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Nonverbal Communication in a Caribbean MedicalSchool: “Touch Is a Touchy Issue”Stella Williams a , Michelle Harricharan b & Bidyadhar Sa aa Centre for Medical Sciences Education, University of the West Indies, St. Augustine,Trinidad and Tobagob Southampton Education School, University of Southampton, Southampton, United KingdomPublished online: 18 Jan 2013.

To cite this article: Stella Williams , Michelle Harricharan & Bidyadhar Sa (2013) Nonverbal Communication in a CaribbeanMedical School: “Touch Is a Touchy Issue”, Teaching and Learning in Medicine: An International Journal, 25:1, 39-46, DOI:10.1080/10401334.2012.741534

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Teaching and Learning in Medicine, 25(1), 39–46Copyright C© 2013, Taylor & Francis Group, LLCISSN: 1040-1334 print / 1532-8015 onlineDOI: 10.1080/10401334.2012.741534

Nonverbal Communication in a Caribbean Medical School:“Touch Is a Touchy Issue”

Stella WilliamsCentre for Medical Sciences Education, University of the West Indies, St. Augustine,Trinidad and Tobago

Michelle HarricharanSouthampton Education School, University of Southampton, Southampton, United Kingdom

Bidyadhar SaCentre for Medical Sciences Education, University of the West Indies, St. Augustine,Trinidad and Tobago

Background: The heath communication curriculum at theTrinidad campus of the University of the West Indies was devel-oped out of practices advocated in large Western countries. Manystudents and tutors observed that the nonverbal skills advocatedin these approaches did not fit the complex cultural dynamics ofthe Caribbean. Purpose: A study was developed to understand theproblems Caribbean students faced with these nonverbal commu-nication practices. Methods: Thirty-six students representing dif-ferent Caribbean territories were randomly selected from the twocompulsory communication skills courses: Communication Skillsfor Health Personnel and Communication Skills for the HealthProfessions class list. These students participated in 4 focus groupdiscussions (FGD). The FGD questions were formulated on thenonverbal skills advanced in the Calgary–Cambridge Guide to thedoctor–patient interview. Results: The findings supported the viewthat recommended nonverbal skills were in conflict with expecteddoctor–patient behavior in different Caribbean territories. Stu-dents felt that nonverbal communication needed to be treated withgreater cultural sensitivity. Conclusions: These findings stimulatedchanges to the health communication program. This article identi-fies changes made to the communication skills program in responseto cultural difference.

INTRODUCTIONWaves of mass immigration into Western Europe, Australia,

and the United States have encouraged these countries to ad-

We thank the students from the various islands of the Caribbeanwho voluntarily participated in this study. We particularly thank thereviewers for their guidance and suggestions.

Correspondence may be sent to Stella Williams, University of theWest Indies, Faculty of Medical Sciences—Center for Medical ScienceEducation, Eric Williams Medical Sciences Complex Eastern MainRoad, Champs Fleurs, Port of Spain, Trinidad and Tobago. E-mail:stella.williams@sta.uwi.edu

dress new cultural challenges in the classroom.1–10 Out of thediscourse arise terms such as multicultural/intercultural educa-tion,11,12 culturally relevant pedagogy,13 and social justice.12,14

These challenges are not particular to large Western countries.They surface in the Caribbean region as well, as our experienceat the Faculty of Medical Sciences (FMS) in the University ofthe West Indies (UWI), Trinidad, demonstrates. Our experienceof cultural diversity, however, and the problems it generates, isnotably different. This is because these challenges emerge in acountry that has historically experienced the tensions of multi-culturalism. In Trinidad and Tobago, diversity—with its accom-panying intercultural awareness and dialogue—is normative.Our attitude to the challenges of diversity is therefore differentfrom that of countries that are only now experiencing the so-ciocultural and political impacts of multiculturalism. It is basedon our own experience of diversity. This article concentrates onthe changes made to the pedagogy of a medical communicationprogramme to meet the needs of a diverse Caribbean studentsetting. These changes were developed out of a Caribbean in-terpretation of culturally relevant pedagogy (CRP).13

