Cultural Competence and the Culture of Medicine
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《新英格兰医药杂志》
The phrase "cultural competence" arises often in discussions about improving medical education and health care in the United States. It is usually used to refer to a body of knowledge, skills, attitudes, and behavior in which physicians ought to be trained if they are to deliver "sensitive," "empathetic," "humanistic" care that is "respectful" of patients, involves effective "patient-centered communication," and responds to patients' "psychosocial issues and needs." It is commendable that the authors who address these attributes think of them as professional abilities that can be taught and implemented in clinical training, rather than primarily as virtues associated with moral character. Unfortunately, such authors almost invariably fail to recognize that their own culture also merits enlightened examination, for it is far from a neutral background against which other cultures may be measured.
"Cultural competence" is most often invoked in relation to the increasingly diverse, multicultural composition of U.S. society and the challenges of caring for patients of black, Hispanic, or to a lesser extent, Asian origin. The term is applied particularly to settings in which there are conspicuous ethnic, racial, and economic disparities in the quality of and access to health care. Strikingly, the concept does not usually encompass the distinctive cultural attributes of U.S. society that shape the attitudes and values of the country's inhabitants — health care professionals and patients alike. There is, for example, a detectable "Americanness" in the optimistic belief in medical science and technology, in their limitless progress and promise, their vigorous application, and their power to "overcome" disease, that pervades our society and is pronounced in medical training.
If discussions of cultural competence ignore U.S. culture, they also neglect what psychiatrist and medical anthropologist Arthur Kleinman calls the "culture of biomedicine" and its effects on physicians trained in modern Western medicine. It may be argued, for example, that even the scientific concepts and language through which biomedical knowledge is conveyed (such as the notions of "helper" cells and "killer" cells in immunology) are culturally shaped. Because of Kleinman's work in this area, writer Anne Fadiman sought his opinion on the gulf between the beliefs held by the parents of a gravely ill Hmong child and the diagnostic conviction of the American physicians who cared for her. The parents understood their daughter's malady in terms of "soul loss" caused by a spirit, and they believed it should be treated with Hmong herbal medicines, the ceremonial ministrations of a traditional practitioner, and the sacrificing of animals. The doctors believed the girl had severe epilepsy that should be treated with a continuous regimen of strong anticonvulsant drugs.
Questioned about the tragedy that resulted, Kleinman remarked on the physicians' obliviousness of their immersion in the culture of their profession: "As powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture?"1
In addition to failing to acknowledge the underlying values and assumptions of biomedicine that patients may not share, most considerations of cultural competence neither identify nor explore the culture of medical training grounds. U.S. medical educators keep a careful annual count of the numbers of faculty members, applicants for admission, and enrolled students. Because of their interest in increasing the proportion of women and members of "underrepresented minority groups" in their student body, they pay special attention to these subgroups. Nevertheless, their reports do not usually analyze the effects of the composition of the student body and faculty on the value system of the medical school, its cultural ambience, and the implicit and explicit attitudinal messages that the educational process transmits. The significance for the cultural environment of the medical school of such phenomena as the continuous burgeoning of the number of full-time faculty members (and the decrease in the number who actually teach medical students), the escalating rate of turnover among medical school deans, the steady increase in the number of female students, and the intractably slow growth in the number of minority students remains largely unexamined.
Given the lack of attention to these aspects of culture, it is not surprising that no systematic consideration has been given to the ways in which changes in the economic, political, and ideological outlook on the larger American scene, and in the health care system in particular, may affect the attitudes and values with which students undertake medical studies — including their reasons for pursuing a medical career and their conceptions of what it will be like to be a doctor. Medical educators, in other words, do not apply the concept of cultural competence to furthering their own understanding of the students they teach or the milieu in which they convey attitudes, values, and behavior integral to patient care.
The recognition of these blind spots opens up the question of how a more broad-gauged cultural competence that is professionally relevant and functional can be taught effectively enough to be put into practice. Such training would entail more than raising consciousness about the importance of cultural patterns and intercultural differences, improving communication skills, or role-modeling interactions with patients. Of fundamental importance would be the systematic acquisition of in-depth knowledge and understanding of at least one society other than one's own. This sort of learning experience, at once cognitive and attitudinal, is essential to opening up cultural perspectives and overcoming provincialism — by helping one to see more clearly the characteristics of one's own society and culture and heightening one's appreciation of commonalities and differences among cultures. It may also enhance physicians' attunement to the cultural nuances of their interactions with patients and their families. And it may help them to acknowledge their occasional need for intermediaries to assist them in deciphering aspects of these relationships.
