Training providers in culturally responsive and competent care enhances the quality of patients’ experiences and produces care for providers, which enhances work satisfaction by reducing confl ict and stress. Addressing these issues requires that anthropologists have ethnographic immersion in the health care setting to familiarize themselves with clinical aspects of physicians’ consultation, diagnosis, and therapeutic activities. These experi- ences sensitize anthropologists to medicine’s stresses, limitations, and burdens and pro- vide perspectives necessary for communicating with physicians in their accustomed language and conceptual frameworks.
To be successful in clinical settings, anthropologists must understand and adapt to biomedical culture. Johnson (1991) outlines a variety of strategies for such adaptation, providing perspectives from which to bridge physician and patient models to accommo- date the effects of cultural factors on illness and healing.
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Guidelines for Working in Clinical Settings
Johnson (1991) provides a number of guidelines to assist social scientists in preparing for work in clinical settings. These are based on the perspectives of consultation-liaison psychiatry, which provides services to other physicians in managing the psychosocial problems associ- ated with patient care. Anthropology contributes to clinical care through explanations pro- vided by systems approaches, emic perspectives based in participant observation, use of the explanatory model, and cultural relativism. An awareness of the culture of medicine and its sensitivities is important. An appreciation of institutional patterns and providers’ perspectives is essential for the development of programs of change that do not violate the local cultural systems and their norms. Anthropologists’ history of criticism of biomedicine makes it impor- tant to adopt a nonjudgmental approach.
As in all fi eld work, a familiarity with the overall clinical culture and socialization process is important. Cross-training in another health discipline obviously enhances access. A knowledge of medical cultures can derive from a review of material on medical education and professional socialization, familiarization with the language of medicine, and immersion in clinical settings to acclimate to the culture. Participation in the “attending rounds,” particularly those at chal- lenging early morning hours, exposes one to a basic aspect of medical activity and shows a commitment to professional concerns.
Anthropologists can contribute to medical care by teaching providers how to use sys- tems perspectives to understand clients’ behavior, placing individual actions and concerns within their sociocultural context. Anthropology’s systems perspectives also lend them- selves to addressing the institutional dynamics that affect patient care. Anthropologists can make contributions to care through the role of a cultural broker in mediating between dif- ferent subsystems (professional or organizational). The biopsychosocial perspective and general systems theory are the frameworks within which patient and clinician behaviors are addressed. Understanding a patient begins with family systems and community perspec- tives and extends into the broader bureaucratic and political systems. This situation- oriented consultation examines the factors in a patient’s life milieu that contribute to the patient’s health problems, particularly compliance with treatment. Physician behavior is similarly approached in a systems perspective that considers the different professional cultures (phy- sicians, nurses, administrators, etc.) and subcultural systems within the hospital. Following the consultation-liaison psychiatry approach, patient problems are also analyzed through a physician-oriented approach that looks at the contribution of treatment providers and their institutional settings to patient problems. Analysis of the hospital as a cultural system can contribute to an understanding of the systemic dysfunctions that produce diffi culties for patients and physicians, including confl icts among providers or different divisions of health care institutions.
APPLICATIONS
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Fadiman (1997) suggests that the explanatory model could have provided a tool to prevent the disaster that occurred in the case of Lia Lee. Eliciting patients’ perspectives reveals the psychosocial and cultural dimensions of their responses to treatment and how the condition and treatment relate to a patient’s life. Consideration of patients’ perspec- tives reveals disagreements and helps resolve noncompliance. The quality of patient care can be enhanced by assessing dimensions of care concerned with ensuring physical com- fort and well-being; respecting patients’ values, preferences, and communication styles;
providing emotional support and addressing fears; ensuring the involvement of family and friends; and coordinating and integrating different care services and ensuring continuity and appropriate transition (Delbanco, 1992). Kleinman (1980) points to the importance of also considering the macrosocial economic, political, and other structural factors affecting the microsocial clinical views of illness behavior and patient-doctor interactions. Culture is a vital aspect of health because it is fundamental to the health behaviors of patients and providers.