TRINIDAD AND THE UWIThe cultural backdrop of this research is a Caribbean island

with a colonial history that brought people of Amerindian, Span-ish, French, African, English, Portuguese, Syrian, Lebanese,East and South Asian, South American, and mixed heritages to-gether.15–18 The culture that exists today reflects a syncretism ofelements from different beginnings, but this is not without ten-sions. Since gaining independence in 1962, the different ethnicgroups in Trinidad have been involved in sustained interculturaldialogue to come to terms with their multicultural heritage.19

Trinidadians thus live in a space of constant cultural dialogueand negotiation, where symbols of difference, and actively man-aging difference, are normative.20,21 This situation is unlike that

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in larger Western nations that are only now grappling with theimpact of mass immigration and out of which new cultural ap-proaches to health communication are emerging.21

In 1995, the FMS Trinidad introduced two health communi-cation courses to train Caribbean medical students to commu-nicate confidently across a range of medical situations. Lack-ing in health communication resources of its own, the healthcommunication program drew heavily from international re-search and accepted practice. Experience with the materials,however, showed that international practice did not always fitlocal/regional cultural expectations.

The doctor–patient interview is the foundation upon whichmedical communication skills are taught in the program. TheCalgary–Cambridge Guide to the medical interview22 is taughtas the preferred practitioner/patient interviewing technique, asit combines several antecedent interviewing models. Concep-tualized and tested in the West, the nonverbal elements of theCalgary–Cambridge Guide were not always well received inour multicultural, majority non-Western, classroom. Studentsobserved to the lecturer and course tutors that the steps putforward by the guide were not always compatible with theirindividual cultures. The behavioral expectations of doctors andpatients in different territories differed so much with the tech-niques advanced in the guide that many students could not rec-oncile the gap between the theory and what they knew fromexperience would work in their individual territories. Studentsare also required to demonstrate these skills individually or ingroups for assessment. This produced an even greater problem,as students not only studied concepts that were at odds with theircultural beliefs but were asked to practice them as well. This,we noted, reduced many students’ confidence in the courses.

OBJECTIVESAgainst this background, the present research was under-

taken (a) to investigate Caribbean medical students’ culturalperspectives on the nonverbal communication skills taught inclassrooms and (b) to use the findings to improve the deliveryof communication skills courses.

RESEARCH LANDSCAPECultural competence in healthcare is receiving considerable

attention in the literature. As higher education classrooms arechanging internationally, so too are the healthcare settings inwhich students are expected to work when they graduate.23,24

Healthcare professionals increasingly recognize that they needa variety of culturally specific communication skills if they areto function effectively in their new, increasingly global prac-tices.24,25 This contributes feelings of uncertainty and disem-powerment among many practitioners who are unsure abouthow to face patients from diverse backgrounds.25 Training stu-dents in delivering culturally competent care, it is argued, shouldhelp practitioners to address their uncertainty about intercul-tural communicative situations and to perform more effectivelyin their future practice.26 These international issues underscore

the need to teach culturally competent communication skills tofuture health professionals.

There is also a clear and growing ethnic/racial disparity inheathcare abroad. Patients from minority, particularly immi-grant cultures are not receiving the kinds and quality of health-care that is delivered to majority groups.27–29 This disparity mayextend “from the inability of a health provider to offer culturallyappropriate health care services to multiethnic patients basedon cultural and linguistic barriers” (para. 4).29 In fact, linguis-tic barriers to healthcare figure particularly in the literature onthe growing ethnic/racial disparity in health care in the UnitedStates.30–36

As the Caribbean region is so culturally diverse, it is im-portant that students leave medical school with the tools andskills that would help them to perform capably in their homecountries.26,37 This requires “a close match between societaldemands and needs, and the curriculum” (para. 1).37 Tertiarylevel teaching and the curriculum must ultimately aim to matchreal-world practice as far as possible. Calls for improved at-tention to cultural issues in health professionals’ education anduniversity training must therefore be met with conviction andcommitment.29,38,39

