The National Conference on Primary Health Care Access will be publishing each of the named lectures presented at the annual conferences. Below is Dr Clasen’s presentation of the Odegaard Lecture from 1996.
The Third Charles E. Odegaard Lecture, Presented at the Sixth National Conference on Primary Health Care Acces, Colonial Williamsburg, Virginia, March 1996 “The Culturally Incompetent Physician”
Presented by: Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio:
While I recognized the controversial nature of this title, I chose it anyway because it captured most closely the few thoughts that I may put forth regarding this concept. I suppose one could ask the question, how can one be culturally incompetent? Rather, we are considering the “oughts and shoulds” in our yearning for a society that has healthcare as a right, and not a privilege.
The American Academy of Family Physicians, and our constituent chapters, has put forth the noble idea that all Americans should have their own physician – a physician who knows them and their families, whose values and culture lies in the midst of their family units. Taking the concept of the genogram, or the family organ as Jack Rodnick whimsically mused about, and moving its concept beyond the psychosocial data base into the realm of family mythology. Personally, I think the genogram is a powerful tool.
When the genogram is considered at the level of family mythology, we can approach the health belief systems that guide many of our personal decisions in matters of health and illness. These belief systems also guide our notions of adherence with medical authority, or with the teachings and beckonings of health providers.
An entire hour could be devoted to issues of compliance or adherence; yet, we as healthcare professionals know that most compliance occurs in the milieu of a trusting relationship that is culturally competent. In this major thrust, that creating a real change in behavior, occurs best when the message is negotiated in one’s own language, articulated with the proper mixture of science, theology, and always love. There is little doubt that a culturally competent care giver is more valuable than the high priest of technology who possesses 100% knowledge to heal, but who lacks the human translation about how to heal.
Does the title of this presentation suggest that our medical school graduates are inadequately prepared to deal with a diverse population? Does the title imply that interpersonal skills are not fully developed or as finely honed as they should be by graduation? Does it imply that 20th century physicians have been egocentric, dogmatic creature and practitioners of the art? Does it imply that 20th century physicians have not made tremendous strides in conquering disease and delaying premature death? The title was not selected to caste blame, shame, or dispersions on 20th century medical education, it was selected to look forward into the 21st century – pondering the questions about what knowledge, skills, and attitudes are needed to equip the 21st century physician. What types of educational activities will prepare the medical student of the future to enter this profession, and what are the threats and promises of such a career?
To loosely paraphrase an old adage: “a physician is frequently in error, but never in doubt.” For those in the audience who are not physicians, I want to assure you that ego strength is required to deal with pain and suffering, and demands a decisive, take charge approach, and is more egocentric than George Patton, especially when life and death matters hang in the balance.
As a consumer of healthcare, we prefer to be clients or customers when the issues are superficial; however, when the issues are weakness, being sick unto death, being rendered helpless, we more likely want to be a patient of a loving, caring physician who will guide us through the storm to the shoreline of restoration, health, and well-being.
We have accepted the culture of medicine that does not like “wimps” but strongly favors the direct approach, aggressive intervention, hard data, hard facts, “heal with steel,” and “when in doubt cut it out”. The culture of medicine is portrayed on the television series, “ER.” Notice all the language of medicine used to describe the culture of medicine: hard Science, hard facts, conquering the disease and aggressive intervention. I won’t comment on the term physician extender to describe physician assistants or advance practice nurses as part of the psychosexual language used to describe workers in US medical culture.
When my wife’s parents went to the radio-oncologist to enlist his help in addressing my mother-in-law’s inoperable lung cancer, they were asked the following question: Do you want the palliative dose or the curative dose of radiation? My mother in law is a fifth generation Texan, and my father-in-law grew up on the plains of Kansas, both are highly learned people, and how do you expect they answered that question? Suffice it to say that they did not opt for the palliative approach. Four years later, without a trace of cancer on bronchial biopsy, I would say they made the right decision. US medicine gives you the option for the palliative approach or the curative approach. It is the wimp factor versus aggressive intervention, and aggressive intervention wins.
Think of your own family. Rationing healthcare is good in concept, but not for my family. After all, managed care has brought us coronary artery by-pass surgeries for $9000 in some markets, and the price is still falling. Major coronary artery plumbing jobs are becoming routine, and there is no doubt that carotid endarterectomies improve the potential to live life without stroke complications.
