Teaching transcultural skills to medical students in France. A qualitative study of a focus group

Teaching transcultural skills to medical students in France. 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A qualitative study of a focus group Rahmeth RADJACK, Anaïs OGRIZEK, Amalini SIMON, Agathe BERANGER, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3941207/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Academic instruction about the impact of culture on health care (through cultural representations of diseases, the body, and various treatments) is sparse in France, although this topic is widely taught in other countries with substantial immigration, especially Canada and United States. Medical students' reception of this instruction must be assessed in the French context, where the consideration of cultural diversity is controversial, even taboo. Objectives: We seek to describe the effect of a course on transcultural issues in medicine among second- and third-year medical students, especially on their behavior, on the patient-student relationship, and on their perceptions of migrant patients; we also aim to identify the aspects of the course that have the greatest effect on these young students. Methods: Two focus groups (at the first and last course sessions) were conducted with 38 medical students who had participated in the optional course "Transcultural approach to the physician-patient relationship" at the Université Paris Cité medical school in 2023. Results: Our qualitative analysis of the focus group transcripts showed four themes: the place of the mother tongue at the hospital; equity and humanity in caring for the vulnerable; the balance between professional neutrality and the use of cultural identity as a resource to improve the care relationship; and the effects of the course on the students' position toward the health-care team and the patient. Discussion: The two focus groups showed the course had a transformative effect on the students in their awareness of cultural prejudices, but also in enabling them to dare to consider cultural dimensions and to recognize the importance of interpreters. Conclusion : A discussion group is an appropriate format for a course on transcultural approaches for this public of young learners and makes it possible to focus on its global themes and foundations. Culture medical pedagogy medical students migration discrimination decentering transcultural skills interpreters in medical care Introduction Cultural data are the ingredients of every human relationship. Cultural elements are often present in both the individual and collective psyches and therefore in that of every patient, as they pass through moments and periods of difficulty: chronic disease, birth, and death. The relations between these moments and quality of life, standards of care, risks, and viability are concepts simultaneously individual and shared, modulated by family history, religious orientations, and life trajectories — all elements that refer to broad sets of meanings [1]. Applying the transcultural approach means taking into account how culture affects the representations and treatments of diseases [2]. It is useful in second line and when necessary [2, 3]. For example, in our institutions, we frequently see patients give a cultural meaning, a cultural theory to explain a chronic disease that medicine cannot cure [4]. In some situations of poor adherence to treatment or even refusal of care, a program of intercultural mediation, that is, a transcultural consultation led by our team, [1] may be indicated [2, 4, 5]. Cultural mediation is regularly practiced with migrant populations who request it or by the professionals who treat them — who care for patients with sickle-cell anemia [6, 7], support HIV-positive patients [8], or manage unaccompanied minors [9], hepatitis B [10], or incurable autoimmune chronic diseases [4], as well as in the maternity ward [11]. Without being an expert in transcultural issues, any health-care provider can be taught to be aware of the role that culture can play in care: they can acquire transcultural skills. These are defined by a dynamic posture toward the acquisition of skills (working with an interpreter, adapt one's interview techniques, learning actively from the other) and attitudes (nonjudgmental and nondiscriminatory toward minority populations) for thinking about care and disease across two cultures, while considering culture as a dynamic process in constant change [3, 12, 13, 14, 15]. In English-speaking countries, including Canada, the transcultural perspective has been taught in the basic foundation curriculum for medical studies for more than 50 years. This is not the case in France. In particular, these countries regularly consider the concepts of empowerment and institutional racism (including inequalities of access to care despite benevolent intentions) [16, 17]. Attention is paid to all acculturation-related stress, that is, the stress linked to facing a different world, which transforms one's identity and can sometimes be associated with precarious living conditions. Acculturation is recognized as a risk factor for decompensation of both physical and psychological/psychiatric diseases [18, 19]. Microagressions also cause harm: insults or attitudes (intentional or not) that communicate hostile or contemptuous messages targeting people solely on the basis of their membership in a marginalized group [20]. In France, only those who take an active interest have access to instruction in medical or transcultural anthropology through specialized university degrees, research masters' degrees, or optional seminars for interns and residents in psychiatry. This public comprises people who already have experience with this field and/or are aware of the importance of having access to other representations of care. Our transcultural team receives numerous requests for training from professionals across France (in departments providing psychiatric and somatic care as well as in academic and other education-related settings). This training is provided by the Babel Center [2] (a European resource center for transcultural clinical practices) or by instructors in psychiatry and psychology from our establishments (Cochin Hospital and Avicenne Hospital, located respectively in Paris and the Paris metropolitan region). For years, raising awareness of these issues among the youngest students in medical fields was considered inappropriate; the idea, especially in psychiatry, was to learn the basic semiology before knowing where knowledge can be deconstructed. Nonetheless, studies from the USA show that medical students are more malleable and more likely to adopt cultural skills before they become anchored in various practices or habits [21, 22]. Marie Rose Moro has pioneered an earlier integration of the cultural dimension in the medical school at université Paris Cité, as an optional module and then since 2017 an optional course for second- and third-year medical students [3] . This transcultural program's objective is to transmit to students simultaneously knowledge about medical anthropology useful for medical practice and interpersonal skills for dealing with populations considered vulnerable, including but not limited to cultural minorities. The impact of this course has never been evaluated, and for now it has not spread widely to other French medical schools. The history of France and its values linked to republican universalism [23] make it still more difficult to implant the transcultural approach here, even though the international literature clearly recognizes the need for — and recommends — the acquisition of transcultural skills in countries receiving substantial numbers of immigrants [12, 13, 14]. The cultural perspective is regularly silenced because hospitals are among the republican institutions in which everyone, professional and patient alike, has interiorized a sort of taboo about talking about different ways of thinking. These universalist positions avoid any insistence on the difference between communities or cultural groups. Others underline the need to recognize the specific needs of minorities and to find appropriate responses to these needs [23]. It is nonetheless not forbidden to interrogate some religious or cultural aspects that constitute an important part of an individual's identity and regularly affect the representation of a disease or of what is happening at any given moment in the patient's life. It is thus possible that the reception of transcultural programs or courses will be different in France, because of the republican ideology. Objectives This study's principal objective is to describe the impact of the transcultural course on second- and third-year medical students. Specifically, we sought to assess any changes in their practices and their perceptions toward migrant patients before and after a course in transcultural competences. This study also has a secondary objective. Based on the program of the supplementary optional course for second- and third-year medical students in 2023, which included varied formats (lectures, discussion groups, and role-playing) and content ranging from general themes to topics more focused on medical anthropology, we describe here the types of classes that had the greatest impact on these young students and seek to uncover the factors explaining their effect. We will then consider new pedagogical tools that may be useful for this public's study of this theme in view of the difficulty of addressing the cultural differences in France in professional settings. Methodology This qualitative study comprised pedagogical experiments conducted while teaching a course entitled "Transcultural approach to the physician-patient relationship." We aimed to evaluate the effects of this 15-hour course on these (second- and third-year) medical students — on their behavior, on the patient-medical student relationship, on their perceptions of the migrant patients between the start and the end of the program. This program included five classes of three hours each, over a three-month period. We conducted two focus groups: one at the first class and the other at the last. Each focus group lasted two hours and included all 38 students who had chosen to enroll in this optional class. The department secretary sent information about the focus groups and the class to the students by email and collected their consent forms. We audio-recorded both focus groups, with the students' consent, and transcribed them in full. Two teachers led the first focus group, based on a semi-structured discussion (Table 1); both had expertise in the transcultural approach in psychiatry and in mediation in health-care and educational settings. RR was the leader-moderator, and a psychologist (AS) co-hosted and observed the session. RR alone led the second, more evaluational, focus group, also based on a semi-structured discussion (Table 2). -Insert Table 1. First focus group: semi-structured discussion- -Insert Table 2. Second focus group- Method of qualitative analysis: RR transcribed both focus group sessions in full. During her first complete replay of the recording, she made annotations as a start to the analysis. We then conducted a discourse analysis, linked to the interactions, and a content analysis, to extract and regroup the emerging themes. This triangulated analysis is based several rereadings. We used axial coding for each thought unit of the transcript (the categories grouped the ideas they conveyed), classed into themes and subthemes. The results synthesize the most important themes and ideas expressed, illustrated by the most characteristic quotations. We also note the findings we considered most unexpected. Results Participants' profile This group of students is particular in its cultural diversity, as shown below during the detailed presentation of the self-introductions and in comparison with previous years. Students stated the following cultural affiliations: Breton, Iraqi, Egyptian, Tunisian, Moroccan, Algerian, French, sometimes mixed ( métis ), Malagasy, Sri Lankan, Indian, Chinese, Swedish, and English. Around half appeared to speak several languages. They were evenly distributed between second- and third-year students. Many came from the "LAS" ( L icence A ccès S anté ) pathway (a new, nontraditional route into medical studies in France, with health as the minor and a social science as the major during the first year of university). They had done short practical internships, but without considering themselves to be in the front line in a care relationship. None had any experience in psychiatry. Participation in both sessions was highly satisfactory. Each of the illustrative direct quotations below (from the transcript) comes from a different student. We identified four principal themes: The place of the mother tongue at the hospital: inside or outside the framework? Equity and humanity in caring for the vulnerable The balance between professional neutrality and the use of cultural identity as an advantage for the care relationship The effects of the transcultural course on the students' attitude toward the health-care team and the patient. 