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    Thursday, September 02, 2004

    Prejudging: There's a movement in academic medicine called cultural competency that's beginning to take root. The idea is that we need to be trained to be sensitive to people from other cultures. Here's an example:

    Being competent in cross–cultural functioning means learning new patterns of behavior and effectively applying them in the appropriate settings.  For example, a teacher with a class of African–American children may find that a certain look sufficiently quiets most of the class.  Often African–American adults use eye contact and facial expression to discipline their children.  However, this is not effective with all African–Americans.  Intra–group differences, such as geographic location or socioeconomic background, require practitioners to avoid overgeneralizing.  With other students, one might have to use loud demanding tones, quiet non–threatening language, or whatever is appropriate for those students.  The unknowing teacher might offend some students and upset others by using the wrong words, tone, or body language.  Being culturally competent means having the capacity to function effectively in other cultural contexts.

    This week's New England Journal of Medicine provides more examples (subscription required):

    Consider the case of a Hispanic woman with hypertension whose blood pressure had been difficult to control for more than two years. A workup had ruled out secondary causes, and she had received various antihypertensive medications. Finally, an exploration of her perception of hypertension revealed that although she said she took her medication every day, she believed she knew when her blood pressure was high and therefore took it at different times of the day and sometimes not at all. Asking this patient about her understanding of the cause of hypertension clarified her perspective. This discussion provided an opportunity for reeducation and negotiation about medication.

    And then there are the Italians:

    Or consider the case of an elderly Italian woman whose son asked her surgeon not to inform her that she had metastatic colon cancer. A culturally competent clinician discovered that the son thought it would "kill" his mother to know the truth. This scenario is common in many cultures, but decision-making and truth-telling processes vary from family to family. Exploring the reasons for and consequences of this preference for secrecy leads to negotiation and an ethically appropriate compromise whereby the patient may be informed of her condition in a way that is agreed on by the family.

    Or the Chinese:

    In response to the proper inquiry, a Chinese man with limited English proficiency who was treating his asthmatic daughter with herbal remedies (in addition to her prescribed inhalers) explained that this tradition had been passed down for generations. Once the herbal treatment was revealed, the appropriate use of inhalers could be reviewed and reemphasized.

    You don't have to be "culturally competent" to tease out these kinds of details from patients' lives. You just have to be humanly competent. Each of those examples could have occurred in any ethnic group. It's a mistake to train young doctors to think of each ethnic group as a cultural stereotype. There are as many different types of families among Chinese, Italians, Hispanics, etc. as there are among Boston brahmins. It's much better to approach every patient with an open mind, and to make as few assumptions as possible about them.


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