I presume many of you have become acquainted with Dossey’s book entitled “Healing Words.” For those who have not read this or seen the PBS series which devoted time to explore mind/body relationships, I will cite one study which was performed on patients in coronary care units. This was a double blind study with matched control groups and experimental groups. The groups which received prayer had significantly better outcomes than the group not prayed for. Despite the curative approach used by my mother-in-law’s oncologist, she received prayers from the Christian Medical Society and prayers offered from a variety of religious faiths.
There is a meditative tradition in almost every major religion: Buddhism, Christianity, Hinduism, Islam, and Judaism, and these major religions emerge from the same source of power (in my humble opinion).
There is healing in the words and traditions of these faiths because they are connected to the concept of a loving God as we know him or her to be. Ghandi said,”I am a Hindu, I am a Christian, I am a Jew…Imperfect ourselves, we should be gentle to others.” The notion of healing words, meditation, soft intervention, and gentleness are the entrée to the next addition to the 21st culture of medicine.
There is no question that a pluralism of values which embraces the culture of US medicine will emerge in the next century. I am hoping that women entering medicine will not try to out Patton General Patton. I hope that entering students will already have an acquaintance with sorrow, grief, and human suffering.
Being a creature of the culture of medicine, one day I prescribed an antibiotic to a woman who was suffering from a moderate to severe pneumonitis. In the community health center where I was practicing, we had our own pharmacy. This prescription was costly and on our “use sparingly list.” I told this woman that I was giving her ”Gorilla-cillin.” She looked at me and a tear came to her eye. I asked, “what is wrong?”
She replied, “You have cared for my mother better than any doctor ever has, but I thought you were different.” “Different,” I queried? Then she looked at me and asked, “are you calling me a Gorilla… A monkey? Do you think that I am too stupid to know the real name of the antibiotic?” I almost fainted. She cared enough to tell me that I was a culturally incompetent physician who was not sensitive to a racial connotation and too elitist to use the name Augmentin. I told her that now I could see my incompetence, and used the term only to imply the strength of the antibiotic and nothing else.
What I loved the most about working with the African American community in Houston was the dignity and wisdom of people who entrusted their health care in me. I had just enough cultural competence to learn from this dear woman. When she understood what I had meant, and that I had meant no harm, our relationship grew even stronger. We brushed tears from our eyes, and I had gained more appreciation for cultural awareness and sensitivity.
In the same community health center, a very ill subset of diabetic patients were getting sicker. In this group hemoglobin A1C’s were climbing, and visual and extremity complications were worsening. The physician group asked our diabetic teaching nurse, Gloria O, to break out of her prescribed protocols, and render this group of patients intensive outpatient care. Listening to her counsel her patients in a new way, I heard her use language and imagery that I had never heard her use before.
With some patients she was gentle, and methodical- teaching life style modification. With others she talked about which dress she would wear when she attended their funeral. Ms. O was culturally competent and effective. By all parameters, this group became healthier. Here was a nurse practitioner who was more powerful therapeutically than a team of physicians. I learned a lot about the power of multi-disciplinary teams, and about cultural competence in changing behavior.
I could turn this into a personal confessional detailing the numerous mistakes that I have made regarding my own cultural naivety, so I will turn to other examples of cultural incompetence. I will relate the story of a second year resident who chased a patient through and out of the waiting area for wanting to discuss a termination of her pregnancy. As he yelled out scripture, the frightened patient ran out and never came back. When I attempted to counsel the resident, he quoted scripture to me. “Thou shall not kill.” I quoted back the first commandment: “ I am the Lord your God. You shall have no other gods before me.” – not even your best definition of me.
These stories illustrate examples of attitudinal incompetence, laced with elitism, sexism, and intolerance. Gayle Stephens has pointed out wisely that practitioners of medicine’s shortcomings are not usually due to a lack of knowledge; rather, they are the result of character issues deep within. I have even heard the rumor that more reasoning abilities of medical students decline over the course of their medical education. Can this be so? Is a medical education destructive?
Many of us have been through a medical education, and have our own war stories to tell. Can the countless hours, sleepless nights, pimping, roundsmanship, and open harassment mold and inspire the culturally competent physician for the 21-st century? To be a physician for human beings, you must first be a human being. How does medical education care for the personhood of the medical student or resident? What is being done – other than Pelligrino – to assist students as they ponder ethical dilemmas? What is being done to foster true character building experiences which enable our students to encounter illness, evil, death, and violence and render hope, compassion, caring, and maybe even cure.
What will the 21st century be like in medical education? If we know the answers, we could begin our curricular revisions now. We know that our nation is aging, and that Gerontology and Geriatric Medicine begs for compassion in the curriculum. The racial mix of the nation is changing rapidly. We know the race, culture, and ethnicity are such that diversity can be used to make the US the most creative nation on earth. Stratification and separation may preclude us the rich blessings of our diverse heritage. We know that hatred and bigotry have evil roots and tentacles, and the politics of fear may prevail.
