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Shattering Culture

Shattering Culture: American Medicine Responds to Cultural Diversity

Mary-Jo DelVecchio Good
Sarah S. Willen
Seth Donal Hannah
Ken Vickery
Lawrence Taeseng Park
Copyright Date: 2011
Published by: Russell Sage Foundation
Pages: 260
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  • Book Info
    Shattering Culture
    Book Description:

    "Culture counts" has long been a rallying cry among health advocates and policymakers concerned with racial disparities in health care. A generation ago, the women’s health movement led to a host of changes that also benefited racial minorities, including more culturally aware medical staff, enhanced health education, and the mandated inclusion of women and minorities in federally funded research. Many health professionals would now agree that cultural competence is important in clinical settings, but in what ways? Shattering Culture provides an insightful view of medicine and psychiatry as they are practiced in today’s culturally diverse clinical settings. The book offers a compelling account of the many ways culture shapes how doctors conduct their practices and how patients feel about the care they receive. Based on interviews with clinicians, health care staff, and patients, Shattering Culture shows the human face of health care in America. Building on over a decade of research led by Mary-Jo Good, the book delves into the cultural backgrounds of patients and their health care providers, as well as the institutional cultures of clinical settings, to illuminate how these many cultures interact and shape the quality of patient care. Sarah Willen explores the controversial practice of matching doctors and patients based on a shared race, ethnicity, or language and finds a spectrum of arguments challenging its usefulness, including patients who may fear being judged negatively by providers from the same culture. Seth Hannah introduces the concept of cultural environments of hyperdiversity describing complex cultural identities. Antonio Bullon and Mary-Jo Good demonstrate how regulations meant to standardize the caregiving process—such as the use of templates and check boxes instead of narrative notes—have steadily limited clinician flexibility, autonomy, and the time they can dedicate to caring for patients. Elizabeth Carpenter-Song looks at positive doctor-patient relationships in mental health care settings and finds that the most successful of these are based on mutual “recognition”—patients who can express their concerns and clinicians who validate them. In the book’s final essay, Hannah, Good, and Park show how navigating the maze of insurance regulations, financial arrangements, and paperwork compromises the effectiveness of mental health professionals seeking to provide quality care to minority and poor patients. Rapidly increasing diversity on one hand and bureaucratic regulations on the other are two realities that have made providing culturally sensitive care even more challenging for doctors. Few opportunities exist to go inside the world of medical and mental health clinics and see how these realities are influencing patient care. Shattering Culture provides a rare look at the day-to-day experiences of psychiatrists and other clinicians and offers multiple perspectives on what culture means to doctors, staff, and patients and how it shapes the practice of medicine and psychiatry.

    eISBN: 978-1-61044-752-2
    Subjects: Sociology, Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. About the Authors
    (pp. ix-x)
  4. Acknowledgments
    (pp. xi-xvi)
    Mary-Jo DelVecchio Good
  5. Chapter 1 Shattering Culture: An Introduction
    (pp. 1-30)

    How does culture matter in American medicine and health care? This query motivated the ethnographic studies of health-care institutions and psychiatric clinics that are the heart of this volume.

    For many decades, American medicine and its institutions of patient care have attended to the cultural distinctiveness of patients and carried out missions to redress inequalities in access to medical services for the poor, for ethnic and racial minorities, and for new immigrants and refugees.¹ However, despite years of effort to institutionalize culturally sensitive and competent care and to reach out to serve and provide equitable care to minority patients, two...

  6. PART I Cultural Environments of Hyperdiversity

    • [PART I Introduction]
      (pp. 31-34)

      How are health-care institutions responding to the changing demographics, the changing composition of health-care teams, and the increasingly complex configurations of identity that shape the contemporary United States? The four chapters that follow consider both the institutional challenges and the human dilemmas that health-care providers and institutions must confront as they strive to serve an increasingly diverse—and rapidly changing—array of patients and communities. The authors of these chapters, all sociologists and anthropologists, each bring a distinct orientation to this project’s core questions. Seth Hannah, a sociologist specializing in inequality, race and ethnic relations, and cultural studies of medicine...

    • Chapter 2 Clinical Care in Environments of Hyperdiversity
      (pp. 35-69)

      Traditionally home to a rich mix of ethnicities from various European backgrounds and a substantial African American population, Boston has been one of the most diverse and segregated cities in the country. In recent years, however, the nature of this diversity has shifted and become more complex. The loosening of neighborhood residential segregation and new waves of immigration from Latin America, Asia, Africa, and elsewhere have dramatically altered the ethnic landscape. Since 1970, the proportion of nonwhite residents in Suffolk County has increased from 18 to nearly 50 percent, and the number of foreign-born residents from 13 to 28 percent.¹...

    • Chapter 3 Pas de Trois: Medical Interpreters, Clinical Dilemmas, and the Patient-Provider-Interpreter Triad
      (pp. 70-93)

      As more and more patients with limited English proficiency (LEP) arrive at United States health centers seeking medical care, many patient-provider dyads are expanding to include an additional party—a medical interpreter. For all parties involved, this substantive change in the traditional provider-patient dyad involves an array of new and distinct clinical challenges. This chapter considers the dynamics and complexities of this emerging clinical pas de trois (Wadensjö 1998).

      This chapter draws on thirteen interviews conducted with professional medical interpreters employed at four health-care settings, including two academic medical centers, a community health center with a generic orientation, and a...

