Medical training acts as a “secondary socialisation
process”, predominantly through a hidden curriculum
which “instils behaviours, attitudes, and values among
trainees”1. It has been argued that increased
secularisation of society and medical practice2 is creating
an observable trend towards radical secularism, the active
erasure of religion, with modern medicine described as
being “hostile” to religion and spirituality3.Meanwhile,
religious diversity is increasing in the UK, with minority
religions over-represented compared to the general
population and just over 10% of doctors identifying as
Muslim4, although, this is likely to be an underestimate
due to stereotype threat and identity concealment
reported by Muslims5.
Research also demonstrates that religion/spirituality has
an influential role in medical student socialisation, and
can be a protective factor in moderating emotional stress,
compassion, work-life balance and interpersonal
relationships with colleagues1.Acculturation theory, from
the field of group relations in psychology, can be a useful
lens to explore the interaction between Muslim learners
and their learning environment, analogous to migrating to
a secular-atheist dominant “host” culture of UK medical
institutions.
Research shows that religious medical students can
struggle with issues around identity and self- esteem but
they are also more likely to use faith-based methods as
positive coping mechanisms, experience less empathy
fatigue, and report increased religiosity as medical school
progresses.1 However, students can also experience
religious discrimination that adversely impacts educational experience and outcomesat several points
across medical school, and is more pronounced during
clinical placements6.
For Muslim medical students and residents, the
experience of religious discrimination is amplified by
Islamophobia, with compounding intersectional forces of
gender and race, often referred to as “The Triple
Penalty”7. Islamophobia occurs on a spectrum; from
biases, prejudices and micro aggressions to overt
discrimination, resulting in pervasive marginalisation and
exclusion.
The Manchester Muslim Student Guide (MMSG), co-
produced by medical students, faculty and educators8, is
a guide which aims to highlight practical steps that can
foster inclusion and wellbeing for Muslim medical
students. Areas covered in the guide include prayer
rooms, religious practices, dress codes, and strategies to
address discrimination and Islamophobia. The authors of
the guide reflect on the value of empowerment-led
student advocacy and the importance of faculty
engagement and accountability. However, many
challenges and conflict remain. In a recent GMC survey,
amongst Asian medical trainees, Muslims were found to
have lower pass rates9. Studies on differential attainment
have consistently shown that a suboptimal learning
environment is the main contributor, rather than
individual learner deficit10.
Accultration theory as theoretical lens
Drawing on the work of Berry, acculturation theory can
be a useful lens to understand the processes of adaptation and accommodation to underpin advocacy work on faith
and cultural inclusion in medical training. It has been
used extensively in research looking at International
Medical Graduates (IMGs) experiences11-13.
Acculturation is “the dual process of cultural and
psychological change that takes place as a result of
contact between two or more cultural groups and their
individual members…resulting in various forms of
mutual accommodation and longer-term psychological
and sociocultural adaptations between both groups”14.
From the perspective of the non-dominant group, two
critical factors determine the acculturation strategies
adopted: the desire to maintain cultural identity and
heritage, and the desirability of intercultural contact14.
Acculturation can result in four outcomes: integration,
where individuals preserve their cultural identity whilst
simultaneously maintaining intercultural contact to
facilitate participation as an integral part of a larger social
network; separation, where individuals turn inwards
towards their heritage culture and disengage from
involvement with other cultural groups; assimilation,
where individuals shed their culture and become
absorbed in the dominant culture; and marginalisation,
where there is limited interest in having relations with
others and in maintaining their own cultural heritage,
which often occurs due to enforced heritage loss and in
response to experiences of discrimination and
exclusion14.
Additionally, there are three observable behavioural
shifts that can be observed: cultural learning, culture
shedding and culture conflict15. Culture shedding is
associated with assimilation, whereas integration
involves cultural learning with limited cultural
shedding15. The opposite is the case with marginalisation
and separation is a consequence of a lack of bothcultural
shedding and cultural learning15. Additionally, conflict
and stress in the process of acculturation can result in
acculturative stress, with specific manifestations around
poor mental health, feelings of alienation and heighted
psychological and psychosomatic symptoms15. These are
consistent with discriminatory and exclusionary
experiences reported in the MMSG16.
Acculturation at the individual level is termed
psychological acculturation and different adaptation
outcomes have been identified15. These include
adjustment, where there is increased congruence between
the individual and environment, and is often the strategy
intended by the term adaptation; reaction, where there is
retaliation against the environment to increase
congruence; and withdrawal, which can be voluntary or forced exclusion and results in removal of the individual
from the environment15. Importantly, Berry demonstrates
that assimilation is not the only way to acculturate and
adjustment is not the only way to adapt15. In wider
research, policy and political narratives around British
Muslims, integration can be highly charged with
Islamophobic and racist overtones underpinned by
assimilatory objectives17. This distinction is important to
understand for both Muslim learners and educators.
On an institutional level, adaptations can be divided into
accommodations and modifications. In simple terms,
accommodations change how a student learns, whereas
modifications change what a student learns18 . However,
terminology is often confused with all three terms used
interchangeably. This is problematic as it may give the
impression that faith/cultural adaptations are in response
to learner deficit, which contradicts the prevailing
literature around differential attainment highlighted
above.