1. The place of the mother tongue at the hospital: inside or outside the framework? Empathy through role-playing. At the last session, the students debated the language they could speak at the hospital. At the beginning, opinions were not unanimous or even consensual. One student claimed to be able to manage by using Google Translate in his daily life as a physician. For me, Google Translate is enough for what we are asked at the hospital, even to inform a patient about a serious disease. Using Google Translate, that could dehumanize the situation (one student's response). Nuances and precautions surrounded the use of a language spoken fluently by the student in a professional context, as it can tip over into a form of intimacy but also a feeling of illegitimacy, all the while having advantages. During one short internship, a patient didn't speak French, he was more at ease in his language. He was smoking in the room, but didn't say so to the physician, but he told me. If the patient asks "do you speak this language, Arabic?" Of course I do it. That would help him. I don't do it first. Someone said it's stigmatizing. Just because you're Arab doesn’t mean you speak Arabic. It gives me pleasure to be able to facilitate a patient's care and for him not to feel left out. More broadly, the approach to cultures at the hospital puts people more or less at ease (first focus group). RR: Are you more or less comfortable? Student (male): Yes Another student (female): Me, no. I'm afraid [the patient will] feel stigmatized, even if it has to do with his illness, and I'm not necessarily comfortable with that. Another student (male): I don't see why you're asking this question, because in medicine, you can ask any questions, there aren't any taboos. The topic of language was one of the principal themes, as frequently mentioned spontaneously. A role-playing game was improvised and co-constructed around the use of an interpreter in a situation where a diagnosis of type 2 diabetes would be announced to a North African woman who did not speak French. This game made it possible to experiment with the difficulty of improvising interpretation without being a professional interpreter and also to put ourselves in the shoes of family members who serve as interpreters. She understood what I was saying, but the words weren't exactly medical. That reminds me of when I had to explain what a coronary angiography is in my language; it was super hard. The interview was slow and impoverished, with many hesitations and several returns toward the "doctor" for details. The student playing the interpreter translating the first sentence addressed the student playing the physician: "wait, what did you say?" The way you organize sentences is different. In French you cannot say exactly the same thing as in Arabic. I tried word for word and that didn't work, so I am going to try to change (student). Empathy developed toward the non-French speaking families. One student mentioned an experience of potential abandonment. It's more in the relationship with the patient. There are patients who will understand very little without an interpreter. You feel their abandonment. Some students reported a positive experience of intracultural connection that legitimated their right to speak their language in a health-care setting. I'm in my third year and from Sri Lanka . I was in a short internship, and j was able to help in a situation where the patient did not speak French at all and did speak my language. So I was able to construct a family tree to identify a genetic characteristic. 2. Equity and humanity in caring for the vulnerable Institutional mistreatment was another theme repeatedly and spontaneously raised at the last session. There really is a difference between patients with vulnerabilities, and those who don't have any. There are patients who are smiling, making jokes with the doctors, etc. They are going to be asked for their opinions much more often; we're going to involve them much more in their care. For the patients who are a little tired, a little fragile, or who have trouble speaking French, it’s different. One of the most striking class sessions, according to the students, covered the impact of the history of French colonialism on the institutions and of collective story on the individual. A more holistic view of discrimination cites the responsibility of the institution or even the State. I couldn't imagine so many young people committing suicide in French Guiana, for example. The administration and the French state have a responsibility in this. Some say they have a keen awareness of issues in hospitals and a desire to change practices. As we start our life at the hospital as medical students, it's new to us and we see it a little naively. So we can see the structural inconsistencies that people who have been there for 10 years no longer see at all. But we're also at the bottom of the ladder and we can't really afford to change it. This course helps us as individuals but it would be interesting to have interventions in the departments, for collective changes, because it's hard, alone, to induce these changes. Talking about a Parisian hospital facing cultural diversity: In a short internship, for a patient who didn't speak French, I proposed an interpreter; they just told me that it was impossible. … From what I've seen, they try to provide good care to patients, even if they don't speak French. Several students showed a desire to treat patients as human beings. The objective is to understand and support the patient, to understand them holistically; for me it's not just a rubric, but it's not becoming close friends. There was a woman who didn't speak French, only English; her baby was a month old. Common sense was essential: this is a mother who is very worried. If she speaks English, we'll speak English, we're not going to look further… Basically it's a human being, a person in pain. Respect the codes, have time to ask supervisors if we can get an interpreter or speak the language … really, we're not going to get too familiar, but there's an urgent need. 3. The balance between professional neutrality and the use of cultural identity as a resource for the care relationship Several students mentioned that professionals' neutrality in the health-care relationship is illusory, or even a paradoxical command that is contradictory to a good care relationship. At the beginning of my internships, I tried to stay neutral, to keep up a barrier. Since I've accepted all this, I've allowed myself to be myself, because you can't be anything but yourself, and well that changes everything . Speaking the patient's language, you can take a place that's different from that of the physician. At the same time I tell myself, proximity, there's not only risks, there are also advantages; so it depends on the situation. And this, all while being prudent: Even if you're not neutral per se, getting too close to a patient, not just culturally, but emotionally, can prevent you from making a difficult medical decision. It can end up by creating a distance. You must not feel obligated to do it; if you don't, you shouldn't; if you do, it's intimacy. This led to questions about the use of one's personal identity or experiences, and the need to take into account one's reactions to the patient's otherness. To add a little nuance, this proximity can break the isolation there is at the hospital. I don't have a language to share with the patient, but when I've been to the city or country, the patient comes from, it lets me say, "ah yes, I've been there, it was lovely." It can build confidence and serve the relationship rather than harm it. To overcome the phenomenological splitting between the personal world and the professional world, students did an introduction exercise to experiment with talking about their identity and their languages without feeling threatened about talking about it — feeling authorized to do so. At the beginning of these introductions, the first students timorously mentioned their cultural identity as professionals. Sometimes it was expressed with humility or discomfort: I'm Elsa [4] ; I'm also in my third year, and like [the person before me], my cultural heritage doesn't go back very far. Third year, the same, there's not enormous diversity in my culture. (Eva) But the introductions evolved progressively: Second year, I'm French on my mother's side, and Swedish on my father's. (Marie) The students thus expressed the possibility of saying their chosen affiliations and showing the complexity in their identities and their feelings of belonging: Although my parents had different cultural origins, I don't really feel attached to any other culture than that of France (Tom). Second year, Tunisian origins; culturally I identify most with the countries where I've lived the longest. RR: which country? Student: England and Iraq. By the end, the introduction of identity was more complete and without complexes: I'm in my second year; culturally I'm Breton, but my mother doesn't know her origins exactly. I'm attached to French culture. Before medicine, I did language sciences, and we did courses in sociology and the transcultural approach to languages; I found that pretty interesting. Third year, family from China, born in France. In my personal experience, I've had to balance between Chinese and French culture and in my internships, that's facilitated my links with some patients. (Estelle) 4. Transcultural skills course: its impact on the students' attitude toward the health-care team and the patient Students spontaneously verbalized their expectations during the round of initial introductions. These were either related to the language barrier or to their awareness of the importance of considering cultural factors, or their willingness to learn how to use/manipulate culture as a lever in the therapeutic relationship. What I want to say is that I've already had to face patients in my internship who didn't speak French, and I didn't really know what to do. I didn't grow up in France but in Algeria. As my parents were doctors, I had the opportunity to see the health-care system there and in France and I find I've learned a lot from that. My parents are from a different culture. I chose this course to improve myself. I don't have good memories of their experiences in health care. I will try later not to make the same mistakes, to have a more open mind, to know each patient's culture and to be able to adapt to their personalities, let's say. During an internship, there was a patient who spoke my language, and I wanted to know how to use our culture, how to do it. During the evaluation session, the students described the course as useful, but different from other medical school courses. There are more people enrolled in the optional courses that prepare you for examinations: ER, case reports, pediatrics, plus clinical or useful. This has been useful but differently. It's harder to see that it's useful. You're not necessarily aware that there are these problems when you're not interested in that at all. Their self-assessments of the effect on clinical skills of these transcultural classes are very much about a more critical judgment of standard practices. In an internship last week, a patient didn't speak French very well, and that was clear: he didn't know how to explain his answer in French very well or he didn't answer the question well. He said, "I don't know." We came back with the entire team ... and the physician, I realized at the history-taking, the physician just talked louder when the patient didn't understand. I wouldn't have realized this before, and I was a little ashamed of that. After that, I did a history with another student, I tried to show with gestures so that he would understand what I was asking . Some pointed out the importance of adopting an active and open posture that shows the willingness to create a bond and can allow the relationship to be positively transformed. By their example, they lead other professionals to ask questions about their own actions. My co-interns said, 'come on let's go'. I didn't understand anything, although in fact we could have had the information, just by taking the time, saying, ok that won't necessarily be super clear. I'm not going to understand everything and won't explain it that well, but at least let's make the effort. The patient might be frustrated to not be able to explain because of the language barrier. I let the patient talk more. When they tell the story of their disease, I listen much more to how they live it and how they explain it to themselves. Vigilance for forms of institutional abuse between the first and last class sessions allowed them to dare to try to modify practices. I told them when I described the situation, I said that the language barrier is very very slight [contrary to what the file says], there were little things that I didn't understand, but was that linked to age or to confusion instead? Sometimes it's complicated to know everything that's happening to us. Some felt more comfortable taking a stand, felt justified in expressing doubts all the while being respectful of the chain of command, and daring to have strong opinions. That changed my perspective, but my place in the chain of command made it hard for me to say, 'excuse me, I wouldn't have done it like that,' not when we are all together in the room with the patient. It depends on the situation, but when you want to say something important, you have to argue for that position. We have other patients, but for this patient, it's necessary and important. Or simply felt comfortable with the cultural approach: Sort of the same for me this morning with a patient from Guadeloupe, for the history, I tried to focus on other aspects, and I felt comfortable. Maybe the patient didn't feel like