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Essay

Anthropology in the Clinic: The Problem


of Cultural Competency and How to Fix It
Arthur Kleinman*, Peter Benson

patients of a certain ethnicitysuch as, practical understanding of an episode


the Mexican patientare assumed (see Box 1).
to have a core set of beliefs about Historically in the health-care
illness owing to xed ethnic traits. domain, culture referred almost solely
Cultural competency becomes a series to the domain of the patient and
of dos and donts that dene how family. As seen in the case scenario
to treat a patient of a given ethnic in Box 1, we can also talk about the
background [10]. The idea of isolated culture of the professional caregiver
societies with shared cultural meanings including both the cultural background

C
ultural competency has become would be rejected by anthropologists, of the doctor, nurse, or social worker,
a fashionable term for clinicians today, since it leads to dangerous and the culture of biomedicine
and researchers. Yet no one can stereotypingsuch as, Chinese believe itselfespecially as it is expressed in
dene this term precisely enough to this, Japanese believe that, and so institutions such as hospitals, clinics,
operationalize it in clinical training and onas if entire societies or ethnic and medical schools [14]. Indeed, the
best practices. groups could be described by these culture of biomedicine is now seen
It is clear that culture does matter in simple slogans [1113]. as key to the transmission of stigma,
the clinic. Cultural factors are crucial Another problem is that cultural the incorporation and maintenance
to diagnosis, treatment, and care. factors are not always central to a case, of racial bias in institutions, and the
They shape health-related beliefs, and might actually hinder a more development of health disparities
behaviors, and values [1,2]. But the across minority groups [1518].
large claims about the value of cultural
competence for the art of professional Culture Is Not Static
care-giving around the world are simply Box 1. Case Scenario: Cultural In anthropology today, culture is
not supported by robust evaluation Assumptions May Hinder not seen as homogenous or static.
research showing that systematic Practical Understanding Anthropologists emphasize that culture
attention to culture really improves
A medical anthropologist is asked by
clinical services. This lack of evidence
a pediatrician in California to consult in
is a failure of outcome research to take
the care of a Mexican man who is HIV Funding: Our work on cultural aspects of clinical care
culture seriously enough to routinely
positive. The mans wife had died of AIDS has been supported by the Michael Crichton Fund,
assess the cost-effectiveness of culturally Harvard Medical School, and by a National Institute of
one year ago. He has a four-year-old son
informed therapeutic practices, not a Mental Health Training Grant on Culture and Mental
who is HIV positive, but he has not been Health Services (5T32MH018006-21).
lack of effort to introduce culturally
bringing the child in regularly for care.
informed strategies into clinical settings Competing Interests: The authors declare that they
The explanation given by the clinicians
[3]. have no competing interests.
assumed that the problem turned on a
radically different cultural understanding. Citation: Kleinman A, Benson P (2006) Anthropology
Problems with the Idea of Cultural in the clinic: The problem of cultural competency and
Competency What the anthropologist found, though, how to x it. PLoS Med 3(10): e294. DOI: 10.1371/
was to the contrary. This man had a near journal.pmed.0030294
One major problem with the idea of
complete understanding of HIV/AIDS
cultural competency is that it suggests DOI: 10.1371/journal.pmed.0030294
and its treatmentlargely through the
culture can be reduced to a technical
support of a local nonprot organization Copyright: 2006 Kleinman and Benson. This is
skill for which clinicians can be trained an open-access article distributed under the terms
aimed at supporting Mexican-American of the Creative Commons Attribution License,
to develop expertise [4]. This problem
patients with HIV. However, he was a which permits unrestricted use, distribution, and
stems from how culture is dened in reproduction in any medium, provided the original
very-low-paid bus driver, often working
medicine, which contrasts strikingly author and source are credited.
late-night shifts, and he had no time
with its current use in anthropology
to take his son to the clinic to receive Arthur Kleinman is Chair and Esther and Sidney
the eld in which the concept of Rabb Professor in the Department of Anthropology
care for him as regularly as his doctors
culture originated [59]. Culture is at Harvard University, and Professor of Psychiatry
requested. His failure to attend was not and Medical Anthropology at Harvard Medical
often made synonymous with ethnicity,
because of cultural differences, but rather School, Boston, Massachusetts, United States of
nationality, and language. For example, America. Peter Benson is a PhD candidate in medical
his practical, socioeconomic situation. anthropology in the Department of Anthropology
Talking with him and taking into account at Harvard University, Cambridge, Massachusetts,
his local world were more useful than United States of America.
The Essay section contains opinion pieces on topics
of broad interest to a general medical audience.
positing radically different Mexican * To whom correspondence should be addressed.
health beliefs. E-mail: kleinman@wjh.harvard.edu