Applying acclutration theory
When groups choose to acculturate, there are large
variations in the way they do this and even engage in the
process15. At the sociocultural level, the two groups, in
this case Muslim learners (students and residents) and
secular educators, may have some initial ideas about
preferences or goals they wish to achieve, as well as the
steps that need to be taken to achieve them15. The
strategic goals set by the groups of which individuals are
members of influence longer term outcomes both in
terms of sociocultural and psychological adaptations19.
It is important to note that whilst adaptations in both
groups are implied, most changes occur in the non-
dominant group15. This is partly because individuals from
the non-dominant group do not always have complete
autonomy over their choice of acculturation strategies
and outcomes20, such as due to an absence of
psychological safety, as evidenced by the reluctance to
report concerns amongst medical students experiencing
discrimination6. Additionally, the strategies of the HC
society in relation to the two critical factors of
identity/heritage attachment and contact desirability also
determines outcomes11.
Furthermore, the experience of religious discrimination
and Islamophobia amongst Muslim students points to
cultural conflict, separation and acculturative stress,
which can contribute to poor adaptation, negatively
impacting educational experience and outcomes16.
Pioneering work by Ying Fei Heliot explores the intersection of religion in the workplace and highlights
how religion/occupation identity tensions have a negative
impact on psychological wellbeing and work outcomes
amongst healthcare staff20, which is relevant to Muslim
residents who have a dual role as learners and service
providers.
The term “host receptivity” has been used to describe the
HC’swillingness to accommodate those from other
cultures and provide opportunities to participate in local
social communication processes’21. It is argued that for
integration to occur, there are key attributes that the
dominant society must possess: open and inclusive
orientation and a willingness for mutual
accommodation21. However, the dominant group
significantly influences the way in which acculturation
takes place, with four possible objectives: melting pot,
segregation, exclusion and multiculturalism15. This is
relevant when considering the strategies that medical
institutions adopt to accommodate faith and belief, a
protected characteristic under the Equality Act21.
When assimilation is sought by the dominant
acculturating group, it is termed “melting pot”, when
separation is forced through, it is called “segregation”,
when marginalisation is imposed, it is termed
“exclusion”, and when diversity is an accepted feature
inclusive for all ethnocultural groups, it is termed
“multiculturalism”15. Inconsistencies and conflicts
between these acculturation preferences can be sources of
difficulty for acculturating individuals and result in
acculturative stress.
The hidden curriculum can be a particularly potent
source of acculturative stress for Muslim learners,
through shaping sociocultural norms and behavioural
practices, such as alcohol-fuelled social gatherings.
Additionally, the formal curriculum, can perpetuate
exclusion of Muslim medical students both in form, such
as timetabling during Friday prayers, which is a source of
moral conflict and distress for students who wish to pray,
andcontent, being focused on colonial Eurocentric
concepts of health and healing. Thus, the current learning
environment resembles a melting pot that is not open,
inclusive or adaptive.
Towards a middle way: cultural humility
In current trends of increasing cultural and religious
diversity amongst the medical student body, equality,
diversity and inclusion (EDI) initiatives must move away
from promoting melting pots to multiculturalism within
medical institutions. As Berry writes: “we all ask: how can peoples of different cultural backgrounds encounter
each other, seek avenues of mutual understanding,
negotiate and compromise on their initial positions, and
achieve some degree of harmonious engagement?”14.
Research in the NHS demonstrates that where religious
and occupational identities are actively brought into
alignment, occupational practice is enhanced and creates
the possibility of integration such as empathy in caring
professions20. This can be extended to
student/residentlearning and the positive development of
professionalism and achievement of capabilities.
Ward and Szabo present an integrated framework for
social learningexperienced by“non-natives”23. Here, this
translates to non-nativeMuslim learners in a religiously-
hostile learning environment3 who need to undergo social
learning to develop behavioural and sociocultural
adaptation, in addition to the early learning and
psychological adaptation that takes place during
acculturation11.23.The framework references personal and
situational factors which shape antecedents of culture
learning, and learning strategies, processes and outcomes,
which over time lead to behavioural and sociocultural
intercultural competence23.
Cultural (or intercultural) competence, is described as
‘the ability to communicate effectively and appropriately
in intercultural situations based on one’s intercultural
knowledge, skills and attitudes’24. However, the focus on
cultural competence training seen in current EDI
initiatives is based on short-term interventionswhich are
unlikely to be effective24. Cultural humility CH) is an
alternative practical and sustainable approach which has
a reflexive and practical ethos and focused on
developmental processes emphasising process-in-context.
CH places emphasis on self-awareness and relationships
and shifts the focus from cognitive approaches towards
socio-emotional skills26.
CH places onus on those holding privilege to recognise
and challenge assumptions and redress power imbalances
at interpersonal and institutional levels. This can create
cultural safety, as an outcome of conscious efforts to
address power differentials and biases26. Practically, this
involves setting up “brave spaces” for regular respectful
dialogue, learning and reflection based oncuriosity,
courage and compassion. Drawing on acculturation
theory, cultural humility is thus likely to increase cultural
contact and learning and decrease cultural shedding,
conflict and acculturative stress, associated with
improved integration and adjustment, whilst avoiding the
extreme strategies and outcomes of assimilation/ melting
pots on the one hand, and separation/segregation and marginalisation/exclusion on the other. CH can therefore
promote positive outcomes of sociocultural integration
and psychological adjustment with thriving multicultural
learning environments which welcome and celebrate
religious diversity and where each learner flourishes.
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