talking about it. But I tried to put him at ease, so that he could talk about it. Sometimes it's complicated because you're in a professional setting, and he can think that it's not the place, though here it's medical and sometimes it's necessary, sometimes it's correlated. The person you're talking to has to show they're open. You have to talk about it, and that depends on how you approach it. You have to use tact and not generalize about the country. Others asked for more cultural knowledge. I don't want a course that's too theoretical for each country, that would be too linearized. In the field, I want to know what the cultural difference is and how to ask questions about it. A little theory wouldn't hurt either Discussion 1. The effect of focus groups: transformational learning This is the first study in France to evaluate the pedagogical aspects of instruction in transcultural skills. The analysis of the two focus group shows an effect that exceeded the initial description of expectations and the final course evaluation. We observed a transformational effect after each focus group for several elements. We noted a decentering process at work in the students during these groups. It allowed them to leave their cultural presumptions behind and move toward cultural openness in recognizing that there are several equally valid ways of representing a situation, a disease, an education. Progressively from the first course, the students were transformed and showed each other nuances. At the end, their responses took up transcultural guidelines they had not even known initially [3, 12] and reminded us of the principles of a learning society. This result was also found in a qualitative study among first- and second-cycle medical students in the USA; most participants identified the learners as a stronger voice for transformation [24]. In the various theories of groups used in psychology, it is recognized that the process of identification within groups has an especially impactful effect when it convinces itself. We could talk about a form of transcultural midwifery in these focus groups, within which the instructors play the role of the "third-instructed", to use Michel Serres's expression 25]: in the sense of a knowledge broker, facilitating reflexive positions among professionals. At the end of each focus group, the students managed to overcome their resistance, which is one of the strong points of transcultural teaching. The question of languages illustrates this particularly well: at the first course, no one thought of using an interpreter at the hospital, even when the patient did not speak French; at the last course, the students dared to play the interpreter physically and experiment with how hard it is. The experience of decentering was initiated by the introductions in the first session. The presentation of identities changed as the focus group progressed, with increasingly elaborate and complexified introductions, but without invading their intimacy. The students experienced success in remaining professional while talking about culture. These real-life exercises testing the reactions of students or professionals facing the otherness reflected back to them by the patient allowed them to work on what Georges Devereux defined as one of the theoretical foundations of the transcultural approach in health-care relationships and in research: cultural countertransference [26]. According to the feedback the students provided at the focus group at the last session, they were able to explore the complexity of the transcultural situation by being reflexive. This group process, facilitated by two experienced transcultural teachers, led to what Mezirow theorized as transformational learning [27]. Observing the changes between the first focus group and the last made it possible to examine the third level of Kirkpatrick's evaluation model [28], which assesses the changes in students' behaviors in the first interactions after the session, as well as the impact on their satisfaction and knowledge. The fourth level is difficult to evaluate here, as it involves the effects on the patient of the students' instruction in this topic. 2. "Do we have the right to talk about culture at the hospital?" "Do we have the right to talk about culture?" was one of the principal questions. At one time, the republican heritage made it inappropriate to talk about cultural otherness in hospitals [23]. Every person living in France is educated about that very early on in every public space. If one mentions the other's difference, one might be thought to be pointing it out as something that excludes them, even though this comment might simply reveal a true desire, a curiosity to encounter them in their entirety, with the complexity and wealth of cultural ingredients that characterize them. Moreover, it is possible, even necessary, in some situations of care. Today, the French national authority for health [5] recommends the use of interpreters' services in France. Thus a form of mediation can already take place for any health (or social) professional, with the help of an interpreter and if they know how to work with them effectively in practice. The plan set up by the French government to acknowledge the needs and work of staff in health-care facilities and to improve the attractiveness of public hospitals to employees after the COVID-19 pandemic, is also based on the need to provide comprehensive management of those with the greatest difficulties and to set up systems to provide interpreting services. In practice, however, there is a great deal of reluctance, often based on financial or time considerations, or on the fact that we don't know how to deal with a third party who might get in the way of the relationship. The study by Lachal et al. [29] on the effects of cultural mediation with an interpreter at Necker Children's Hospital (Paris) nonetheless shows a reduction in the costs of care from the perspectives of both public health and health economics: they observed less use of the ER, fewer hospitalizations, and more effective outpatient follow-up for children with serious chronic diseases. Moreover, the parents were more at ease with the treatment plan, because they fully understood it and felt that they were listened to and heard. The students' questioning focused largely on their use of their own culture to improve an intracultural care relationship. They were able themselves to list its strengths and limitations. The need to be understood and not judged means rediscovering familiarity, facilitated by an intercultural perspective, that is, that the patient and the health professional can understand each other based on shared cultural references. Battaglini et al. [30] noted, for example, that during pregnancy, migrant women from the Middle East most often see a physician of origins similar to their own. The Muslim women encountered by Tsianakas and Liamputtong [31] in Australia prefer to see female physicians during their pregnancy. It is nonetheless not necessary to be of the same culture as the patient to be able to talk about the cultural dimension. Adapting one's questions and sometimes one's framework makes it possible to show a non-judgmental posture, open to different cultural elements [3]. Help from an interpreter can lay the foundations for sharing representations and mutual understanding in an ethical process, even for families who speak the host-country language somewhat [32]. Using an interpreter, beyond the function of translating the words, helps patients to assert themselves, since they are assured that a professional will understand them. Moreover, the interpreter can shed light on cultural misunderstandings. Finally, the patient's use of their mother tongue enables them to express their experiences and emotions more than they can in a second language. These interviews are often more productive. What course format is most appropriate? Comparison with the international literature The medical students said that they appreciated a discussion group as the priority format, but would also have liked still more theoretical classes on the anthropological aspects. Nonetheless, the nature of the questions and themes considered showed the need for the course to approach as a prerequisite the global and fundamental principles of the transcultural approach. This study also confirmed that it can be an appropriate moment in the medical curriculum to introduce this course, despite the students' young age and their lack of practical experience in first-line treatment; nonetheless, some adaptations are needed. The program has been revised in the light of these findings, with on the one hand a more multidisciplinary perspective, and on the other hand an approach targeting the theme of discrimination. Finally, we will be using more dynamic and creative methods, inspired by the international literature. The next course will begin with an integrated first focus group. The format of discussion groups appears effective against one specific aspects of epistemic injustice in health [33]. Cultural minorities, in particular those who do not master the language, are probably among the populations who endure the most injustice, from those who doubt a patient's word or take them least seriously (testimonial injustice). They are surely subjected to hermeneutic or interpretive injustice, that is, that linked to the cultural distance between the physician and patients of a different culture, whose ability to understand is called into doubt, along with the ability to interpret their own experience). A doctoral dissertation in psychiatry that conducted a scoping review of racial prejudice in medicine lists the training programs for medical students about this injustice and its harms [34]. Most of the articles concern medical pedagogy in the USA and Canada. The cohorts ranged from 500 [21, 22] to as many as 3500 students in their first years of medical school. The most frequent formats are lecture cycles, but sometimes more creative techniques with smaller groups are used. Some notable formats include a discussion between students and trainers after a guided observation of a work of art dealing with race [35], or a relationship-based workshop and toolkit held during a conference of family medicine instructors [36], and a one-week immersion program in local Maori communities for third-year students [37]. This instruction can also take place in the form of supervision in institutions with individuals of different status (i.e., students and professionals) [38]. Workshops including an individual virtual-reality experience of racism have directed at professionals and teachers themselves, and are then followed by discussions [39]. The programs evaluated most highly by the students for the improvement in their knowledge and their self-evaluated skills were often the small-group discussions. Several of these North American studies concluded that these young students were finally more able to undergo transformative transcultural experiences than more experienced doctors who had been in practice for several years. Finally, simulation for physicians is also under development on the topic of the acquisition of cultural competence, mainly in psychiatry. In Massachusetts, Padilla et al. [40] are experimenting with a "culturally appropriate evaluation" examination known as OSCE ( Objective Structured Clinical Examination) . The OSCE uses the DSM 5 cultural formulation interview to help make interns in psychiatry more at ease in conducting this interview. Pantziaras et al. [41, 42] have evaluated the effectiveness of simulation methods in psychiatry to teach caring for traumatized refugees; it was measured by a questionnaire about interns' confidence in their ability to provide this care. 3. Limitations and Perspectives The number of participants was higher than usual for a focus group format. Nonetheless the exchanges were rich, dense, interactive, and respectful. The selection bias associated with the cultural diversity of the students in the group because of their interest in this course might have compensated for this limitation . Despite this selection bias, unknown to the instructors at the time of the focus group, the students' questions demonstrated an absence of theoretical knowledge on this subject and even a naive form of ignorance on some practical points. It is therefore possible to imagine that knowledge was sparse among the students who had not chosen this option. Perspectives The dynamism of the students in these focus groups, the diversity emerging from the courses described in the international literature review, and the need to examine closely the epistemic injustices in health in France are all arguments for devoting more creativity to courses teaching transcultural skills and approaches in France. We could imagine, for example, plays written by patients or students and followed by debate, such as Gross describes, on cultural themes or a discussion group about reflexive practices between interns (or medical students) in various disciplines, writing resolutions on the model of GEPRI [43]. Our study has led to the creation of a MOOC. Its purpose is pedagogical, aiming to clarify how to work with an interpreter, point out the errors to avoid, and the good practices, and provide video support. It is difficult to assess the impact of this course in students' clinical practices and daily lives. A potential subsequent study might follow the model of Van Ryn et al. [44], which measured implicit racial