It should be needless to say that this was wrong. In
addition to all the examples that can be given of other non-European cultures
were far more advanced (think the Arab world for mathematics and science, China
for all kinds of things), all cultures are different. They do not just have “strengths”
and “weaknesses”, or areas in which one is “better”, but differences which have
developed to serve the needs that existed where they lived. Weather, for a
start, makes a difference in the types of crops grown or how housing is
designed. In addition, of course, different cultures share many similarities.
This allows for, for example, religious ecumenism, in which folks of different
religions can come together based upon the values that they share. In the US today,
we have seen great advances in understanding not only that differences between
cultures do not mean one is better than another, but also that similarities between
people usually exceed differences. Recently, we are seeing great strides
against racism, sexism, jingoism, and all the other “isms” that promote hatred
instead of understanding. Unfortunately, however, we also see a backlash from
people who feel threatened by the idea that other people, whom they have
disparaged and discounted, are indeed their equals. This has gone beyond
attitudes; it has led not only to violence, but to legislation enshrining prejudice,
hatred, and discrimination. I hope this will get better, but it might get worse
One way that we have on tried to address this issue in medical education has been discussions between small groups of students about how they see common phenomena in the world, in their communities, in families, and relationships. The more diverse a class is, the richer these discussions become and the more the students learn that what they think of as “regular” is in fact just as much a cultural belief as that of other people. Of course, this also can reveal assumptions that they may make about what is “normal” that are not normal for others, particularly regarding financial and socioeconomic issues. Or, for instance, whether the police are seen as your protectors or your persecutors.
This becomes an important entry point for examining medical
culture, which certainly exists and carries its own beliefs and prejudices, as
do most professions. These beliefs are no more, or less, “true” than sociocultural
beliefs. Because medicine involves not only extensive interaction with other
people who are not immersed in the culture but, even more, extensive power over
the lives and health of those people, coming to grips with what you (and your teachers)
believe because, well, we all believe it, rather than what is based in
evidence, is important. This is more difficult because a big part of the
socialization to a profession such as medicine is for a novice who is from
outside that culture to learn the jargon, way of thinking, and indeed
prejudices that characterize it, and this can have negative as well as positive
For example, our medical students usually enter perfectly capable of speaking English (and perhaps other languages) and conversing with others and communicating ideas and information. As part of becoming doctors, they learn new language, new terms, new acronyms, new meanings, and eagerly repeat them as evidence of their acculturation. Unfortunately, this can become an obstacle to communication with their patients, who do not speak this language. One example: a couple of sentences ago, I used “positive” and “negative” in their usual English senses of “good” and “bad”. However, when doing medical tests (lab, imaging, biopsies) a positive result is usually bad, and a negative result is good. But when a doctor, or student, informs a patient that their results are negative, it is common for the patient to react with fear, since this sounds like a bad thing. We urge them to say “normal”. Whew, that’s a relief!
Some other issues of medical culture are address in an Op-Ed
by Robert Pearl in the Los Angeles Times of May 16, 2021, “How
doctor culture sinks US health care”. A big part of Dr. Pearl’s critique in
the distinct bias, not only in physician attitudes but in medical journal articles,
towards intervention and procedures rather than prevention. This, he notes
correctly, is very much tied to money, since physicians and hospitals and
health systems (which are increasingly the physicians’ employers) stand to make
much more money from them. Medical journals are more likely to print articles
with positive (there is that word again!) results, demonstrating that a
procedure had benefit, than negative results, demonstrating that, actually, compared
to something – or nothing – else, something (or nothing) that was easier,
cheaper, less interventive, and less dangerous, it had no better outcomes. Of
course, anyone can see that knowing this information, that doing something is
not worthwhile, is at least as important as knowing that something works well.
However, the inclination (or perhaps prejudice) among most physicians is to do something, to intervene; aside from making money, it makes them feel that they have skills, are justified, are important. Unfortunately, this is also an attitude quite prevalent among their patients, who want something done to help their problem – to cure their disease, or increase their lifespan, or improve the quality of that life, and in particular to ease their pain. But doing something does not always improve things, and can definitely increase the risk of harm. We need to know what works (and what doesn’t), and in what circumstances, and what the dangers are, and what the alternatives are, and their potential benefits and risks, and then have discussions together about what, in the specific circumstance a specific person is in, what would be the best choice for them.
This effort is likely to overlap with more traditional sociocultural
and religious beliefs, which can have an influence on what a person thinks
would be best for them. Communication around this requires care, and a real
effort on the part of the medical professional to understand and to make their
own thoughts clear and clearly expressed. This is even more complicated when,
as is the case, physicians are from a pretty narrow slice of the American
population, racially, culturally, and economically (and, again, a good argument
for increasing its diversity). As in all situations where there is a power
differential (and in medical care, the greater power lies with the physicians
and health systems) it is incumbent on those with greater power to make the
effort to understand those with less. And, at least as important, to not make
decisions for and about people based on only your understanding – or worse,
assumptions – about what they want, or are because of race, religion,
gender, national origin, etc. Doctors, even when they are well-meaning (and all
of them are not always) too often allow themselves to fall victim to the ecological
fallacy, and confuse “condition X is more common in population Y” with “the patient
is a member of group Y so probably has condition X”.
It is, of course, also very important to recognize that all interventions and procedures are not a bad idea; indeed, they are often the best treatment. And, also, that not everything sold as “preventive” is really so; plenty of tests and treatments called preventive are not proven to prevent anything. It is not easy to overcome prejudices and beliefs.
But understanding that we all have culture, and trying to not be bound by it and doing our best to understand that of others, is a good start.