Of whether something as dynamic as culture can be

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of whether something as dynamic as culture can be effectively known from within the highly normative theories of engagement that are central to medical education. Culture, including institutional cultures, should therefore be examined carefully and rigorously. To establish what is and is not culturally normative, broad generalisations run the risk of defining cultural lifeways as themselves pathological, with indiscriminate application of normative stereotypes to diverse beliefs, patterns of acting, and systems of meaning. Sensing the presence of a shared value relates little or not at all to how a member of a society might or might not respond to that value. Cultural competence courses can as much inadvertently strengthen culturally associated stereotypes that physicians hold about patients, thereby making it more diffi cult for doctors to perceive their own biases and the effect that these could have on diagnosis and treatment decisions. 94 Training courses need themselves, therefore, to be developed competently. Cultural competence training at its worst creates an idea of culture as a thing “made synonymous with ethnicity, nationality and language”, 64 and that can be taught as though it can be satisfied using a checklist—do this, not that. Under such conditions, doctors who have been trained in cultural competence can often misattribute cultural reasons to patient issues, rather than recognise that patient diffi culties can be equally economic, logistic, circumstantial, 64 or related to social inequality. Those studying health care need to appreciate what is as yet unknown and the processes by which new knowledge can be obtained. To teach culture as a fixed perspective on illness and clinical behaviour risks the promotion not only of mediocre care, but also of poor strategies to address diffi culties that emerge in socially complex treatment environments. Such practices and assumptions are especially harmful because they are exacerbated by health-care students’ insecurities about knowledge and evidence. They are also made more harmful when educational hierarchies encourage students to emulate authoritatively their senior doctors who themselves might be at odds with the relevance of culture. Mistaking compliance for competence Many medical students believe that equality of care is best ensured by a doctor’s refusal to use ethnic, racial, or religious characteristics as clinically salient diagnostic criteria. In doing so, these students support Dogra’s 51 claim that the a priori acceptance of racial and ethnic distinction by doctors is, by nature, problematic. Yet, diffi culties arise if doctors insist that patients present themselves in ways that doctors understand as culturally neutral. To ask female Muslim patients to remove their veils during diagnosis, for instance, or to request that a family of Hasidic Jewish patients not bring food into hospital might seem only to ignore the relevance of religious affi liation. But those who find these practices meaningful deem such requests hostile. Although to
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  • Summer '18
  • Jeanne Hughes
  • Lancet

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