Patient-Provider Relationship Building
Importance of Medical Interview The medical interview is important for obtaining information needed for diagnosis; it is also important as a means for developing the doctor-patient relationship within which the patient’s collaboration with the proposed treatment is achieved. Aldrich (1999) emphasizes the role of the medical interview in establishing the provider’s interest in the patient, communicating an empathic response on the part of the provider that, in turn, helps establish a relationship in which the patient feels comfortable communicating health concerns.
Aldrich (1999) emphasizes medical interviewing needs to focus on patients’ concepts of illness and their views regarding their condition; these concerns are elicited by the explanatory model (discussed in Chapter Two). Interviewing must be sensitive to cultural communication styles, including global aspects related to directness, disclosure, and other dimensions exemplifi ed under social interaction rules. To encourage disclosure, the inter- viewer needs to adopt a nonjudgmental attitude and give feedback to indicate understand- ing of the patient’s concerns.
Differences between providers’ and clients’ explanatory models need to be addressed without judgment or ridicule of clients’ perspectives. If the differences in clients’ explan- atory models are signifi cant blockages with respect to the adoption of a provider’s recom- mendations, those differences need to be carefully examined. Providers should explain their own views and the reasons they have for a particular diagnosis and treatment recom- mendations. If the confl icting explanatory models do not interfere with treatment and compliance, the differences may not need to be addressed. If providers feel they need to understand these differences, further elicitation of the client’s beliefs and placing those beliefs in cultural context are recommended.
If clients’ beliefs and explanations do interfere with medical treatment, an explana- tion of the basis for those beliefs, their justifi cation, and patient education regarding bio- medical knowledge may be an appropriate part of treatment. O’Connor (1995) suggests
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addressing confl icts between client and provider explanatory models in terms of beliefs systems and values and with respect to
Cultural evaluations of the signifi cance of the illness Concerns regarding the social implications of treatments Religious beliefs regarding the nature of the condition Impacts on lifestyle created by the condition or treatment Means for negotiating between provider and client models
Intercultural contact inevitably produces confl icts and misunderstandings because of cultural differences; consequently, an active approach to minimizing and resolving con- fl ict is necessary for cultural competence. Confl ict is worsened by typical personal and cultural approaches of attributing confl ict to personal failings of others. This normal ten- dency to engage in assigning blame (or attribution) needs to be replaced by a conscious decision to understand the other’s behavior as culturally reasonable, seeing the situation from the other’s point of view and his or her personal and cultural defi nition of the situa- tion. Cross-cultural problem resolution can be achieved by identifying, describing, and analyzing the problem from both cultures’ points of view to negotiate a solution that combines both cultures’ concerns and perspectives.
Negotiation Negotiation is necessary to provide culturally competent care. Negotiation provides the mechanism for resolving differences in perceptions, desired treatment pro- cesses, and goals of treatment. Without negotiation, the likely outcome is an effort at eth- nocentric imposition of the biomedical culture and values. Effective negotiation requires both specifi c cultural knowledge and generic cross-cultural negotiation and confl ict reso- lution skills. Negotiating linkages between the medical culture and the culture of patients involves a brokering process that enables a conceptual sharing of provider and patient explanatory models. “Managing professional and patient models requires providers’
awareness of impacts of personal and professional values, shared cultural biases, and conventional metaphors of self, others, the body, and emotions on clinical assessment and decision making” (Kleinman, 1982, pp. 87–88). This cultural self-awareness and other cultural awareness provide a basis for recognizing the sources of difference and mediation between these two cultural perspectives. Kleinman’s model uses “genuine negotiation” to make a patient ultimately responsible for fi nal decisions. Kleinman sug- gests that it requires a determination of who (patient, family) should make decisions and the culturally appropriate forms and contexts for negotiation.
Kleinman (1982) outlines an eight-stage negotiation approach (which may be expanded or contracted as needed) as a basis for achieving patient compliance:
Physician elicits explanatory model and illness problems from patient’s perspective Physician presents own explanatory model and proposed treatments in lay terms Patient or physician shift models to form working alliance
Physician acknowledges and clarifi es physician and patient discrepancies
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Patient and physician negotiate changes to reach a mutually agreeable treatment Physician offers compromises to confl icts and attempts to implement them Physician acts as expert adviser, patient as fi nal arbiter
Physician and patient plan for ongoing monitoring of agreement and participation O’Connor (1995) suggests the following approaches to support the negotiation of an agreed-on treatment plan:
Express an attitude of openness and the willingness to cooperate Explain in everyday language the providers’ recommendations
Explicate the reasons for disagreement with the patient’s beliefs or preferences Accept preferred treatments not in confl ict with patient’s interests
Engage in shared decision making
Compromise on issues regarding religious beliefs
Adopt cultural behaviors that communicate trust and respect Understand the patient’s goals in treatment
These approaches require an ability to place the patient in the context of the cultural sys- tem that shapes his or her illness behaviors and healing responses. Anthropologists use a variety of perspectives for contextualizing patients’ concerns.
