the-lancet---culture-and-health.pdf

Although to blame culture is problematic the fact

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meaningful deem such requests hostile. Although to blame culture is problematic, the fact that culture is factored out of clinical settings might merely show some acknowledgment of the extent to which it is inherently so diffi cult to assess. Most students are encouraged to equate competence with achievement of clinical compliance—culturally competent doctors are those who learn to use the social capital of patients, families, and communities to achieve measurable clinical results. Such models of care, 64 which increasingly conceptualise doctors as health-care vendors, only succeed when goals set by managers and administrators are similar to those of patients. However, they will not solve issues generated by deep social diff erence. Rigid conduits for giving care in which doctors invariably emerge as non-patient-oriented replace personal Social capital is defined as the valued social networks and reciprocal social bonds that sustain human engagement and cooperation
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The Lancet Commissions www.thelancet.com Vol 384 November 1, 2014 1617 relationships and clinical freedom. Mid-career dis- satisfaction and depression are common in health-care workers as patient distrust of providers grows. 95 Care recipients increasingly perceive novel patient empowerment programmes as attempts to devolve responsibilities from caregivers to the patients themselves. For example, packaged service programmes can widen gaps for those who cannot access them, leaving the poor to be blamed while the wealthy are treated as consumers with assets to spend. In HIV public health messages, for instance, patients in high-income countries are repeatedly informed that their infections are manageable and that they are healthier than they might think; whereas campaigns in low-income countries barrage the so-called uninformed patients with messages about how they are less healthy than they could possibly imagine. 96 Under such circumstances, what can students be taught? In the worst cases, they are taught that patients will agree if doctors speak positively, look the patient in the eye, and exude whatever warmth and closeness might be needed to cajole patients into following therapeutic instructions. Although such enforced behaviours might sway patients under specific clinical circumstances, they do not show clinicians how patients will behave outside of the clinic. And while patient–doctor interactive training can produce an immediate expression of compliance on the part of patients in doctors’ offi ces, doubts about treatment effectiveness can re-emerge soon after patients leave the clinic. Polite patients who go on to ignore the agreement that the physician thought had been established in the clinical encounter are later labelled as non-compliant, when in fact the physician mistakenly thought he or she had convinced the patient to follow his or her instructions. Such misunderstandings do little but reinforce sociocultural stereotypes.
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