prejudice during the medical school curriculum among 3547 non-African-American medical students, with exposure to 3 interventions (formal and informal programs and interracial contact) and assessed whether or not these implicit biases diminished over time. The implicit bias (officially, "implicit association test," IAT) is a tool that may be useful for measuring this result [45, 46]. It will be performed at the beginning of the first session of the optional transcultural course, and then at the end. Simultaneously a panel of students who did not participate in this course would also take the IAT at the same intervals and thus allow a form of comparison. Conclusion Transcultural teaching can take different forms. The aim is always to inculcate the acquisition of know-how and interpersonal skills (a set of attitudes, knowledge, and abilities) to develop quality care for migrant populations. Beyond the theoretical concepts of anthropology taught, the emphasis is placed on the necessary consideration of care providers' own implicit and explicit prejudices, with encouragement not to abrade human complexity. The pedagogical tools aim at adapting the questions, the framework, and our posture to promote the sharing of representations around various diseases and obtaining keys to understanding often complex issues. The format of the course — as an interactive discussion group — is suitable for a public of young medical students. Declarations Ethics approval and consent to participate Before the first class, all students enrolled in this optional module received information about the focus groups and provided their consent, after assurance that the course would be identical if there was even only one refusal (and in this case, the pedagogical experiment would not have been performed). The informed consent was obtained from all of the participants. The data were anonymized. The recordings were destroyed after they had been transcribed. Because this study involved no care data, no IRB number was necessary. The appropriate ethics committee (CHU Martinique IRB 2023/038) approved this protocol in 2023. Only adults took part in the study. Consent for publication Consent for publication was mentioned in the information given to the students. Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests The author declares that they have no competing interests . Funding Not applicable Authors' contributions RR conducted the study and drafted the manuscript. AS conducted the study with RR. ML and AB contributed to the writing of the report. AO, HC, and AM read and approved the final manuscript. MA P adapted the manuscript format to that of BMC. MRM allowed the study to be conducted, supervised it, and authorized the recruitment of students. Acknowledgments We thank all of the students who participated in this study, as well as the université Paris Cité. Author information The principal authors (RR, AO, AS, HC, AM, and ML) belong to the team of Marie Rose Moro, who is also an author of this article, and a leader in transcultural psychiatry in France. The first author has been a practicing child psychiatrist and a teacher for 13 years in the discipline of transcultural approaches in medicine and education (instruction of masters students in research, specific university diplomas, and professional training for health care and education staff). References De Plaen S. L’homme et la mort. Ou à propos du façonnement culturel des réalités biologiques. In Nago Humbert (dir.), Soins palliatifs pédiatriques, Coll. Intervenir. Montréal : Hôpital Sainte-Justine ; 2004 : 515-536. Moro MR. Guide de psychothérapie transculturelle: soigner les enfants et les adolescents. Soigner les enfants et les adolescents. Paris : In Press ; 2021. Radjack R, Ludot-Grégoire M, Guessoum SB, Moro MR. Évaluation clinique en situation transculturelle. EMC – Psychiatrie, 2022:1-10 [Article 37-714-A-10] Bouznah S. La médiation transculturelle : pratiques et fondements. L’Autre. 2020; 21(1): 20-29. Giacobi C, Bouznah Z, Moro MR. Savoirs, pouvoir et imagination. 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(1972) Ethnopsychanalyse complémentariste, Flammarion, Paris, réédition, 1985. Mezirow J. Transformative learning: theory to practice. New Directions for Adult and Continuing Education. 1997; 74, 5-12. Kirkpatrick DL. Evaluating Training Program—The Four Levels. San Francisco, CA: Berret-Koehler Publishers, Inc. 1994. Lachal J, Escaich M, Bouznah S, Rousselle C, De Lonlay P, Canoui P, Moro MR, Durand-Zaleski I. Transcultural mediation programme in a paediatric hospital in France: qualitative and quantitative study of participants’ experience and impact on hospital costs. BMJ Open. 2019; 9(11). Online https://bmjopen.bmj.com/content/9/11/e032498 Battaglini A, Gravel S, Boucheron L. Les mères immigrantes, pareilles pas pareilles! Facteurs de vulnérabilité propres aux mères immigrantes en période périnatale, Direction de la santé publique de Montréal-Centre, Rapport de recherche 2000 : 230 p. Tsianakas V, Liamputtong P . What women from Islamic background in Australia say about care in prenatal testing and antenatal care. Midwifery. 2002; 18(1): 25-34. Tribe R. Working with interpreters In: Bhugra D, editor. Oxford textbook of migrant psychiatry. Oxford: Oxford University Press; 2020. p.335-342 Carel H, Kidd IJ. Epistemic injustice in healthcare: a philosophial analysis. Med Health Care Philos . 2014; 17 : 529–40. Mouhab A. Préjugés basés sur l’origine supposée en clinique et formation médicale : une scoping review. Thèse de psychiatrie soutenue le 16 octobre 2023 (Antilles) Godley B, Dayal D, Manekin E, Estroff S. Toward an Anti-Racist Curriculum: Incorporating Art into Medical Education to Improve Empathy and Structural Competency. Journal of medical education and curricular development. 2020;7 White-Davis T, Edgoose J, Brown Speights JS, Fraser K, Ring JM, Guh J, et al. Addressing Racism in Medical Education An Interactive Training Module. Fam Med. 2018;50:364‑8 Crampton P, Dowell A, Parkin C, Thompson C. Combating Effects of Racism Through a Cultural Immersion Medical Education Program. Academic Medicine. 2003;78:595‑8 Reliford A, Berry OO, Burgos JJ, Liaw KRL. Holding space for facilitated dialogues on antiracism in academic medicine. Journal of the American Academy of Child & Adolescent Psychiatry. 2022;61:953‑6 Roswell RO, Cogburn CD, Tocco J, Martinez J, Bangeranye C, Bailenson JN, et al. Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine. Acad Med. 2020;95:1882‑6 Padilla A, Benjamin S, Lewis-Fernandez R. Assessing Cultural Psychiatry Milestones Through an Objective Structured Clinical Examination. Acad Psychiatry. 2016 Aug;40(4):600-3. doi: 10.1007/s40596-016-0544-9. Epub 2016 Apr 15. PMID: 27084719. Pantziaras I, Fors U, Ekblad S. Innovative Training with Virtual Patients in Transcultural Psychiatry: The Impact on Resident Psychiatrists’ Confidence. PLoS ONE. 2015; 10(3): e0119754. doi:10.1371/journal.pone.0119754 Pantziaras I, Fors U, Ekblad S. Training with virtual patients in transcultural psychiatry: do the learners actually learn? J Med Internet Res. 2015; Feb 16;17(2):e46. doi: 10.2196/jmir.3497. PMID: 25689716; PMCID: PMC4376199. Gross O, Gagnayre R. Diminuer les injustices épistémiques au moyen d’enseignements par et avec les patients : l’expérience pragmatiste de la faculté de médecine de Bobigny. Canadian Journal of Bioethics/Revue canadienne de bioéthique. 2021 ; 4(1), 70–78. https://doi.org/10.7202/1077628ar Van Ryn M, Hardeman R, Phelan SM, Burgess DJ, Dovidio JF, Herrin J, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30:1748‑56 FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC MedEthics. 2017;18(1):19. Haider AH, Schneider EB, Sriram N et al. Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions. JAMA Surg. 2015;150(5):457-64 Footnotes [1] The Maison de Solenn, at Cochin Hospital's department of child and adolescent psychopathology, and at Avicenne Hospital [2] https://center-babel.fr/ [3] French medical studies begin in their first year as undergraduates. After 6 years and a nationwide ranking examination, students begin interships and residencies [4] all first names are pseudonyms [5] www.has-sante.fr « Interprétariat linguistique dans le domain de la santé », 2017 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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A qualitative study of a focus group","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCultural data are the ingredients of every human relationship. Cultural elements are often present in both the individual and collective psyches and therefore in that of every patient, as they pass through moments and periods of difficulty: chronic disease, birth, and death. The relations between these moments and quality of life, standards of care, risks, and viability are concepts simultaneously individual and shared, modulated by family history, religious orientations, and life trajectories — all elements that refer to broad sets of meanings [1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApplying the transcultural approach means taking into account how culture affects the representations and treatments of diseases [2]. It is useful in second line and when necessary [2, 3]. For example, in our institutions, we frequently see patients give a cultural meaning, a cultural theory to explain a chronic disease that medicine cannot cure [4]. In some situations of poor adherence to treatment or even refusal of care, a program of intercultural mediation, that is, a transcultural consultation led by our team,\u003csup\u003e[1]\u0026nbsp;\u003c/sup\u003emay be indicated [2, 4, 5]. Cultural mediation is regularly practiced with migrant populations who request it or by the professionals who treat them — who care for patients with sickle-cell anemia [6, 7], support HIV-positive patients [8], or manage unaccompanied minors [9], hepatitis B [10], or incurable autoimmune chronic diseases [4], as well as in the maternity ward [11].\u003c/p\u003e\n\u003cp\u003eWithout being an expert in transcultural issues, any health-care provider can be taught to be aware of the role that culture can play in care: they can acquire transcultural skills. These are defined by a\u0026nbsp;dynamic posture toward the acquisition of skills (working with an interpreter, adapt one's interview techniques, learning actively from the other) and attitudes (nonjudgmental and nondiscriminatory toward minority populations) for thinking about care and disease across two cultures, while considering culture as a dynamic process in constant change [3, 12, 13, 14, 15].\u003c/p\u003e\n\u003cp\u003eIn English-speaking countries, including Canada, the transcultural perspective has been taught in the basic foundation curriculum for medical studies for more than 50 years. This is not the case in France. In particular, these countries regularly consider the concepts of empowerment and institutional racism (including inequalities of access to care despite benevolent intentions) [16, 17]. Attention is paid to all acculturation-related stress, that is, the stress linked to facing a different world, which transforms one's identity and can sometimes be associated with precarious living conditions. Acculturation is recognized as a risk factor for decompensation of both physical and psychological/psychiatric diseases [18, 19]. Microagressions also cause harm:\u0026nbsp;insults or attitudes (intentional or not) that communicate hostile or contemptuous messages targeting people solely on the basis of their membership in a marginalized group\u0026nbsp;[20].