Professional Documents
Culture Documents
In today’s multicultural society, assuring quality health 7). Some efforts have focused on important struc-
care for all persons requires that physicians understand tural changes, including training bilingual and bicul-
how each patient’s sociocultural background affects his or tural providers, instituting interpreter services, and
her health beliefs and behaviors. Cross-cultural curricula
developing culturally and linguistically specific liter-
have been developed to address these issues but are not
ature and health care resources (8). However, many
widely used in medical education. Many curricula take a
categorical and potentially stereotypic approach to “cul-
feel that providers themselves should be trained to
tural competence” that weds patients of certain cultures care for patients of different sociocultural back-
to a set of specific, unifying characteristics. In addition, grounds (6 –14). Such training programs often em-
curricula frequently overlook the importance of social fac- phasize cultural sensitivity but do not teach practical
tors on the cross-cultural encounter. This paper discusses a cross-cultural skills. Other attempts to educate pro-
patient-based cross-cultural curriculum for residents and viders rely heavily on a categorical construct that
medical students that teaches a framework for analysis of lumps patients of similar cultures into groups and
the individual patient’s social context and cultural health outlines their “characteristic” values, customs, and
beliefs and behaviors. The curriculum consists of five the- beliefs (15–17). Although this knowledge can be
matic units taught in four 2-hour sessions. The goal is to
helpful, the suggestion that members of particular
help physicians avoid cultural generalizations while im-
ethnic or racial groups behave in characteristic ways
proving their ability to understand, communicate with,
and care for patients from diverse backgrounds.
risks stereotypic oversimplification. For example,
would a poor, black Cuban immigrant residing in
This paper is also available at http://www.acponline.org. Harlem fit into the African American or Hispanic
profile? How would he compare with an upper
Ann Intern Med. 1999;130:829-834. middle– class Mexican American? This contrast also
highlights the importance of socioeconomic factors,
From New York Presbyterian Hospital–New York Weill Cornell which are often underemphasized in cultural com-
Medical Center, New York, New York. For current author ad-
dresses, see end of text. petency programs (18 –20). A clear need exists for a
more discerning approach.
We present the ideology and structure of a patient-
It is much more important to know what sort of a patient has a based cross-cultural curriculum that we have devel-
disease, than what sort of disease a patient has. oped and implemented. It represents a melding of
–William Osler (1)
medical interviewing techniques with the sociocul-
C oncern about cultural competence in health tural and ethnographic tools of medical anthropol-
care has increased in recent years as providers ogy. The curriculum comprises a set of concepts and
and policymakers strive to close the gap in health skills taught in five thematic modules that build on
care between people of different sociocultural back- one another over four 2-hour sessions.
grounds (2, 3). Medical providers today face the
challenge of caring for patients from many cultures
who have different languages, levels of accultura- Structure and Content
tion, socioeconomic status, and unique ways of un-
derstanding illness and health care. Patient satisfac- Module 1: Basic Concepts
tion and compliance with medical recommendations Culture is defined as a shared system of values,
are closely related to the effectiveness of communi- beliefs, and learned patterns of behaviors (21) and
cation and the physician–patient relationship (4). is not simply defined by ethnicity. Culture is also
Because sociocultural differences between physician shaped by such factors as proximity, education, gen-
and patient can lead to communication and rela- der, age, and sexual preference. In interactive small
tionship barriers (5), teaching physicians the con- groups, participants reflect on their own cultures
cepts and skills needed to overcome these barriers and how these influence their personal perspectives
should lead to improved outcomes. on illness and health care. They also explore the
Implementation of culturally competent health extent to which the “medical culture” has become
care has been sparse and generally inadequate (6, incorporated into their cultural outlook (22). Self-
© 1999 American College of Physicians–American Society of Internal Medicine 829
At first, Dr. Ragin worked very hard. He received patients every day from morning
till dinner-time, performed operations, and even did a certain amount of midwifery.
Among the women he gained a reputation for being very conscientious and very good
at diagnosing illnesses, especially those of women and children. But as time passed he
got tired of the monotony and the quite obvious uselessness of his work. One day he
would receive thirty patients, the next day thirty-five, the next day after that forty, and
on from day to day, from one year to another, though the death rate in the town did
not decrease and the patients continued to come. To give any real assistance to forty
patients between morning and dinner-time was a physical impossibility, which meant
that his work was a fraud, necessarily a fraud. He received twelve thousand out-
patients in a given year, which bluntly speaking meant that he had deceived twelve
thousand people.
Anton Chekhov
“Ward 6”
Lady with Lapdog and Other Stories
Penguin; 1964:144
Submitted by:
Sue Anne Brenner, MD
Emory University School of Medicine
Atlanta, GA 30322
Submissions from readers are welcomed. If the quotation is published, the sender’s name will be acknowl-
edged. Please include a complete citation (along with the page number on which the quotation was found),
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