Where medical classes are nationally and culturally diverse,pedagogy takes on an even more pivotal role. In response to in-creasing population diversity in the United States, United King-dom, and Canada, literature on incorporating cultural diversitytraining in medical education has been steadily on the rise.40,41

The approach that we take, CRP, does not appear to have a sig-nificant role within this growing discourse. Other approaches tointercultural medical education have been discussed, but these“lack conceptual clarity” (p. 198).42 In some cases, diversitytraining is treated as “a curricular ‘add-on”’ rather than “be-ing thoughtfully and thoroughly integrated into medical edu-cation curricula” (pp. 1178–1179).43 As these approaches havebeen developed in response to rising multiculturalism/diversityin large Western nations, they do not fit our context. In heranalysis of approaches to “cross-cultural” undergraduate medi-cal education in North America, Reitmanova presented two di-rections from which cross-cultural medical education has beentreated—cultural competence and critical culturalism.42 The for-mer concentrates on building cultural awareness and sensitivityin students, whereas the latter is concerned with being criti-cal about and questioning the impact of diversity on medicalcare. What is still missing in her analysis is a focus on teachingcultural content to a culturally diverse student body—none ofwhom are part of any dominant culture. This is where the currentresearch is located.

CRP plays a crucial role in many educators’ general profes-sional development.13,44–46 However, we cannot find any appli-cation of the perspective in medical education. CRP

uses student culture in order to maintain it and to transcend thenegative effects of the dominant culture. The negative effects arebrought about, for example, by not seeing one’s history, culture orbackground represented in textbook or curriculum. . . . It is a ped-agogy that empowers students intellectually, socially, emotionally,

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and politically by using cultural referents to impart knowledge, skills,and attitudes. These cultural referents . . . are aspects of the curricu-lum in their own right. (pp. 17–18)47

CRP was devised to give voice and cultural expression to BlackAmerican students within a White-dominated curriculum to helpthem succeed in an educational system that marginalized them.This idea cannot be directly transplanted into a Trinidad-baseduniversity where there is no clear dominant culture directingthe curriculum. However, with its focus on the students’ ownexperiences as legitimate aspects of the curriculum, CRP hasa lot to offer our Caribbean context. Regional lecturers havea duty to build and deliver a curriculum that is reflective andrespectful of students’ vast cultural experience, and CRP can goa long way in facilitating this process.

The Calgary–Cambridge Guide22 recognizes 10 facets ofnonverbal communication in the doctor–patient interview: pos-ture, proximity, touch, body movement, facial expression, eyebehavior, vocal cues, use of time, physical presence, and envi-ronmental cues. Despite efforts to combine global norms for thedoctor–patient interview, the Calgary–Cambridge guide bearsfew references to cultural awareness. Step 66 (of 71) advisesstudents to take the “patient’s lifestyle, beliefs, cultural back-ground, and abilities into consideration” when communicatingwith them (p. 193). The authors also discuss cultural and socialdiversity in a brief section at the end of the text (pp. 215–221),but their treatment of the issue suggests that there is a standard(normative) procedure for the medical interview to which ad-justments can be made in intercultural circumstances.22 Cultureseems peripheral to the guide. The model also does not provideexplanations or guidelines on how the interview can be usedflexibly given a patient’s background, nor does it adequatelydiscuss how deeply culture is embedded in the doctor–patientinterview. Indeed, the guide was designed to help practitionersnavigate the doctor–patient interview. Culture is problematized,but addressing the complexities of the problem is not the objec-tive of the guide.

METHODOLOGYQualitative approaches were adopted to realize the objectives.