\u0026nbsp;In France, only those who take an active interest have access to instruction in medical or transcultural anthropology through specialized university degrees, research masters' degrees, or optional seminars for interns and residents in psychiatry. This public comprises people who already have experience with this field and/or are aware of the importance of having access to other representations of care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur transcultural team receives numerous requests for training from professionals across France (in departments providing psychiatric and somatic care as well as in academic and other education-related settings). This training is provided by the Babel Center\u003csup\u003e[2]\u003c/sup\u003e (a European resource center for transcultural clinical practices) or by instructors in psychiatry and psychology from our establishments (Cochin Hospital and Avicenne Hospital, located respectively in Paris and the Paris metropolitan region). For years, raising awareness of these issues among the youngest students in medical fields was considered inappropriate; the idea, especially in psychiatry, was to learn the basic semiology before knowing where knowledge can be deconstructed. Nonetheless, studies from the USA show that medical students are more malleable and more likely to adopt cultural skills before they become anchored in various practices or habits [21, 22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMarie Rose Moro has pioneered an earlier integration of the cultural dimension in the medical school at université Paris Cité, as an optional module and then since 2017 an optional course for second- and third-year medical students\u003csup\u003e[3]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis transcultural program's objective is to transmit to students simultaneously knowledge about medical anthropology useful for medical practice and interpersonal skills for dealing with populations considered vulnerable, including but not limited to cultural minorities. The impact of this course has never been evaluated, and for now it has not spread widely to other French medical schools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe history of France and its values linked to republican universalism [23] make it still more difficult to implant the transcultural approach here, even though the international literature clearly recognizes the need for — and recommends — the acquisition of transcultural skills in countries receiving substantial numbers of immigrants [12, 13, 14]. The cultural perspective is regularly silenced because hospitals are among the republican institutions in which everyone, professional and patient alike, has interiorized a sort of taboo about talking about different ways of thinking. These universalist positions avoid any insistence on the difference between communities or cultural groups. Others underline the need to recognize the specific needs of minorities and to find appropriate responses to these needs [23]. It is nonetheless not forbidden to interrogate some religious or cultural aspects that constitute an important part of an individual's identity and regularly affect the representation of a disease or of what is happening at any given moment in the patient's life. It is thus possible that the reception of transcultural programs or courses will be different in France, because of the republican ideology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study's principal objective is to describe the impact of the transcultural course on second- and third-year medical students. Specifically, we sought to assess any changes in their practices and their perceptions toward migrant patients before and after a course in transcultural competences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study also has a secondary objective. Based on the program of the supplementary optional course for second- and third-year medical students in 2023, which included varied formats (lectures, discussion groups, and role-playing) and content ranging from general themes to topics more focused on medical anthropology, we describe here the types of classes that had the greatest impact on these young students and seek to uncover the factors explaining their effect.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe will then consider new pedagogical tools that may be useful for this public's study of this theme in view of the difficulty of addressing the cultural differences in France in professional settings.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Methodology","content":"\u003cp\u003eThis qualitative study comprised pedagogical experiments conducted while teaching a course entitled \"Transcultural approach to the physician-patient relationship.\" We aimed to evaluate the effects of this 15-hour course on these (second- and third-year) medical students — on their behavior, on the patient-medical student relationship, on their perceptions of the migrant patients between the start and the end of the program. This program included five classes of three hours each, over a three-month period.\u0026nbsp;\u003c/p\u003e\u003cp\u003eWe conducted two focus groups: one at the first class and the other at the last. Each focus group lasted two hours and included all 38 students who had chosen to enroll in this optional class.\u003c/p\u003e\u003cp\u003eThe department secretary sent information about the focus groups and the class to the students by email and collected their consent forms. We audio-recorded both focus groups, with the students' consent, and transcribed them in full.\u003c/p\u003e\u003cp\u003eTwo teachers led the first focus group, based on a semi-structured discussion (Table 1); both had expertise in the transcultural approach in psychiatry and in mediation in health-care and educational settings. RR was the leader-moderator, and a psychologist (AS) co-hosted and observed the session. RR alone led the second, more evaluational, focus group, also based on a semi-structured discussion (Table 2).\u0026nbsp;\u003c/p\u003e\u003cp\u003e-Insert Table 1. First focus group: semi-structured discussion-\u003c/p\u003e\u003cp\u003e-Insert Table 2. Second focus group-\u003c/p\u003e\u003cp\u003e\u003cem\u003eMethod of qualitative analysis:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eRR transcribed both focus group sessions in full. During her first complete replay of the recording, she made annotations as a start to the analysis. We then conducted a discourse analysis, linked to the interactions, and a content analysis, to extract and regroup the emerging themes. This triangulated analysis is based several rereadings. We used axial coding for each thought unit of the transcript (the categories grouped the ideas they conveyed), classed into themes and subthemes. The results synthesize the most important themes and ideas expressed, illustrated by the most characteristic quotations. We also note the findings we considered most unexpected.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants\u0026apos; profile\u0026nbsp;\u003c/em\u003eThis group of students is particular in its cultural diversity, as shown below during the detailed presentation of the self-introductions and in comparison with previous years. Students stated the following cultural affiliations: Breton, Iraqi, Egyptian, Tunisian, Moroccan, Algerian, French, sometimes mixed (\u003cem\u003em\u0026eacute;tis\u003c/em\u003e), Malagasy, Sri Lankan, Indian, Chinese, Swedish, and English. Around half appeared to speak several languages.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThey were evenly distributed between second- and third-year students. Many came from the \u0026quot;LAS\u0026quot; (\u003cstrong\u003e\u003cem\u003eL\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eicence \u003cstrong\u003eA\u003c/strong\u003ecc\u0026egrave;s \u003cstrong\u003eS\u003c/strong\u003eant\u0026eacute;\u003c/em\u003e) pathway (a new, nontraditional route into medical studies in France, with health as the minor and a social science as the major during the first year of university). They had done short practical internships, but without considering themselves to be in the front line in a care relationship. None had any experience in psychiatry.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipation in both sessions was highly satisfactory. Each of the illustrative direct quotations below (from the transcript) comes from a different student.\u003c/p\u003e\n\u003cp\u003eWe identified four principal themes:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe place of the mother tongue at the hospital: inside or outside the framework?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEquity and humanity in caring for the vulnerable\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe balance between professional neutrality and the use of cultural identity as an advantage for the care relationship\u003c/li\u003e\n \u003cli\u003eThe effects of the transcultural course on the students\u0026apos; attitude toward the health-care team and the patient.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e1. The place of the mother tongue at the hospital: inside or outside the framework? Empathy through role-playing.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the last session, the students debated the language they could speak at the hospital. At the beginning, opinions were not unanimous or even consensual. One student claimed to be able to manage by using Google Translate in his daily life as a physician.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFor me, Google Translate is enough for what we are asked at the hospital, even to inform a patient about a serious disease.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUsing Google Translate, that could dehumanize the situation (one student\u0026apos;s response).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNuances and precautions surrounded the use of a language spoken fluently by the student in a professional context, as it can tip over into a form of intimacy but also a feeling of illegitimacy, all the while having advantages. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDuring one short internship, a patient didn\u0026apos;t speak French, he was more at ease in his language. He was smoking in the room, but didn\u0026apos;t say so to the physician, but he told me.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf the patient asks \u0026quot;do you speak this language, Arabic?\u0026quot; Of course I do it. That would help him. I don\u0026apos;t do it first. Someone said it\u0026apos;s stigmatizing. Just because you\u0026apos;re Arab doesn\u0026rsquo;t mean you speak Arabic.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt gives me pleasure to be able to facilitate a patient\u0026apos;s care and for him not to feel left out.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMore broadly, the approach to cultures at the hospital puts people more or less at ease (first focus group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRR: Are you more or less comfortable?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudent (male): Yes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnother student (female): Me, no. I\u0026apos;m afraid [the patient will] feel stigmatized, even if it has to do with his illness, and I\u0026apos;m not necessarily comfortable with that.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnother student (male): I don\u0026apos;t see why you\u0026apos;re asking this question, because in medicine, you can ask any questions, there aren\u0026apos;t any taboos.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe topic of language was one of the principal themes, as frequently mentioned spontaneously. A role-playing game was improvised and co-constructed around the use of an interpreter in a situation where a diagnosis of type 2 diabetes would be announced to a North African woman who did not speak French. This game made it possible to experiment with the difficulty of improvising interpretation without being a professional interpreter and also to put ourselves in the shoes of family members who serve as interpreters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShe understood what I was saying, but the words weren\u0026apos;t exactly medical.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThat reminds me of when I had to explain what a coronary angiography is in my language; it was super hard.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe interview was slow and impoverished, with many hesitations and several returns toward the \u0026quot;doctor\u0026quot; for details.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe student playing the interpreter translating the first sentence addressed the student playing the physician: \u0026quot;wait, what did you say?\u0026quot;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe way you organize sentences is different. In French you cannot say exactly the same thing as in Arabic. I tried word for word and that didn\u0026apos;t work, so I am going to try to change (student).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEmpathy developed toward the non-French speaking families. One student mentioned an experience of potential abandonment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026apos;s more in the relationship with the patient. There are patients who will understand very little without an interpreter. You feel their abandonment.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome students reported a positive experience of intracultural connection that legitimated their right to speak their language in a health-care setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;m in my third year and from Sri Lanka\u003c/em\u003e.\u003cem\u003e\u0026nbsp;I was in a short internship, and j was able to help in a situation where the patient did not speak French at all and did speak my language. So I was able to construct a family tree to identify a genetic characteristic.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Equity and humanity in caring for the vulnerable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional mistreatment was another theme repeatedly and spontaneously raised at the last session.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere really is a difference between patients with vulnerabilities, and those who don\u0026apos;t have any. There are patients who are smiling, making jokes with the doctors, etc. They are going to be asked for their opinions much more often; we\u0026apos;re going to involve them much more in their care. For the patients who are a little tired, a little fragile, or who have trouble speaking French, it\u0026rsquo;s different.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne of the most striking class sessions, according to the students, covered the impact of the history of French colonialism on the institutions and of collective story on the individual. A more holistic view of discrimination cites the responsibility of the institution or even the State.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI couldn\u0026apos;t imagine so many young people committing suicide in French Guiana, for example. The administration and the French state have a responsibility in this.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome say they have a keen awareness of issues in hospitals and a desire to change practices.