Cultural competency has become a fashionable term for clinicians and researchers.
Yet no one can define this term precisely enough to operationalize it in clinical
training and best practices.
It is clear that culture does matter in the clinic. Cultural factors are crucial to
diagnosis, treatment, and care. They shape health-related beliefs, behaviors, and
values [1,2]. But the large claims about the value of cultural competence for the
art of professional care-giving around the world are simply not supported by robust
evaluation research showing that systematic attention to culture really improves clinical
services. This lack of evidence is a failure of outcome research to take culture seriously
enough to routinely assess the cost-effectiveness of culturally informed therapeutic
practices, not a lack of effort to introduce culturally informed strategies into clinical
settings [3].
Problems with the Idea of Cultural Competency
One major problem with the idea of cultural competency is that it suggests culture
can be reduced to a technical skill for which clinicians can be trained to develop
expertise [4]. This problem stems from how culture is defined in medicine, which contrasts
strikingly with its current use in anthropology—the field in which the concept of
culture originated [5–9]. Culture is often made synonymous with ethnicity, nationality,
and language. For example, patients of a certain ethnicity—such as, the “Mexican patient”—are
assumed to have a core set of beliefs about illness owing to fixed ethnic traits.
Cultural competency becomes a series of “do's and don'ts” that define how to treat
a patient of a given ethnic background [10]. The idea of isolated societies with shared
cultural meanings would be rejected by anthropologists, today, since it leads to dangerous
stereotyping—such as, “Chinese believe this,” “Japanese believe that,” and so on—as
if entire societies or ethnic groups could be described by these simple slogans [11–13].
Another problem is that cultural factors are not always central to a case, and might
actually hinder a more practical understanding of an episode (see Box 1).
Box 1. Case Scenario: Cultural Assumptions May Hinder Practical Understanding
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. Talking with him and taking into account his “local world” were more useful
than positing radically different Mexican health beliefs.
Historically in the health-care domain, culture referred almost solely to the domain
of the patient and family. As seen in the case scenario in Box 1, we can also talk
about the culture of the professional caregiver—including both the cultural background
of the doctor, nurse, or social worker, and the culture of biomedicine itself—especially
as it is expressed in institutions such as hospitals, clinics, and medical schools
[14]. Indeed, the culture of biomedicine is now seen as key to the transmission of
stigma, the incorporation and maintenance of racial bias in institutions, and the
development of health disparities across minority groups [15–18].
Culture Is Not Static
In anthropology today, culture is not seen as homogenous or static. Anthropologists
emphasize that culture is not a single variable but rather comprises multiple variables,
affecting all aspects of experience. Culture is inseparable from economic, political,
religious, psychological, and biological conditions. Culture is a process through
which ordinary activities and conditions take on an emotional tone and a moral meaning
for participants.
Cultural processes include the embodiment of meaning in psychophysiological reactions
[19], the development of interpersonal attachments [20], the serious performance of
religious practices [21], common-sense interpretations [22], and the cultivation of
collective and individual identity [23]. Cultural processes frequently differ within
the same ethnic or social group because of differences in age cohort, gender, political
association, class, religion, ethnicity, and even personality.
The Importance of Ethnography
It is of course legitimate and highly desirable for clinicians to be sensitive to
cultural difference, and to attempt to provide care that deals with cultural issues
from an anthropological perspective. We believe that the optimal way to do this is
to train clinicians in ethnography. “Ethnography” is the technical term used in anthropology
for its core methodology. It refers to an anthropologist's description of what life
is like in a “local world,” a specific setting in a society—usually one different
from that of the anthropologist's world. Traditionally, the ethnographer visits a
foreign country, learns the language, and, systematically, describes social patterns
in a particular village, neighborhood, or network [24]. What sets this apart from
other methods of social research is the importance placed on understanding the native's
point of view [25]. The ethnographer practices an intensive and imaginative empathy
for the experience of the natives—appreciating and humanly engaging with their foreignness
[26], and understanding their religion, moral values, and everyday practices [27,28].
