in the Clinic: The Problem of Cultural Competency and How to Fix It

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Citation Kleinman, Arthur, and Peter Benson. 2006. “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” PLoS Medicine 3 (10) (October 24): e294. doi:10.1371/ journal.pmed.0030294.

Published Version 10.1371/journal.pmed.0030294

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patients of a certain ethnicity—such as, practical understanding of an episode the “Mexican patient”—are assumed (see Box 1). to have a core set of beliefs about Historically in the -care illness owing to fi xed ethnic traits. domain, culture referred almost solely Cultural competency becomes a series to the domain of the patient and of “do’s and don’ts” that defi ne how family. As seen in the case scenario to treat a patient of a given ethnic in Box 1, we can also talk about the background [10]. The idea of isolated culture of the professional caregiver— societies with shared cultural meanings including both the cultural background ultural competency has become would be rejected by anthropologists, of the doctor, nurse, or social worker, a fashionable term for clinicians today, since it leads to dangerous and the culture of biomedicine Cand researchers. Yet no one can stereotyping—such as, “Chinese believe itself—especially as it is expressed in defi ne this term precisely enough to this,” “Japanese believe that,” and so institutions such as hospitals, clinics, operationalize it in clinical training and on—as if entire societies or ethnic and medical schools [14]. Indeed, the best practices. groups could be described by these culture of biomedicine is now seen It is clear that culture does matter in simple slogans [11–13]. as key to the transmission of stigma, the clinic. Cultural factors are crucial Another problem is that cultural the incorporation and maintenance to diagnosis, treatment, and care. factors are not always central to a case, of racial bias in institutions, and the They shape health-related beliefs, and might actually hinder a more development of health disparities behaviors, and values [1,2]. But the across minority groups [15–18]. large claims about the value of cultural competence for the art of professional Culture Is Not Static care-giving around the world are simply Box 1. Case Scenario: Cultural In anthropology today, culture is not supported by robust evaluation Assumptions May Hinder not seen as homogenous or static. research showing that systematic Practical Understanding Anthropologists emphasize that culture attention to culture really improves A medical anthropologist is asked by clinical services. This lack of evidence a pediatrician in California to consult in is a failure of outcome research to take the care of a Mexican man who is HIV culture seriously enough to routinely Funding: Our work on cultural aspects of clinical care positive. The man’s wife had died of AIDS assess the cost-effectiveness of culturally has been supported by the Michael Crichton Fund, one year ago. He has a four-year-old son , and by a National Institute of informed therapeutic practices, not a Mental Health Training Grant on “Culture and Mental who is HIV positive, but he has not been lack of effort to introduce culturally Health Services” (5T32MH018006-21). bringing the child in regularly for care. informed strategies into clinical settings The explanation given by the clinicians Competing Interests: The authors declare that they [3]. have no competing interests. assumed that the problem turned on a radically different cultural understanding. Citation: Kleinman A, Benson P (2006) Anthropology Problems with the Idea of Cultural in the clinic: The problem of cultural competency and Competency What the anthropologist found, though, how to fi x it. PLoS Med 3(10): e294. DOI: 10.1371/ was to the contrary. This man had a near journal.pmed.0030294 One major problem with the idea of complete understanding of HIV/AIDS cultural competency is that it suggests DOI: 10.1371/journal.pmed.0030294 and its treatment—largely through the culture can be reduced to a technical support of a local nonprofi t organization Copyright: © 2006 Kleinman and Benson. This is skill for which clinicians can be trained aimed at supporting Mexican-American an open-access article distributed under the terms to develop expertise [4]. This problem of the Creative Commons Attribution License, patients with HIV. However, he was a which permits unrestricted use, distribution, and stems from how culture is defi ned in very-low-paid bus driver, often working reproduction in any medium, provided the original medicine, which contrasts strikingly author and source are credited. late-night shifts, and he had no time with its current use in anthropology— to take his son to the clinic to receive Arthur Kleinman is Chair and Esther and Sidney the fi eld in which the concept of care for him as regularly as his doctors Rabb Professor in the Department of Anthropology culture originated [5–9]. Culture is at Harvard University, and Professor of Psychiatry requested. His failure to attend was not often made synonymous with ethnicity, and at Harvard Medical because of cultural differences, but rather School, Boston, Massachusetts, of nationality, and language. For example, his practical, socioeconomic situation. America. Peter Benson is a PhD candidate in medical anthropology in the Department of Anthropology Talking with him and taking into account at Harvard University, Cambridge, Massachusetts, his “local world” were more useful than United States of America. The Essay section contains opinion pieces on topics positing radically different Mexican of broad interest to a general medical audience. * To whom correspondence should be addressed. health beliefs. E-mail: [email protected]

