Received: 26 August 2020 | Revised: 14 January 2021
DOI: 10.1111/medu.14464
M E D I C A L E D U C AT I O N I N R E V I E W
Invoking culture in medical education research: A critical
review and metaphor analysis
Margaret Bearman1 | Paige Mahoney1 | Joanna Tai1
Christopher Watling4
1
Centre for Research in Assessment
and Digital Learning (CRADLE), Deakin
University, Melbourne, Vic., Australia
2
School of Clinical Sciences at Monash
Health, Monash University, Melbourne, Vic.,
Australia
3
Department of Anaesthesia and
Perioperative Medicine, Monash Health,
Melbourne, Vic., Australia
4
Centre for Education Research and
Innovation, Schulich School of Medicine and
Dentistry, Western University, London, ON,
Canada
Correspondence
Margaret Bearman, Centre for Research in
Assessment and Digital Learning (CRADLE),
Deakin University, Melbourne, Vic.,
Australia.
Email: margaret.bearman@deakin.edu.au
© 2021 John Wiley & Sons Ltd and The Association for the Study of Medical Education
Medical Education. 2021;55:903–911. 
| Accepted: 28 January 2021
| Damian Castanelli1,2,3 |
Abstract
Introduction: ‘Culture’ is a word frequently invoked within medical education litera-
ture to explain challenges faced by learners in practice. While social settings and
practices are widely acknowledged as critical influences on medical education, there
is vast variability in how the term ‘culture’ is employed. This may lead to confusion,
resulting in assumptions and oversights.
Objective: This critical literature review aims to characterise how the term ‘culture’ is
explicitly and implicitly conceptualised in medical education research.
Methods: Four leading English language journals in the medical education field were
searched in a twelve-­month period for research papers or reviews that mentioned
culture in title or abstract in a substantive way. A content analysis was undertaken of
extracted definitions. In addition, metaphor analysis was used to identify conceptual
metaphors, which were subsequently clustered thematically.
Results: Our search yielded 26 papers, 8 of which contained definitions, mostly from
the organisational literature. We interpreted nine conceptual metaphors related to
how the term culture was employed (terroir, divider, dominant force, toxic force, ob-
stacle, microclimate, object, brand and holdall) in four categories (unchanging, pow-
erful, can adapt around, can be used).
Discussion: This critical review reveals that medical education as a field: 1) draws
most explicitly from the organisational literature; 2) invokes culture in multiple means
but in ways that privilege either acontextual human agency or all-­powerful social
forces; and 3) regards culture as a negative or neutral force but rarely a positive one.
There is a notable absence around conceptualisations of 'culture' that allow educa-
tor, student and administrator agency but at the same time acknowledge the deep
forces that various social settings and practices exert. Other literatures investigating
learning cultures and cultural reflexivity focus on this nexus and may provide possible
means to advance considerations of culture within medical education research.
wileyonlinelibrary.com/journal/medu | 903
904 | BEARMAN et al.
1 | I NTRO D U C TI O N
Medical education researchers often invoke the term ‘culture’ to
better illuminate challenges in medical education that cannot be
adequately understood through the lens of the individual learner.
Social settings and practices are widely acknowledged to pow-
erfully impact both what and how health professionals learn.
Accordingly, culture is increasingly referenced, mythologised and
blamed within the medical education literature. While culture
has been studied and conceptualised within many different aca-
1
demic traditions, references to culture within medical education
research tend to be ill-­d efined, if defined at all. This means the
term ‘culture’ may conflate or confuse a range of abstract con-
cepts. Discussions invoking culture may therefore obscure as
much as they illuminate, complicating attempts to foster either
learner adaptation or system-­wide change. Understanding of the
range of ways that the term ‘culture’ is employed in the literature
is presently lacking. As the word is already invested with complex
and overlapping meanings, medical education researchers need a
means of understanding culture without reducing the word to a
single and possibly simplistic definition. Without this, researchers
may find themselves misunderstanding each other's work, unable
to advance the field. By investigating the ways in which medical
education researchers both implicitly employ and explicitly define
‘culture’, we hold a mirror up to our field's practices, revealing as-
sumptions, successes and oversights.
Culture is one of those challenging terms, like engagement, 2-­4
which has multiple and diffuse research traditions, but also gen-
eral meaning as a lay concept. For example, an organisational
scholar might see culture as assumptions, beliefs and values linked
to a particular institution while an identity theorist may consider
culture bounded by the social group, not the specific setting.1
Understanding how these terms are explicitly defined is an import-
ant first step. However, authors tend not to directly define ‘culture’
and so, when they refer to ‘surgical culture’, ‘institutional culture’ or
‘bringing about culture change’, it can be difficult to precisely de-
termine what is meant. Clearly, this can lead to confusion. How this
confusion might be avoided is less obvious.