We have those that believe that the economic pie is only so large- that if somebody gets something, there is less to go around. This mentality exists among many physicians. The creation of wealth and capital is a concept missed somewhere in the education. We know that different languages will be spoken in this land. We know that HIV to be a sentinel event with other incurable conditions to follow.
And, the re-emergence of infectious diseases will tax our public health systems. We know that environmental pollution, chemical warfare, biologic warfare, and the disposal of nuclear waste will become more intense problems in the next century. We also know that racial disparities as expressed in mortality and morbidity rates largely disappear at the top of the economic scale.
At this conference, A. J. Henley alluded to the fact that economic disparity and deprivation was more important to good health than access to healthcare. Correcting the economic problems would do more for the health of vulnerable and indigent people than medicine.
Many of us have an inkling that despite our total embracement of private medicine, a public sector will re-emerge as a dominant force in healthcare. The argument for the demise of managed healthcare is one that I won’t make here, but I predict it will happen. However, concepts of accountability, contracts for quality, and continuous quality improvement are here to stay in some form or another. Our students need strategies to incorporate these concepts into their own self-monitoring, self-measuring, and life- long educational strategies.
Evidence based medicine which Al Berg so eloquently described in Maui with the otitis media scenario and population medicine best articulated by capitated payment programs are examples of practicing in new ways. I remember Mark Babitz articulated the futility of going room to room to room as the community became less healthy. I remember Mark learning about culturally competency when he prescribed ampicillin to a migrant farm worker who lack refrigeration – because he was living in the car.
The day of the lone ranger, solo practitioner is over, and every small group practice in American is for sale. If solos are gone, then groups and intelligently crafted teams will be the future stage for the practice of medicine. Let us examine the future player.
One of the most enlightening experiences of teaching at a primary care medical school is that our strongest learning lab is the community. The teaching community is the most powerful ally that we have in teaching cultural competence. In Family Medicine our strongest teaching strategy is the teaching family. It is not the “Fam Scam” of the genogram; rather, it is the myriad of appropriate strategies that might be used in the context of this person’s family and health belief system.
In our department we lend teaching expertise to the advanced practice nursing curriculum as well as the physician assistant training program. We participate in the multi-professional course where medical students, nursing students, allied health students, and seminary students work and learn together. We learn cultural competence by learning from a diverse group of people.
Dr. Leroy, who, by the way, was recently cited as one of America’s top 50 positive role models as a physician, teaches a course entitled “Economics, Society, and Medicine.” He welcomes our students during orientation. He tells them how he learned to be culturally appropriate and sensitive to the many people of the Appalachian culture whom he serves in his community health center. He even listens to and enjoys country western music, which was not the music in the home in which he grew up. In the first week of medical school, students begin their introduction to clinical medicine course, and the Department of Family Medicine has 20% of the curricular time of the first two years.
We have a teaching associates program and a curriculum that we brought to the national predoctoral meeting of the STFM in January 1995. In this program, non-MDs teach students the knowledge, skills, and attitudes needed to conduct a sensitive physical examination on both men and women. An OB resident from another school tried to tell one of our students that a group of feminists was teaching them an impractical approach. Our students were not intimidated because the patients gave them positive feedback. We believe our students do better in early cancer detection for rectal, prostate, breast, and pelvic cancers.
When we needed pediatric patients in order to teach our students the skills of physical examination of children, we were invited into a community elementary school so that our medical students could perform histories and physical examination on 5 and 6 year olds. What a thrilling experience for the medical students, and for the kids who enjoyed the rapport with the medical students. Incidentally, when I came to help precept the experience, a woman approached me and said, “Hello, I am a Community Health Advocate and I want to know how information derived from these examinations will be communicated to the parents and care-givers of these children.” Good question.
These Community Health Advocates were trained in our Center for Healthy Communities, a project led by Cheryl Maurana, and resulted in the empowerment of community advocates who are not afraid to say to a powerful figure in medicine – just a minute, how is this experience going to help our community. One little boy who was examined by my group of students had a blood pressure of 1388/88. At age 5 ½, this may have been his first access to a comprehensive pediatric examination. Another child had a raging otitis media, while another appeared to have a urinary tract infection.