PLoS Medicine | www.plosmedicine.org 1673 October 2006 | Volume 3 | Issue 10 | e294 is not a single variable but rather Box 2. The Explanatory Models of illness is recast into technical disease comprises multiple variables, affecting Approach categories something crucial to the all aspects of experience. Culture is experience is lost because it was not inseparable from economic, political, • What do you call this problem? validated as an appropriate clinical religious, psychological, and biological • What do you believe is the cause of concern [34]. conditions. Culture is a process this problem? Rather, explanatory models through which ordinary activities and • What course do you expect it to take? ought to open clinicians to human conditions take on an emotional tone How serious is it? communication and set their expert and a moral meaning for participants. knowledge alongside (not over and • What do you think this problem does Cultural processes include above) the patient’s own explanation inside your body? the embodiment of meaning in and viewpoint. Using this approach, psychophysiological reactions [19], • How does it affect your body and your clinicians can perform a “mini- the development of interpersonal mind? ethnography,” organized into a series attachments [20], the serious • What do you most fear about this of six steps. This is a revision of the performance of religious practices condition? Cultural Formulation included in the [21], common-sense interpretations • What do you most fear about the fourth edition of the Diagnostic and [22], and the cultivation of collective treatment? Statistical Manual of Mental Disorders and individual identity [23]. Cultural (DSM-IV) (see Appendix I in [35]) (Source: Chapter 15 in [38]) processes frequently differ within the [36,37]. same ethnic or social group because of differences in age cohort, gender, A Revised Cultural Formulation political association, class, religion, not eat pork; some Jews, including the Step 1: Ethnic identity. The fi rst step ethnicity, and even personality. corresponding author of this paper, is to ask about ethnic identity and love pork.) Ethnography emphasizes determine whether it matters for the The Importance of Ethnography engagement with others and with the patient—whether it is an important It is of course legitimate and highly practices that people undertake in their part of the patient’s sense of self. As desirable for clinicians to be sensitive local worlds. It also emphasizes the part of this inquiry, it is crucial to to cultural difference, and to attempt ambivalence that many people feel as acknowledge and affi rm a person’s to provide care that deals with cultural a result of being between worlds (for experience of ethnicity and illness. This issues from an anthropological example, persons who identify as both is basic to any therapeutic interaction, perspective. We believe that the optimal African-American and Irish, Jewish and and enables a respectful inquiry into way to do this is to train clinicians in Christian, American and French) in a the person’s identity. The clinician ethnography. “Ethnography” is the way that cultural competency does not. can communicate a recognition that technical term used in anthropology And ethnography eschews the technical people live their ethnicity differently, for its core methodology. It refers to mastery that the term “competency” that the experience of ethnicity is an anthropologist’s description of suggests. Anthropologists and clinicians complicated but important, and that what life is like in a “local world,” a share a common belief—i.e., the it bears signifi cance in the health-care specifi c setting in a society—usually primacy of experience [29–33]. The setting. Treating ethnicity as a matter one different from that of the clinician, as an anthropologist of of empirical evidence means that its anthropologist’s world. Traditionally, sorts, can empathize with the lived salience depends on the situation. the ethnographer visits a foreign experience of the patient’s illness, and Ethnicity is not an abstract identity, country, learns the language, and, try to understand the illness as the as the DSM-IV cultural formulation systematically, describes social patterns patient understands, feels, perceives, implies, but a vital aspect of how life is in a particular village, neighborhood, and responds to it. lived. Its importance varies from case or network [24]. What sets this to case and depends on the person. It apart from other methods of social The Explanatory Models Approach defi nes how people see themselves and research is the importance placed on One of us [AK] introduced the their place within family, work, and understanding the native’s point of “explanatory models approach,” social networks. Rather than assuming view [25]. The ethnographer practices which is widely used in American knowledge of the patient, which can an intensive and imaginative empathy medical schools today, as an interview lead to stereotyping, simply asking the for the experience of the natives— technique (described below) that patient about ethnicity and its salience appreciating and humanly engaging tries to understand how the social is the best way to start. with their foreignness [26], and world affects and is affected by illness. Step 2: What is at stake? The second understanding their religion, moral Despite its infl uence, we’ve often step is to evaluate what is at stake as values, and everyday practices [27,28]. witnessed misadventure when clinicians patients and their loved ones face an Ethnography is different than and clinical students use explanatory episode of illness. This evaluation may cultural competency. It eschews the models. They materialize the models include close relationships, material “trait list approach” that understands as a kind of substance or measurement resources, religious commitments, and culture as a set of already-known (like hemoglobin, blood pressure, or X even life itself. The question, “What is factors, such as “Chinese eat pork, rays), and use it to end a conversation at stake?” can be asked by clinicians; Jews don’t.” (Millions of Chinese are rather to start a conversation. The the responses to this question will vary vegetarians or are Muslims who do moment when the human experience within and between ethnic groups, and

