Understand The Culture of Your Practice

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. Culture can be seen as an integrated pattern of learned beliefs and behaviors that can be shared among groups and includes thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and customs. (Robins et al., 1998b)… Culture should not be considered “exotic” or about “others.” We all are influenced by and belong to multiple cultures.” (IOM)

The Culture of Western Medicine and Individual Medical Practices

Self-reflection is essential to the cross-cultural learning process. Without understanding that everyone has a culture, we can have a tendency to treat culture as if it were a “thing.” This reification of culture – making it into something concrete – leads to erroneous beliefs such as “some people have more culture than others” or “there is no American culture because this nation is a melting pot of other cultures.” Healthcare professionals in the United States benefit enormously from understanding the multiple cultures they personally identify with, especially the culture of their profession. Also important, but often overlooked, is the culture of the specific setting where a provider sees patients. A large FQHC has a culture different from a small private practice, and the patient experience will obviously be different in each setting. It follows that each and every private practice has a unique culture, an integrated pattern of learned beliefs and behaviors that become established through daily workplace interactions over time. Values – codified or not – drive established routines and ways of interacting and communicating. Expectations of roles and relationships are shared among people who work together, especially in well-established care teams. Expectations of roles and relationships also extend to patients and families, but it can be difficult to communicate those expectations to people outside the culture. This very disconnect  between expectations shows up in poor patient engagement and compliance.

The Impact on Patient Engagement

The intrinsic challenge in patient engagement is bringing people who do not belong to the medical culture into a highly specific cultural setting and convincing them they can and should engage.  As human beings, we develop our self-esteem and identity within particular cultural contexts. Without a clear sense of our own cultural identity in any situation, a person will tend to experience confusion and a sense of isolation. Our resistance to being put in situations that trigger such discomfort is natural. In medical settings, this discomfort can manifest as distrust, passiveness in communication with providers, and poor compliance.

Providers, Care-Teams, and Staff as Cultural Mediators

Each time a patient feels disoriented and powerless in our complex system of care, the position of being an “outsider” is reinforced. Typically, the boundaries between the medical culture and the patient are first experienced when the patient attempts to access appropriate care. If the patient in search of a doctor does not speak English fluently, has limited health literacy, and is unfamiliar with western medicine, this very first step of engagement with the health care system can be especially overwhelming. Far too often it is overwhelming for even the “mainstream” American. Though providers and staff can not, in the broadest sense, change the healthcare system, they are agents for change on a daily basis when it comes to patient experience. Providers, care teams, and staff, act as bridges, go-between, and mediators for the medical culture and the patient.

Providers Set the Standard for Engagement

Cultural Mediators have to be effective communicators because nothing creates a sense of isolation faster for a patient than struggling to be understood. Providers who want better patient engagement need to set the example for expectations around communication, and in doing so, demonstrate for their patients and families a lot about the medical culture.

 Demonstrate Active Engagement

• Seek real understanding.
• Use skills like teach back – practice until seamless and comfortable
• Emphatically encourage questions
• Do more than just “offer” interpreters – use them effectively
• Avoid becoming doctor “off-centered” in the quest for patient-centered care
• Adapt care for differences in culture, language proficiency, and literacy

The patient’s physical and emotional experience of well-being is absolutely personal. What could possibly be more personal? And yet too often the experience of health care runs completely contrary to this essential fact. The gap between the patient and the culture of medicine is too great. Providers who really understand this aspect of patient experience will avoid reinforcing the boundary that keeps patients feeling like outsiders in their own care.