    • Chapter 4 Praying Along: Interfaith Chaplaincy and the Politics of Translation
      (pp. 94-111)

      “I think I’m lucky,” an interfaith chaplain at a major research hospital in Boston said. “Because I get to talk about things like feelings and faith. And prayer. And all of those questions that are hard, like, ‘What’s the meaning of life?’ and ‘Why is this terrible thing happening?’ And I’m allowed to do that and I get paid to do that. And so part of my role here is to give people permission to speak about these things. I remember one neurologist [who] said, ‘That mother was talking to spirits! Can you believe that?’ And I said, ‘So? I...

    • Chapter 5 Clinician-Patient Matching
      (pp. 112-130)

      The prospect of “matching” patients with providers on the basis of shared language, race-ethnicity, or cultural background has recently emerged as a potentially promising strategy for reducing disparities in mental health outcomes. Despite considerable interest in matching over the past fifteen years, especially in psychology, it remains unclear whether these efforts are meaningful, mythical, or perhaps even misguided. Although a wide variety of studies have been conducted in recent years to assess matching’s efficacy, findings remain equivocal. In the early 1990s, a number of large-scale quantitative studies demonstrated positive associations between concordant patient-provider matches and a variety of standard outcome...

  7. PART II Clinical Cultures, Clinical Realities

    • [PART II Introduction]
      (pp. 131-136)

      The six chapters in “Clinical Cultures, Clinical Realities“ reach into the heart of our project’s investigations. The authors bring a unique mix of insider and outsider experiences and perspectives to their chapters. Antonio Bullon, Lawrence Park, and Marina Yaroshenko are psychiatrists in academic clinical practice, on the front lines providing care and directing clinics and services; they speak from inside the profession and as researchers of the profession. Joseph Calabrese and Sadeq Rahimi are anthropologists and also trained psychotherapists. Elizabeth Carpenter-Song, a psychological anthropologist, has extensive research experience with patients with psychiatric diagnoses. Sarah Willen, an anthropologist with a special...

    • Chapter 6 Portrait of a Psychiatrist
      (pp. 137-151)

      As these personal reflections from Dr. Z. suggest, the tendency within American biomedicine to advance a model of culturally competent care conceals a not-so-hidden possibility of misguided—and misleading—presumption, assumption, and stereotyping. Our overall study findings suggest these forms of stereotyping—especially when they intersect with increasing pressures toward efficiency, routinization, bureaucratization, and legalistic defensiveness—often interfere with clinicians’ professional mandate to approach each patient as a unique person who desires, and indeed deserves, personalized clinical attention.

      In this chapter, we explore these distancing tendencies from the perspective of Dr. Z., a Soviet-trained psychiatrist who, after completing her clinical...

    • Chapter 7 Psychiatry in a Flat World
      (pp. 152-167)

      According to Clive Unsworth, the Golden Age of psychiatry as a profession started in the late nineteenth century and continued through the twentieth, but never made it to the twenty-first (1991, 1993). Yet in recent years, startling advances in neuroscience and psychopharmacology have given psychiatrists powerful new tools with potential to improve the lives of patients with psychiatric disorders. Despite these advances, the profession is challenged by a growing “disparities” movement pushing for psychiatry to be more responsive to the needs of diverse racial, ethnic, cultural, religious, and socioeconomic groups and to reduce barriers to access and care (Smedley, Stith,...

    • Chapter 8 Recognition in Clinical Relationships
      (pp. 168-183)

      As Previous chapters in this volume describe in detail, the framing of the study responds to dramatic changes in clinical populations that mirror broad demographic trends toward greater diversity in the population of the United States. In this context, evidence is accumulating that something is deeply wrong in the delivery of health care in the United States, marked particularly by the growing awareness of striking disparities in use and outcomes of health care among minority and low-income populations. Specific to mental health concerns, not only do these populations bear a disproportionate burden of mental illness, they are also less likely...

    • Chapter 9 “The Culture of Medicine” As Revealed in Patients’ Perspectives on Psychiatric Treatment
      (pp. 184-199)

      The introduction to this volume notes a shift in emphasis from the patient’s cultural background to the culture of medicine in explanations of the production of disparities in care (Good et al. 2003). This shift reflects the development of a more complex and encompassing understanding of culture, one that goes beyond the equation of culture with the pentad of racial-ethnic categories of identity and encompasses the cultural orientations and assumptions of medical institutions. Given this new focus, the questions we asked patients in the study included a contextual explanation: “We are trying to understand the experience of treating patients with...

    • Chapter 10 The Paper Life of Minority and Low-Income Patient Care
      (pp. 200-216)

      Throughout this book, we explore how a variety of social factors exogenous to clinical medicine, narrowly conceived, are critical mediators of experiences of clinicians and patients and the quality of care. Central to our analysis is an argument about the role of new forms of ethnic diversity, what we have calledhyperdiversity. However, our investigations found that the culture of medicine that shapes clinician experience and practice is deeply influenced by administrative and financial requirements, as well as by the meaning and values that give distinctive form to American medicine.

      We approach our analyses from two vantage points—that of...

    • Chapter 11 Physicians’ Perspectives on Financial Barriers to Equitable Care
      (pp. 217-234)

      The chapters in this volume have focused on the role of culture in the process of delivering and accessing health care. However, cultural dynamics play out in the larger context of an evolving system of health-care finance and insurance that powerfully conditions the equitable provision of care. Although equal access to health care is considered by some a fundamental right of citizenship, access to care significantly varies between racial and ethnic groups and between individuals with different levels of income and education.¹

      During the five years we were in the field for this study, major political battles were waged at...

  8. Index
    (pp. 235-244)