Cross Cultural Medicine

Author: J. Carey Jackson, MD, MPH, MA
Date Authored: February 19, 2020

Why EthnoMed?

EthnoMed aims to be a convenient source for social and cultural details relevant to clinical care. EthnoMed was developed through relationships between programs at Harborview Medical Center in Seattle and several of the larger ethnic communities we serve. The website intends to provide cultural context when working with immigrants and refugees in our area. It is also an entrée to “cross-cultural” practice.

Cultural context is critical for patient care. The cultural details relevant for diagnosis and treatment include dietary practices, religious life, healing practices, traditional beliefs, cultural norms, and social routines. These details are important background information for busy clinicians seeing members of these communities, especially if the patient’s culture is far from the dominant culture norm. It is easy to make covert cultural assumptions while taking a history or designing a therapeutic plan. To inquire about differences, and design care congruent with the differences, is safe patient-centered care. Usually patients are too young, too old, or too sick to routinely provide this context. Moreover, most people are not in the habit of explaining the historical background to their culture and daily lives.

Who is EthnoMed for?

EthnoMed was developed for clinicians and health care providers working with immigrant and refugee populations in the greater Seattle area. Our website provides information about immigration, cultural norms and values, experience with Western medicine, culture specific information and tools pertinent to the clinical encounter, and translated/culturally tailored information for patients. Our audience includes:

Primary care providers
Pediatricians
Community health workers
Nurses
Dietitians
Medical librarians
Social workers
Health educators
Others working with immigrant and refugee populations

What is Cross-cultural medicine and why does it matter?

In brief, cross-cultural medicine is not a specialty or an exotic addition to “normal” medicine. Cross-cultural medicine is simply recognizing that the history-taking and treatment plans of medical practice and the organizational structure in which it is practiced is “situated” socially and culturally, and that position is often one of privilege for the clinician and the system that trains clinical staff and contextualizes clinical medicine. The cultural assumptions made by clinicians can be irrelevant to patients from other cultures and so knowing some detail about their culture can help clinicians ask better questions about daily life to get a history or design a treatment plan that includes their resources, family structure, social roles, and diet.

There is still a great deal of diversity within these communities, e.g. minority religions, languages, and unique identities. It is impossible to be competent in the details of a culture and so the information on EthnoMed is intended to help develop more-informed questions for patients. In this way it is a process of openness to differences and to alternative daily routines that are relevant to patient care. This attitude of openness and curiosity is sometimes called “cultural humility.” (See Practicing Cultural Humility when Serving Immigrant and Refugee Communities)

Cross-cultural medicine then, is “de-positioning oneself” and seeing that both the position of the provider and that of the patient often have different social and cultural contexts. This is especially true because “Western” medicine itself is a cultural system. In this way, nearly all encounters are “cross-cultural.” Simply review the long history of the practice of medicine in Western culture to see how what was once normal is now malpractice and, in some cases, a criminal offense.

OK then what is Western medical culture?

Culture is constructed of the language, routines, and the history that produced those languages and routines, rituals, and relationships (gender, class, caste, professions, kinship), but underlying all of it is power. By power we mean who has or gets time, money, resources, and authority; and how these get used is determined and normalized by a culture. In American medicine the language, history, authority, and professional relationships of Euro-American business, science, and healing practices are the bedrock of current clinical practice.

In this way the phrase “cross-cultural” refers to the double awareness of the patient’s culture, but more importantly, the cultural assumptions of biomedicine and the specialized language and practices of biomedicine.

What is this double awareness?

First, it is an awareness of the culture and practice of one’s specialty in medicine and how that invisibly shapes authority within relationships, resources, use of time, and what seems right or normal. For example, trauma surgeons in the operating room have a very different sense of time, relationships (to anesthesia, pathology, radiology, nursing, and the injured patient) than does the psychiatrist in a community mental health setting. Each would not recognize the daily routines of the other and yet they share language, references, assumptions about the body, they are parts of a culture, and are themselves a sub-culture.

Second, it is an awareness of the complex cultures of patients and how they may differ markedly from the culture of medicine or one’s other sub-cultures as noted above. This is what EthnoMed informs.

Most of us participate in many cultures. For example, if one is a Korean, radiologist, Southern Baptist, heterosexual, mom; then, she participates in the cultures of Western medicine, gendered motherhood, Korean language and culture (perhaps), and protestant Christianity. The assumptions and norms and demands of each culture are often in conflict with one another, leaving her to decide which set of norms and values “win” or is acted upon. This often creates internal conflict, but the social context frequently determines which culture and values come to the fore and so decisions can shift when the context shifts. When this radiology physician finds patient care in conflict with her maternal role or her conservative Christian values she struggles to manage the competing cultural norms.

Why is American Medicine considered Western, isn’t it bioscience?

Western medicine is the cultural product of scientific inquiry, capitalist business, European history, and the resulting clinical systems produced in Europe and European America over the past 300 years. As a consequence, for many years the norms of Christianity, the language of religious scholarship (Greek and Latin), patriarchy (male power), and Northern European social organization (privacy, property, individualism, autonomy, profit) were consistent with the practice of Western medicine.

If all of one’s cultures are all aligned and rarely conflict with one another or with medical culture, then it is likely that one’s shared cultures evolved consistently with those other cultural norms. As a consequence, a heterosexual Caucasian American, protestant, father, surgeon, former Navy Seal, and baseball player would find some, but little conflict between medicine and his other cultural norms. The invisibility of this alignment and lack of conflict is what it means to have privilege. Specifically, the cultural system inherent in medicine evolved with these other cultural systems to support one’s position of authority, one’s values, and one’s social roles.

Why should we change this?

Because Western medical practice has as a central tenant: “Do no harm.” If we are not patient-centered and safe, we do harm.

America is increasingly aware of its diversity. This diversity has always been the case, and at one time before large numbers of Apache, Mohawk, Sioux, Huron, Tohono O’odham and Seminole (to name only a few) were stripped of their languages and almost exterminated, America was an even more diverse place. American culture is struggling to change and come to terms with the dominance of one culture, one gender, and one race over many others; with this, there is a rear guard action, or a back lash….hence the struggle.

In the interim, as the culture evolves, American medicine attempts to serve an increasingly complex array of cultures, e.g gay men and lesbians, Somalis, Filipinos, Vietnamese, Jehovah’s Witnesses, and veterans of foreign wars.

We know there are queer Catholic Filipino veterans getting care in clinics. Cultural humility is the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person].” This attitude recognizes the impossibility of knowing the myriad details about Visayan language, and the practices of Catholicism, and the struggle to be a Catholic, and a soldier and to maintain a “queer” identity. Instead, the clinician’s attitude of openness produces a process of history taking, inquiry, and then a treatment plan that are centered and shaped around the patient and their varied daily routines.

As a consequence, informed clinical practice is open to difference and has an informed double awareness…it is “cross–cultural or trans-cultural.”

EthnoMed then, is a repository of cultural details as a resource to foster the practice of “cross-cultural” medicine and thereby encourage an attitude of cultural humility.