More definitions may not necessarily bring more clarity. ‘Culture’
as a concept comes with deep ontic and epistemic associations,
which may be more tacit than explicit. A balance should be struck
between the need for a shared understanding with the need to ac-
commodate the use of a term often employed loosely and described
divergently in a range of theoretical traditions.
Metaphors may provide a useful orientation to the assumptions
that underpin the use of the word ‘culture’. Metaphors serve to make
5
abstract concepts more concrete. For example, the commonly used
metaphoric expression LIFE IS A JOURNEY captures a sense that liv-
ing is about moving through constantly changing environments. This
pairs with what Lakoff and Johnson term a conceptual metaphor,
LIFE IS TRAVELLING, which captures both the abstract and con-
crete conceptualisations. The predominance of this conceptual met-
aphor is indicated by an associated ‘coherent system of metaphorical
expressions’; thus, LIFE IS TRAVELLING entails metaphoric expres-
sions such as CARRYING BAGGAGE or MISSING THE BOAT.
Metaphor analysis has been previously used in medical educa-
tion to identify underlying conceptions of phenomena. For exam-
ple in Rees, Knight and Cleland's work,6 the conceptual metaphor
ASSESSMENT RELATIONSHIPS AS WAR was derived from inter-
preting metaphoric expressions such as ‘Do I want to be the one that
fires that bullet and stops them?’ (p 460) and ‘You should have just
hit me with it, you should have smacked me in the face with it’ (p. 460).
Schmitt7 notes that metaphor analysis can be useful to ‘bring the use
of metaphors and the practices associated with this to the conscious
level’ (p. 360). By highlighting the metaphors associated with the
term ‘culture’ within the medical education literature, researchers
and practitioners can debate the value of various understandings
of culture within medical education, complementing the explicit de-
scriptions found in definitions.
This literature review undertakes a critical examination of the
literature, exploring explicit definitions of culture and implicit con-
ceptualisations through metaphor analysis. The overall objective is
to characterise how the term ‘culture’ is employed in the medical
education literature. Through this, we seek to develop a nuanced
vocabulary to inform how culture is discussed and debated within
the medical education literature.
2 | M E TH O DS
2.1 | Overview
This is a critical analysis of the recent literature, similar to McGrath
et al’s review, which examined the use of the term ‘community of
practice’,8 or Brown et al’s9 examination of how learning theory is
employed in general practice literature. It seeks to describe how cul-
ture is invoked. The metaphor analysis was conducted using Schmitt's
systematic approach7 to deriving ‘collective metaphorical models’.
Our dataset was those metaphoric expressions that have entailment
relationships with the term ‘culture’. As Schmitt suggests,7 research-
ers group metaphoric language under more abstract metaphorical
concepts, using the phrasing ‘culture is …’, until all metaphors are
listed under a concept. In this way, underlying abstract conceptuali-
sations are surfaced through their concrete manifestations.
2.2 | Sample
As with other critical analyses,8,9 we have used a systematic search
strategy focused within key medical education journals. We chose a
recent 12-­month period to ensure we were reviewing contemporary
literature that would adequately reflect current conceptualisations
of culture. The four journals we have selected are all English lan-
guage and represent the highest impact factors in the field: Medical
Education, Academic Medicine, Medical Teacher and Advances in
Health Sciences Education (AHSE). When determining this sample, we
BEARMAN et al.
noted that these reflected a range of research approaches. Academic
Medicine represents the North American tradition, while the other
journals are more European or international in scope. Medical Teacher
is a more practical journal; Advances in Health Sciences Education
has a broader health professional/health sciences authorship. We
searched within these using EbscoHost and MEDLINE Complete,
with the following inclusion criteria: (a) the term ‘cultur*’ appears in
the title and/or abstract with the exclusion of the term ‘sociocul-
tural’ due to its specific associations with learning theory; (b) papers
were published in the twelve months from June 2018 to June 2019,
including early online; and (c) papers report on empirical research or
reviews, excluding editorials and commentaries.
The initial search yielded 69 papers. These were reviewed against
an extraction framework that located culture within each paper, in-
cluding a section on how culture was employed within the paper. As
culture is a lay term and can therefore be mentioned without being
a core concern of the research, we identified peripheral or tokenistic
references and excluded them.
2.3 | Content analysis of definitions
We extracted definitions of culture or types of culture from the pa-
pers and analysed these for common terms, as well as similarities and
differences in meaning.
2.4 | Metaphor analysis
7 5
We drew from both Schmitt's and Lakoff and Johnson's founda-
tional work to frame our metaphor analysis. We employed the fol-
lowing concepts and definitions:
• Conceptual metaphor: the underlying conceptual abstraction that
helps make sense of the phenomenon.
