Bioethics Discussion Blog: Being “Culturally Competent” vs Caring for a Patient’s Concerns

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Monday, December 04, 2006

Being “Culturally Competent” vs Caring for a Patient’s Concerns

“A medical anthropologist is asked by a pediatrician in California to consult in the care of a Mexican man who is HIV positive. The man's wife had died of AIDS one year ago. He has a four-year-old son who is HIV positive, but he has not been bringing the child in regularly for care. The explanation given by the clinicians assumed that the problem turned on a radically different cultural understanding. What the anthropologist found, though, was to the contrary. This man had a near complete understanding of HIV/AIDS and its treatment—largely through the support of a local nonprofit organization aimed at supporting Mexican-American patients with HIV. However, he was a very-low-paid bus driver, often working late-night shifts, and he had no time to take his son to the clinic to receive care for him as regularly as his doctors requested. His failure to attend was not because of cultural differences, but rather his practical, socioeconomic situation.”

The medical profession is being encouraged to engage in becoming culturally competent. That is, for the medical profession to be able to understand and behave constructively towards patients’ cultural backgrounds in hopes of providing more compassionate and effective care. But as the above story from the article “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It” by Arthur Kleinman and Peter Benson in PloS Medicine, an online open-access journal, suggest and the authors explain, making cultural assumptions may not be valid in a particular case and actually hinder practical understanding. In their story they conclude, in place of stereotyping the patient,“talking with him and taking into account his ‘local world’ were more useful than positing radically different Mexican health beliefs.”

The authors give another example story where therapy didn’t fully work, the example emphasizing the importance of using “culturally appropriate terms to explain people’s life stories” rather than terms usual in medical culture..

The authors give healthcare workers six steps in dealing with a patient of another culture, however they conclude by writing that “If we were to reduce the six steps of culturally informed care to one activity that even the busiest clinician should be able to find time to do, it would be to routinely ask patients (and where appropriate family members) what matters most to them in the experience of illness and treatment. The clinicians can then use that crucial information in thinking through treatment decisions and negotiating with patients.”

This, the authors feel “is much different than cultural competency. Finding out what matters most to another person is not a technical skill. It is an elective affinity to the patient. This orientation becomes part of the practitioner's sense of self, and interpersonal skills become an important part of the practitioner's clinical resources. It is what Franz Kafka said 'a born doctor' has: 'a hunger for people'. And its main thrust is to focus on the patient as an individual, not a stereotype; as a human being facing danger and uncertainty, not merely a case; as an opportunity for the doctor to engage in an essential moral task, not an issue in cost-accounting.”

Please click on the link above and read the entire article with the references (not included in the extracts above) and let me know what you think. Have you and your physician come from different cultures (besides the obvious medical culture) and how was your relationship with the physician handled? ..Maurice.

2 Comments:

At Tuesday, December 12, 2006 10:01:00 AM, Blogger james gaulte said...

Thanks for an excellent posting.I blogged about an great article by Dr. Linda M. Hunt of Mich.State.Here is the link
http://www.parkridgecenter.org/Page1882.html
It expresses a very similar line of thinking.

 
At Thursday, February 15, 2007 9:14:00 PM, Anonymous Coranth Gryphon said...

The most frightening comment I'd ever heard was in a Medical Ethics class. The teacher was talking about differences in culture and heritage and ethnicity, and made the following comment: "We need to be tolerant of other cultures until we can mainstream them."

I pointed out to that teacher, in no uncertain terms, that she clearly had no concept of either tolerance or diversity.

The annecdotal story about the father who was a bus-driver raises the same point. The problem my Medical Ethics teacher had was that she saw other cultures as boxes and labels, and assumed everyone in that box thought and acted the same. She assumed stereotypes, and then assumed automatic conformance with those stereotypes. Which defeated the entire concept of tolerance and diversity.

Just like the clinicians in the example assumed that the problem was cultural. Culture is only part of who we are. It's a set of initial suggestions, proposed beliefs, and a few starting assumptions. But if think of a culture -- or a race or a nationality or an age group -- as a label that creates conformity, then we have forgotten the concept of diversity.

It takes a lot more effort to see everyone as an individual. To push our assumptions and preconceptions aside and find out the truth as it pertains to each unique person. It's certainly more difficult to work with individuals than with sterotypes and boxes and labels.

But unless we are willing to make that effort, unless we are willing to take the time to see each person as an individual, then all we are doing is pretending to tolerate them until we can mainstream them into whatever mould we've chosen for them.

And that's neither respect for diversity, nor cultural competence.

 

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