Dimensions of Culture

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For many years, cultural factors were largely absent from health care dialogues around patient-centered care and medical home initiatives. The current strong emphasis on cultural factors in medical care mirrors the rapid demographic changes in this country, and cultural competency has now become a favorite buzzword of policy makers, researchers, medical educators, and health care providers. The term cultural competency is most often used, but there is also debate about its applicability; its detractors say the word competency suggests one is either competent or incompetent, which in turn points towards a kind of pass/fail attitude that necessitates measurement. Measurement, however, follows being able to define and codify "competency" - which most of us would agree is a work still in process. Even with CLAS Standards in place (National Standards on Culturally and Linguistically Appropriate Services) one only has to follow conversations on relevant list servs to see that people are still debating what it means to be culturally competent. The CLAS standards are primarily directed at health care organizations, and though individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible, the standards contribute little to the challenges of somehow measuring individuals' cross-cultural knowledge, skills, and attitudes.

What Is Culturally Sensitive Care?

As a cross-cultural communications instructor, I prefer the term culturally sensitive care, defined as an extension of patient centered-care that includes paying particular attention to social and cultural factors in managing medical encounters with patients from very different social and cultural backgrounds. In practice this boils down to giving health care providers a set of tools - questions and skills for negotiation based on cultural knowledge - which they can incorporate into their interactions with patients from diverse cultural backgrounds. Examples include finding out about the patient's history of present illness, their health beliefs and use of alternative treatments, their expectations of care, and any culturally-based family dynamics that guide decision-making processes. The literature supports the fact that it is important for physicians to not only be aware of cultural factors, but to demonstrate their ability to manage and negotiate them in order to improve health outcomes.

A basic premise of culturally sensitive care is that health care professionals must be able to recognize the client's culture, their own culture, and how both affect the patient-provider relationship. The following are key in addressing this important premise:

• Everyone has a culture.
• There is an American medical culture and it is very different from many of the cultures that our patients and their families come from.
  
• We need to understand where our American medical culture differs from other cultures in significant ways that impact communication and influence health outcomes for patients.
  
• Resistance to cultural difference is part of being human, and reactions to cultural difference are automatic, often subconscious, and can have strong influence on the patient-provider relationship.
  
• A provider's culture is influenced by his/her own personal values and beliefs, as well as those of the western medical culture.
  
• A provider's ability to communicate effectively in cross-cultural interactions is greatly enhanced by his/her grasp of cross-cultural communication skills.
  
• Culturally sensitive care requires a broad understanding of how culture affects health beliefs and behaviors.
  
• Providing linguistically appropriate care requires being able to assess the need for interpreters in the clinical setting and interact with interpreters effectively.

Understanding Your Own Culture

"In all affairs it's a healthy thing now and then to hang a question mark on the things you have long taken for granted." -- Bertrand Russell

Self-reflection is crucial to the cross-cultural learning process. Without understanding that everyone has a culture, and that knowledge of one's own culture is crucial, we have a tendency to reduce learning about culture to a manual-based approach, applying lists of dos and don'ts too rigidly and thereby stereotyping. Self-reflection begins with gaining knowledge about dimensions of culture and learning to apply these informed generalizations to our own culture. We thus develop a baseline for making effective comparisons about cultural differences and understand better why we respond in different situations the way we do.

Western Medical Culture

For American health care professionals, knowing about one's own culture is inseparable from knowing Western medical culture. In American culture, a person's life work informs their identity to such a large degree it sometimes seems that the credo should be "you are what you do." Some of the core values of Western medical culture are caring, empathy, truthfulness, promoting health and autonomy, and respecting an individual's choices. It is important to recognize that the health care system in the United States and some other Western countries assumes the autonomy of the patient, as seen in the Patient Self Determination Act which secures this right legally for all patients in the U.S. However, the applicability of this act to patients from various cultural backgrounds has often been debated. (Refolo 1992, Ersek 1998). In collectivist cultures, the good of the individual is often so enmeshed with the good of the family or in-group that family members may have a greater say in health care decisions than the patient does in some circumstances. For example, in many countries, family members may become very upset if a physician reveals bad news directly to a patient. Thus, physicians will not value truth-telling in the same way American doctors do because it would be culturally appropriate for them to withhold negative information from patients, especially terminal diagnoses. Even in the United States, families of certain cultural backgrounds may be more likely to prefer this approach (Blackhall et al. 1995). Some Navajos, for example, may consider it inappropriate to make mention of any negative future events because voicing them is akin to wishing them to happen.

Truth-telling is a good example of how differently people from individualist and collectivist cultures value the role of physicians. This is also a great example of why self-reflection is crucial. A physician who understands that his/her own expectations and behaviors are based on his/her culture will be more likely to consider that families may have very different expectations. He/she will be more inclined to check things out first - for example by asking who will be involved in decision making. The literature shows that patient-provider relationships are enhanced by bringing critical questions to the surface, such as: Who have you asked for help/advice about this health problem? How, and by whom, are decisions made by your family about health care? Who should be present for support or to help in decision-making? These and other questions will be explored in greater depth in upcoming newsletters.

As we begin the second year of cross-cultural communication workshops, it is important for us to hang a key question mark of our own. Why are we dedicating time to becoming more culturally aware, sensitive, and responsive? Hopefully we aren't just jumping on the proverbial cross-cultural bandwagon, directed by CLAS Standards and the extensive literature supporting cultural competence in health care. In presentations for over sixty private pediatric practices, the anecdotes and conversations shared by attendees are the best indication that the answer to this question lies in the personal dedication of individuals helping kids and families every day.

References
Michael A. Refolo, The Patient Self-Determination Act of 1990: Health Care's Own Miranda, 8 J. CONTEMP. HEALTH L. & POL'Y 455, 467-68 (1992).
Leslie J. Blackhall, MD et al, Ethnicity and Attitudes Toward Patient Autonomy. JAMA. 1995;274(10):820-825.The Elements of Providing Culturally Sensitive Care