This was because we wished to understand the cultural mean-ings of the nonverbal practices for the students. Focus groupdiscussion (FGD) with the students was used to generate thedata. The focus group sessions were designed to facilitate stu-dent reflection and discourse through “an open situation, havinggreater flexibility and freedom” (p. 273).48

Two compulsory communication skills courses, Communi-cation Skills for Health Personnel and Communication Skillsfor the Health Professions, are offered to all 1st-year students atthe Faculty of Medical Sciences. The students of Class 2007–08were the target population of the present research (Table 1 andFigure 1). Out of the total 398 student intake, 45 Caribbeanstudents were randomly selected using their country of originas a parameter. The selected students were asked to take part inthe study via their student e-mail account. Of the 45 contacted,

TABLE 1Frequency and corresponding percentage of students fromdifferent countries at Faculty of Medical Sciences in the

University of the West Indies St. Augustine in the Year 1 forthe academic year 2007—08

Countries of Origin Frequency %

Barbados 31 7.8Bahamas 14 3.5Botswana 9 2.3British Virgin Islands 1 0.3Belize 2 0.5Dominica 7 1.8Grenada 1 0.3Jamaica 8 2.0Montserrat 2 0.5St. Lucia 3 0.8St. Vincent & the Grenadines 2 0.5Turks & Caicos 1 0.3Trinidad & Tobago 317 79.6Total 398 100.0

36 (80%) students responded positively. These 36 students, rep-resenting different Caribbean islands (Table 2), participated infour independent, 30-min FGD sessions, which took place onthe FMS campus over a 2-week period. The FGD sessions werescheduled based on the students’ availability and willingness toattend the interview sessions.

From the 36 students, nine were randomly assigned to eachof four independent FGD sessions.49 Each focus group sessionwas videotaped and conducted by a trained student moderator.The researchers attended each session at the beginning to brief

FIG. 1. Pie diagram showing percentage of students from different countries.(Color figure available online).

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TABLE 2Frequency of students selected from different countries at Faculty of Medical Sciences in the University of the West Indies

St. Augustine in the academic year 2007–08 for the FGD

St. Vincent & Trinidad &Countries Bahamas Barbados Belize Dominica Grenada Jamaica the Grenadines Tobago Total

Students Selectedfor Focus GroupDiscussion

3 5 1 2 1 3 2 19 36

the students on the purpose of their study and to formally acquireconsent.

Focus groups were guided by questions raised from a listof the 10 nonverbal skills of posture; proximity; touch; bodymovement, including gestures; facial expression; eye behavior;vocal cues, including accent; use of time; physical presence; andenvironment, endorsed by the Calgary–Cambridge Guide.22 Ateach session a definition of each skill was explained to students,and they were each given a copy of the FGD questions that wereto be discussed (Table 3). The participants were asked to discussif and/or how each was used in their own country with regard tothe doctor–patient interview.

All course participants were aware of the importance of non-verbal skills in the doctor–patient encounter as prescribed inthe theories detailed in their course manuals and practiced inindividual, pair, and group role-play sessions. Moreover, defi-nitions, explanations, and metrics relevant to their assignmentswere detailed in their course manuals.

The four discussion sessions were first transcribed. Eachresearcher then coded the transcriptions separately. We clus-tered units of relevant meaning, determined themes from clus-ters, summarized themes, and then met to compare findings.We merged all the findings into spreadsheets and then col-laboratively abstracted and reduced the data. We interrogated

TABLE 3Questions for focus group discussion (FGD)

Cultural Barriers to Implementing Nonverbal Skills in the Caribbean Health Communication Classroom

Five groups of students were asked to attend FGD. The following questions guided the FGD.

1. Occulesics (eye behavior, eye contact, gaze and staring) are considerably important in the doctor–patient interview. How dothe suggested techniques for effective eye behavior identified by western theorists affect your cultural sense of comfort?(Example – establish and maintain eye contact . . . )

2. Proxemics – another aspect of nonverbal communication taught in class – how do you value your personal space – what isyour view of the models taught? (Example – decrease horizontal and vertical space . . . )

3. Haptics – touch – non invasive touch (touch on knee, elbow) or hugs are part of the nonverbal model of doctor/patientcommunication – how do your cultural norms respond to this?

4. Kinesics – body language (body movements—hand and arm, gestures, fidgeting, nodding, foot and leg movements—andfacial expressions: raised eyebrows, frown, smile and crying)—has also been identified as an important nonverbal skill indoctor-patient encounters. To what extent are Caribbean cultural norms affected by suggested theories on kinesics?

