medicine, discussed in a later section. Four extra-curricular events were recorded, including one-off events (for example, UCL Change Day) and annually occurring events (for example, UCL Student Support talks), which focused on four themes: stigmatised groups, patient experience, challenging power hierarchies and disability. Nine instances of diversity-related scholarly activity were recorded, spanning three themes: patient experience, ethics and human rights and challenging power hierarchies.

Figure 1:

Wind rose diagram showing the relative coverage of Liberating the Curriculum themes across years (Source: Authors, 2021)

There were several limitations to this gap analysis project. First, the data collected may not be representative of all relevant teaching, especially of informal teaching that is subject to variability (Wachtler and Troein, 2003), and may be limited by reporting bias. Second, as these themes were derived from consensus among UCL staff and students, they are not exhaustive and demonstrate considerable overlap. It must be noted that this curriculum improvement exercise was framed within the context of diversity rather than decolonisation (see Icaza and Vázquez, 2020). However, the project helped us develop our inquiry into subsequent decolonising work. In the first two years, the majority of sessions consist of small-group work to encourage deep learning, alongside some didactic lectures (Dao et al., 2017). This study reflected that it did not distinguish between intended, taught and received curricula (Kelly, 2009; Plaza et al., 2007). It is also noted that diversity themes were associated by students with sessions that course leads had not themselves identified as diversity-related, indicating that the received curriculum had diverged from the intended curriculum (Wachtler and Troein, 2003) and had not accounted for the hidden curriculum (Hafferty and Castellani, 2009; Hafferty and Franks, 1994; Lempp and Seale, 2004).

To address this discrepancy between the taught and received curriculum, two UCL grant-funded student, staff, patient and public engagement events were organised by our team: ‘Practically Creating an Inclusive Curriculum’ in 2017 and ‘Decolonising the Medical Curriculum’ in 2018 (Chow et al., 2020; Gostelow et al., 2018). These were platforms for educators and students to exchange their reflections on the UCLMS curriculum alongside members of the public and to share their experiences of the healthcare system. The open format encouraged active participation and contributions from the varied audience. Some findings supported results from the curriculum mapping exercise, including a presentation of a study revealing that UCL medical students were reticent to raise concerns about discrimination they experienced from medical professionals (Johnson et al., 2018), mirroring the low coverage of ‘challenging power hierarchies’ in CPP teaching. Other themes that were covered include the awarding gap in medical training, the history of medical and scientific racism, misidentifying clinical signs in darker skin tones, the eugenics inquiry at UCL and the relation of biomedicine to traditional and indigenous healing systems. Following the second event, we changed the terminology of our project to ‘Decolonising the Medical Curriculum’ (2021) in response to student feedback and the growing decolonising movement within higher education. We outlined six areas of decolonising in medicine: the body, the curriculum, learner experience, learner space, professional behaviour and ideas of healing (Lokugamage et al., 2020a: 267), to account for how the formal curriculum represents only one aspect of the wider framework.

In response to these initial findings, we implemented several changes within the UCLMS curriculum. An additional teaching session was developed to address how medical students can raise concerns through official channels, highlighting policies in place to protect students and keep their concerns anonymous. A review of teaching materials was conducted to ensure that they reflected the diversity and heterogeneity of patient populations, including case studies that featured patients of different ethnicities and pictured signs such as anaemia (having a low amount of red blood cells), cyanosis (lack of oxygen) and rashes across different skin colours and types (see Mukwende et al., 2020).

The decolonising agenda encompasses dismantling barriers to healthcare faced by groups oppressed under colonial regimes, including indigenous people, minority ethnic individuals, women, people with disabilities and people who are non-heterosexual or gender non-conforming. As part of the Equality, Diversity and Inclusion (EDI) team, we developed a half-day LGBT+ health programme for first-, second-, fourth- and fifth-year students based on input from LGBT+ service users and student feedback from previous years (Salkind et al., 2019). This session covered appropriate terminology to describe sexual orientation and gender identity and how to take medical histories from LGBT+ patients. It included a 45-minute session with a transgender-identifying patient. Students reported positive outcomes from this session, including increased confidence when communicating with patients who are LGBT+ and identifying their needs.