Cultural Effects on Care
A basic role of clinically applied anthropology is to facilitate understanding between cli- ents and physicians and as patient advocates and advocates for broader health concerns that facilitate institutional operations and enhance the well-being of clients and providers.
This provides a context for an activist role for medical anthropology. Clinicians need to be aware of the sociopolitical context affecting practice and clients and to facilitate that adaptation proactively. Traditionally, the primary role of cultural information in clinical medicine and public health was indicating areas in which to change the behavior and life- style of cultural groups. Cultural perspectives are also needed to understand and change behavior of providers and institutions to provide more appropriate services. Culture has important infl uences on who will use services, under what conditions, and for what prob- lems. The adaptation of health services to clients’ perceptions and expectations is essen- tial for their success.
Anthropological contributions to clinical medicine are based on conveying an under- standing of patients’ cultural backgrounds, their illness beliefs, and health-seeking behav- iors and motivations, which can play an important role in understanding their complaints and the care they want. This enables providers to incorporate the patient into the overall treatment plan that addresses not only disease but illness and sickness as well. Cultural
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understandings that can enhance clinical relations by addressing factors affecting access to and presentation for biomedical treatment include such features as (Harwood, 1981;
Kleinman, 1988a, 1988b) Meaning of symptoms
Factors affecting the recognition of symptoms and disease Concepts of disease or illness and theories of its causes and cures Conceptions of body and bodily functions and their meanings
Expressions (language, metaphor) of dysphoria, pain, and sick-role behavior Emotional reactions to illness, sickness, disease, and symptoms
Social networks for managing illness
Contributions of culture, family, and community to causation of disorders Impacts of sickness on social life, roles, behavior, work, and family relations Descriptive data on how culture and social organizations affect health
Effects of government, social policy, and health bureaucracies on health care access Relation of morals and religious systems to conceptions of health
Syncretic approaches and simultaneous multiple-sector use patterns Potentially dangerous popular or folk-sector practices
Patient expectations of the clinical encounter
Patient communication processes and disclosure norms Client group familiarity with clinical language and procedures Interactional norms and intercultural confl icts
Decision-making processes
Issues affecting compliance, expectations, obligations, family dynamics Cultural dietary and drug use patterns
Client group’s everyday activities Client’s psychocultural dynamics
Cultural dynamics of clinical communication
Enhancement of diagnostic interview processes with ethnographic knowledge Effects of clinician’s culture on diagnostic processes
Effects of professional biases on clinical encounters
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Using Culture to Care for Biomedical Practitioners
A crisis for biomedicine derives from the loss of faith and trust by patients and problems with biomedicine’s delivery that together produce dissatisfaction for both patients and providers (Hahn, 1995; Press, 1982). Resolving providers’ burnout can be addressed by making their job easier using the perspectives of anthropological medicine to facilitate their care of patients. Resolving patients’ alienation requires addressing patients’ per- spectives and adopting an advocacy approach to remedy the ineffective distribution of health care. Biomedicine faces challenges that can be addressed by understanding cul- tural effects on health behavior. Challenges range from patients’ dissatisfaction and loss of respect for physicians to physicians’ dissatisfaction with their profession and the con- trol over them exercised by government, administrative bureaucracies, and health organi- zations. Physicians suffer from high levels of stress-related conditions (e.g., suicide, depression, and addiction). Physicians face alienation in relations with their patients and the systems that control their practice. Physicians need help, and the crisis that biomedi- cine faces calls for changes, but physicians do not want change imposed on them.
The alternative is that physicians attempt to change their own practices using guidance from medical anthropology. Central problems facing biomedicine involve interpersonal style, community relations, professional image, and communication competence (Press, 1982).
