Patient variety is the norm, not an exception,
Zanting et al. write in their Advances in Health Science Education paper. Despite this, one of the most important ways that patient variety presents itself is (and as the title of their paper implies) never even defined.
To prepare medical students for encounters with an increasingly diverse patient population … although … approaches start from the assumption that culture matters in communication, education, and skills development, few seem to define
cultureexplicitly. Instead, they tacitly assume its meaning is familiar, implicitly conceptualising it in a certain way nonetheless.
Backing up beyond the scope of this paper, the inciting issue that gives rise the authors’ discussion is the fact that medical education does not prepare future physicians to encounter “patient variety”, specifically, a variety in culture. Once we have that central problem in view, the next question becomes, “What is the main obstacle to preparing a medical student to interact with other cultures?” This is where Zanting et al. come in.
In the authors’ review of relevant literature, they tease out four distinct views of culture. Culture can be:
- a fixed patient characteristic (e.g., in the “cultural competence” approach)
- multiple fixed characteristics (e.g., in literature on intersectionality)
a dynamic outcome impacting social interaction
(as defined in “cultural humility”)- a power dynamic (expressed in “critical consciousness”)
If the problem is that newly-minted physicians are ill-prepared to deal with a plurality of cultures, each of these viewpoints implicitly expresses an obstacle to tackling that problem.
If culture is one fixed characteristic, it is a “static fact,” a category to which someone belongs and inherently part of that person. The obstacle expressed by this view of culture is that clinicians don’t have the skills and knowledge to communicate effectively with this particular culture. In this view, the solution is clear enough: specific skills-oriented training to acquire cultural knowledge, skills, attitudes, and awareness.
Instead of one fixed identity, culture may also be viewed as multiple, intersecting identities. This is still a view of culture as inherent to the person, but instead of one thing, it is the combination of many categories to which the person belongs. In this view, instead of a lack of training about one identity, the obstacle to handling diversity in the clinic is that the multiple, “mutually reinforcing identities” are not being included and considered in clinical decision-making. As Zanting et al. summarize it, it was reported that case descriptions and pictures should include categories of differences other than culture, sex/gender, and class as equally important patient identities
.
Culture “as a dynamic outcome” moves the “location” of culture from the individual to between individuals. In other words, culture is not a category or combination of categories. Culture is something present in the social interactions that make us up. It is “dynamic” in the sense that the social interactions that result from culture in turn continuously form and shape our culture. This view of culture as a dynamic interaction also places the obstacle to better clinical outcomes between the patient and clinician: no clinician can know the sum total of all the experiences that a patient is bringing to their interaction. This is why this view of culture is most closely connected with thoughts on “cultural humility”, which aims to cultivate a mutually respectful patient-physician relationship.
The final view of culture the authors identify takes the view of culture between persons, and adds that all of us are a part of systems and power dynamics which influence those interactions. Medicine as a whole is not separate from the policies and politics which has historically given preference to particular identities and “Western perspectives,” for example,
. The obstacle to being a physician among diverse patients, then, is that we are the inheritors of oppresive hierarchies. There are many strategies present in literature which Zanting, et al. identify as solutions. They all flow from an awareness that we are the inheritors of a legacy, and that advocacy and awareness, rather than conformity, can help challenge the preference for certain groups and marginalization of certain others.normal ranges
that are primarily based on Caucasian populations
The story analysis part of my brain appreciates the buildup of this sequence: “culture” starts as one thing, then it is many things, then it grows to an interaction, and finally to encompassing all of Western civilization. There is also a kind of dialogue in this paper. After each summary of a particular view of culture, there is a “Critical views” analysis which argues against that view and sets the stage for the next perspective. Again, this builds in a very pleasing way. If this discussion were between two characters, it would read something like this:
“Culture is one thing that is different about the other person. We need education on how to talk to a person in that culture.”
“That’s a reductive approach, don’t you think? Imagine claiming, ‘It’s okay, I took a class, now I’m competent to talk to Black people in the clinic.'”
“Okay, so what if we recognized that culture is a bunch of different things about the other person?”
“That’s better. But it still flattens people: even if we include a long list of characteristics and identities one person has, it still doesn’t capture the complexity of what people’s experiences actually are.”
“Fine. So let’s acknowledge that these things are very complex, and that we really don’t know what someone’s experiences have been like, even if we know quite a bit about the person’s demographics.”
“That’s good, and it still doesn’t acknowledge that even if we have that humility, we still have to deal with a difference in power. I mean, look at us. We’re wearing white coats, and that puts us in a position of authority and status.”
“That’s definitely something to be aware of. So… what do we do about it?”
“‘It’ being hundreds of years of medicine’s involvement in Western imperialism, colonialism, racism, and an increasing pressure from private equity to extract profits from sick people?”
“Well, when you put it like that… yikes.”
“‘Yikes’ is right.”
Health professionals of all kinds should absolutely be taught that medicine and health are not politically neutral disciplines, defined solely by their noble altruism. (The Tuskeegee experiments are a great place to start.) On the other hand, asking a second-year medical student to undo past health professions’ abuses with a few self-reflection exercises is daunting, to put it mildly. Zanting et al. reflect this: scepticism [of viewing culture as a power dynamic] was more concerned with the operationalization rather than the conceptualization of the notion.
If the issue at hand, as we’ve been assuming, is helping clinical practitioners achieve better outcomes in a world with increasingly diverse patient populations, an awareness of systems’ effects on patients can only help. The concrete skill most needed when meeting a patient in an exam room, however, is knowing that most of the experiences that shaped them and the interaction you are about to have are hidden from view. To be clear about my own biases in this discussion, cultural humility has been a guide to my own communications with health professions, both personally and professionally. I think it points the way to a set of tools which can be taught and used at the personal level and which have an appropriately complex (and humble) view of what might be informing the other person’s thoughts and actions.
Sources
The article reviewed: Zanting, Albertine, Janneke M. Frambach, Agnes Meershoek, and Anja Krumeich. “Exploring the Implicit Meanings of ‘Cultural Diversity’: A Critical Conceptual Analysis of Commonly Used Approaches in Medical Education.” Advances in Health Sciences Education 30, no. 3 (2025): 859–77. https://doi.org/10.1007/s10459-024-10371-x.
Featured Image: Diverse Crowd at Berlin Art Event by DNA. Art Club used under the Pexels license.