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Dissertation.Aguilar.Pdf (6.542Mb) Copyright by J. Ernest Aguilar 2008 The Dissertation Committee for John Ernest Aguilar certifies that this is the approved version of the following dissertation: BEYOND CULTURAL COMPETENCY: USING LITERATURE TO FOSTER SOCIALLY CONSCIOUS MEDICINE Committee: Anne Hudson Jones, Ph.D., Chairperson Howard Brody, M.D., Ph.D. Robert Bulik, Ph.D. Sayantani DasGupta, M.D., M.P.H. Harold Y. Vanderpool, Th.M., Ph.D. Cary W. Cooper, Ph.D. Dean, Graduate School BEYOND CULTURAL COMPETENCY: USING LITERATURE TO FOSTER SOCIALLY CONSCIOUS MEDICINE by John Ernest Aguilar, B.S., M.Div. Dissertation Presented to the Faculty of the Graduate School of The University of Texas Medical Branch in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy The University of Texas Medical Branch August 2008 Dedication For Andrea, Julia, Mia, C. J., and Gabriella Preface Throughout the course of my ministerial training and formation, I was required to meet with a spiritual director on a regular basis. One of the individuals who guided me was a religious sister. Once a week, she took time from her busy schedule of pastoral care, community organizing, and homeless advocacy to sit and listen to me reflect upon my self- discoveries as a dishwasher in a kitchen that served the clients of a medical recovery center for homeless men and women. She was not usually very assertive in her approach. Mostly, she would sit and listen as I tried to sound as eloquent and as spiritual as I possibly could. She would ask questions, and on occasion she would encourage me to consider a different perspective on a situation. She would occasionally suggest that I read an article or an essay or that I attend some event in the community. Towards the end of our time together, during a conversation in which I shared my frustration over some social ill or another, she leaned forward, stopped me by placing her hand on mine, and said, Ernie, your injustice button works just fine. After all these months, we know that. It’s going to be up to you now to learn what do when that button gets pushed. Indignation is a start, but it is never enough. Use your intellect and use your experience and learn how to see your way out of the anger that explodes each time you encounter some new injustice. I knew enough then, at twenty-three years of age, to take note and to write the words she spoke that day in the unused journal that was the sole occupant of the bottom drawer of my desk. I would not know for some time, however, what to do with her advice. Yet as I drew ii near to the end of this dissertation I began to realize that, in many ways, I have been responding to her challenge throughout my time at the Institute for the Medical Humanities. These four and a half years have been a search for intellectual schema from which to argue for a greater call to justice and solidarity with those who suffer. Sister Marcella encouraged me to begin my work from within my own lived experience. Thus, I began my research for this dissertation by recalling my own experiences of attending training programs for cultural competency. As a health-care chaplain of many years, I spent a great many Saturdays in workshops and training sessions where I listened as presenters described the socially disruptive grieving process of African-Americans, the primitive health practices of Mexicans, and the debilitating need to succeed in Asians. Participants were instructed to tolerate the occasional animal sacrifice, to overlook the excessively large families of cultural minorities, and never to tell an Asian patient that she has a terminal illness.1 Somehow, despite the animosity that was communicated, participants were expected to understand the importance of showing respect for the cultural differences they would encounter in patients. I will admit here that (for a very brief time) when I attended my first training session, I was quite taken with the idea. I was persuaded by the presenters as they argued that training in cultural differences would lead to greater justice in health care. Yet my appreciation for the project quickly faded. I grew frustrated with the content of the programming and the attitude of the presenters. Unfortunately, despite Sister Marcella’s advice, I spent a great deal of time at the mercy of my injustice button. I did not take the 1 The negative representation of these concepts is intentional. Very often, presenters expressed condescending attitudes towards the “traditional” practices of “primitive” minorities. iii time to formulate an intellectual critique of the material that was presented. Instead, I settled for being a thorn in the side of presenters who, seemingly, were accustomed to participants who were less vocal and less antagonistic. As I was unable to formulate a rational objection to the material, my comments were dismissed and my questions were ignored. I soon realized that I needed to find a new path to explore my questions and to articulate my objections to training programs in cultural competency. The ways in which many training programs in cultural competency reinforce the patterns of dominance that lead to racial disparities would become only a part of the work. In the course of my research and writing, I came to understand the issues at a much deeper level than I had anticipated. Fortuitously, my proposed response (the use of literary works and the development of narrative skills in medical education) proved to be even more applicable at the deeper levels of the issues I explored. I trust that Sister Marcella would be pleased that I have finally taken her advice. iv Acknowledgments I am truly grateful for the expert guidance of my mentor, Dr. Anne Hudson Jones, and the members of my dissertation committee. Their insights and their challenges moved me in unexpected directions where new discoveries were possible. Dr. Sayantani DasGupta’s willingness to participate and contribute from such a distance enriched my work in ways that I could not have anticipated. I would like to thank the faculty at the Institute for the Medical Humanities (IMH). They have taught me well, and I trust that they are pleased with what I have accomplished. I would especially like to thank Dr. Michele Carter, the chairperson of my qualifying examination committee, and Dr. Harold Vanderpool, who served as my first advisor. My successes at the IMH were built upon the work of the many educators who have challenged and inspired me over the years. I thank my instructors at the Washington Theological Union, the University of Texas at Austin, and the Zaragoza Air Base Schools. I thank the many individuals who have guided and accompanied me in my search for justice. I am thankful for those individuals who agreed to be interviewed. Their insights proved invaluable. I would especially like to thank Dr. Alejandro Morales for his generosity. I am grateful for having spoken with my uncle Mr. Guadalupe Salinas regarding events that continued to haunt him. He died on July 15, 2008. I extend my thanks to Dr. Helena María Viramontes for her permission to reprint her short story “The Cariboo Cafe.” Although I do not have the space to list each of them by name or to describe all that they have done to keep me grounded, I am grateful for my many friends who have loved me through this challenging experience. I thank my parents, Juan and Margie Aguilar, my brother Christopher Aguilar, and my sister-in-law Corazón Aguilar for their unwavering belief that I could do this—a confidence that served to replenish my own. They may not have always known what I was doing, but they never doubted that I could do it. Finally, I know that this dissertation would not have been possible without David Aguilar, my loving husband. He enthusiastically uprooted his life to join me on this journey. Even when overwhelmed with his own studies, his support and encouragement never faltered. I thank him for knowing when to make me work, when to get me to play, and when to let me sleep. v Abstract Beyond Cultural Competency: Using Literature to Foster Socially Conscious Medicine Publication No._____________ John Ernest Aguilar, Ph.D. The University of Texas Medical Branch, 2008 Supervisor: Anne Hudson Jones Abstract: For at least the past three decades, training programs in cultural competency have enjoyed increasing popularity in medical schools and in continuing medical education. Proponents of cultural competency generally hold that when physicians and other health-care professionals are trained in cultural issues, there will be a reduction in race-based disparities in both the access to and the quality of health care. Yet there has been little evidence to support this claim. Further, a conceptual analysis of cultural competency suggests that this type of training may serve only to maintain or further aggravate the current state of affairs faced by cultural and racial minorities. New pedagogical models are needed. These models will need to include an opportunity (and the support) for the unlearning of old patterns of viewing society. Participants will need to reflect on the social factors and structures that are more likely to lead to race-based vi disparities. These factors include but are not limited to a legacy of interracial hostility and mistrust, the unjust distribution of social power, and a defective understanding of the proper posture to be taken towards the one that is other. Educational theories that promote participatory, transformative, and reflective learning experience must be used to shape new educational efforts.
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