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is not a single variable but rather Box 2. The Explanatory Models of illness is recast into technical disease
comprises multiple variables, affecting Approach categories something crucial to the
all aspects of experience. Culture is experience is lost because it was not
inseparable from economic, political, What do you call this problem? validated as an appropriate clinical
religious, psychological, and biological What do you believe is the cause of concern [34].
conditions. Culture is a process this problem? Rather, explanatory models
through which ordinary activities and What course do you expect it to take? ought to open clinicians to human
conditions take on an emotional tone How serious is it? communication and set their expert
and a moral meaning for participants. knowledge alongside (not over and
What do you think this problem does
Cultural processes include above) the patients own explanation
inside your body?
the embodiment of meaning in and viewpoint. Using this approach,
psychophysiological reactions [19], How does it affect your body and your clinicians can perform a mini-
the development of interpersonal mind? ethnography, organized into a series
attachments [20], the serious What do you most fear about this of six steps. This is a revision of the
performance of religious practices condition? Cultural Formulation included in the
[21], common-sense interpretations What do you most fear about the fourth edition of the Diagnostic and
[22], and the cultivation of collective treatment? Statistical Manual of Mental Disorders
and individual identity [23]. Cultural (DSM-IV) (see Appendix I in [35])
(Source: Chapter 15 in [38])
processes frequently differ within the [36,37].
same ethnic or social group because
of differences in age cohort, gender, A Revised Cultural Formulation
political association, class, religion, not eat pork; some Jews, including the Step 1: Ethnic identity. The rst step
ethnicity, and even personality. corresponding author of this paper, is to ask about ethnic identity and
love pork.) Ethnography emphasizes determine whether it matters for the
The Importance of Ethnography engagement with others and with the patientwhether it is an important
It is of course legitimate and highly practices that people undertake in their part of the patients sense of self. As
desirable for clinicians to be sensitive local worlds. It also emphasizes the part of this inquiry, it is crucial to
to cultural difference, and to attempt ambivalence that many people feel as acknowledge and afrm a persons
to provide care that deals with cultural a result of being between worlds (for experience of ethnicity and illness. This
issues from an anthropological example, persons who identify as both is basic to any therapeutic interaction,
perspective. We believe that the optimal African-American and Irish, Jewish and and enables a respectful inquiry into
way to do this is to train clinicians in Christian, American and French) in a the persons identity. The clinician
ethnography. Ethnography is the way that cultural competency does not. can communicate a recognition that
technical term used in anthropology And ethnography eschews the technical people live their ethnicity differently,
for its core methodology. It refers to mastery that the term competency that the experience of ethnicity is
an anthropologists description of suggests. Anthropologists and clinicians complicated but important, and that
what life is like in a local world, a share a common beliefi.e., the it bears signicance in the health-care
specic setting in a societyusually primacy of experience [2933]. The setting. Treating ethnicity as a matter
one different from that of the clinician, as an anthropologist of of empirical evidence means that its
anthropologists world. Traditionally, sorts, can empathize with the lived salience depends on the situation.
the ethnographer visits a foreign experience of the patients illness, and Ethnicity is not an abstract identity,
country, learns the language, and, try to understand the illness as the as the DSM-IV cultural formulation
systematically, describes social patterns patient understands, feels, perceives, implies, but a vital aspect of how life is
in a particular village, neighborhood, and responds to it. lived. Its importance varies from case
or network [24]. What sets this to case and depends on the person. It
apart from other methods of social The Explanatory Models Approach denes how people see themselves and
research is the importance placed on One of us [AK] introduced the their place within family, work, and
understanding the natives point of explanatory models approach, social networks. Rather than assuming
view [25]. The ethnographer practices which is widely used in American knowledge of the patient, which can
an intensive and imaginative empathy medical schools today, as an interview lead to stereotyping, simply asking the
for the experience of the natives technique (described below) that patient about ethnicity and its salience
appreciating and humanly engaging tries to understand how the social is the best way to start.
with their foreignness [26], and world affects and is affected by illness. Step 2: What is at stake? The second
understanding their religion, moral Despite its inuence, weve often step is to evaluate what is at stake as
values, and everyday practices [27,28]. witnessed misadventure when clinicians patients and their loved ones face an
Ethnography is different than and clinical students use explanatory episode of illness. This evaluation may
cultural competency. It eschews the models. They materialize the models include close relationships, material
trait list approach that understands as a kind of substance or measurement resources, religious commitments, and
culture as a set of already-known (like hemoglobin, blood pressure, or X even life itself. The question, What is
factors, such as Chinese eat pork, rays), and use it to end a conversation at stake? can be asked by clinicians;
Jews dont. (Millions of Chinese are rather to start a conversation. The the responses to this question will vary
vegetarians or are Muslims who do moment when the human experience within and between ethnic groups, and