But at what stage in the training of medical students could such "cosmopolitan education" take place?2 Is there any space for it in the rapidly paced, biomedically crammed course of learning they undergo? Who on the faculty would be qualified to teach it? Would physicians-in-training consider it medically relevant and vital enough to be motivated to learn what it has to teach them? Or would such education more appropriately be accomplished during their college years? If so, should achieving some degree of cultural competence in this way be a precondition for admission to medical school?
Prerequisite to any attempt to heighten medical students' consciousness of the cultural components of the medicine they learn, and the contexts in which they are taught to be doctors, is increasing the awareness among the faculty members of medical schools of these dimensions of the educational process and their own relationship to them. With some input from medical anthropologists, sociologists, and historians, they might build into the curriculum learning experiences conducive to insights about the patterns of medical culture — including the culture of the medical school and the subcultural attributes of various medical specialties — that are implicitly conveyed to students.
Such medical–cultural issues reflect a larger set of questions with which U.S. medical educators have grappled for almost a century — namely, how medical schools can augment their efforts to teach what they have variously called the "social," "psychosocial," "humanistic," "behavioral," "nonbiomedical," and "ethical" components of health and illness. Seen from this vantage point, "cultural competence" is old wine in new bottles — the vocabulary now in vogue for describing one of the most persistent problems in medical education.3,4
Source Information
Dr. Fox is a professor emerita in the Department of Sociology and a senior fellow of the Center for Bioethics at the University of Pennsylvania, Philadelphia.
References
Fadiman A. The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, and Giroux, 1997.
Nussbaum MC. Patriotism and cosmopolitanism. In: Cohen J, ed. For love of country: debating the limits of patriotism. Boston: Beacon Press, 1996:2-16.
Christakis NA. The similarity and frequency of proposals to reform US medical education: constant concerns. JAMA 1995;274:706-711.
Fox RC. Is medical education asking too much of bioethics? Teaching the "nonbiomedical" aspects of medicine: the perennial pattern. Daedalus 1999;128:1-25.(Renée C. Fox, Ph.D.)
"Cultural competence" is most often invoked in relation to the increasingly diverse, multicultural composition of U.S. society and the challenges of caring for patients of black, Hispanic, or to a lesser extent, Asian origin. The term is applied particularly to settings in which there are conspicuous ethnic, racial, and economic disparities in the quality of and access to health care. Strikingly, the concept does not usually encompass the distinctive cultural attributes of U.S. society that shape the attitudes and values of the country's inhabitants — health care professionals and patients alike. There is, for example, a detectable "Americanness" in the optimistic belief in medical science and technology, in their limitless progress and promise, their vigorous application, and their power to "overcome" disease, that pervades our society and is pronounced in medical training.
If discussions of cultural competence ignore U.S. culture, they also neglect what psychiatrist and medical anthropologist Arthur Kleinman calls the "culture of biomedicine" and its effects on physicians trained in modern Western medicine. It may be argued, for example, that even the scientific concepts and language through which biomedical knowledge is conveyed (such as the notions of "helper" cells and "killer" cells in immunology) are culturally shaped. Because of Kleinman's work in this area, writer Anne Fadiman sought his opinion on the gulf between the beliefs held by the parents of a gravely ill Hmong child and the diagnostic conviction of the American physicians who cared for her. The parents understood their daughter's malady in terms of "soul loss" caused by a spirit, and they believed it should be treated with Hmong herbal medicines, the ceremonial ministrations of a traditional practitioner, and the sacrificing of animals. The doctors believed the girl had severe epilepsy that should be treated with a continuous regimen of strong anticonvulsant drugs.
