A Developmental Model of Ethnosensitivity in Family Practice Training

Journal article

By: Jeffrey M. Borkan and Jon Neher

Date: March-April 1991

Source: Jeffrey M. Borkan. "A Developmental Model of Ethnosensitivity in Family Practice Training." Family Medicine (March-April 1991).

About the Author: Trained as a family physician, Jeffrey Borkan works in both family medicine and medical anthropology. He has split his career between the United States and Israel, working as a researcher, educator and clinician. Borkan has been influential in guiding medical education curricula and health policy decisions, and is a recognized authority in mixed method research (using both qualitative and quantitative analysis methods in the same study). As of 2005, Borkan is Professor and Chair of the Department of Family Medicine and Physician in Chief for Memorial Hospital of Rhode Island/Brown Medical School. Jon Neher holds the positions of Clinical Professor at the University of Washington and Assistant Director for Curriculum at Valley Medical Center's Family Medicine department in Washington. He has spent his career working in medical education and curriculum development. He is regarded for his work in promoting residency training and enjoys the pressure of opening up his practice to residency review.

INTRODUCTION

Family physicians are one of the first medical professionals the public contact when concerned about their health care. As most societies in North America have a diverse cultural population, the patient walking into the doctor's office could be from any number of ethnic backgrounds. Research in the United States, Canada, United Kingdom, and New Zealand has shown that the visible minority population receives a lower standard of health care than that of the western Caucasian population. Borkan and Neher ask why that is the case and what can be done from a family physician's training point of view.

Language barriers, spiritual beliefs, cultural differences, income, residential situation and location, are all cited as being challenges to receiving appropriate medical care. Borkan and Neher assert that cross-cultural medicine is a natural and important part of family practice.

It is not possible to anticipate every cultural exposure a physician will incur during the life of his or her practice. Medical schools have taken some steps to implement ethnosensitivity training into their curriculum. Mostly, such training occurs during the first or second year of medical school and can last from a three-hour discussion to a year-long immersion into different cultures. Practice-based learning sessions, small group discussions, role-playing, video analysis, and multicultural presenters are popular ways to teach cross-cultural sensitivity. Although medical schools can try to include ethnosensitivity training in their curricula, there is a lack of consistency in educational quality.

PRIMARY SOURCE

ABSTRACT

Cross-cultural medicine is a normal and important part of family practice. Unfortunately, its acceptance andimplementation into family practice training programs has been limited….

Cross-cultural medicine has been introduced into academic family medicine repeatedly over the last ten years, yet it has not taken hold in any substantial way….

The barriers are many: the core family medicine curriculum is already quite full, cross-cultural literature often appears too exotic or to romanticized to apply to the "usual" doctor-patient encounter, and Western medicine continues to be primarily focused on pathophysiology rather than the patient's experience of illness and the biopsychological model. An additional problem with implementing any standard curriculum is that trainees have varying capacities both to accept cultural differences and to integrate cross-cultural tools and insights into practice….

… The authors' goals were to create a system that evaluates a trainee's level of cross-cultural sophistication, minimizes jargon, normalizes ethnicity as a part of every doctor-patient encounter, and can easily be implemented by family medicine faculty….

Ethnosensitivity is desirable in family practice for several reasons. Not only does it support the stated goals of integrating appreciation for the whole person and the behavioral sciences into clinical practice, but it also advances doctor-patient communication and presumably patient satisfaction….

Cognitive strategies useful in combating denial [of cultural insensitivity] are first aimed at fostering the simple awareness of cultural differences and then helping trainees make finer distinctions within ethnic or cultural groups. For example, rather than just recognizing an individual as "Latino," they should be able to identify the social and cultural attributes of Mexicans, as opposed to Puerto Ricans or El Salvadorians. Methods might include lectures from authorities, educational cultural events focusing on a specific ethnic group in the community (such as "Native American Day"), games, demonstrations, and even home visits. A particularly appropriate simulation game is "Baf'a Baf'a." Easily modifiable to medical situations, this game encourages participants to examine cross-cultural differences in communication and meaning.