• Expressive metaphor: the metaphoric language used to allude to a
conceptual abstraction.
• Entailments: expressive metaphors associated with an overarching
conceptual metaphor.
Each of the team members coded five papers to interpret how
culture was metaphorically positioned with the papers, producing
an initial list of conceptual metaphors using an extraction template.
Two authors (MB & PM) thematically collated these into an initial
list of nine overarching conceptual metaphors, which were dis-
cussed and reviewed by the full team. The team then coded at least
five papers each for the presence of these metaphors, followed by
comprehensive discussion of methods. Identifying conceptual met-
aphors based primarily on their entailments was chosen as the pre-
ferred way forward (see the results section for an example of this
process). All papers were then coded by MB and PM, and the full
team discussed, reviewed and finalised the list of metaphors. The
names of the conceptual metaphors were reviewed and debated;
| 905
we sought terms that would be readily understood internationally.
At this final stage, we observed thematic similarities between met-
aphors and categorised them accordingly. This extensive iterative
consensus-­building process was informed by our diverse intellectual
backgrounds: three medically qualified (CW, DC and JT), two prac-
tising clinicians (CW and DC) and three predominantly educational
researchers (MB, JT and PM).
3 | R E S U LT S
3.1 | Description of papers
Twenty-­six papers were included in the final yield, investigating
diverse phenomena including palliative care, medical student ex-
change programs and work-­based assessment. See Table S1 for
further details. They used a range of methods: qualitative (12); quan-
titative (8), mixed methods (3) or review (3). The empirical studies
were set in diverse locations: Canada (7), USA (5), cross-­national, in-
cluding literature reviews (5), Australia (1), Italy (1), Netherlands (1),
South Korea (1), Switzerland (1) and UK (1).
3.2 | Definitions
Eight papers explicitly defined culture or similar (eg learning culture)
as described in Table 1. Almost all of these appeared to derive pre-
dominantly from the organisational literature, and this was reflected
by overt and implied references to organisations or institutions.
Almost all papers made explicit reference to culture being located
within a particular setting such as institution or context, although
Mulder et al10 distinguished between an overarching professional
culture, which existed across settings, and a microculture, which
was located in a particular environment. The organisational deriva-
tion of the definitions was also reflected in the many shared terms
that described components of culture. These included references
to: behaviours (5), values (5), norms (4), beliefs (3), assumptions (3),
attitudes (3) and practices (2). Five papers had a specific subfocus:
learning (2), assessment (1), racism (1) and professions (1). Three pa-
pers made reference to the implicit or tacit nature of culture or some
elements of it.
3.3 | Metaphors
We interpreted nine dominant metaphors through focusing on the
entailments. Table 2 lists the metaphors, with illustrations of associ-
ated entailments from the text. To provide more insight into how this
table was developed, we provide an example of how we derived a
conceptual metaphor from the expressive metaphors, which formed
its entailments.
The first step towards deriving the metaphor CULTURE IS
TERROIR was noticing that a number of expressive metaphors
906 | BEARMAN et al.

TA B L E 1 Definitions of culture within the collected literature

Culture is part
Paper Definition(s) of … Particular focus Key components
11
Gupta et al ‘Culture is defined as a system of shared Environment/ General Shared assumptions, values,
assumptions, values, beliefs, and norms existing context beliefs and norms
within an environment’. (p.7)
Blouin et al12 ‘Culture: The set of shared attitudes, values, goals, Institution/ General Shared attitudes, values,
and practices that characterises an institution or organisation goals and practices
organisation’ (source: OED) (p. 666)
Griffiths et al13 ‘For the purpose of this paper, assessment culture is Institution/ Assessment Attitudes, behaviours and
defined as the attitudes, behaviors, and beliefs of organisation culture beliefs
individuals within an institution that support “the
assessment of student learning outcomes” (Weiner
2009)’. (p. 812)
Jackson et al14 ‘Norms, values, and basic assumptions that govern Unclear General Norms, values and basic
daily operations’ (p. 170) assumptions
Mulder et al10 ‘[…] the set of implicit messages about values, Profession General and also Values, norms, attitudes and
norms, and attitudes that learners infer from professional behaviours -­implicit
the behavior of individual role models as well culture/
as from group dynamics, processes, rituals, and microculture
structures […] These values, norms, attitudes, and
related behaviors can be summarized as “culture”’
(p. 36)
‘According to Champy, specific versions of a
professional culture result from collective problem
solving when groups face contradictions and
tensions between underlying professional values.