5. Vocalics – voice qualities (includes accents, speech errors, silence, loudness, pitch, tempo, cadence, rate of speech, nasalityand tone) are also suggested as appropriate communication strategies. How do these suggested techniques affect oralcommunication styles in the Caribbean?

6. The effective us of Chronemics – use of time: early, late, on time, over time, rushed, slow to respond) is also identified as animportant strategy in the doctor–patient interview. To what extent to cultural norms in the Caribbean affect the use of timesuggested by Western theories?

7. To what extent does appearance (gender, body shape, clothing, grooming, race) impact on doctor–patient communicationencounters in the Caribbean?

8. To what extent does environment (location, furniture placement, lighting, temperature and colour) impact on doctor–patientcommunication encounters in the Caribbean?

9. Considering all aspects of nonverbal communication – to what extent do you have a problem/s with any items listed in thewestern model taught in class?

10. General comments on non verbal communication and how it affects your sense of comfort.

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expressions that were indecipherable or that generated con-flicting interpretations among the researchers by revisiting thevideotapes.

RESULTSAnalysis of videos and transcripts from the FGD supported

the view that aspects of the course material were in conflictwith expected nonverbal doctor–patient behavior in differentCaribbean territories. Students expressed cultural differenceswith all the nonverbal behavior discussed, particularly touch,proximity, eye contact, and accent. Many students consideredtouch, proximity, and eye contact as invasive actions that neededto be used with care in the doctor–patient encounter.

Barbadian students indicated that touch is considered a nec-essary part of the doctor–patient encounter. Students from theother islands, however, believed that this behavior should berestricted to task-oriented touching only. In Trinidad and To-bago the results were mixed. For Muslims and some Hindus, allforms of touch needed to be carefully regulated. Some Muslimwomen were not against shaking hands with a doctor. Accord-ing to Islamic law, a male doctor must not care for femalepatients; therefore, handshakes should occur only among fe-males. One Hindu female student stated that even task-orientedtouching is culturally determined as it is considered more ac-ceptable for her doctor to “sound” her from the back and notthe front of her body. Several Jamaicans iterated that male–maletouching is heavily regulated in their country. This extends todoctor–patient encounters as well where no male–male nontasktouching is expected. Overall, touch was considered “a touchyissue” (Bahamian student), firmly dictated by the cultural mean-ings associated with gender and age.

Proximity and eye contact received similar responses. Manycultures in the Caribbean show deep respect for the elderly ofthe community. Although international practice embraces eyecontact as relationship forming, in communities such as thosein Tobago, for example, it is considered disrespectful to lookinto the eyes of an elder, male or female. A doctor makingeye contact with an elderly patient as a symbol of respect orreassurance would be deeply misunderstood in this territory.Further, in some territories such as the Bahamas and Jamaica,students indicated that closer proximities are considered inva-sive rather than reassuring, and therefore care must be takenwhen using this nonverbal skill in the doctor–patient interview.These findings were in stark contrast to the methods embracedby the Calgary–Cambridge Guide, which informed the curricu-lum, widening the gap between classroom teaching and expectedpractice.

Language surfaced as an important theme in three of thediscussion sessions. The issue emerged out of the discussion onaccent. These data proved significant for the changes we eventu-ally made to the course. In line with accepted academic standardsat the UWI, students are cautioned against using their local Cre-ole for class presentations and assignments. Respondents from

different islands, however, showed different perspectives on theuse of Standard English in professional circumstances. SomeBarbadians and Jamaicans preferred the use of a more standardversion, as this, they said, was generally expected of medicalprofessionals in their country. Others preferred to use an ac-ceptable local version of English. The Trinidadian students inparticular unanimously stressed that they preferred to use anappropriate version of the local Creole in health contexts ratherthan Standard English. This was in line with a trend that haddeveloped during class sessions where regional students hadbegun to use their local language in class simulations and pre-sentations.

