Map of life expectancy at birth from Global Education Project.

Thursday, April 14, 2005

Cultural Competency

According to the U.S. Office of Minority Health,

“Cultural and linguistic competence is a set of congruent behaviors, attitudes and policies that come together in a system, agency or among professionals that enables effective work in cross-cultural situations . . . .’Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors and needs presented by consumers and their communities.

People usually think of this as meaning, here we are, European-American doctors and our minions of nurses and social workers and so on, and here come these strange foreigners to our clinic or hospital. We must learn of their exotic ways so that we can more effectively persuade them to swallow our pills. A decade ago, a small industry sprang up of people doing "cultural competency trainings" in which they would explain that Puerto Ricans believe in mal de ojo (the evil eye), and Cambodians complain about their livers when they can't get an erection, and so forth. Once you knew these things, you were presumably "culturally competent."

Well, I think we need to extend this concept. Californians believe in the healing power of crystals. Catholics light candles and pray to the Virgin. Baseball players never change their socks until they lose.

Come to think of it, I have a better idea. It's not everybody else who's weird, it's doctors. Doctors have all spent 7 years or more together learning how to talk their own language and think their own strange thoughts. Barbara Korsch is a pediatrician who figured this out 30 years ago: "Terms such as nares, peristalsis and Coombs titre were Greek to the patients. A 'lumbar puncture' was interpreted as meaning an operation to drain the lungs. In more than half the cases we recorded, the physicians resorted to medical jargon. This did not necessarily leave the patient dissatisfied; some patients were impressed and even flattered by such language. There's no question that unless the patient understands you, the clinical diagnosis or treatment will be poor. So, talk English - instead of medical."

Good idea, but it's not just about vocabulary. It's also about subject matter. Elliot Mishler calls it The Voice of Medicine vs. the Voice of the Lifeworld. The lifeworld is, well, reality. Where we live. We have jobs, families, friends, recreation, interests. What makes us sick is not our idiopathic hypertension or our halix rigidus -- it's not being able to do the things we want or need to do, or our pain and suffering, or watching people we care about who can't do something or who feel pain. Whether we are going to take your pills or eat your rabbit food or do your exercises or let you cut us open has everything to do with whether it enables us to do the things we need to do or makes it even harder; with whether we understand what the hell you are talking about or think you actually said the opposite; with whether you listen to us, let us ask questions, believe us when we tell you the pills are making us sick, allow us to be anxious or to doubt you. It has nothing to do with our Coombs titres or our eosinophils or our proteinuria.

And it doesn't make any difference if we were born in Paramus New Jersey and call it New Joisey, or we come from the mountains of Guatemala and speak Quechecal.

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