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAs we start our life at the hospital as medical students, it\u0026apos;s new to us and we see it a little naively. So we can see the structural inconsistencies that people who have been there for 10 years no longer see at all.\u003c/em\u003e \u003cem\u003eBut we\u0026apos;re also at the bottom of the ladder and we can\u0026apos;t really afford to change it.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis course helps us as individuals but it would be interesting to have interventions in the departments, for collective changes, because it\u0026apos;s hard, alone, to induce these changes.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTalking about a Parisian hospital facing cultural diversity:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn a short internship, for a patient who didn\u0026apos;t speak French, I proposed an interpreter; they just told me that it was impossible. \u0026hellip; From what I\u0026apos;ve seen, they try to provide good care to patients, even if they don\u0026apos;t speak French.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral students showed a desire to treat patients as human beings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe objective is to understand and support the patient, to understand them holistically; for me it\u0026apos;s not just a rubric, but it\u0026apos;s not becoming close friends.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere was a woman who didn\u0026apos;t speak French, only English; her baby was a month old. Common sense was essential: this is a mother who is very worried. If she speaks English, we\u0026apos;ll speak English, we\u0026apos;re not going to look further\u0026hellip; Basically it\u0026apos;s a human being, a person in pain. Respect the codes, have time to ask supervisors if we can get an interpreter or speak the language \u0026hellip; really, we\u0026apos;re not going to get too familiar, but there\u0026apos;s an urgent need.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. The balance between professional neutrality and the use of cultural identity as a resource for the care relationship\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral students mentioned that professionals\u0026apos; neutrality in the health-care relationship is illusory, or even a paradoxical command that is contradictory to a good care relationship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAt the beginning of my internships, I tried to stay neutral, to keep up a barrier. Since I\u0026apos;ve accepted all this, I\u0026apos;ve allowed myself to be myself, because you can\u0026apos;t be anything but yourself, and well that changes everything\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSpeaking the patient\u0026apos;s language, you can take a place that\u0026apos;s different from that of the physician. At the same time I tell myself, proximity, there\u0026apos;s not only risks, there are also advantages; so it depends on the situation.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnd this, all while being prudent:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEven if you\u0026apos;re not neutral per se, getting too close to a patient, not just culturally, but emotionally, can prevent you from making a difficult medical decision.\u003c/em\u003e \u003cem\u003eIt can end up by creating a distance.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou must not feel obligated to do it; if you don\u0026apos;t, you shouldn\u0026apos;t; if you do, it\u0026apos;s intimacy.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis led to questions about the use of one\u0026apos;s personal identity or experiences, and the need to take into account one\u0026apos;s reactions to the patient\u0026apos;s otherness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTo add a little nuance, this proximity can break the isolation there is at the hospital. I don\u0026apos;t have a language to share with the patient, but when I\u0026apos;ve been to the city or country, the patient comes from, it lets me say, \u0026quot;ah yes, I\u0026apos;ve been there, it was lovely.\u0026quot;\u003c/em\u003e It can build confidence and serve the relationship rather than harm it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo overcome the phenomenological splitting between the personal world and the professional world, students did an introduction exercise to experiment with talking about their identity and their languages without feeling threatened about talking about it \u0026mdash; feeling authorized to do so.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the beginning of these introductions, the first students timorously mentioned their cultural identity as professionals. Sometimes it was expressed with humility or discomfort:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;m Elsa\u0026nbsp;\u003cstrong\u003e\u003csup\u003e[4]\u003c/sup\u003e\u003c/strong\u003e; I\u0026apos;m also in my third year, and like [the person before me], my cultural heritage doesn\u0026apos;t go back very far.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThird year, the same, there\u0026apos;s not enormous diversity in my culture. (Eva)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBut the introductions evolved progressively:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecond year, I\u0026apos;m French on my mother\u0026apos;s side, and Swedish on my father\u0026apos;s. (Marie)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe students thus expressed the possibility of saying their chosen affiliations and showing the complexity in their identities and their feelings of belonging:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAlthough my parents had different cultural origins, I don\u0026apos;t really feel attached to any other culture than that of France (Tom).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecond year, Tunisian origins; culturally I identify most with the countries where I\u0026apos;ve lived the longest. RR: which country? Student: England and Iraq.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBy the end, the introduction of identity was more complete and without complexes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;m in my second year; culturally I\u0026apos;m Breton, but my mother doesn\u0026apos;t know her origins exactly. I\u0026apos;m attached to French culture. Before medicine, I did language sciences, and we did courses in sociology and the transcultural approach to languages; I found that pretty interesting.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThird year, family from China, born in France. In my personal experience, I\u0026apos;ve had to balance between Chinese and French culture and in my internships, that\u0026apos;s facilitated my links with some patients. (Estelle)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Transcultural skills course: its impact on the students\u0026apos; attitude toward the health-care team and the patient\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents spontaneously verbalized their expectations during the round of initial introductions. These were either related to the language barrier or to their awareness of the importance of considering cultural factors, or their willingness to learn how to use/manipulate culture as a lever in the therapeutic relationship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat I want to say is that I\u0026apos;ve already had to face patients in my internship who didn\u0026apos;t speak French, and I didn\u0026apos;t really know what to do.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI didn\u0026apos;t grow up in France but in Algeria. As my parents were doctors, I had the opportunity to see the health-care system there and in France and I find I\u0026apos;ve learned a lot from that.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMy parents are from a different culture. I chose this course to improve myself. I don\u0026apos;t have good memories of their experiences in health care. I will try later not to make the same mistakes, to have a more open mind, to know each patient\u0026apos;s culture and to be able to adapt to their personalities, let\u0026apos;s say.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDuring an internship, there was a patient who spoke my language, and I wanted to know how to use our culture, how to do it.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the evaluation session, the students described the course as useful, but different from other medical school courses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere are more people enrolled in the optional courses that prepare you for examinations: ER, case reports, pediatrics, plus clinical or useful. This has been useful but differently. It\u0026apos;s harder to see that it\u0026apos;s useful. You\u0026apos;re not necessarily aware that there are these problems when you\u0026apos;re not interested in that at all.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTheir self-assessments of the effect on clinical skills of these transcultural classes are very much about a more critical judgment of standard practices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn an internship last week, a patient didn\u0026apos;t speak French very well, and that was clear: he didn\u0026apos;t know\u0026nbsp;\u003c/em\u003ehow to \u003cem\u003eexplain his answer in French\u0026nbsp;\u003c/em\u003e\u003cem\u003every well\u003c/em\u003e \u003cem\u003eor he didn\u0026apos;t answer the question well. He said, \u0026quot;I don\u0026apos;t know.\u0026quot; We came back with the entire team ... and the physician, I realized at the history-taking, the physician just talked louder when the patient didn\u0026apos;t understand. I wouldn\u0026apos;t have realized this before, and I was a little ashamed of that.\u003c/em\u003e \u003cem\u003eAfter that, I did a history with another student, I tried to show with gestures so that he would understand what I was asking\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eSome pointed out the importance of adopting an active and open posture that shows the willingness to create a bond and can allow the relationship to be positively transformed. By their example, they lead other professionals to ask questions about their own actions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMy co-interns said, \u0026apos;come on let\u0026apos;s go\u0026apos;. I didn\u0026apos;t understand anything, although in fact we could have had the information, just by taking the time, saying, ok that won\u0026apos;t necessarily be super clear. I\u0026apos;m not going to understand everything and won\u0026apos;t explain it that well, but at least let\u0026apos;s make the effort. The patient might be frustrated to not be able to explain because of the language barrier.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI let the patient talk more. When they tell the story of their disease, I listen much more to how they live it and how they explain it to themselves.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVigilance for forms of institutional abuse between the first and last class sessions allowed them to dare to try to modify practices.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI told them when I described the situation, I said that the language barrier is very very slight [contrary to what the file says], there were little things that I didn\u0026apos;t understand, but was that linked to age or to confusion instead? Sometimes it\u0026apos;s complicated to know everything that\u0026apos;s happening to us.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome felt more comfortable taking a stand, felt justified in expressing doubts all the while being respectful of the chain of command, and daring to have strong opinions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThat changed my perspective, but my place in the chain of command made it hard for me to say, \u0026apos;excuse me, I wouldn\u0026apos;t have done it like that,\u0026apos; not when we are all together in the room with the patient.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt depends on the situation, but when you want to say something important, you have to argue for that position. We have other patients, but for this patient, it\u0026apos;s necessary and important.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOr simply felt comfortable with the cultural approach:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSort of the same for me this morning with a patient from Guadeloupe, for the history, I tried to focus on other aspects, and I felt comfortable.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaybe the patient didn\u0026apos;t feel like talking about it. But I tried to put him at ease, so that he could talk about it. Sometimes it\u0026apos;s complicated because you\u0026apos;re in a professional setting, and he can think that it\u0026apos;s not the place, though here it\u0026apos;s medical and sometimes it\u0026apos;s necessary, sometimes it\u0026apos;s correlated. The person you\u0026apos;re talking to has to show they\u0026apos;re open.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou have to talk about it, and that depends on how you approach it. You have to use tact and not generalize about the country.