IMPLEMENTATIONThe findings prompted gradual changes to the course. As we

stated earlier, our experience of cultural diversity in Trinidadand Tobago framed our approach to diversity in the classroom.Difference is now the central concept governing our teach-ing; difference (and building an awareness of and sensitivity tothat difference) is the standard—it is not treated as an adjustmentto accepted practice. Although we initially focused on nonver-bal behavior, the analysis showed that the course as a wholeneeded to have a more intercultural perspective to reflect andtend to the students’ needs. Increasing intra- and interculturalhealth communication competence emerged as our main goal intaking the course forward. In this article, cultural competencerefers to “a set of congruent behaviours, attitudes, and policiesthat come together in a system, agency, or among professionalsthat enables effective work in cross-cultural situations.”50 At thecore of the modified course design is a perspective that con-siders flexibility to cultural differences as the standard, not anadjustment to an accepted theoretical standard or model.

Two main issues surfaced as central to developing flexibilityas the behavioral norm in the doctor–patient interview. Thesewere cultural awareness and cultural sensitivity. Together theseconcepts laid the groundwork for the new, modified curricu-lum and our pedagogy. Promoting sustained intercultural dis-course in the classroom emerged as the most productive meansof achieving our goals. What follows is an account of the alter-ations that have been made to the health communication coursesat the FMS to promote cultural sensitivity and awareness at alllevels of the doctor–patient encounter and in our teaching.

Previously, we perceived the course material as acceptedpractice; class discussions and examinations were geared to-ward helping students understand and reach that standard. In-tercultural discussion was an addendum in that approach, anadjustment to an accepted standard. Our perspective has sincechanged, and we are now using the published material as a stim-ulus for intercultural dialogue. By “dialogue,” we mean that weare complementing tutorial discussions with collaborative andengaging explorations of the cultural dimensions of the coursematerial. These explorative exchanges are meant to be reflectiveand integrative, with the aim of building group understanding

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and awareness.51,52 The cumulative knowledge gained from thissustained dialogue is embraced as valuable course material, notsimply supplementary information.47 This is what distinguishesour perspective from the “embracing diversity for diversity’ssake”5,53 approach taken by many higher education institutionsembarking on internationalization. As Lee argued, dialogue en-courages critical and independent thinking and better preparesstudents for the rigorous demands of a global society.5

Adjustments to the delivery of the course have focused onthe sharing of cultural norms. A “cultural session” at the startof the semester was initiated with international students fromBotswana, along with volunteers from other Caribbean islands(namely, the Bahamas, Barbados, Belize, Jamaica, St. Vincent& the Grenadines, and St. Lucia) who shared aspects of oneanother’s cultures with the Health Communication class. Thestudents were also invited to share aspects of Trinidadian (host)culture that were unusual to them. Students from India, Canada,and the United States also joined in the discussion. This ex-change served as an eye-opener to the Trinidadian students,who were able to see themselves as others saw them. It alsoestablished intercultural understanding among the different cul-tures in the classroom and helped our students to become moreculturally conscious, an awareness we hope to fuel throughoutthe Health Communication program.

As of 2009 all health communication lectures are deliveredonline. These are complemented by small, face-to-face groupworkshops. The administrative move from face-to-face to onlinelectures provided us with the tools we required to increase dia-logue in the classroom. Significantly, we were able to increasethe mandatory weekly workshops from 1 to 2 hours per week.Workshops provide the ideal space for intercultural dialogue asthey take place in smaller, conversation-friendly rooms consist-ing of small groups of 18 to 20 (maximum) students from differ-ent medical disciplines and countries. Originally an encouragingspace for discussing and understanding lecture concepts throughcases, workshops now extend their function to initiate and man-age intercultural dialogue around lecture concepts, cases, andvisual material such as photographs, film clips, newspaper andjournal articles, and cartoons. Facilitated by tutors, these ses-sions currently look at if/how the material can be adjusted towork in the different societies represented in the class. Tutorsnow sensitize students to the ways in which age, gender, family,and kinship, as well as issues of respect and disrespect, are in-terpreted by different societies, encouraging students to exerciseflexibility in their medical practice. Students are encouraged toengage in cultural dialogue that extends and applies their knowl-edge in practical, real-world contexts. The course material hasbecome deeply enriched through these cultural exchanges.

