Cultural Competence and Biomedicine

For many, culture has come to mean “the way we do things around here,” but that’s not quite right. More correctly put, it is “what we take for granted around here.” In other words, practices that are incorporated so deeply into a group’s way of life so as not to require conscious thought are parts of that group’s culture. For instance, no one questions why we speak English in America (although in “My Fair Lady,” it is noted that America was one place where English completely disappeared!) We are born into a society of English speakers; we learn it at home and school. We use it in the course of everyday life. (If you are beginning to tire of this list, it just proves my point: English is an element of American culture that doesn’t have to be explained.)

When commentators talk about cultural competence, they generally refer to the ability of a medical provider to relate to patients from different cultures. Thus, Anglo providers are encouraged to become familiar with Hispanic or Russian or Hmong culture and language, presumably so as to be better able to get along with, understand and treat such patients. (An Internet search for “medical Spanish” yielded 22 million hits, including an ad for a smartphone app.) Medical students and residents are warned about cultural faux pas when dealing with representatives of non-Anglo cultures. In the medical encounter, one such faux pas is the direct approach of a Hispanic woman without getting “permission” from her husband or father.

But what about the culture of medicine itself? The way medicine is practiced in this country is a culture unto itself, with its own values, myths, practices and ideologies. Some of the values are rationality, measurement and scientific method. Elements of biomedical ideology include a hierarchy in which other workers are subordinate to physicians and their decisions, as well as framing the participants in medical encounters as knowledgeable experts treating ignorant patients, so as to justify the expectation that patients will follow “doctors’ orders.”

The transparency of this culture to its providers makes it difficult for them to transcend it in any encounter, not just encounters with representatives of non-mainstream cultures. Speaking “medicalese” is merely the tip of the iceberg. Doctors who neglect the culture of medicine may perpetuate practices learned in training without considering whether or not they are in the patient’s best interest. Instead, such cultural practices (such as tonsillectomy for persistent childhood sore throat) may result in much mischief.

What is needed is a thoroughgoing self-consciousness on the part of providers so as to take the differences between biomedical and lay culture into account, and when appropriate, transcend medical culture to adopt a more personal perspective.

When providers examine their own culture and step out of it to deal with patients as persons (and not simply bearers of broken machinery) they may rediscover the joy of genuine, healing human connections that prompted a medical career in the first place. And patients may be happier and more willing to follow through with recommendations.