We use the term “professional microculture” to
refer to such specific versions of a professional
culture’. (p. 37)
Phelan et al15 ‘Manifestations of racism in medical school Institution/ General and also Informal norms and observed
culture and climate. These variables represented organisation racism behaviours
informal norms and observed behaviors (ie,
hidden curriculum) that indicate the “climate” of
the organization and how race and racial equity
are discussed and understood among faculty and
students’. (p. 1180)
Ramani et al16 ‘Organizational culture refers to the beliefs of Institution/ General and also Assumptions, beliefs, explicit
a community, which guide their perceptions organisation learning culture values, visible behaviours;
and behavior. Schein described three levels of shared beliefs practices and
culture that influence organizational behavior: values.
assumptions and beliefs that form the foundation
of the culture (level 1), espoused values that
underscore the organization's purpose and desired
image (level 2), and visible day-­to-­day behavior,
which is often a compromise between stated
values and practical needs (level 3). Organizational
culture also interacts with identity (members’
feelings about their organizational mission) and
image (how the organization is viewed by others)
to direct community behaviour’. (p. 1348)
‘…a learning culture defined by Watling and
colleagues and Watling as the shared beliefs,
practices, and values that underpin how the
profession designs the education of its learners’
(p. 1348)
Shepherd ‘Learning cultures can be understood as the Environment/ Learning culture Practices, behaviours,
et al17 combination of practices, behaviors, attitudes, context attitudes, patterns
patterns of decision making, relationships, and of decision-­making,
valued systems of thought that form a particular relationships, systems of
learning context’ (p. 1160) thought
BEARMAN et al.
TA B L E 2 Metaphors interpreted from the collected literature
Category Metaphor Description
Unchanging Culture is terroir Culture ‘grows’—­it is organic,
particular and recognisable
Culture is a divider Culture separates people into
distinctive groups
Powerful (but not Culture is a dominant Culture ensures people abide
necessarily fixed) force by rules or established
norms and resistance is
difficult (or impossible)
Culture is a toxic Culture is a poisonous
force presence that spreads a
negative influence
Can adapt around Culture is an obstacle A force that looms large but
can be navigated around
Culture is Culture differs according to
microclimate location/context, but can be
learnt about, prepared for
and adjusted to
Can be used Culture is an object Culture is a kind of resource
that can be possessed,
controlled, compared,
qualified (‘poor or good’),
implemented, managed,
improved or doled out
Culture is a brand Culture is a label which can be
adopted or an aspirational
state
Culture is a holdall Culture is a convenient term
to contain a diverse range of
concepts. It can be tokenistic
| 907
Number of
papers Illustrations of entailments (added bold)
5 ‘...the surrounding culture within which a
physician grows has a significant impact on his
or her development’. (p.192)18
‘...the routines that they embed tend
to endure because they are deeply rooted in
professional culture’. (p.80) 19
5 ‘… which implies students’ cultural/ linguistic
differences alone impede their ability to meet
academic outcomes’. (p.692)20
‘Most participants highlighted surgical culture,
explicitly describing what it means to be a
surgeon and how some think surgeons fit
a particular mold. One Latino participant
commented: “Surgery is kind of clubby …”’
(p.1331)21
8 ‘If the dominant medical culture and way of
being a physician is through a curing or healing
role…’ (p.929)22
‘Culture [defined as] norms, values, and basic
assumptions that govern daily operations’
(p.170)14
9 ‘...medical culture may create toxic counter-­
pressures in the effort to build a more resilient
workforce’. (p.192)18
‘...current university cultures damaging
relationships, creating a loss of motivation, and
raising feelings of devalue’. (p.945)23
4 ‘The culture surrounding [post-­interview
communication] may be difficult to overcome
via guidelines alone...’ (p.1367)24
‘...a culture of “niceness” […] was perceived as
an impediment’ . (p.81)19
9 ‘...what was successful and deemed good
practice in one learning culture was not
necessarily the same in another culture’
(p.1161)17
‘...we operationalized professional microculture
as the result of a process of group coping with
different demands and their underlying values’.
(p.41)10
11 ‘...Kogan et al (2017) encourage establishing
a culture that invites learners to practice
authentically while being observed and to
welcome feedback’. (p.453)25
‘...recognise both professionally and culturally
appropriate (and inappropriate) behaviours and
make judgements about them’. (p.738)26
10 ‘...assessment culture is defined as the
attitudes, behaviors, and beliefs of
individuals within an institution that
support “the assessment of student learning
outcomes” …’ (p.812) 13
‘…the new culture must be lived…’ (p.451) 25
3 ‘…may be informed by local culture and religion –­
if these two can be separated at all’. (p.1297) 27
‘...delivery of critical content about race, culture,
structural inequalities, and health disparities
within a set of virtual patient cases...’ (p.550)28
908 | BEARMAN et al.
entailed with the term ‘culture’ were associated with plants. In
table 2, row 1, examples are given of words such as growing and
deeply rooted. These expressions also seemed to be linked to met-
aphoric notions of permanence such as embedded and enduring.
