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LAST week The Lancet published the outcomes of its Commission on Culture and Health.
In a wide-ranging document, whose contributors included anthropologists, social scientists, historians, theologians and doctors, the authors concluded that the links between culture and health have been widely underestimated and neglected, to the detriment of global health and health care.
Of health care they wrote: “The failures of health-care provision are magnified by the cultural assumption that biomedical practices — being scientific and evidence-based — are value free, that culture is something that scientists themselves do not have, and that culture hinders science …”
The concept hits home in Australia, where it is increasingly recognised that medicine has its own culture, and that willingness to examine this culture is key to improving health care for Aboriginal and Torres Strait Islander people.
This week, MJA InSight provides an opportunity to reflect on some cultural aspects of medicine that are holding us back, and how they might change.
Rapid response systems — teams deployed in hospitals to attend to patients with deteriorating clinical signs — have the potential to save many lives, according to experts writing in the MJA, but in order to do this they must be a whole-of-hospital endeavour.
Commenting for one of our news stories, anaesthetist and senior hospital clinician Ross Kerridge acknowledged that the inconvenience and disruption that results from participating in one of these teams can cause “significant resentment and resistance” for some intensive care doctors.
He observed: “It would appear that the problem is a cultural one — that doctors and nurses remain acculturated to the traditional hierarchical response system, and see unpredictable calls … as an inappropriate impost on their time”.
Another of our stories reports a study published in the MJA that found the damage to doctors’ health and happiness is worse if they experience aggression from a co-worker than if the aggressor is an external person.
In response, an expert on doctors’ health acknowledged that some health workplaces have a “bullying culture” and that junior doctors need to be taught “resilience strategies”, including the ability to label and resist bullying behaviours.
An unquestioned cultural norm for doctors has been private acceptance of visits, gifts, payments and hospitality from pharmaceutical companies. There is currently much discussion within the profession about how these relationships should work, but a recent announcement from the Australian Competition and Consumer Commission (ACCC) might take one aspect out of our hands.
In his comment this week, health journalist and academic Ray Moynihan details the ACCC’s proposal that all “relevant transfers of value” such as speakers fees, consultancies, sponsorship and even meals should be made public “to reduce the likelihood of undermining the independence of health care professionals”.
The Australian medical workforce relies heavily on international medical graduates (IMGs) to fill the gaps in rural areas but, according to the authors of an article published in the MJA, the restrictions, the regulatory requirements and conditions we impose on these doctors are “unparalleled in the developed world”.
In researching for our news story on this topic, we learned that, more than 2 years after a parliamentary inquiry made 45 recommendations for reform, things are finally beginning to change.
The authors believe the treatment of IMGs is “irreconcilable with principles of equity and mateship that are at the core of Australian society” but some would say it is also consistent with our culture of protecting ourselves from the wider world.
In her column this week Jane McCredie invokes the racial politics that are informing our “isolationist” response to the Ebola outbreak in West Africa.
That cultural factors are hard to change is undeniable. Even when presented with evidence that another way is better, as Ross Kerridge told us, in hospitals “culture eats evidence for breakfast”.
Yet the authors of The Lancet article warn that continuing to ignore it is not an option: “If biomedical culture does not acknowledge its own cultural basis or incorporate the relevance of culture into care pathways and decision making, then the waste of public and private resources will continue to cripple health-care delivery worldwide.”
Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight
Dr Thomas Insel (Psychiatric Time – “Atonement”):
“…what do we in the mental health community need to atone for?
For some, it may be the culture of blame and shame perpetuated for years by clinicians who explained all mental illness as being caused by trauma and evil parents. For others, it may be the singular reliance on medication and modifying behavior rather than holistic care and provision of skills. Others will name the paternalistic structure of mental health care, which can undermine rather than empower individuals and their families…
Mental disorders are … complex problems… with challenges at every level from neurons to neighbourhoods… Too often, we have been guided more by religion than science. That is, so much of mental health care is based on faith and intuition, not science and evidence. …we put a premium on listening and compassion…. But not enough of our care has been standardized to a high level of quality, as expected in the rest of medicine.”
Let’s refer struggling/anxious kids EARLY to specialist dev paeds (ie USE EBM). Let’s be humble and rely on the research and employ methods that have been shown to work best.
I have two comments about Medical culture in Australia
“It would appear that the problem is a cultural one — that doctors and nurses remain acculturated to the traditional hierarchical response system…”
What a lofty view from the academic lookout! If only ICU staff where a little less reluctant to interrupt the care of sick patients in their unit. Silo thinking it must be. One wonders (behind one’s desk) about the origins of such backward attitudes seen last in pilots doing checklists and surgeons wielding knives.
Would it, alternatively, not rather appear that doctors and nurses remain acculturated to the traditional system whereby you don’t ask someone else to do your homework? With the vast and increasing majority of RSS callouts requiring good clinical – not critical – care, it is high time to objectively take stock: rapid response systems staffed by ICU doctors and nurses are filling a wide gap not of runaway patient deterioration but of middle grade and senior home unit staff presence on wards