PLoS Medicine | www.plosmedicine.org 1674 October 2006 | Volume 3 | Issue 10 | e294 will shed light on the moral lives of contrary to the view of the expert as Box 3. Case Scenario: The patients and their families. authority and to the media’s view that Importance of Using Culturally Step 3: The illness narrative. Step technical expertise is always the best Appropriate Terms to Explain 3 is to reconstruct the patient’s answer. The statement “First do no People’s Life Stories “illness narrative” [38]. This involves harm by stereotyping” should appear a series of questions (about one’s on the walls of all clinics that cater Miss Lin is a 24-year-old exchange explanatory model) aimed at acquiring to immigrant, refugee, and ethnic- student from in graduate school in an understanding of the meaning of minority populations. And yet since the United States, where she developed illness (Box 2). culture does not only apply to these symptoms of palpitations, shortness The patient and family’s explanatory groups, it ought to appear on the walls of breath, dizziness, fatigue, and models can then be used to open up of all clinics. headaches. A thorough medical work- a conversation on cultural meanings Step 6: The problems of a cultural up leaves the symptoms unexplained. A that may hold serious implications for competency approach. Finally, step 6 psychiatric consultant diagnoses a mixed care. In this conversation, the clinician is to take into account the question depressive-anxiety disorder. Miss Lin should be open to cultural differences of effi cacy—namely, “Does this is placed on antidepressants and does in local worlds, and the patient should intervention actually work in particular cognitive-behavioral psychotherapy, recognize that doctors do not fi t a cases?” There are also potential with symptoms getting better over a six- certain stereotype any more than they side-effects. Every intervention has week period; but they do not disappear themselves do. potential unwanted effects, and this completely. Step 4: Psychosocial stresses. Step is also true of a culturalist approach. Subsequently, the patient drops out 4 is to consider the ongoing stresses Perhaps the most serious side-effect of of treatment and refuses further contact and social supports that characterize cultural competency is that attention to with the medical system. Anthropological people’s lives. The clinician records the cultural difference can be interpreted consultation discovers that Miss Lin chief psychosocial problems associated by patients and families as intrusive, comes from a Chinese family in Beijing— with the illness and its treatment (such and might even contribute to a sense one of her cousins is hospitalized with as family tensions, work problems, of being singled out and stigmatized chronic mental illness. So powerful is fi nancial diffi culties, and personal [3,11,12]. Another danger is that the stigma of that illness for this family anxiety). For example, if the clinicians overemphasis on cultural difference that Miss Lin cannot conceive of the described in the case scenario in Box 1 can lead to the mistaken idea that if idea that she is suffering from a mental had carried out step 4, they could have we can only identify the cultural root disorder, and refuses to deal with her avoided the misunderstanding with of the problem, it can be resolved. American health-care providers because their Mexican-American patient. The The situation is usually much more they use the terms “anxiety disorder” and clinician can also list interventions to complicated. For example, in her “depressive disorder.” In this instance, improve any of the patient’s diffi culties, infl uential book, The Spirit Catches You she herself points out that in China such as professional therapy, self- and You Fall Down , Ann Fadiman shows the term that is used is treatment, family assistance, and that while inattention to culturally or a stress-related condition. On the alternative or complementary medicine. important factors creates havoc in anthropologist’s urging, clinicians Step 5: Infl uence of culture on the care of a young Hmong patient reconnect with Miss Lin under this label. clinical relationships. Step 5 is to with epilepsy, once the cultural issues examine culture in terms of its are addressed, there is still no easy infl uence on clinical relationships. resolution [33]. Instead, a whole new just what patients have; clinicians Clinicians are grounded in the world series of questions is raised. also participate in cultural worlds. A of the patient, in their own personal physician too rigidly oriented around network, and in the professional Determining What Is at Stake for the classifi cation system of biomedicine world of biomedicine and institutions. the Patient might fi nd it unacceptable to use lay One crucial tool in ethnography is The case history in Box 3 gives classifi cations for the treatment. the critical self-refl ection that comes an example of how simply using For the late French moral from the unsettling but enlightening culturally appropriate terms to explain philosopher Emmanuel Levinas, in experience of being between social people’s life stories helps the health the face of a person’s suffering, the worlds (for example, the world of the professionals to restore a “broken” fi rst ethical task is acknowledgement researcher/doctor and the world of the relationship and allows treatment to [39]. Face-to-face moral issues patient/participant of ethnographic continue. This case is not settled, nor is precede and take precedence over research). So, too, it is important to it an example of any kind of technical epistemological and cultural ones train clinicians to unpack the formative competency. But there are two [40]. There is something more effect that the culture of biomedicine illuminating aspects of this case. First, it basic and more crucial than cultural and institutions has on the most is important that health-care providers competency in understanding the life routine clinical practices—including do not stigmatize or stereotype of the patient, and this is the moral bias, inappropriate and excessive use patients. This is a case study of an meaning of suffering—what is at stake of advanced technology interventions, individual. Not all Chinese people fi t for the patient; what the patient, at a and, of course, stereotyping. Teaching this life story, and many contemporary deep level, stands to gain or lose. The practitioners to consider the effects Chinese now accept the diagnosis of explanatory models approach does not of the culture of biomedicine is depression. Second, culture is not ask, for example, “What do Mexicans

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