The overall sense associated with these expressive metaphors was
that this organic conception of culture was about being rooted in a
particular type of soil. Thus, we came to the overarching conceptual
metaphor CULTURE IS TERROIR and its associated definition: cul-
ture ‘grows’—­it is organic, particular and recognisable.
Once we derived all the overarching conceptual metaphors, we
then thematically clustered them into four categories, according to
the apparent implications of each metaphor. We noticed that some
metaphors implied that culture was constant and not possible to
change (terroir, divider); some implied that culture exerted power
over individuals (dominant force, toxic force); others suggested peo-
ple could adapt or navigate around culture (obstacle, microclimate);
and still others portrayed culture as malleable and could be used or
invoked (object, brand, holdall).
4 | D I S CU S S I O N
This critical review of the literature reveals the complexity of en-
gagement with the term ‘culture’. On the one hand, analysis of ex-
plicit definitions within a subset of eight articles reveals a strong
emphasis on culture as being about behaviours, values, norms, be-
liefs, assumptions and attitudes that are found within a particular
organisation or context. On the other hand, the metaphor analy-
sis reveals a much more complex view of how the term culture is
employed across all 26 papers. It suggests the underlying concep-
tions of the term ‘culture’ sit along a continuum: from culture as im-
moveable to culture as usable and malleable. This is reminiscent of
structure-­agency debates, the decades-­old argument about whether
social context or human agency is a predominant force driving social
behaviours. The metaphors that emphasise human agency are most
likely to treat culture as almost a-­contextual: objects, brands and
holdalls. At the other extreme, terroir is entirely context-­bound—­to
extend the metaphor, no other soil will grow produce that ‘tastes’
the same. The two other categories position culture as powerful but
navigable, albeit not necessarily changeable and with underlying
negative connotations. Overall, the four metaphors associated with
harmful effects (divider, dominant force, toxic force and obstacle) sit
towards the ‘immoveable’ end of the axis. The three metaphors that
are neutral in their effect (microclimate, object and holdall) are as-
sociated with greater human agency. The two metaphors that have
somewhat positive connotations (terroir and brand) are found at ei-
ther end of the continuum. The overall impression is that difficult to
shift cultures are viewed as harmful or problematic, while culture
as something that can be controlled or manoeuvred around is much
more benign.
As the definitional analysis suggests, the most coherent ex-
planations of culture within the review are found in those papers
that situate themselves in the organisational literature, which tends
to emphasise how humans can manipulate institutional cultures.
Increasingly, organisational scholars treat culture pragmatically, as
a set of resources that can be arranged and harnessed to effect
positive change within workplaces.1 Indeed, explicit definitions of
culture tended to align with conceptual metaphors such as brand,
product and microclimate, all of which supported the notion of cul-
ture as something that could be utilised or at the very least prepared
for. However, from a sociological perspective, settings are very per-
sistent and difficult to change. 29 While valuable in its pragmatism,
the organisational approach may overlook the deeply embedded
nature of culture and its sometimes pervasive negative influence, as
indicated by metaphors such as terroir or toxic force, respectively.
This reveals the problems in describing culture effectively: it appears
medical education researchers find it difficult to discuss culture in a
way that allows educators, students and administrators agency but
at the same time acknowledges the deep forces that various social
settings exert.
We turn to other literature, from sociology and education
more broadly, to investigate how researchers from further afield
have resolved this tension. We first draw from the general edu-
cation literature to discuss how we might place this tension front
and centre of research endeavours into learning culture. We then
consider how researchers, including ourselves, may benefit from
explicitly focusing on how we invoke the term ‘culture’ within our
research.
The intersection of people and social settings and practices is
a significant one to medical education. As the collected literature
reveals, researchers have explored how culture impacts learning or
considered how culture influences certain practices. However, as
discussed, this review exposes a gap: the collected work uses the
term ‘culture’ in a way that often elides the reciprocal relationship
between what people can do and what the environment affords. This
interaction is critical to changing people and cultures alike; individu-
als and the broader social grouping must jointly shift practice as they
are constitutive of each other. Hodkinson, Biesta and James’30 work
on learning cultures notes the significance of that space where social
structures and individual agency are entangled and co-­constitutive.
