79 whether or not competence involves physicians

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acceptance that meanings can differ. 79 Whether or not competence involves physicians developing clinical variables that encourage patients to make their own choices, 80 competence in culture needs production of clinical spaces within which misunderstandings can be bridged. 81,82 Caregivers need time to create meaning, saving unnecessary expenses. Competence is the nurturing of communication between caregivers and patients to remove barriers to care. 50,63 Therefore, cultural competence can no longer be considered only “a set of skills necessary for physicians to care for immigrants, foreigners, and others from ‘exotic’ cultures”. 61 Moreover, cultural competence should not concern itself exclusively with perceived differences. Culture is less successful when it functions as a medium through which medicine translates clinical realities to uninformed others than when it produces new social circumstances that successfully contextualise clinical knowledge. A new technique called the Bloomsbury Cultural Formulation 75 exemplifies such a commitment, and should be reviewed carefully for its potential application in all clinical settings (panels 1 and 2). Competence and evidence-based medicine Although a glaring need exists for cultural competence awareness and training in both public health policy and clinical care, the cultural determinants of health behaviour need to be better understood and compared with prevalence rates that suggest genetic causes of illness in ethnic and racial minorities. Although the central goal of evidence-based medicine is to reduce disease burden through measures that have been proven to be both effective and effi cient, it is rarely associated with sociocultural factors affecting disease burden and outcome. Because values and behaviour are largely socially conditioned, to understand the cultural factors that influence treatment-seeking behaviours and treatment adherence is crucial to maximise health outcomes. A strong evidence base for the treatment of diabetes, for example, enables doctors to reduce the effect of symptoms, but only if patients present themselves for treatment. Likewise, accurate advice on management of diabetes will improve the patient’s health, but only if the patient puts the advice into practice. Health care, therefore, fails to be effective if patients either do not make use of health care to which they are entitled or do not adhere to treatment regimens. Type 2 diabetes is a case in point—for a disease whose major causes are known (as are rates of mortality and morbidity, preferred treatments, and modes of prevention), compliance is only between 40% and 60% even in the most privileged economies, 89 with findings from studies in Scotland, for example, showing that only a third of patients adhere to therapeutic rec- ommendations (in the Tayside Region).
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  • Summer '18
  • Jeanne Hughes
  • Lancet

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