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.
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 ...