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

97 although humanitarian concerns might then drive

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97 Although humanitarian concerns might, then, drive competence training, compliance issues are sometimes viewed as a managerial annoyance. However, active patient and user engagement improve care when other compliance and adherence strategies fail. 98,99 For this reason, social encounters cannot be wholly replaced by technical innovations because in the best cases, student health providers (doctors, nurses, midwives, and therapists) learn that therapeutic en- counters are events in which outcomes can be improved by genuine care. They also learn that respect and esteem are key factors to assist patients in discovering new meaning through the suffering that illness creates. Much of social science has devoted itself to showing how new kinds of meaning can be created when patients and carers work together and are mutually respectful. 100 In view of the brevity of competence training and the limitations placed on health-care providers, one might reasonably ask whether a little knowledge is a dangerous thing. This diffi culty is compounded by short-term managerial demands for outputs, creating little time for cultures of care to emerge. To unpack such goal tending takes time, trust, and patience—therapeutic time for both patients and doctors, but also for managerial overseers who otherwise haunt clinical encounters, leaving caregivers and patients fearful, if not depressed. In this regard, the system needs to change, as health-care administrators and policy makers are in much need of critical study. Such large-scale diffi culties in the culture of care are not easily addressed, and new approaches to teaching competence in medical schools therefore vary substantially. 50,101,102 To rethink cultural competence is a challenge. Cultural competence is caring competence. Not only does it include an awareness of diverse patient needs, it also demands some awareness of medicine’s own cultural practices, including its prejudices, assumptions, and institutional values. Those professionals who are at odds with such hierarchies often find their motives questioned. Rural primary care doctors, who openly acknowledge the importance of social work, regularly complain that their treatment strategies are perceived as time-wasting and second-class by hospital-based colleagues. 103,104 Nursing has become so undesirably subservient that some countries cannot survive without a massive influx of immigrant caregivers into their workforces. Even the invention of family practitioner subspecialties has not helped, 105–107 frequently leaving family practitioners to be lumped in with countercultural or other forms of so-called alternative medicine. 108 In short, cultural competence is the tail end of a much bigger issue involving professional prestige hierarchies, a scarcity of education, and basic cultural ignorance on the part of medical educators. If medical schools need to make ends meet by indirect revenues on grants and profit-making clinical services, and by a dependency on philanthropy, why should they be focused on education,
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