In a more interpretive fashion, the medical trainee needs to be aware that everyone has ethnicity. Such differences are often not apparent on the surface. Because a patient's looks somewhat like a provider and speaks the same language does not imply that they share the same worldview….

Superiority In the superiority stage, trainees admit to the presence of other cultures and of cultural differences but tend to rank them according to their own value systems. Usually this results in their own culture being seen as the most advanced and other worldviews as being somewhat flawed. Negative stereotyping is perhaps the most obvious manifestation of this stage. In addition, such trainees may hold rigidity to the precepts of their "provider culture," Western biomedicine. Members of other provider cultures, such as chiropractors, homeopaths, and midwives, may be denounced as holding traditional health care systems may be scoffed at. These condescending attitudes may drive patients into cowed silence or out of the healthcare center altogether.

Occasionally someone will come to view another culture as superior and attempt to wholly adopt it in a process of "reversal." "Going native" is a common occupational hazard among anthropologists, foreign service agents, and others who work in an isolated manner in a diverse spectrum of cultures. This involves identification with a group's attitudes, beliefs, and practices to the exclusion of one's own. In family practice, this phenomenon is commonly seen in first year residences who return from their internal medicine or surgery rotations with scowling disapproval of family practice and its weaknesses. Although reversal may seem to be more developmentally advanced than simple cultural superiority, it in fact implies denigration of one's own culture.

Several cognitive strategies exist for dealing with superiority. The main goal is to make the trainee aware of the relative strengths and weaknesses of each system, including his or her own. Similarities, rather than differences, between cultures, value systems, and ethnic groups are to be stressed during this stage….

Minimization Minimization involves acknowledging that cultural differences do exist but viewing them as unimportant against a backdrop of basic human similarities. This is an extremely seductive attitude for trainees, since it is reinforced by dominant American and Western medical views. The "melting pot" concept minimizes the importance of ethnic differences and devalues immigrant cultural practices and beliefs, promoting "pan-Amercanisms" instead. Most medical training emphasizes the reductionist model, stressing biochemistry and pathophysiology while deemphasizing the medical effects of personality, family structure, and socio-cultural factors. Nonphysiologic attributes are seen as marginal, exotic, or quaint.

The same reductionist model that purports that "we are all the same under the skin" gives a false sense of efficiency and clarity to the trainee who can treat all individuals without need of lengthy history taking or without acknowledging confounding psychological variables. The standard presentation of patients, "A seventy-two-year-old male with X, Y, and Z," strips the individual of nearly all identifying social characteristics, including name….

Relativism At this stage, ethnic and cultural differences are at last acknowledged and respected. The worldviews of other cultures are no longer seen as threatening and their value is intellectually accepted. Ethnocentric biases are put aside, and the trainee is able to view other cultures without ego-salvaging distortions. In effect, the trainee says, "I know that people have cultural differences and that those differences are important in understanding their behavior." An actual knowledge of specific cultural differences, however, is not implied….

There are two major problems encountered by trainees in the stage of cultural relativism. The first is being over-whelmed by the sheer mass of cultural information they assume they have to absorb and integrate. In a training process that stresses complete mastery over detail, it is little wonder that residents may exclaim, "I'm not even comfortable with my level of knowledge in biochemistry, physiology, and neuroanatomy. I don't have time to learn Chinese herbalism and acupuncture too!"…

The second major problem encountered in the stage of cultural relativism is wrongly ascribing important data about physical, emotional, and social illness to ethnicity rather than pathology. This occurs because the trainee is unaware of the value system of the patient….

Empathy Empathy involves the trainee's ability to shift his or her frame of reference so as to experience events as a patient might. Vital to this process is an understanding of the patient's value system and worldview. It is a much more sophisticated response than "sympathy."…

Empathy may facilitate communication between practitioner and patient, thereby enhancing diagnostic accuracy, compliance, and patient satisfaction….

