All clinicians know the importance and influence of culture in the practice of medicine. When cultural differences are ignored or overlooked, not only are patients left feeling isolated and belittled by their healthcare providers, but extensive research shows that such actions frequently lead to poorer health outcomes. Some in the field of medical education have looked to ethnography to better prepare future doctors to validate and integrate cultural considerations into their clinical practice. These educators have developed a three-step approach; what they call the “mini-ethnographic interview.”
The first step of this approach is to ask the patient about her ethnic identity and determine whether it matters for the patient i.e. whether it is an important part of the patient’s sense of self. As part of this inquiry, it is crucial to acknowledge and affirm a person’s experience of ethnicity and illness. This is basic to any therapeutic interaction, and enables a respectful inquiry into the person’s identity. The clinician can communicate a recognition that people live their ethnicity differently, that the experience of ethnicity is complicated but important, and that it bears significance in the health-care setting. Treating ethnicity as a matter of empirical evidence means that its salience depends on the situation.
The second step is to evaluate what is at stake as patients and their loved ones face an episode of illness. This evaluation may include close relationships, material resources, religious commitments, and even life itself. The question, “What is at stake?” can be asked by clinicians; the responses to this question will vary within and between ethnic groups, and will shed light on the moral lives of patients and their families.
Finally, step three consists of examining culture in terms of its influence on clinical relationships. Clinicians are grounded in the world of the patient, in their own personal network, and in the professional world of biomedicine and institutions. One crucial tool in ethnography is the critical self-reflection that comes from the unsettling but enlightening experience of being between social worlds (for example, the world of the researcher/doctor and the world of the patient/participant of ethnographic research). So, too, it is important to train clinicians to unpack the formative effect that the culture of biomedicine and institutions has on the most routine clinical practices—including bias, inappropriate and excessive use of advanced technological interventions, and, of course, stereotyping.
Teaching practitioners to consider the effects of the culture of biomedicine is contrary to the ethnocentric view of the expert as authority and to the media’s view that technical expertise is always the best answer. The statement “First do no harm by stereotyping” should appear on the walls of all clinics that cater to immigrant, refugee, and ethnic-minority populations. And yet, since culture does not only apply to these groups, it ought to appear on the walls of all clinics.
If we were to reduce the three steps of culturally informed care to one activity that even the busiest clinician can find time to do, it would be to routinely ask patients (and when appropriate family members) what matters most to them in the experience of illness and treatment. The clinicians can then use that crucial information in thinking through treatment decisions and negotiating with patients. Finding out what matters most to another person is not a technical skill. It is an elective affinity to the patient. This orientation becomes part of the practitioner’s sense of self, and interpersonal skills become an important part of the practitioner’s clinical resources. It is what Franz Kafka said, “a born doctor” has: “a hunger for people.”
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