The authors usefully suggest two questions to guide future educa-
tional research. The first of these is as follows: ‘what can be done
to enhance the likelihood of valuable learning in any [learning] cul-
ture?’.30 This question is essentially one of culture changes and is
relevant to other issues of concern in medical education; for exam-
ple, ensuring guidelines are taken up appropriately24 or the need
for diversity in virtual patient cases. 28 By addressing this question,
researchers explore how those within the culture learn and hence
change. At the same time, researchers can ask the following: ‘what
is/should be the valuable learning in any particular [learning] culture,
or for any particular learner or group of learners?’.30 This considers
how learners can draw from a particular place of situated learning
and comes to the important point that not all learners experience a
culture equally. These questions provide useful framing prompts for
those in medical education who seek to maximise learning within
complex clinical practice.
BEARMAN et al.
Our metaphor analysis reveals far more than a research focus;
rather, it surfaces how researchers tacitly and overtly conceptual-
ise culture in relationship to their research. Archer's work on the
31,32
relationship between structure/culture and agency offers a
means to navigate the interplay between a tacit understanding of
culture and an explicit research focus. From Archer's perspective,
the human condition is ‘[p]artly free, autonomous and enabled by
structural circumstances, but also partly restricted, constrained and
even conditioned by them …’.32 She proposes reflexivity—­the delib-
erate contemplation of the influence of social setting on self and vice
versa33—­as a means of agentically crossing the schism. This type of
thinking may assist in further investigations of culture, no matter
how it is conceptualised, defined or invoked. The implication is that
we as researchers need to contemplate the influence of culture upon
ourselves and vice versa.
The term ‘cultural reflexivity’ has already been coined to account
for the relationship between researchers and culture. Aronowitz
34
et al’s discussion of cultural reflexivity proposes a surfacing of the
relationship between the researcher and culture as part of the re-
search process. This work provides both a warning of cultural mis-
recognition (and possibly misappropriation) and also a metaphoric
employment of culture as a lens, explicitly illustrated in the following
quote: ‘…a cultural lens can explain why health conditions coexist
and why behaviors may not change in response to informational
campaigns or to increased access to health-­promoting resources’ (p.
S407). This type of critical acknowledgement of the role of culture,
and of the researchers’ own relationship with it, is currently scarce in
the literature and might provide very useful understandings of social
phenomena within medical education. It also provides a more posi-
tive association with culture than that described within this review.
4.1 | Strengths, limitations and reflexivity
In conducting a critical literature analysis, we have made a number
of key decisions that have framed this work. Firstly, we come with
a range of existing views of culture; indeed, we and our colleagues
are represented within the work included in this review. However,
we have discussed and debated notions of culture throughout this
review, informed by our prior familiarity with the organisational,35-
­37
sociocultural29,38-­40 and critical theory or similar41-­43 literatures.
Secondly, we searched for a year's worth of literature in what we
regard as the most influential medical education journals. The time-­
frame is a limitation as discourses change and, as with any form of
qualitative research, a smaller number of particular texts are nec-
essary for an in-­depth understanding but cannot be comprehen-
sive. The focus on a smaller number of higher-­ranking journals is
balanced against conducting a more comprehensive search, which
may have been more far-­reaching but possibly less salient. Next,
we have explored the use of the term ‘culture’; however, there are
many ways in which medical education researchers may conceptual-
ise culture, some of which may not specifically reference this term.
| 909
These may instead employ specific theoretical language common
to sociocultural perspectives such as ‘communities of practice’39
or habitus.40 While papers using these terms may have broadened
our understanding of how culture is conceptualised, they would not
have furthered our understanding of how the term ‘culture’ itself is
used. Finally, a metaphor analysis is highly interpretive. Our analysis
perhaps does not reflect the reviewed authors’ views of culture, or
even how they represent this in concrete terms within their paper.
However, we think it is an appropriate tool to understand the con-
cept in its most abstract sense, to reveal the deeper associations
within the collected literature.
5 | CO N C LU S I O N S
Researching culture is complex. In this literature review, we have re-
sisted calls to precisely define culture since we argue that it will not
resolve the disparities and nuances within the literature. However,
what this metaphor analysis reveals is that medical education as a
field: 1) draws most from the organisational literature and signifi-
cantly less from sociological or other conceptualisations; 2) invokes
culture in a variety of ways that privilege either acontextual human
agency or all-­powerful social forces; and 3) regards culture as a nega-
tive or neutral force but rarely a positive one. Other literature on
learning cultures and cultural reflexivity may help explore a territory
which is mostly overlooked: how people can effectively influence
a culture while recognising the strong forces exerted by the social.
AC K N OW L E D G E M E N T S
None.
C O N FL I C T O F I N T E R E S T
None.
AU T H O R C O N T R I B U T I O N S
MB conceptualised the study, designed the review approach,
conducted the analysis and led the writing of the manuscript. PM
conceptualised the study, contributed to design of the review ap-
proach, conducted the search, conducted the analysis and critically
reviewed the manuscript for important intellectual content. JT
conceptualised the study, contributed to design of the review ap-
proach, contributed to the search, conducted the analysis and criti-
cally reviewed the manuscript for important intellectual content.