When our first year students needed patients to interview during their medical interviewing course, a cadre of older hospital volunteers became our willing patients. Students, patients, and faculty all found the experience authentic, significant, and important. Objective structured clinical examinations (OSCEs) are useful and a powerful device for assessment. But the teaching community has more to offer than scripted scenarios. The HIV, the geriatric, and the human sexuality selectives all use community patients and a host of non-MD teaching personnel. How could we teach geriatrics without Marshall Kapp’s insight into the legal issues of competence and aging? How could we teach community health without the faculty diversity found within that department?
Lest you think that we are soft science haven, I can also cite our trauma service which handles major trauma and has statistics which are half the national morbidity and mortality rates. Directors across the country rate our students as good as and better than graduates from other institutions.
What’s the secret at the Wright State University School of Medicine? Part of it is in the admissions process and the values that stand behind that process. With a 40 to 1 applicant to acceptance ratio, we could fall into the trap of being a mainstream medical school. We look for the student who has the academic base, then we look further. The key is to find the student that has had substantial involvement with community over a long period.
In this look, we seek students who have become acquainted with human suffering and who have made a connection with people who suffer, and who continue their involvement with people in these communities. We also find a racial mix of students who reflect the racial composition of our geographic area of western Ohio. Without students who reflect our community, we could not be evolving into a leading school in producing culturally competent physicians.
Last fall, Carole Bland and Michael Rosenthal assisted all the schools of Ohio when they became visiting faculty at our statewide conference on changing admissions practices of the seven Ohio medical schools. We are looking to change the mix of candidates likely to enter primary care versus specialty care medicine. The conference provided research data that suggests that the medical classes can be manipulated at the front end.
I still have trouble convincing our own admissions committee that we should seek students with science and math GPAs around 3.5, because those with a GPA higher than 3.75 are more in love with science than with people. Listen to what your own committees would say to the notion of lowering standards, especially when the non-cognitive attributes of the culturally competent physician are still so ill-defined and foreign to the current culture of medical education as well as US medicine.
The emergence of the culturally competent physician also includes in-depth training in medical cultural anthropology and language skills that go beyond medical Spanish or the meager attempts at using a translator. Cross cultural/cross racial advanced doctor-patient communication skills are imperative, and the place to learn these skills is early in the medical education process.
Dr. Leroy has told me that he likes the students to take his course early, before their medical education has jaded them, and the current acculturation process of medical education has taken the wonderment of people out of the equation. I believe that medical cultural anthropology is more intense and needed than is biochemistry. Memorizing the Kreb cycle for the 7th time does little to wipe tears away from people who need relief from pain and suffering.
The WSU School of Medicine model starts with admissions values, continues with the powerful presence of Family Medicine throughout all years of the curriculum, involves many non-MD educators, and an invested teaching community.
The will to create the conditions for the emergence of the culturally competent physician is an intricate process, and is different at each institution. The team concept of medicine of the future requires excellence in interpersonal and intraprofessional communication abilities. Much of this is driven by personal values and the institutional values that comprise the medical school of tomorrow.
A model that resembles the priestly model of care may be relevant here. The priestly model involves the concepts of teaching, suffering, and celebrating. Teaching involves patient education and behavioral change. Suffering involves the intimate acquaintance with sorrow, grief, loss, anger, and failure. Celebrating is the essential ingredient for renewal and inspiration found in healing, care, comfort, and cure.
Are we telling our students to celebrate and dance? Do we dance with them? Are we distanced from sorrow and suffering? Have we taught in such a way that behavior changes and outcomes improve? Are we the role models of the culturally competent physician? Are we skilled in low tech, high touch medicine? Are we competent to stand with our patients through the threats and promises of technology and for the omnipresent aggressive approach which promises cure rather than palliation?
As John Mitling has taught us through his eloquent research, a family physician in every count in America means less cost and an improvement in morbidity and mortality statistics. Can this model be so wonderful? I believe the potential for all medical specialties lie in the renewal and transformation of the culture of American medicine that must begin in our medical schools. I have given several examples of what is meant by cultural competence, and have cited our early beginnings at our institution to create the culturally competent physician.
Can this interface between high technology, clinical excellence, and cultural competence occur? Of course, it can and should. Cultural competence is the attitudinal soul of the transformation of the culture of US medicine. Rather than the oak tree which stands fast in the storm, the strength of the future practitioner is that of a willow tree: many branches, the ability to change shape as conditions change, and a tree that can withstand storm and wind. It is the blending of soft and hard sciences, with faculty role models to help US medical students cope with suffering, teach new ways, and to celebrate always.
After all, there will come a time when lions and lambs will graze together, every tear will be wiped away, and there will be no more death. The promise of the parousia is no more or less possible than the cultural transformation of medicine, and the obvious impact this transformation will have on issues of access to health care.