Questioned about the tragedy that resulted, Kleinman remarked on the physicians' obliviousness of their immersion in the culture of their profession: "As powerful an influence as the culture of the Hmong patient and her family is on this case, the culture of biomedicine is equally powerful. If you can't see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else's culture?"1
In addition to failing to acknowledge the underlying values and assumptions of biomedicine that patients may not share, most considerations of cultural competence neither identify nor explore the culture of medical training grounds. U.S. medical educators keep a careful annual count of the numbers of faculty members, applicants for admission, and enrolled students. Because of their interest in increasing the proportion of women and members of "underrepresented minority groups" in their student body, they pay special attention to these subgroups. Nevertheless, their reports do not usually analyze the effects of the composition of the student body and faculty on the value system of the medical school, its cultural ambience, and the implicit and explicit attitudinal messages that the educational process transmits. The significance for the cultural environment of the medical school of such phenomena as the continuous burgeoning of the number of full-time faculty members (and the decrease in the number who actually teach medical students), the escalating rate of turnover among medical school deans, the steady increase in the number of female students, and the intractably slow growth in the number of minority students remains largely unexamined.
Given the lack of attention to these aspects of culture, it is not surprising that no systematic consideration has been given to the ways in which changes in the economic, political, and ideological outlook on the larger American scene, and in the health care system in particular, may affect the attitudes and values with which students undertake medical studies — including their reasons for pursuing a medical career and their conceptions of what it will be like to be a doctor. Medical educators, in other words, do not apply the concept of cultural competence to furthering their own understanding of the students they teach or the milieu in which they convey attitudes, values, and behavior integral to patient care.
The recognition of these blind spots opens up the question of how a more broad-gauged cultural competence that is professionally relevant and functional can be taught effectively enough to be put into practice. Such training would entail more than raising consciousness about the importance of cultural patterns and intercultural differences, improving communication skills, or role-modeling interactions with patients. Of fundamental importance would be the systematic acquisition of in-depth knowledge and understanding of at least one society other than one's own. This sort of learning experience, at once cognitive and attitudinal, is essential to opening up cultural perspectives and overcoming provincialism — by helping one to see more clearly the characteristics of one's own society and culture and heightening one's appreciation of commonalities and differences among cultures. It may also enhance physicians' attunement to the cultural nuances of their interactions with patients and their families. And it may help them to acknowledge their occasional need for intermediaries to assist them in deciphering aspects of these relationships.
But at what stage in the training of medical students could such "cosmopolitan education" take place?2 Is there any space for it in the rapidly paced, biomedically crammed course of learning they undergo? Who on the faculty would be qualified to teach it? Would physicians-in-training consider it medically relevant and vital enough to be motivated to learn what it has to teach them? Or would such education more appropriately be accomplished during their college years? If so, should achieving some degree of cultural competence in this way be a precondition for admission to medical school?
Prerequisite to any attempt to heighten medical students' consciousness of the cultural components of the medicine they learn, and the contexts in which they are taught to be doctors, is increasing the awareness among the faculty members of medical schools of these dimensions of the educational process and their own relationship to them. With some input from medical anthropologists, sociologists, and historians, they might build into the curriculum learning experiences conducive to insights about the patterns of medical culture — including the culture of the medical school and the subcultural attributes of various medical specialties — that are implicitly conveyed to students.
Such medical–cultural issues reflect a larger set of questions with which U.S. medical educators have grappled for almost a century — namely, how medical schools can augment their efforts to teach what they have variously called the "social," "psychosocial," "humanistic," "behavioral," "nonbiomedical," and "ethical" components of health and illness. Seen from this vantage point, "cultural competence" is old wine in new bottles — the vocabulary now in vogue for describing one of the most persistent problems in medical education.3,4
Source Information
Dr. Fox is a professor emerita in the Department of Sociology and a senior fellow of the Center for Bioethics at the University of Pennsylvania, Philadelphia.
References
Fadiman A. The spirit catches you and you fall down: a Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, and Giroux, 1997.
Nussbaum MC. Patriotism and cosmopolitanism. In: Cohen J, ed. For love of country: debating the limits of patriotism. Boston: Beacon Press, 1996:2-16.
Christakis NA. The similarity and frequency of proposals to reform US medical education: constant concerns. JAMA 1995;274:706-711.
Fox RC. Is medical education asking too much of bioethics? Teaching the "nonbiomedical" aspects of medicine: the perennial pattern. Daedalus 1999;128:1-25.(Renée C. Fox, Ph.D.)