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The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care

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Abstract

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is “culturally competent.” We explore the diverse methods that cultural competence trainings use to foster a health care provider’s ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.

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Notes

  1. A pseudonym, as are all the names of individuals presented herein.

  2. Another approach to eliminating disparities in quality of health care is through workforce diversity programs. These initiatives promote the recruitment of more minority health care providers to increase access to and quality of health care for medically underserved and minority patients (Shaw 2010). Yet the distribution of access to medical professions in the U.S. continues to ensure that health care providers are disproportionately white and economically privileged (Steinecke and Terrell 2010; Sullivan and Mittman 2010).

  3. In addition, cultural competence trainings are also rapidly becoming an important site for the construction of cultural difference in the clinic as ethnic categories are simultaneously being created, reified, and contested. In a related study, Epstein describes the ways in which new federal requirements to include racial and ethnic minority populations in medical research have produced new understandings of ethnicity through the emerging science he terms “recruitmentology,” the increasingly-researched effort to “enroll so-called hard-to-recruit populations for clinical studies” (2007, p. 15).

  4. For anthropological investigations of elements of this process, see Borovoy and Hine (2008), Jenks (2009), Ong (1995), Sargent and Larchanché (2009), Taylor (2003b), and Good et al.’s Shattering Culture project funded by the Russell Sage Foundation. Mattingly (2006) describes urban U.S. hospitals as “border zones” and identifies popular culture as a key resource mobilized by health care personnel seeking to practice medicine across ethnic and economic differences.

  5. Others have addressed this topic and related or narrower aspects of it using the terms cultural competence, cultural sensitivity, cultural awareness, and cultural humility. For reviews of this voluminous literature in medicine and public health, see Beach et al. (2005), Anderson et al. (2003); Kehoe et al. (2003), and Manson (2003). For anthropological treatments of themes of difference, liberalism, and multiculturalism in culturally appropriate health care, see Taylor (2003b), Borovoy and Hine (2008), Kowal (2008), Willen et al. (2010), Kleinman and Benson (2006), Dorazio-Migliore et al. (2005), Anderson et al. (2007), Benson and Thomas (2010), and Sargent and Larchanché (2009), among others.

  6. The full text of the CLAS regulations can be found at http://www.omhrc.gov/templates/content.aspx?ID=87.

  7. A private nonprofit organization, the Joint Commission is often known by its former name, the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO (pronounced “jay-co”). While accreditation is voluntary, it is linked to insurance reimbursement and thus its mandates and guidelines have the force of law (or, absent legal sanctions, even greater force). At the DiversityRx conference in Minneapolis in September 2008, Susan Shaw attended a workshop sponsored by the Joint Commission to gather attendees’ input on applying CLAS standards to Joint Commission accreditation standards. In one small group, a hospital employee encouraged the Joint Commission to develop strict standards for hospitals to demonstrate cultural competence. “You guys have a lot of power!” she said, emphasizing the force of Joint Commission standards for hospitals seeking accreditation. In 2010, when posters to the Culture and Health listserv applauded these efforts, one critic bemoaned the efficacy of these non-governmental regulations over law and jurisprudence by commenting sardonically, “It is a pleasure to announce JCAHO’s new standards since that somehow gets people’s attention unlike federal law from 1964 which they find less compelling…go figure.”

  8. For more information on QI in health care, see Jencks and Wilensky (1992), Scally and Donaldson (1998), and Shortell et al. (1998).

  9. A pseudonym.

  10. For convenience, we will refer to these administrators as “cultural competence coordinators,” though as indicated in their email signature files, job titles range from “coordinator of cultural services” to “transcultural nurse specialist” to “advanced practice educator” to “language access coordinator,” among many others.

  11. While some might see text from the Internet as de-contextualized, we argue that the Internet is simply another frequently used context for communication. Lysloff argues that “on-line communities…are as ‘real’ (or imagined) as those off line” (2003, p. 236) in part because of the consequences that online interactions have for “lived worlds” (p. 234). The participants on the Culture and Health listserv are professionals who are deeply invested in the policies and practices of cultural competence and whose production of “online” selves is critically linked to their “real-world” selves. (For more about the production of self in online contexts, see Broad and Joos (2004).) As listserv participation does not afford the opportunity for “real-world” ethnographer-interviewee collaborative meaning creation, we have triangulated these data with other more traditional forms of ethnography such as in-person interviews and participant-observation (Robinson 2001).