These problems result from class and cultural differences and medical theories alienated from the communities that physicians serve. These problems that confront medicine can be addressed by integrating anthropological medicine into biomedical practice (Hahn, 1995).
A basic problem is the challenge to professional competence caused by the variety of cultures for which physicians provide care. Cultural knowledge and cross-cultural skills can facilitate providers’ tasks with information and perspectives that reduce ambiguity, uncertainty, confl ict, and misunderstanding. Understanding the social and cultural dimen- sions of health and health behavior facilitates a cultural and psychosocial analysis of ill- ness and healing that can guide providers’ adaptations. These promote the well-being of providers by addressing uncertainties through information and interpersonal capabilities.
Cultural information about clients and biomedical culture can help improve physicians’
understandings of themselves and their work by identifying unconscious assumptions, values, and motivations that underlie their practice and the behavior of their patients. For example, Johnson (1991) suggests that physicians need to be aware of their unconscious desires to control their patients. Cultural knowledge can contribute to more effective ways of meeting this need by permitting more accurate predictions of patient behavior, skills in negotiating compliance, and greater fl exibility in the care of patients.
Part of providing healing for practitioners involves processes that change their commu- nity image and client relationships. The social image of physicians is affected by their lack of connection with the life-worlds of their clients and their clients’ lack of accessibility to their services. Changing physicians’ images requires that they take activist roles in commu- nity health development and policy formation and serve as mediators and facilitators in pub- lic health and clinical contexts. The development of family practice and the neighborhood decentralization of medical resources are partial solutions to accessibility (Press, 1982).
Paying more attention to the effects of illness and treatment on everyday life and adjusting medical procedures and schedules to accommodate actual life conditions is important to
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enhancing sensitivity of services. Physicians can change their relationships with patients through a social advocacy approach in which health care providers accept a broader social responsibility to address the structural constraints that affect health and well-being. A more equitable allocation of health resources is making physicians’ care more accessible. Service to communities is a part of healing, a relationship that can provide personal benefi ts to health providers, a “helper’s high,” a “sense of well-being, satisfaction, and self-esteem that may bathe helpers after their good works” (Walsh, 1990, pp. 210–211).
Providers are further challenged by clients’ dissatisfaction with the impersonal aspects of biomedical care and the inability of biomedicine to address many of the social causes and contributory factors to disease. Use of the explanatory model helps bridge the concep- tual gap between providers and patients, enhancing an understanding of patients’ illness and sickness behavior, and consequently enabling providers to be more responsive.
Anthropologists can also assist overall care by facilitating management of the psychocul- tural dynamics of illness. A central need is sensitivity to the impact of illness and treatment on patients’ everyday lives, addressing the psychosocial concomitants of disease, the social burdens of sickness and treatments, and their effects on the family. Medical anthropolo- gists facilitate physicians’ challenges to provide appropriate treatment responses, guiding
African Americans’ Cross-Cultural Interactions with Biomedicine
African Americans are often suspicious of doctors and the medical system to such extreme degrees that effective clinical communication and disclosure may be seriously impaired. Various historical factors have contributed to the distrust of doctors (Bailey, 2004), including their use of African Americans in medical experiments. This has often been done without their knowl- edge or consent and has actually contributed to the spread of disease in the African American community. The infamous Tuskegee study left African American men with syphilis untreated for decades even though antibiotics were available. The study was proposed in the scientifi c interest of determining if blacks and whites responded to syphilis differently; its continuation for decades suggests that other racist elements were involved in the decisions. This has led to a general distrust of government health initiatives and treatment programs. Providers are more likely to be effective in working with African American patients if they recognize that there is a likelihood of a serious distrust of the doctor. Cross-cultural communication skills become tools at establishing more effective relations and overcoming the burdens of history.
A signifi cant feature of the intercultural relations of African Americans with biomedicine is the feeling of a lack of respect from doctors. Doctors in the United States often try to put their patients at ease (or in their place?) by using fi rst names: “Hi, I am Dr. Jones, how are you doing, Mary?” This might make some people feel more comfortable, but to African Americans, this is often seen as reinforcing a power relationship. Respect can be shown by addressing adults as “Mister” or “Mrs.” unless told otherwise by the patient.
BIOCULTURAL INTERACTIONS
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