Notes on “Shattering Culture: American Medicine Responds to Cultural Diversity” by Mary-Jo DelVecchio Good (Editor) et al.

The world is changing, the people are moving, the demographics are being reshaped, especially in the US where there are so many immigrants. This book presents a collection of works that describe how are health-care institutions responding to this changing demographics, including issues within the institutional policies and the personal human dilemmas in serving the diverse and constantly changing group of patients.

Although it is clear that cultural diversity often covaries with racial and ethnic classifications, we must remember that cultural diversity can exist within ethnic groups as well, and other dimensions of culture (such as those deriving from class background or education). Through various examples we are shown that traditional classificatory schemes, such as based on ethnicity, turn out to be inadequate and inappropriate within the “new” hyperdiverse environment. 

The concept of hyperdiversity is based on the premise that diversity is not just about culture, but can also exist along many dimensions that transcend superficial features, such as phenotype, mother tongue, or nationality. Also, hyperdiversity is not just about patients, as, we are reminded, that “it is no longer reasonable to presume a dichotomy between “mainstream clinician/ ‘Other’ patient”; often, these roles are reversed”. A cultural environment of hyperdiversity is a social setting that is highly diverse (in terms of race and ethnicity as well as social class, immigration status and religion), dynamic (unstable or undergoing change), and multidimensional (individuals may choose to identify with broad racial and ethnic categories or narrower categories such as country of origin, neighborhood, or sexual orientation). In these settings, racial and ethnic classification is more difficult, and the link between census-based racial and ethnic identities and culture is likely to be weak or broken .

Thus, we are called to rethink our understanding of culture, which is often viewed as a source of pathology or as a “curious flash of exotic” – often an obstacle to diagnosis and treatment. Fortunately, many clinicians are sincerely interested in finding ways through those cultural gaps and finding ways to communicate effectively, and respectfully, with their patients., and many healthcare institutions have taken direct action and sought to minimize cultural mis- understandings and improve the quality and effectiveness of patient care. 

We see that the importance of not relying on external racial and ethnic identity markers to generate assumptions about behavioral qualities and cultural orientations can not be underestimated. Within resistance to using race and ethnicity as a basis for cultural assumptions, clinicians and support staff  interviewed for this book advocate an individualized approach to taking culture into account. They do not claim that culture does not matter, but instead argue that in their experience, “broad, identity-based indicators of cultural difference are too blunt of an instrument; when used, the unique characteristics of individuals are lost” .

This approach does not suggest that group-based markers of cultural difference must be ignored, but rather that there must be developed  new criteria to distinguish between patients for whom conventional racial-ethnic-cultural categories make sense and those for whom they do not.

In addition, it may be hard to determine when the use of group categorization for clinical purposes is appropriate. Common forms of group identities that work in one clinical context may not work in another. This is especially true in hyperdiverce communities. The text offered several examples of medical professionals who instead of relying solely on group-based treatment protocols that instruct appropriate treatment for patients of different ethnic backgrounds, spend additional time probing the patient and seek out additional information from other members of the treatment team.

These collateral sources may have more knowledge about the cultural norms of ethnic groups they are unfamiliar with, calling for a mix of individual exploration and the use of so called “cultural brokers”, such as interpreters, members of particular community, chaplains, relatives, etc., who can help fill in the gaps of cultural differences. Here it is important to be aware of the fact that by seeking the advice of cultural brokers or others who share the cultural identity of the patient, identity is being used as a proxy for culture, which can have an impact on treatment experience. However, the major obstacle to such approach is the issue of time constraint, which limits the doctors’ ability to collect precise cultural information about their patients. 

Another strategy sometimes used in an effort to bridge cultural differences is clinician-patient matching on the basis of shared cultural or racial-ethnic characteristics, that was thought  to strengthen clinician-patient rapport and improve outcomes among ethnic-minority patients. However, research proved that a significant minority of patients, particularly recent immigrants and refugees, do not prefer ethnically similar clinicians for fear that their personal information will leak to members of their community. What is more, despite common sense notions that matching is effective, the preponderance of evidence from peer-reviewed studies does not show positive effects.

Through the works of the interdisciplinary team of authors who have contributed to this book we learn that racial and ethnic classification system is extremely complicated, the clear boundaries between groups are difficult to recognize, which makes it difficult to bind cultural traits with racial and ethnic identity.

This knowledge brings us (once again) to the value and importance of developing cultural sensitivity, which would permit us to interact and serve those from different cultural backgrounds without having to necessarily define their cultural belonging. A culturally sensitive practitioner ideally would be open to understanding any patient and recognizing the patient’s needs without being knowledgeable of the cultural traditions the patient belongs to.