  12. For more on health care providers’ and medical students’ responses to such trainings, see Willen et al. (2010), Jenks (2009), and contributors to Good et al. (forthcoming).

  13. See also the helpful discussion on the differences between these approaches in Anderson et al. (2007). Calls for patient-centered health care, for instance, are a frequently discussed cross-cultural approach; see, e.g., Din-Dzietham et al. (2004), Epstein and Street (2007) and Lo (2010). A small but growing literature on culturally “Other” health care providers poses interesting and related questions about difference in the clinical encounter, exploring the ways in which changed power relations (when the physician is Indian–American, for example) inflect discourses of culturally appropriate health care as they play out in practice in the clinic (e.g., Dorgan et al. 2009).

  14. It is worth noting that oft-cited formulations of the “problem” of cultural difference, whether in the clinic, the school, or the ballot box, discursively locate the “problem” with those who are deemed “other” or different. In fact, as pointed out by many cultural competence educators who post to the Culture and Health listserv, the “problem” posed by the existence of cultural difference is frequently located with members of the so-called mainstream or majority populations who are unwilling or unable to accommodate language or other differences in the public sphere.

  15. http://www.gagalanti.com/case_studies/cases_by_topic.html, accessed 11 Nov 2010.

  16. On diversity as a social value, see Ahmed (2009), Hannah (2008), Mercer (1994), and Morgen (1988), among others. In a recent critique based on methodological insights from research with stigmatized populations, Benson and Thomas (2010) extend the concept of cultural competence to include the ethical dimensions of relations between researchers and participants and between clinicians and providers. The authors call for greater attention to the “personal disposition” of the researcher/clinician in cross-cultural encounters and for the ongoing importance of situational ethics.

  17. This dynamic of self-control echoes the Christian pastoral emphasis on mastery of the self described by Foucault (Martin 1988).

  18. From: http://www.medpagetoday.com/Surveys/, Survey from Week of 16 Jun 2008:

    Should diversity training be a requirement for physician licensure and renewal? accessed 10 June 2010.

  19. Pigg (2001) discusses the didactic nature of biomedical “trainings” for outreach workers in developing countries and their emplotment within broader contexts of language and modernity.

  20. This is in contrast to, for example, the “empowerment” and consciousness-raising programs discussed by Cruikshank (1999), Sharma (2008), and others, which take as their target low-income, minority, and otherwise marginalized groups. Margaret McLaren describes feminist consciousness-raising groups of the 1970s as, in Foucauldian terms, both practices of the self and practices of freedom, insofar as they as aim at “self-transformation” and “they create new nonnormalizing modes of existence and relationships. Practices of freedom are ethical practices requiring the work of oneself on self” (McLaren 2002, p. 159).

  21. Nancy Fraser observes that “identity politics” as a means of achieving equality “emphasizes psychic structure over social institutions and social interaction [in its explanations of inequality]. Thus, it risks substituting intrusive forms of consciousness engineering for social change” (Fraser 2001, p. 24).

  22. This individualized understanding of ethical care is counter-balanced by other elements of CC, however, such as language access policies and procedures that are more systems-oriented. For example, see related efforts around health literacy (e.g., Health Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF, April 2010. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/literacy/index.html).

  23. In her 2003 article in Academic Medicine, Janelle Taylor cautions that, “medical students as a group may be forgiven for failing to take [their cultural competence courses] very seriously as long as they perceive that they are quite distinct from the real ‘competence’ that they need to acquire. To change this situation will require challenging the tendency to assume that ‘real’ and ‘cultural’ [competence] must be mutually exclusive terms” (Taylor 2003a, p. 559). Situating CC within the frameworks of QI and patient safety could be read as an attempt to equalize medical and cultural competence by linking CC with other technical and ethical concerns such as patient safety.

  24. But, as Hester (forthcoming) and others point out, evidence showing improved health outcomes for those patients whose physicians receive CC training is hard to come by. The strong push for CAHC, in the absence of such evidence, illustrates how arguments for CC training rest as much on beliefs about what should constitute ethical social relations (beliefs which are shaped in part by the political claims of minority health and other advocacy groups) as on the demonstrated effectiveness of such approaches.