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOthers asked for more cultural knowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026apos;t want a course that\u0026apos;s too theoretical for each country, that would be too linearized. In the field, I want to know what the cultural difference is and how to ask questions about it. A little theory wouldn\u0026apos;t hurt either\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003e\u003cem\u003e1. The effect of focus groups: transformational learning\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is the first study in France to evaluate the pedagogical aspects of instruction in transcultural skills.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis of the two focus group shows an effect that exceeded the initial description of expectations and the final course evaluation. We observed a transformational effect after each focus group for several elements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe noted a decentering process at work in the students during these groups. It allowed them to leave their cultural presumptions behind and move toward cultural openness in recognizing that there are several equally valid ways of representing a situation, a disease, an education. Progressively from the first course, the students were transformed and showed each other nuances. At the end, their responses took up transcultural guidelines they had not even known initially [3, 12] and reminded us of the principles of a learning society. This result was also found in a qualitative study among first- and second-cycle medical students in the USA; most participants identified the learners as a stronger voice for transformation [24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the various theories of groups used in psychology, it is recognized that the process of identification within groups has an especially impactful effect when it convinces itself. We could talk about a form of transcultural midwifery in these focus groups, within which the instructors play the role of the \u0026quot;third-instructed\u0026quot;, to use Michel Serres\u0026apos;s expression 25]: in the sense of a knowledge broker, facilitating reflexive positions among professionals. At the end of each focus group, the students managed to overcome their resistance, which is one of the strong points of transcultural teaching. The question of languages illustrates this particularly well: at the first course, no one thought of using an interpreter at the hospital, even when the patient did not speak French; at the last course, the students dared to play the interpreter physically and experiment with how hard it is.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe experience of decentering was initiated by the introductions in the first session. The presentation of identities changed as the focus group progressed, with increasingly elaborate and complexified introductions, but without invading their intimacy. The students experienced success in remaining professional while talking about culture.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese real-life exercises testing the reactions of students or professionals facing the otherness reflected back to them by the patient allowed them to work on what Georges Devereux defined as one of the theoretical foundations of the transcultural approach in health-care relationships and in research: cultural countertransference [26]. According to the feedback the students provided at the focus group at the last session, they were able to explore the complexity of the transcultural situation by being reflexive.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis group process, facilitated by two experienced transcultural teachers, led to what Mezirow theorized as transformational learning [27]. Observing the changes between the first focus group and the last made it possible to examine the third level of Kirkpatrick\u0026apos;s evaluation model [28], which assesses the changes in students\u0026apos; behaviors in the first interactions after the session, as well as the impact on their satisfaction and knowledge. The fourth level is difficult to evaluate here, as it involves the effects on the patient of the students\u0026apos; instruction in this topic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2. \u0026quot;Do we have the right to talk about culture at the hospital?\u0026quot;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Do we have the right to talk about culture?\u0026quot; was one of the principal questions. At one time, the republican heritage made it inappropriate to talk about cultural otherness in hospitals [23]. Every person living in France is educated about that very early on in every public space. If one mentions the other\u0026apos;s difference, one might be thought to be pointing it out as something that excludes them, even though this comment might simply reveal a true desire, a curiosity to encounter them in their entirety, with the complexity and wealth of cultural ingredients that characterize them. Moreover, it is possible, even necessary, in some situations of care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eToday, the French national authority for health\u003csup\u003e[5]\u003c/sup\u003e recommends the use of interpreters\u0026apos; services in France. Thus a form of mediation can already take place for any health (or social) professional, with the help of an interpreter and if they know how to work with them effectively in practice. The plan set up by the French government to acknowledge the needs and work of staff in health-care facilities and to improve the attractiveness of public hospitals to employees after the COVID-19 pandemic, is also based on the need to provide comprehensive management of those with the greatest difficulties and to set up systems to provide interpreting services.\u003c/p\u003e\n\u003cp\u003eIn practice, however, there is a great deal of reluctance, often based on financial or time considerations, or on the fact that we don\u0026apos;t know how to deal with a third party who might get in the way of the relationship. The study by Lachal et al. [29] on the effects of cultural mediation with an interpreter at Necker Children\u0026apos;s Hospital (Paris) nonetheless shows a reduction in the costs of care from the perspectives of both public health and health economics: they observed less use of the ER, fewer hospitalizations, and more effective outpatient follow-up for children with serious chronic diseases. Moreover, the parents were more at ease with the treatment plan, because they fully understood it and felt that they were listened to and heard.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe students\u0026apos; questioning focused largely on their use of their own culture to improve an intracultural care relationship. They were able themselves to list its strengths and limitations. The need to be understood and not judged means rediscovering familiarity, facilitated by an intercultural perspective, that is, that the patient and the health professional can understand each other based on shared cultural references. Battaglini et al. [30] noted, for example, that during pregnancy, migrant women from the Middle East most often see a physician of origins similar to their own. The Muslim women encountered by Tsianakas and Liamputtong [31] in Australia prefer to see female physicians during their pregnancy.\u003c/p\u003e\n\u003cp\u003eIt is nonetheless not necessary to be of the same culture as the patient to be able to talk about the cultural dimension. Adapting one\u0026apos;s questions and sometimes one\u0026apos;s framework makes it possible to show a non-judgmental posture, open to different cultural elements [3]. Help from an interpreter can lay the foundations for sharing representations and mutual understanding in an ethical process, even for families who speak the host-country language somewhat [32]. Using an interpreter, beyond the function of translating the words, helps patients to assert themselves, since they are assured that a professional will understand them. Moreover, the interpreter can shed light on cultural misunderstandings. Finally, the patient\u0026apos;s use of their mother tongue enables them to express their experiences and emotions more than they can in a second language. These interviews are often more productive.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhat course format is most appropriate? Comparison with the international literature\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe medical students said that they appreciated a discussion group as the priority format, but would also have liked still more theoretical classes on the anthropological aspects. Nonetheless, the nature of the questions and themes considered showed the need for the course to approach as a prerequisite the global and fundamental principles of the transcultural approach. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study also confirmed that it can be an appropriate moment in the medical curriculum to introduce this course, despite the students\u0026apos; young age and their lack of practical experience in first-line treatment; nonetheless, some adaptations are needed. The program has been revised in the light of these findings, with on the one hand a more multidisciplinary perspective, and on the other hand an approach targeting the theme of discrimination. Finally, we will be using more dynamic and creative methods, inspired by the international literature. The next course will begin with an integrated first focus group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe format of discussion groups appears effective against one specific aspects of epistemic injustice in health [33]. Cultural minorities, in particular those who do not master the language, are probably among the populations who endure the most injustice, from those who doubt a patient\u0026apos;s word or take them least seriously (testimonial injustice). They are surely subjected to hermeneutic or interpretive injustice, that is, that linked to the cultural distance between the physician and patients of a different culture, whose ability to understand is called into doubt, along with the ability to interpret their own experience).\u003c/p\u003e\n\u003cp\u003eA doctoral dissertation in psychiatry that conducted a scoping review of racial prejudice in medicine lists the training programs for medical students about this injustice and its harms [34]. Most of the articles concern medical pedagogy in the USA and Canada. The cohorts ranged from 500 [21, 22] to as many as 3500 students in their first years of medical school. The most frequent formats are lecture cycles, but sometimes more creative techniques with smaller groups are used. Some notable formats include a discussion between students and trainers after a guided observation of a work of art dealing with race [35], or a relationship-based workshop and toolkit held during a conference of family medicine instructors [36], and a one-week immersion program in local Maori communities for third-year students [37].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis instruction can also take place in the form of supervision in institutions with individuals of different status (i.e., students and professionals) [38].\u003c/p\u003e\n\u003cp\u003eWorkshops including an individual virtual-reality experience of racism have directed at professionals and teachers themselves, and are then followed by discussions [39].\u003c/p\u003e\n\u003cp\u003eThe programs evaluated most highly by the students for the improvement in their knowledge and their self-evaluated skills were often the small-group discussions. Several of these North American studies concluded that these young students were finally more able to undergo transformative transcultural experiences than more experienced doctors who had been in practice for several years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, simulation for physicians is also under development on the topic of the acquisition of cultural competence, mainly in psychiatry. In Massachusetts, Padilla et al. [40] are experimenting with a \u0026quot;culturally appropriate evaluation\u0026quot; examination known as OSCE (\u003cem\u003eObjective Structured Clinical Examination)\u003c/em\u003e. The OSCE uses the DSM 5 cultural formulation interview to help make interns in psychiatry more at ease in conducting this interview. Pantziaras et al. [41, 42] have evaluated the effectiveness of simulation methods in psychiatry to teach caring for traumatized refugees; it was measured by a questionnaire about interns\u0026apos; confidence in their ability to provide this care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3. Limitations and Perspectives\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe number of participants was higher than usual for a focus group format. Nonetheless the exchanges were rich, dense, interactive, and respectful. The selection bias associated with the cultural diversity of the students in the group because of their interest in this course might have compensated for this limitation\u003cem\u003e.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite this selection bias, unknown to the instructors at the time of the focus group, the students\u0026apos; questions demonstrated an absence of theoretical knowledge on this subject and even a naive form of ignorance on some practical points. It is therefore possible to imagine that knowledge was sparse among the students who had not chosen this option.