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will shed light on the moral lives of contrary to the view of the expert as Box 3. Case Scenario: The
patients and their families. authority and to the medias view that Importance of Using Culturally
Step 3: The illness narrative. Step technical expertise is always the best Appropriate Terms to Explain
3 is to reconstruct the patients answer. The statement First do no
Peoples Life Stories
illness narrative [38]. This involves harm by stereotyping should appear
a series of questions (about ones on the walls of all clinics that cater Miss Lin is a 24-year-old exchange
explanatory model) aimed at acquiring to immigrant, refugee, and ethnic- student from China in graduate school in
an understanding of the meaning of minority populations. And yet since the United States, where she developed
illness (Box 2). culture does not only apply to these symptoms of palpitations, shortness
The patient and familys explanatory groups, it ought to appear on the walls of breath, dizziness, fatigue, and
models can then be used to open up of all clinics. headaches. A thorough medical work-
a conversation on cultural meanings Step 6: The problems of a cultural up leaves the symptoms unexplained. A
that may hold serious implications for competency approach. Finally, step 6 psychiatric consultant diagnoses a mixed
care. In this conversation, the clinician is to take into account the question depressive-anxiety disorder. Miss Lin
should be open to cultural differences of efcacynamely, Does this is placed on antidepressants and does
in local worlds, and the patient should intervention actually work in particular cognitive-behavioral psychotherapy,
recognize that doctors do not t a cases? There are also potential with symptoms getting better over a six-
certain stereotype any more than they side-effects. Every intervention has week period; but they do not disappear
themselves do. potential unwanted effects, and this completely.
Step 4: Psychosocial stresses. Step is also true of a culturalist approach. Subsequently, the patient drops out
4 is to consider the ongoing stresses Perhaps the most serious side-effect of of treatment and refuses further contact
and social supports that characterize cultural competency is that attention to with the medical system. Anthropological
peoples lives. The clinician records the cultural difference can be interpreted consultation discovers that Miss Lin
chief psychosocial problems associated by patients and families as intrusive, comes from a Chinese family in Beijing
with the illness and its treatment (such and might even contribute to a sense one of her cousins is hospitalized with
as family tensions, work problems, of being singled out and stigmatized chronic mental illness. So powerful is
nancial difculties, and personal [3,11,12]. Another danger is that the stigma of that illness for this family
anxiety). For example, if the clinicians overemphasis on cultural difference that Miss Lin cannot conceive of the
described in the case scenario in Box 1 can lead to the mistaken idea that if idea that she is suffering from a mental
had carried out step 4, they could have we can only identify the cultural root disorder, and refuses to deal with her
avoided the misunderstanding with of the problem, it can be resolved. American health-care providers because
their Mexican-American patient. The The situation is usually much more they use the terms anxiety disorder and
clinician can also list interventions to complicated. For example, in her depressive disorder. In this instance,
improve any of the patients difculties, inuential book, The Spirit Catches You she herself points out that in China
such as professional therapy, self- and You Fall Down, Ann Fadiman shows the term that is used is neurasthenia
treatment, family assistance, and that while inattention to culturally or a stress-related condition. On the
alternative or complementary medicine. important factors creates havoc in anthropologists urging, clinicians
Step 5: Inuence of culture on the care of a young Hmong patient reconnect with Miss Lin under this label.
clinical relationships. Step 5 is to with epilepsy, once the cultural issues
examine culture in terms of its are addressed, there is still no easy
inuence on clinical relationships. resolution [33]. Instead, a whole new just what patients have; clinicians
Clinicians are grounded in the world series of questions is raised. also participate in cultural worlds. A
of the patient, in their own personal physician too rigidly oriented around
network, and in the professional Determining What Is at Stake for the classication system of biomedicine
world of biomedicine and institutions. the Patient might nd it unacceptable to use lay
One crucial tool in ethnography is The case history in Box 3 gives classications for the treatment.
the critical self-reection that comes an example of how simply using For the late French moral
from the unsettling but enlightening culturally appropriate terms to explain philosopher Emmanuel Levinas, in
experience of being between social peoples life stories helps the health the face of a persons suffering, the
worlds (for example, the world of the professionals to restore a broken rst ethical task is acknowledgement
researcher/doctor and the world of the relationship and allows treatment to [39]. Face-to-face moral issues
patient/participant of ethnographic continue. This case is not settled, nor is precede and take precedence over
research). So, too, it is important to it an example of any kind of technical epistemological and cultural ones
train clinicians to unpack the formative competency. But there are two [40]. There is something more
effect that the culture of biomedicine illuminating aspects of this case. First, it basic and more crucial than cultural
and institutions has on the most is important that health-care providers competency in understanding the life
routine clinical practicesincluding do not stigmatize or stereotype of the patient, and this is the moral
bias, inappropriate and excessive use patients. This is a case study of an meaning of sufferingwhat is at stake
of advanced technology interventions, individual. Not all Chinese people t for the patient; what the patient, at a
and, of course, stereotyping. Teaching this life story, and many contemporary deep level, stands to gain or lose. The
practitioners to consider the effects Chinese now accept the diagnosis of explanatory models approach does not
of the culture of biomedicine is depression. Second, culture is not ask, for example, What do Mexicans

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