Another initiative was the organising of diversity theme-related reflective practice Schwartz Rounds for medical students, first piloted at UCLMS in 2015 (Gishen et al., 2016). Involving both undergraduates and faculty, Schwartz Rounds are led by trained facilitators with the goal of facilitating meaningful conversation and reflection in a confidential forum, to help students sustain empathy through the course of medical training. Following the death of George Floyd and the Black Lives Matter response in May 2020, two Schwartz Rounds based on the theme of racial inequalities at medical school were organised. At each event, a panel of UCLMS students shared openly about their experiences of racism, discrimination and bias within healthcare, prompting other students in the audience to offer their reflections.

In these efforts, students, faculty and service users acted as collaborative ‘agents of change’ (Fielding, 2001; Harland and Wald, 2018) in co-producing curricula. This reflects a decentralised approach we have adopted towards diversifying the medical curriculum at UCLMS (Gishen and Lokugamage, 2019) and beginning to imagine what its decolonisation may look like. Examples of sessions that have been developed over the past few years include teaching on the history of eugenics at UCL, perspectives on disability, feminist perspectives on women’s health (with regard to the birth experience, domestic violence and female genital mutilation), the limitations of evidence-based medicine, sustainability in healthcare, global health economics and the introduction of an online mindfulness platform for UCLMS students. In May 2020, a team of students led the collaborative development of a Decolonising the Medical Curriculum reading list (Wong et al., 2020a) to guide the project, which was circulated to UCLMS faculty and students. They also organised a series of reading groups and a seminar involving student representatives from different medical schools, to discuss how the decolonising agenda may be taken forward in medical education. This team continues to work closely with EDI faculty at UCLMS to review and revise EDI-related CPP sessions, with the purpose of integrating decolonial perspectives on topics such as race, culture and history of medicine into teaching. One such session was a lecture on cultural safety delivered to second-year students, described in an article by one of the authors (Wong et al., 2020b). New CPP sessions were also developed by EDI faculty and students on topics such as racial microaggressions, inclusive history taking and health inequalities.

Some challenges we faced included a lack of ongoing funding for the project and limited curricular space open to input from our working group. There has also been some student resistance to sessions considered extraneous to core medical teaching, such as the newly introduced session on the history of eugenics for second-year students. On the whole, student feedback on the new teaching sessions has been positive so far, but we have yet to organise a follow-up project to comprehensively evaluate the impact of these changes and initiatives. Aside from surveys to ascertain the impact of individual sessions on student experience, it is difficult to measure the longitudinal effect of these teaching sessions on their personal and professional development. It is our hope that in the coming years, we will further develop the infrastructure required to ensure the sustainability of this project. This includes acquiring funding for student-led initiatives, promoting student–staff collaboration and organising periodic reviews of teaching materials across the entirety of the medical curriculum, ensuring that they remain pertinent in addressing forms of discrimination, inequity and injustice within medicine and society at large.

A decolonial shift in medical education

According to guidelines from the General Medical Council (GMC, 2016: 33), the regulatory body for medical education, training and practice in the UK, medical curricula should give students ‘the opportunity to gain knowledge and understanding of the needs of patients from diverse social, cultural and ethnic backgrounds’. However, the implementation of diversity teaching has largely been left to the initiative of individual medical schools (Nazar et al., 2015) and varies widely.

The impetus for a shift towards decolonisation in medical education spans moral, professional and legal domains (Lokugamage et al., 2020a). This shift has been mirrored by initiatives within our broader institutional setting, such as the Why Is my Curriculum White? campaign launched in 2014 at UCL, alongside the Liberating the Curriculum and Dismantling the Master’s House working groups campaigning for institutional action against racial injustice. In 2018 mounting pressure from faculty and students led to an inquiry into the history of eugenics at UCL, producing a report and list of recommendations that were published in February 2020 (Fazackerley, 2018; UCL, 2020a, 2020b).

There is still debate about whether the ‘decolonial demand’ (Gebrial, 2020: 29) can ever be fully realised within a university setting, let alone within a single faculty. Decolonising curricula initiatives usually operate at the level of the formal curriculum, but arguably the most significant changes have to occur within the ‘taken for granted’ (Hafferty and Castellani, 2009: 25) aspects of the hidden curriculum. This signals the need for a reflexive paradigm in our efforts to reform the medical curriculum (Cribb and Bignold, 1999), which we enter into with a sobering cognisance of the limitations of our scope and as members of the institutions we seek to transform. In the roles that the authors of this article occupy – those of a final-year medical student and clinician educators – our main focus is on the implications of this transformation for improving care for our diverse patient population. Towards this goal, in the remainder of this article we outline three scaffolding concepts to frame the process of decolonising the medical curriculum: epistemic pluralism, cultural safety and critical consciousness (see Figure 2). While there is demonstrable overlap between these three areas of inquiry, each offers a lens by which colonial-era power imbalances in medical education can be evaluated within epistemology, diversity teaching and curricular scope respectively.