Ethnography is different than cultural competency. It eschews the “trait list approach”
that understands culture as a set of already-known factors, such as “Chinese eat pork,
Jews don't.” (Millions of Chinese are vegetarians or are Muslims who do not eat pork;
some Jews, including the corresponding author of this paper, love pork.) Ethnography
emphasizes engagement with others and with the practices that people undertake in
their local worlds. It also emphasizes the ambivalence that many people feel as a
result of being between worlds (for example, persons who identify as both African-American
and Irish, Jewish and Christian, American and French) in a way that cultural competency
does not. And ethnography eschews the technical mastery that the term “competency”
suggests. Anthropologists and clinicians share a common belief—i.e., the primacy of
experience [29–33]. The clinician, as an anthropologist of sorts, can empathize with
the lived experience of the patient's illness, and try to understand the illness as
the patient understands, feels, perceives, and responds to it.
Box 2. The Explanatory Models Approach
What do you call this problem?
What do you believe is the cause of this problem?
What course do you expect it to take? How serious is it?
What do you think this problem does inside your body?
How does it affect your body and your mind?
What do you most fear about this condition?
What do you most fear about the treatment?
(Source: Chapter 15 in [38])
The Explanatory Models Approach
One of us [AK] introduced the “explanatory models approach,” which is widely used
in American medical schools today, as an interview technique (described below) that
tries to understand how the social world affects and is affected by illness. Despite
its influence, we've often witnessed misadventure when clinicians and clinical students
use explanatory models. They materialize the models as a kind of substance or measurement
(like hemoglobin, blood pressure, or X rays), and use it to end a conversation rather
to start a conversation. The moment when the human experience of illness is recast
into technical disease categories something crucial to the experience is lost because
it was not validated as an appropriate clinical concern [34].
Rather, explanatory models ought to open clinicians to human communication and set
their expert knowledge alongside (not over and above) the patient's own explanation
and viewpoint. Using this approach, clinicians can perform a “mini-ethnography,” organized
into a series of six steps. This is a revision of the Cultural Formulation included
in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) (see Appendix I in [35]) [36,37].
A Revised Cultural Formulation
Step 1: Ethnic identity.
The first step is to ask about ethnic identity and determine whether it matters for
the patient—whether it is an important part of the patient's sense of self. As part
of this inquiry, it is crucial to acknowledge and affirm a person's experience of
ethnicity and illness. This is basic to any therapeutic interaction, and enables a
respectful inquiry into the person's identity. The clinician can communicate a recognition
that people live their ethnicity differently, that the experience of ethnicity is
complicated but important, and that it bears significance in the health-care setting.
Treating ethnicity as a matter of empirical evidence means that its salience depends
on the situation. Ethnicity is not an abstract identity, as the DSM-IV cultural formulation
implies, but a vital aspect of how life is lived. Its importance varies from case
to case and depends on the person. It defines how people see themselves and their
place within family, work, and social networks. Rather than assuming knowledge of
the patient, which can lead to stereotyping, simply asking the patient about ethnicity
and its salience is the best way to start.
Step 2: What is at stake?
The second step is to evaluate what is at stake as patients and their loved ones face
an episode of illness. This evaluation may include close relationships, material resources,
religious commitments, and even life itself. The question, “What is at stake?” can
be asked by clinicians; the responses to this question will vary within and between
ethnic groups, and will shed light on the moral lives of patients and their families.
Step 3: The illness narrative.
Step 3 is to reconstruct the patient's “illness narrative” [38]. This involves a series
of questions (about one's explanatory model) aimed at acquiring an understanding of
the meaning of illness (Box 2).
The patient and family's explanatory models can then be used to open up a conversation
on cultural meanings that may hold serious implications for care. In this conversation,
the clinician should be open to cultural differences in local worlds, and the patient
should recognize that doctors do not fit a certain stereotype any more than they themselves
do.
Step 4: Psychosocial stresses.
Step 4 is to consider the ongoing stresses and social supports that characterize people's
lives. The clinician records the chief psychosocial problems associated with the illness
and its treatment (such as family tensions, work problems, financial difficulties,
and personal anxiety). For example, if the clinicians described in the case scenario
in Box 1 had carried out step 4, they could have avoided the misunderstanding with
their Mexican-American patient. The clinician can also list interventions to improve
any of the patient's difficulties, such as professional therapy, self-treatment, family
assistance, and alternative or complementary medicine.
Step 5: Influence of culture on clinical relationships.
Step 5 is to examine culture in terms of its influence on clinical relationships.