DC conceptualised the study, contributed to design of the review
approach, contributed to the search, conducted the analysis and
critically reviewed the manuscript for important intellectual con-
tent. CW conceptualised the study, contributed to design of the re-
view approach, contributed to the search, conducted the analysis,
contributed to drafting of the manuscript and critically reviewed
the manuscript for important intellectual content. All authors ap-
proved the final version and are in agreement to be accountable for
all aspects of the work.
910 | BEARMAN et al.
ORCID
Margaret Bearman https://orcid.org/0000-0002-6862-9871
Joanna Tai https://orcid.org/0000-0002-8984-2671
Damian Castanelli https://orcid.org/0000-0002-5377-809X
Christopher Watling https://orcid.org/0000-0001-9686-795X
REFERENCES
1. Watling CJ, Ajjawi R, Bearman M. Approaching culture in medical
education: three perspectives. Med Educ. 2020;54(4):289-­295.
2. Azevedo R. Defining and measuring engagement and learning in
science: conceptual, theoretical, methodological, and analytical is-
sues. Educ Psychol. 2015;50(1):84-­94.
3. Kahu ER. Framing student engagement in higher education. Stud
High Educ. 2013;38(5):758-­773.
4. Tai J, Ajjawi R, Bearman M, Wiseman P. Conceptualizations and
measures of student engagement: a worked example of system-
atic review. In: Zawicki-­Richter O, Kerres M, Bendenlier S, Bond
M, Buntins K, eds. Systematic Reviews in Educational Research.
Wiesbaden: Springer VS; 2020:91-­110.
5. Lakoff G, Johnson M. Metaphors We Live By. Chicago, IL: University
of Chicago Press; 2008.
6. Rees CE, Knight LV, Cleland JA. Medical educators’ metaphoric talk
about their assessment relationships with students: ‘you don’t want
to sort of be the one who sticks the knife in them’. Assess Eval High
Educ. 2009;34(4):455-­467.
7. Schmitt R. Systematic metaphor analysis as a method of qualitative
research. Qual Rep. 2005;10(2):358-­394.
8. McGrath C, Liljedahl M, Palmgren PJ. You say it, we say it, but how
do we use it? Communities of practice: a critical analysis. Med Educ.
2020;54(3):188-­195.
9. Brown J, Bearman M, Kirby C, Molloy E, Colville D, Nestel D.
Theory, a lost character? As presented in general practice educa-
tion research papers. Med Educ. 2019;53(5):443-­457.
10. Mulder H, ter Braak E, Chen HC, ten Cate O. Addressing the hidden
curriculum in the clinical workplace: a practical tool for trainees and
faculty. Med Teach. 2019;41(1):36-­43.
11. Gupta R, Steers N, Moriates C, Wali S, Braddock CHI, Ong M. High-­
value care culture among the future physician workforce in internal
medicine. Acad Med. 2019;94(9):1347-­1354.
12. Blouin D, Tekian A, Harris IB. Do organizational cultures of
Canadian medical schools promote a quality culture? Med Teach.
2019;41(6):662-­667.
13. Griffiths J, Dalgarno N, Schultz K, Han H, van Melle E. Competency-­
Based Medical Education implementation: are we transforming the
culture of assessment? Med Teach. 2019;41(7):811-­818.
14. Jackson CB, Brabson LA, Quetsch LB, Herschell AD. Training trans-
fer: a systematic review of the impact of inner setting factors. Adv
Health Sci Educ. 2019;24(1):167-­183.
15. Phelan SM, Burke SE, Cunningham BA, et al. The effects of racism
in medical education on students’ decisions to practice in under-
served or minority communities. Acad Med. 2019;94(8):1178-­1189.
16. Ramani S, Könings KD, Mann KV, Pisarski EE, van der Vleuten CPM.
About politeness, face, and feedback: exploring resident and fac-
ulty perceptions of how institutional feedback culture influences
feedback practices. Acad Med. 2018;93(9):1348-­1358.
17. Shepherd L, LaDonna KA, Cristancho SM, Chahine S. How medi-
cal error shapes physicians’ perceptions of learning: an exploratory
study. Acad Med. 2019;94(8):1157-­1163.
18. Winkel AF, Robinson A, Jones A-­A , Squires AP. Physician resilience:
a grounded theory study of obstetrics and gynaecology residents.
Med Educ. 2019;53(2):184-­194.
19. Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of
learning. Med Educ. 2019;53(1):76-­85.