Strategies for promoting empathy and advancing the trainee into the stage of integration are basically experiential. Cultural immersion is essential. A year in a Navajo hospital, an afternoon at a flop house, or a few hours wearing a blindfold and having to be escorted are all appropriate techniques….

Integration Cultural integration is the most advanced level of physician awareness. The culturally integrated practitioner is a multicultural individual who has cognitively, emotionally, and socially meshed with several cultures. The successful integrator stands both inside and outside a culture, having both deep understanding and a critical viewpoint. The integrating physician is able to "balance a consideration of universal norms, specific norms, and individual norms in (a) differentiating between normal and abnormal behavior, (b) considering etiologic factors, and (c) implementing appropriate interventions….

… The ability to accept, empathize, and contextually evaluate are goals which are consistent with the highest values of family practice and in keeping with the art of healing within our specialty….

SIGNIFICANCE

In 1991, Borkan and Neher published an assessment guide to anticipate the level of ethnosensitivity of graduating family doctors. Their guide stipulates seven learning levels that can be exhibited by trainees and builds upon earlier work conducted by M. J. Bennett published in 1986. They note that such levels would vary with the different ethnic group the trainee encounters.

At the most basic level of cultural sensitivity, the trainee could be perceived as being fearful of the encounter with a person from a different race. This fear could preclude the trainee's provision of medical care. Denial of any cultural difference could lead to misunderstandings and discontinuity of care. A perception that the trainee's race is superior to the patient's engenders negative stereotypes. Understanding the benefits and disadvantages of each culture, including their own, would help the trainee draw similarities upon which to build a doctor-patient relationship. With the superiority comes minimization and the belief that differences are unimportant in a medical relationship. However, minimizing differences may lead to a loss of the patient's identity, background and lifestyle and the patient becomes a condition rather than an individual person.

As trainees start to understand the differences in cultural relationships, relativism—acknowledging that ethnic and cultural differences exist and should be respected—comes into play. The trainee's frame of reference can then change to empathy and an ability to relate the patient's decision-making and cultural influences. Finally, integration is the level at which a trainee can acknowledge and understand the multicultural aspect of society and meets the goal of societal healing set forth for the role of family physician.

In the United States, there are still problems with racial disparity in relation to the provision of health care. In their update of health disparities literature, published in the Annals of Internal Medicine in 2004, Judith Long and her colleagues state that "black patients receive fewer appropriate medical services than white people." In one program in New Zealand, physician educators are combating the effects of racism through a cultural immersion medical education program. In a 2002 issue of Academic Medicine, they suggest "the principles of cultural immersion, informed by the concept of cultural safety, could be adapted to indigenous and minority groups in urban settings to provide medical students with the foundations for a lifelong commitment to practicing medicine in a culturally safe manner."

Borkan and Neher's assessment guide provides a framework upon which to assess a physician's preparation for working in a multicultural society. However, since Borkan and Neher's paper was published in 1991, few medical school curricula cover ethnosensitivity training in depth. The culturally sensitive physician, therefore, tends to be more a product of career learning and lifestyle choice rather than training before graduation.

FURTHER RESOURCES

Books

Culhane-Pera, Kathleen A., D. E. Vawter, P. Xiong, B. Babbitt, and M. M. Solberg. Healing by Heart: Clinical and Ethical Case Stories of Hmong Families and Western Providers. Nashville, Tenn: Vanderbilt University Press, 2003.

Periodicals

Kagawa-Singer, M., and L. J. Blackhall. "Negotiating Cross-Cultural Issues at the End of Life." Journal of the American Medical Association, vol. 286, no. 23, (2001):2993-3001.

Long, J. A., V. W. Chang, S. A. Ibrahim, and D. A. Asch. "Update on the Health Disparities Literature." Annals of Internal Medicine, vol. 141, (2004):805-812.

Loudon, R. F., P. M. Anderson, P. S. Gill, and S. M. Greenfield. "Educating Medical Students for Work in Culturally Diverse Societies." Journal of the American Medical Association, vol. 282, no. 9, (1999):875-880.