Clinicians are grounded in the world of the patient, in their own personal network,
and in the professional world of biomedicine and institutions. One crucial tool in
ethnography is the critical self-reflection that comes from the unsettling but enlightening
experience of being between social worlds (for example, the world of the researcher/doctor
and the world of the patient/participant of ethnographic research). So, too, it is
important to train clinicians to unpack the formative effect that the culture of biomedicine
and institutions has on the most routine clinical practices—including bias, inappropriate
and excessive use of advanced technology interventions, and, of course, stereotyping.
Teaching practitioners to consider the effects of the culture of biomedicine is contrary
to the view of the expert as authority and to the media's view that technical expertise
is always the best answer. The statement “First do no harm by stereotyping” should
appear on the walls of all clinics that cater to immigrant, refugee, and ethnic-minority
populations. And yet since culture does not only apply to these groups, it ought to
appear on the walls of all clinics.
Step 6: The problems of a cultural competency approach.
Finally, step 6 is to take into account the question of efficacy—namely, “Does this
intervention actually work in particular cases?” There are also potential side-effects.
Every intervention has potential unwanted effects, and this is also true of a culturalist
approach. Perhaps the most serious side-effect of cultural competency is that attention
to cultural difference can be interpreted by patients and families as intrusive, and
might even contribute to a sense of being singled out and stigmatized [3,11,12]. Another
danger is that overemphasis on cultural difference can lead to the mistaken idea that
if we can only identify the cultural root of the problem, it can be resolved. The
situation is usually much more complicated. For example, in her influential book,
The Spirit Catches You and You Fall Down, Ann Fadiman shows that while inattention
to culturally important factors creates havoc in the care of a young Hmong patient
with epilepsy, once the cultural issues are addressed, there is still no easy resolution
[33]. Instead, a whole new series of questions is raised.
Determining What Is at Stake for the Patient
The case history in Box 3 gives an example of how simply using culturally appropriate
terms to explain people's life stories helps the health professionals to restore a
“broken” relationship and allows treatment to continue. This case is not settled,
nor is it an example of any kind of technical competency. But there are two illuminating
aspects of this case. First, it is important that health-care providers do not stigmatize
or stereotype patients. This is a case study of an individual. Not all Chinese people
fit this life story, and many contemporary Chinese now accept the diagnosis of depression.
Second, culture is not just what patients have; clinicians also participate in cultural
worlds. A physician too rigidly oriented around the classification system of biomedicine
might find it unacceptable to use lay classifications for the treatment.
Box 3. Case Scenario: The Importance of Using Culturally Appropriate Terms to Explain
People's Life Stories
Miss Lin is a 24-year-old exchange student from China in graduate school in the United
States, where she developed symptoms of palpitations, shortness of breath, dizziness,
fatigue, and headaches. A thorough medical work-up leaves the symptoms unexplained.
A psychiatric consultant diagnoses a mixed depressive-anxiety disorder. Miss Lin is
placed on antidepressants and does cognitive-behavioral psychotherapy, with symptoms
getting better over a six-week period; but they do not disappear completely.
Subsequently, the patient drops out of treatment and refuses further contact with
the medical system. Anthropological consultation discovers that Miss Lin comes from
a Chinese family in Beijing—one of her cousins is hospitalized with chronic mental
illness. So powerful is the stigma of that illness for this family that Miss Lin cannot
conceive of the idea that she is suffering from a mental disorder, and refuses to
deal with her American health-care providers because they use the terms “anxiety disorder”
and “depressive disorder.” In this instance, she herself points out that in China
the term that is used is neurasthenia or a stress-related condition. On the anthropologist's
urging, clinicians reconnect with Miss Lin under this label.
For the late French moral philosopher Emmanuel Levinas, in the face of a person's
suffering, the first ethical task is acknowledgement [39]. Face-to-face moral issues
precede and take precedence over epistemological and cultural ones [40]. There is
something more basic and more crucial than cultural competency in understanding the
life of the patient, and this is the moral meaning of suffering—what is at stake for
the patient; what the patient, at a deep level, stands to gain or lose. The explanatory
models approach does not ask, for example, “What do Mexicans call this problem?” It
asks, “What do you call this problem?” and thus a direct and immediate appeal is made
to the patient as an individual, not as a representative of a group.
Conclusion
What clinicians want to understand through the mini-ethnography is what really matters—what
is really at stake for patients, their families, and, at times, their communities,
and also what is at stake for themselves. 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 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 [41]. It
is what Franz Kafka said “a born doctor” has: “a hunger for people” [42]. 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 [43].