20. King E, Turpin M, Green W, Schull D. Learning to interact and inter-
acting to learn: a substantive theory of clinical workplace learning
for diverse cohorts. Adv Health Sci Educ. 2019;24(4):691-­706.
21. Ulloa JG, Viramontes O, Ryan G, Wells K, Maggard-­Gibbons M,
Moreno G. Perceptual and structural facilitators and barriers to
becoming a surgeon: a qualitative study of African American and
Latino surgeons. Acad Med. 2018;93(9):1326-­1334.
22. Kilbertus F, Ajjawi R, Archibald DB. You’re not trying to save some-
body from death”: learning as “becoming in palliative care. Acad
Med. 2018;93(6):929-­936.
23. Ajjawi R, Crampton PES, Rees CE. What really matters for suc-
cessful research environments? A realist synthesis. Med Educ.
2018;52(9):936-­950.
24. Chacko KM, Reddy S, Kisielewski M, Call S, Willett LL, Chaudhry
S. Postinterview communications: two surveys of internal medicine
residency program directors before and after guideline implemen-
tation. Acad Med. 2018;93(9):1367-­1373.
25. Lörwald AC, Lahner F-­M, Mooser B, et al. Influences on the im-
plementation of Mini-­CEX and DOPS for postgraduate med-
ical trainees’ learning: a grounded theory study. Med Teach.
2019;41(4):448-­456.
26. Patterson F, Tiffin PA, Lopes S, Zibarras L. Unpacking the dark vari-
ance of differential attainment on examinations in overseas gradu-
ates. Med Educ. 2018;52(7):736-­746.
27. Habicht JL, Kiessling C, Winkelmann A. Bodies for anatomy edu-
cation in medical schools: an overview of the sources of cadavers
worldwide. Acad Med. 2018;93(9):1293-­1300.
28. Krishnan A, Rabinowitz M, Ziminsky A, Scott SM, Chretien
KC. Addressing race, culture, and structural inequality in med-
ical education: a guide for revising teaching cases. Acad Med.
2019;94(4):550-­555.
29. Schatzki TR. The Site of the Social: A Philosophical Account of the
Constitution of Social Life and Change. University Park, PA: Penn
State Press; 2002.
30. Hodkinson P, Biesta G, James D. Understanding learning culturally:
overcoming the dualism between social and individual views of
learning. Vocations Learning. 2008;1(1):27-­47.
31. Archer MS. Routine, reflexivity, and realism. Soc Theory.
2010;28(3):272-­3 03.
32. Chernilo D. Debating Humanity: Towards a Philosophical Sociology.
Cambridge, UK: Cambridge University Press; 2016.
33. Archer MS. Making Our Way through the World: Human Reflexivity
and Social Mobility. Cambridge, UK: Cambridge University Press;
2007.
34. Aronowitz R, Deener A, Keene D, Schnittker J, Tach L. Cultural
reflexivity in health research and practice. Am J Public Health.
2015;105(S3):S403-­S 408.
35. Davies HTO, Nutley SM, Mannion R. Organisational culture and
quality of health care. Qual Health Care. 2000;9(2):111-­119.
36. Schneider B, Ehrhart MG, Macey WH. Organizational climate and
culture. Annu Rev Psychol. 2013;64(1):361-­388.
37. Weber K, Dacin MT. The cultural construction of organizational life:
Introduction to the special issue. Organ Sci. 2011;22(2):287-­298.
38. Holland DC, Lachicotte WS Jr, Skinner D, Cain C. Identity and
Agency in Cultural Worlds. London: Harvard University Press; 1998.
39. Lave J, Wenger E. Situated Learning: Legitimate Peripheral
Participation. Cambridge, UK: Cambridge University Press; 1991.
40. Bourdieu P. The Logic of Practice. Cambridge, UK: Polity Press; 1990.
41. Latour B. Reassembling the Social: An Introduction to Actor-­Network
Theory. Oxford: Oxford University Press; 2005.
42. Butler J. Gender Trouble: Feminism and the Subversion of Identity.
Abingdon: Routledge; 2011.
43. Kemmis S, Wilkinson J, Edwards-­Groves C, Hardy I, Grootenboer
P, Bristol L. Praxis, practice and practice architectures. In: Kemmis
S, Wilkinson J, Edwards-­Groves C, Hardy I, Grootenboer P, Bristol
BEARMAN et al. | 911

L, eds. Changing Practices, Changing Education. Singapore: Springer;

2014:25-­41. How to cite this article: Bearman M, Mahoney P, Tai J,
Castanelli D, Watling C. Invoking culture in medical education

S U P P O R T I N G I N FO R M AT I O N research: A critical review and metaphor analysis. Med Educ.

Additional supporting information may be found online in the 2021;55:903–­911. https://doi.org/10.1111/medu.14464

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