  25. An example of the displacement of responsibility for refusal onto patients, coded as “noncompliance,” can be seen in Borovoy and Hine’s thoughtful ethnographic case study of diabetic Russian émigrés (2008). The ethnographers conclude that physicians’ judgments regarding these “non-compliant” patients are shaped in part by their unreflexive application of the U.S. consumer model of care, coupled with an ideology of personal responsibility. Borovoy and Hine argue that the American consumer model of health care conflicts with émigrés’ understandings of state-run health care and personal autonomy, leading to uncontrolled blood sugar among these patients and physician frustration with their lack of adherence to a “highly rigid approach to diabetes care” (Borovoy and Hine 2008, p. 19).

  26. Another approach to cultural competence that follows from this individualized understanding of culture does not, in contrast, rely on a physician’s self-reflexivity but rather positions the physician as “cultural broker.” Based on in-depth interviews with 24 California physicians (15 of whom identified as members of a racial or ethnic minority group), Ming-Cheng Miriam Lo emphasizes the importance of negotiating different “sense-making schemas” between patient and provider (Lo 2010, p. 485). She outlines four elements of cultural brokerage, each of which requires the health care provider to at least recognize his or her worldview as culturally situated, and provides examples of physician stories about how this recognition can be followed by action (Lo 2010).

  27. On self-reflection as a strategy for “scaffolding knowledge building,” see Lax et al. (2009).

  28. Willen et al. (2010), and contributors to the Good et al. forthcoming collection Shattering Culture, describe reasons for psychiatric residents’ resistance to cultural sensitivity training, including prior experiences with cultural sensitivity trainings, personal experiences of racism, and ethnic and cultural diversity among mental health professionals that potentially limit the relevance of trainings oriented toward majority-culture health professionals treating culturally “Other” patients.

  29. Epstein continues, “This slippage between referencing individuals and groups is a common feature of discourse surrounding the inclusion-and-difference paradigm; it endows the paradigm with legitimacy by associating it with individualism, one of the cherished values of U.S. political culture” (Epstein 2007, p. 139). We would suggest that the appeal of individualistic notions of culture is related to this tendency as well.

  30. Available online at www.nytimes.com/2008/11/14/health/chen11-13.html?_r=1, accessed 9 April 2011.

  31. The webpage carries the disclaimer, “Medpage Today surveys are polls of those who choose to participate and are, therefore, not valid statistical samples, but rather a snapshot of what your colleagues are thinking.” (www.medpagetoday.com/Surveys/, viewed 16 June 2008).

  32. In her article, “The Politics of the Gap,” Emma Kowal distinguishes between “the two pillars of postcolonial logic, remedialism and Orientalism,” which govern liberal efforts to remedy Indigenous health disparities in Australia. She writes, “Remediable difference is a difference amenable to normalization. It promises that what makes Indigenous people culturally distinctive is neither an obstacle to achieving statistical equality nor threatened by this quest. When remediable difference is enacted at the institute, remedialism and Orientalism meet in a happy, if awkward, embrace” (Kowal 2008, p. 343).

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Acknowledgments

This research was supported by the Wenner-Gren Foundation Hunt Postdoctoral Fellowship, and by the University of Arizona Junior Faculty Development program. Special thanks are due to Angela Jenks and Seth Holmes, organizers of this special issue and of the Society of Medical Anthropology panel where this article was first presented; to Janelle Taylor, for her critical feedback at that panel; and to audience members for their constructive questions. The authors wish to acknowledge the very productive comments of our anonymous reviewers for CMP, and also to recognize Amy Stamm for her feedback on an earlier version of this article.

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  1. School of Anthropology, University of Arizona, P.O. Box 210030, Tucson, AZ, 85721-0030, USA

    Susan J. Shaw

  2. School of Anthropology, University of Arizona, Tucson, AZ, USA

    Julie Armin

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Correspondence to Susan J. Shaw.

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Shaw, S.J., Armin, J. The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care. Cult Med Psychiatry 35, 236–261 (2011). https://doi.org/10.1007/s11013-011-9215-1

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