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerspectives\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe dynamism of the students in these focus groups, the diversity emerging from the courses described in the international literature review, and the need to examine closely the epistemic injustices in health in France are all arguments for devoting more creativity to courses teaching transcultural skills and approaches in France. We could imagine, for example, plays written by patients or students and followed by debate, such as Gross describes, on cultural themes or a discussion group about reflexive practices between interns (or medical students) in various disciplines, writing resolutions on the model of GEPRI [43]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study has led to the creation of a MOOC. Its purpose is pedagogical, aiming to clarify how to work with an interpreter, point out the errors to avoid, and the good practices, and provide video support. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is difficult to assess the impact of this course in students\u0026apos; clinical practices and daily lives. A potential subsequent study might follow the model of Van Ryn et al. [44], which measured implicit racial prejudice during the medical school curriculum among 3547 non-African-American medical students, with exposure to 3 interventions (formal and informal programs and interracial contact) and assessed whether or not these implicit biases diminished over time. The implicit bias (officially, \u0026quot;implicit association test,\u0026quot; IAT) is a tool that may be useful for measuring this result [45, 46]. It will be performed at the beginning of the first session of the optional transcultural course, and then at the end. Simultaneously a panel of students who did not participate in this course would also take the IAT at the same intervals and thus allow a form of comparison.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion ","content":"\u003cp\u003eTranscultural teaching can take different forms. The aim is always to inculcate the acquisition of know-how and interpersonal skills (a set of attitudes, knowledge, and abilities) to develop quality care for migrant populations. Beyond the theoretical concepts of anthropology taught, the emphasis is placed on the necessary consideration of care providers' own implicit and explicit prejudices, with encouragement not to abrade human complexity. The pedagogical tools aim at adapting the questions, the framework, and our posture to promote the sharing of representations around various diseases and obtaining keys to understanding often complex issues. The format of the course — as an interactive discussion group — is suitable for a public of young medical students.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore the first class, all students enrolled in this optional module received \u0026nbsp;information about the \u0026nbsp;focus groups and provided their consent, after assurance that the course would be identical if there was even only one refusal (and in this case, the pedagogical experiment would not have been performed). The informed consent was obtained from all of the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data were anonymized. The recordings were destroyed after they had been transcribed. Because this study involved no care data, no IRB number was necessary. The appropriate ethics committee (CHU Martinique IRB 2023/038) approved this protocol in 2023. Only adults took part in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was mentioned in the information given to the students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that they have no competing interests\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRR conducted the study and drafted the manuscript. AS conducted the study with RR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eML and AB contributed to the writing of the report. AO, HC, and AM read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eMA P adapted the manuscript format to that of BMC. MRM allowed the study to be conducted, supervised it, and authorized the recruitment of students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Acknowledgments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all of the students who participated in this study, as well as the universit\u0026eacute; Paris Cit\u0026eacute;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor information\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe principal authors (RR, AO, AS, HC, AM, and ML) belong to the team of Marie Rose Moro, who is also an author of this article, and a leader in transcultural psychiatry in France. The first author has been a practicing child psychiatrist and a teacher for 13 years in the discipline of transcultural approaches in medicine and education (instruction of masters students in research, specific university diplomas, and professional training for health care and education staff).\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDe Plaen S. L\u0026rsquo;homme et la mort. Ou \u0026agrave; propos du fa\u0026ccedil;onnement culturel des r\u0026eacute;alit\u0026eacute;s biologiques. In Nago Humbert (dir.), Soins palliatifs p\u0026eacute;diatriques, Coll. Intervenir. Montr\u0026eacute;al : H\u0026ocirc;pital Sainte-Justine ; 2004 : 515-536.\u003c/li\u003e\n\u003cli\u003eMoro MR. Guide de psychoth\u0026eacute;rapie transculturelle: soigner les enfants et les adolescents. Soigner les enfants et les adolescents. 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Facteurs de vuln\u0026eacute;rabilit\u0026eacute; propres aux m\u0026egrave;res immigrantes en p\u0026eacute;riode p\u0026eacute;rinatale, Direction de la sant\u0026eacute; publique de Montr\u0026eacute;al-Centre, Rapport de recherche 2000 : 230 p.\u003c/li\u003e\n\u003cli\u003eTsianakas V, Liamputtong P . What women from Islamic background in Australia say about care in prenatal testing and antenatal care. Midwifery. 2002; 18(1): 25-34.\u003c/li\u003e\n\u003cli\u003eTribe R. Working with interpreters In: Bhugra D, editor. Oxford textbook of migrant psychiatry. Oxford: Oxford University Press; 2020. p.335-342\u003c/li\u003e\n\u003cli\u003eCarel H, Kidd IJ. Epistemic injustice in healthcare: a philosophial analysis. \u003cem\u003eMed Health Care Philos\u003c/em\u003e. 2014; \u003cem\u003e17\u003c/em\u003e: 529\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eMouhab A. Pr\u0026eacute;jug\u0026eacute;s bas\u0026eacute;s sur l\u0026rsquo;origine suppos\u0026eacute;e en clinique et formation m\u0026eacute;dicale : une scoping review. Th\u0026egrave;se de psychiatrie soutenue le 16 octobre 2023 (Antilles) \u003c/li\u003e\n\u003cli\u003eGodley B, Dayal D, Manekin E, Estroff S. Toward an Anti-Racist Curriculum: Incorporating Art into Medical Education to Improve Empathy and Structural Competency. Journal of medical education and curricular development. 2020;7\u003c/li\u003e\n\u003cli\u003eWhite-Davis T, Edgoose J, Brown Speights JS, Fraser K, Ring JM, Guh J, et al. Addressing Racism in Medical Education An Interactive Training Module. Fam Med. 2018;50:364‑8\u003c/li\u003e\n\u003cli\u003eCrampton P, Dowell A, Parkin C, Thompson C. Combating Effects of Racism Through a Cultural Immersion Medical Education Program. Academic Medicine. 2003;78:595‑8\u003c/li\u003e\n\u003cli\u003eReliford A, Berry OO, Burgos JJ, Liaw KRL. Holding space for facilitated dialogues on antiracism in academic medicine. Journal of the American Academy of Child \u0026amp; Adolescent Psychiatry. 2022;61:953‑6\u003c/li\u003e\n\u003cli\u003eRoswell RO, Cogburn CD, Tocco J, Martinez J, Bangeranye C, Bailenson JN, et al. Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine. Acad Med. 2020;95:1882‑6\u003c/li\u003e\n\u003cli\u003ePadilla A, Benjamin S, Lewis-Fernandez R. Assessing Cultural Psychiatry Milestones Through an Objective Structured Clinical Examination. Acad Psychiatry. 2016 Aug;40(4):600-3. doi: 10.1007/s40596-016-0544-9. Epub 2016 Apr 15. PMID: 27084719.\u003c/li\u003e\n\u003cli\u003ePantziaras I, Fors U, Ekblad S. Innovative Training with Virtual Patients in Transcultural Psychiatry: The Impact on Resident Psychiatrists\u0026rsquo; Confidence. PLoS ONE. 2015; 10(3): e0119754. doi:10.1371/journal.pone.0119754\u003c/li\u003e\n\u003cli\u003ePantziaras I, Fors U, Ekblad S. Training with virtual patients in transcultural psychiatry: do the learners actually learn? J Med Internet Res. 2015; Feb 16;17(2):e46. doi: 10.2196/jmir.3497. PMID: 25689716; PMCID: PMC4376199.\u003c/li\u003e\n\u003cli\u003eGross O, Gagnayre R. Diminuer les injustices \u0026eacute;pist\u0026eacute;miques au moyen d\u0026rsquo;enseignements par et avec les patients : l\u0026rsquo;exp\u0026eacute;rience pragmatiste de la facult\u0026eacute; de m\u0026eacute;decine de Bobigny. Canadian Journal of Bioethics/Revue canadienne de bioéthique. 2021 ; 4(1), 70\u0026ndash;78. https://doi.org/10.7202/1077628ar\u003c/li\u003e\n\u003cli\u003eVan Ryn M, Hardeman R, Phelan SM, Burgess DJ, Dovidio JF, Herrin J, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30:1748‑56\u003c/li\u003e\n\u003cli\u003eFitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC MedEthics. 2017;18(1):19. \u003c/li\u003e\n\u003cli\u003eHaider AH, Schneider EB, Sriram N et al. Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions. JAMA Surg. 2015;150(5):457-64 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[1] The Maison de Solenn, at Cochin Hospital\u0026apos;s department of child and adolescent psychopathology, and at Avicenne Hospital \u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn2\"\u003e\n \u003cp\u003e[2] https://center-babel.fr/\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn3\"\u003e\n \u003cp\u003e[3] French medical studies begin in their first year as undergraduates. After 6 years and a nationwide ranking examination, students begin interships and residencies\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn4\"\u003e\n \u003cp\u003e[4] all first names are pseudonyms\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"ftn5\"\u003e\n \u003cp\u003e[5] www.has-sante.fr \u0026laquo; Interpr\u0026eacute;tariat linguistique dans le domain de la sant\u0026eacute; \u0026raquo;, 2017\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Culture, medical pedagogy, medical students, migration, discrimination, decentering, transcultural skills, interpreters in medical care","lastPublishedDoi":"10.21203/rs.3.rs-3941207/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3941207/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground: \u003c/em\u003eAcademic instruction about the impact of culture on health care (through cultural representations of diseases, the body, and various treatments) is sparse in France, although this topic is widely taught in other countries with substantial immigration, especially Canada and United States. Medical students' reception of this instruction must be assessed in the French context, where the consideration of cultural diversity is controversial, even taboo.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjectives: \u003c/em\u003eWe seek to describe the effect of a course on transcultural issues in medicine among second- and third-year medical students, especially on their behavior, on the patient-student relationship, and on their perceptions of migrant patients; we also aim to identify the aspects of the course that have the greatest effect on these young students.\u003c/p\u003e\n\u003cp\u003eMethods: Two focus groups (at the first and last course sessions) were conducted with 38 medical students who had participated in the optional course \"Transcultural approach to the physician-patient relationship\" at the Université Paris Cité medical school in 2023.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults: \u003c/em\u003eOur qualitative analysis of the focus group transcripts showed four themes: the place of the mother tongue at the hospital; equity and humanity in caring for the vulnerable; the balance between professional neutrality and the use of cultural identity as a resource to improve the care relationship; and the effects of the course on the students' position toward the health-care team and the patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDiscussion: \u003c/em\u003eThe two focus groups showed the course had a transformative effect on the students in their awareness of cultural prejudices, but also in enabling them to dare to consider cultural dimensions and to recognize the importance of interpreters.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e: A discussion group is an appropriate format for a course on transcultural approaches for this public of young learners and makes it possible to focus on its global themes and foundations.\u003c/p\u003e","manuscriptTitle":"Teaching transcultural skills to medical students in France. A qualitative study of a focus group","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-23 07:06:10","doi":"10.21203/rs.3.rs-3941207/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e765f9e-7b53-4c24-a26f-2acc789a2619","owner":[],"postedDate":"February 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-13T07:56:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-23 07:06:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3941207","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3941207","identity":"rs-3941207","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}