Figure 2:

A decolonizing framework for the medical curriculum scaffolded by epistemic pluralism, cultural safety and critical consciousness, with a summary of overarching themes (Source: Authors, 2021)

Conclusion

Mignolo (2002: 73) observes that ‘colonial difference is reproduced in its invisibility’. The elusive focuses of decolonial work pose an insurmountable challenge to all who engage with it – that within a self-perpetuating system structured by coloniality, the task of decolonising will never be complete. There are various limitations to this model, and the three perspectives we have outlined in this article – epistemic pluralism, cultural safety and critical consciousness – only represent a marginal fraction of what decolonising the medical curriculum entails. The call for reform extends to every aspect of medical training: from the inclusion of non-White bodies in teaching imagery (Louie and Wilkes, 2018; Mukwende et al., 2020) to representation of minority ethnic voices in research (Oh et al., 2015); from the history of medicine to its present and future, including the domains of artificial intelligence (Hao, 2020) and planetary health (Horton and Lo, 2015; Lokugamage et al., 2020a); from education around the rights of vulnerable and marginalised populations to health access (Bax and Middleton, 2019; Robinson, 2019; Torjesen, 2019) to re-examining disability models through perspectives from the Global South (Meekosha, 2011) – all while understanding the crucial role that each of these play in health equity (Munro et al., 2020; Rajkomar et al., 2018). Furthermore, while our focus has been on what can be accomplished through the explicit or intended medical curriculum, it neglects the extensive reform required in the implicit and hidden curricula dictated by broader institutional cultures, processes and policies.

The importance of humility and reflexivity should not be understated as we negotiate this rapidly evolving field of inquiry. In this movement, we are venturing into spaces of discussion that are highly emotive and may trigger unconscious biases with deep historical roots (Gishen and Lokugamage, 2019). Those who lead decolonising initiatives at higher education institutions should continue to demonstrate a willingness and patience to engage sincerely with others who are less receptive to this change. It is our hope that these reflections on how the decolonising agenda may transliterate in medical education will serve as a catalyst for radical reform within UCLMS and beyond. Moving forward, we aim to strengthen networks of collaboration between medical schools, faculties and institutions. By drawing from the pool of expertise and innovation across the whole spectrum of stakeholders in our healthcare system, and subverting dominant paradigms of what constitutes meaningful knowledge, we may aspire closer to our goal to humanise medicine.

Authorship statement

Sarah Wong Hui Min, Faye Gishen and Amali Lokugamage conceptualised the article together. Sarah conceived the outline of the article and contributed to the writing of the manuscript from a student perspective. Amali and Faye critically revised the manuscript and provided input from a clinician educator perspective and from their experience with diversifying and decolonising the medical curriculum at UCLMS.

Notes on the contributors

Sarah Wong Hui Min is a final-year medical undergraduate at UCL, London, UK, who undertook an intercalated BSc in medical anthropology in her third year of study. She has been involved in organising student efforts towards decolonising the medical curriculum since 2018.

Faye Gishen is a consultant physician in palliative medicine and Associate Head of the MBBS (Medicine) at UCL, London, UK. She is the academic lead for professionalism. She is Clinical Associate Professor and Principal Fellow of the Higher Education Academy/UCL Arena. The clinical lead for Schwartz Rounds, she has been involved in diversifying and decolonising the medical curriculum since 2016.

Amali Lokugamage is a consultant obstetrician and gynaecologist and Honorary Associate Professor at UCL, London, UK. She is Senior Fellow of the Higher Education Academy/UCL Arena. She is Deputy Lead of the Clinical and Professional Practice department of UCL Medical School and has been involved in diversifying and decolonising the medical curriculum since 2016. She has also been involved in human rights in childbirth since 2014 and has authored articles on the disproportionate maternal mortality in ethnic minorities.

Declarations and conflict of interests

The authors declare no conflicts of interest with this work.