The university’s online learning environment, Moodle, alsobecame important to the dialogue. Up-to-date reading materi-als and medical news stories are now directed to the studentsthrough Moodle. Students are invited to openly question and dis-cuss these readings on Moodle and in their workshops. Further,significant issues that are raised in individual workshops are now

shared with the entire cohort online, ensuring that everyone ben-efits from workshop discussions and has an opportunity to addto the dialogue. Readings and ideas that surface in individualworkshops are also disseminated to the class through Moodle.

The problem-based learning cases that were used to informworkshop discussions have also been modified. Existing caseswere interrogated for cultural bias or insensitivity. Those thatwere considered insensitive were removed, and those with aclear cultural bias were actively analysed in workshops. Wehave also added several new cases in which cultural differenceform the nucleus of escalating problems between the medicalprofessional and the patient. These highlight the implicationsof cultural insensitivity in the medical encounter. We have alsointroduced a module on cultural diversity to heighten awarenessand sensitivity to cultural issues in health contexts.

Trinidadian Creole and other regional Creoles seem to begaining ground as the language of choice in some professionalsituations. The Trinidadian students’ preference for varieties ofthe local Creole is supported in the literature.54–58 Youssef notedthat in Trinidad and Tobago, “people mix varieties includingsome Creole with the Standard . . . producing a blended vari-ety which captures the appropriate level for specific situations”(p. 42).55 Guided by this finding, we are now allowing studentsto express themselves in Creole in class discussions and patientsimulations if they think it is appropriate to the situation. In thisway, the knowledge generated through dialogue and simulationswill bear a closer resemblance to expected real-world practice.By sharing that knowledge with the class, the students’ culturalawareness is increased.

Not only are we encouraging the use of local Creoles indiscussions and simulations but grading rubrics have been re-constructed to facilitate the use of multiple varieties and flexibleoral delivery styles. In the past, simulated assignments and for-mal oral presentations were graded according to Western publicspeaking standards. With respect to delivery of presentations,grades were awarded for appropriate and skilful use of eyecontact, voice, body language, facial expressions, appearance,and posture.59 Definitions and components of effective delivery,however, are culture bound. Therefore, we are now committed todemonstrating sensitivity to these differences in our grading andmarking rubrics. Adjustments to the rubrics now reflect a holis-tic mark that takes differences into consideration. Issues suchas tone, accent, loudness, tempo, pitch, cadence, rate of speech,and nasality are now treated as cultural conditions of effec-tive presentation skills and are graded taking students’ languagebackground and the context of the presentation into account.Grades are distributed based on the overall effectiveness of thepresentation in the context in which it is set.

Students in the 2008–2009 class noted an element of ho-mophobia in the cohort and requested that the topic be givengreater attention in the course. The course manual now exposesstudents to lesbian, gay, bisexual, and transsexual (LGBT) issuesin health communication from a Caribbean context, and we en-courage discussion on LGBT considerations from the students.

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The emphasis is on delivering professional, quality healthcareto all patients and clients, and being respectful to all colleagues,regardless of their background. The students who suggested theamendment also requested that a guest lecturer be invited toinform 1st-year students about LGBT issues. We hope to fulfilthis in the future.

CONCLUSIONStudent feedback on the cultural relevance of an internation-

ally based curriculum informed changes we made to teachingcommunication skills to a diversified, multicultural class of med-ical students in Trinidad until the time of writing, at the end ofthe 2009–2010 academic year. We hope our experience will giveeducators the confidence to make adjustments to match their cul-tural needs—and comfort in knowing that communication skillscan be a cultural challenge. The changes we made to our cur-riculum can form the basis for thinking around the applicabilityof culturally relevant pedagogy in medical education, not just inthe Caribbean, but internationally, in countries now facing thetremendous challenges of mass immigration.

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