. Culture and Pediatric Practice

Culture and Pediatric Practice

Sakena Abedin

The 2002 Institute of Medicine report “Unequal Treatment,” a report on disparities in health care, hypothesizes that unacknowledged sociocultural differences between patient and provider may lead to poor health outcomes. The report also suggests that providers must be educated about the care of diverse patients. This chapter focuses on one aspect of such diversity: culture.

Addressing cultural difference between patient and provider is one goal of the cultural competency programs that have proliferated in medical training and practice settings. In these programs, cultural difference between patient and provider is seen as a gap that must be bridged or crossed in the process of patient care. These programs, which have traditionally focused on the cultural attributes of various groups, raise a range of concerns. One concern is that in summarizing cultural attributes of groups, these courses present stereotypes, the use of which can actually be detrimental to patient care.^1-3 Another concern is that culture becomes “medicalized” or “pathologized,” a process that involves making value judgments about cultural aspects of certain groups.⁴ These critiques call for a different approach to thinking about culture and medicine, an approach that shapes the content of this chapter.

This chapter borrows heavily from the humanities and social sciences and covers 2 different but overlapping ways for thinking about culture and its relationship to the practice of medicine. The first makes use of the work of medical anthropologist Arthur Kleinman and his colleagues on the distinctions between illness and disease.^5,6 The second centers around Rita Charon’s work on narrative medicine.^7,8 Accompanying the description of each framework are ways to apply them in practice. The chapter also includes a discussion of more traditional approaches to culture and medicine, by discussing the practice of co-sleeping. The chapter ends with a brief discussion of socioeconomic status and its relevance to medicine.

CULTURE, ILLNESS, AND DISEASE

A working definition of culture is necessary in order to consider the relationship between culture and the practice of medicine. Anthropologist Janelle Taylor suggests that within medicine, culture is defined, in ways that are too limiting, as “a static set of beliefs and ideas that only other people have.”⁹ The first step toward a broad and more inclusive definition of culture is to recognize that culture is not simply the beliefs and practices of groups of people; culture is the context in which individuals make sense of their experiences. The distinction between illness and disease is a useful one in understanding how culture, defined in this way, is relevant to medicine. Diseases, “abnormalities in the structure and function of body organs and systems,” are what physicians are trained to diagnose and treat.⁵ Illnesses, on the other hand, are what patients experience, and the experience of illness is shaped by culture, along with other factors. The relevance of culture to medicine is about more than quantifying beliefs and cataloging practices of groups of people; it is about understanding how culture shapes the ways that individual patients make sense of disease.

The second part of a more broad and inclusive definition of culture is countering the idea that culture is something that only “other” people have. “Other” here may mean people who are not physicians in general, but it may also mean poor, elderly, or ethnic minority patients; culture is often most visible in these cases. Vignettes from Kleinman and colleagues’ article on culture and medicine are useful in revealing how culture is relevant “to a greater or lesser degree in all clinical transactions.”⁵ Kleinman recounts the story of a 26-year-old Guatemalan woman who believed that her Crohn’s disease was the result of witchcraft by her fiancé’s sister. She did not share this belief with her physicians because of fear of ridicule; she also believed that her physicians had given up on her care. She became angry, withdrawn, and uncooperative. Once her concerns were raised and respectfully addressed by the medical team, who indicated that they did not share her ideas but had not given up on her care, her behavior changed and she cooperated with the treatment regimen. The article also recounts the story of a 38-year-old university professor who was diagnosed with angina but refused to accept the diagnosis and demanded instead the diagnosis of pulmonary embolus. Eventually, it was uncovered that the professor felt that a diagnosis of angina signified the end of an active lifestyle; discovering this misconception allowed his cardiologist to address the patient’s concerns and allowed the patient to accept his diagnosis. Culture shapes the experiences of all patients; it is up to the physician to address culture when it becomes relevant to the relationship between patient and physician.

Kleinman and colleagues offer a guide to eliciting patients’ explanatory models through direct questions (Table 15-1); an explanatory model is the sum of a patient’s ideas about an illness. The questions help the physician obtain a better understanding of how a patient views the physiologic disease processes affecting him or her. They are likely to be of use in the long-term care of a patient diagnosed with a chronic condition; understanding a patient’s explanatory model allows the physician to build a relationship that centers around the patient’s needs. These questions may be also useful in the process of diagnosis of a disease, in trying to get a better sense of the symptoms at play, or to better understand exactly what is at issue. Finally, they can also be of use in understanding the meaning that a particular intervention has for a patient.¹⁰

In primary care pediatrics, disease and illness are not always the issue. Issues that primary care physicians do address often, such as sleep, feeding, and developmental concerns, can also be better understood through the use of these questions. With some modification, the explanatory model questions can be used by the pediatrician interacting with the family of a patient (see Table 15-1). The questions can be used to understand a parent’s anxieties about a child’s problem or disease. They can also be used to assess the parent’s understanding of or particular interpretation of a child’s problem or disease or to understand a parent’s expectations regarding treatment or intervention. Finally, taken as a whole, the questions help to reveal the meaning that the problem or disease has taken on in the family of the patient. All of this information can be of use in the processes of diagnosis and treatment.

CULTURE AND NARRATIVE FRAMEWORKS

If the practice of medicine is about the process of identifying and treating problems, understanding the relevance of culture to medicine requires an understanding of the role of culture in physician-patient communication. This section explores a narrative approach to medicine and how it draws attention to the importance of culture in the communicative aspects of the doctor-patient relationship.

Table 15-1. Eliciting Explanatory Models