Rethinking Clinicians’ Understanding of Culture in Treating Older Adults

“Culture” is a word with a surprisingly recent history. Over the 20th and 21st centuries, English speakers, informed by 20th-century cultural anthropology, have come to use culture to describe the values, beliefs, and practices that are shared by a group of people. Most (though certainly not all) of the time, when the term is used in American English, it refers to a national or ethnic group. Despite its anthropological origins, contemporary anthropologists take issue with the way the word culture is used in clinical training. Cultural competency training often treats culture as a static variable based on the patient’s apparent ethnic identity. As cultural psychiatrist and medical anthropologist Arthur Kleinman has stated, “[c]ulture is a process through which ordinary activities take on an emotional tone and moral meaning” for individuals, including “psychophysiological reactions, the development of interpersonal attachments [and] common-sense interpretation,” among other factors. Kleinman also notes that these are not homogenous within any social group, varying across individuals.

A recent Journal of the American Geriatric Society article shows that, among the medical fields, an improved understanding of culture is particularly important in geriatrics. As decades of ethnographic study have demonstrated, there is tremendous cross-cultural variation not only in understandings of illness and the role of healers, but also in how people understand aging, the life course, interpersonal relationships, and even death. Aggarwal presents cultural competency initiatives as well-intended attempts to manage “the challenges of caring for a growing, ethnically diverse, aging population,” which ultimately fall short due to an oversimplified, outdated understanding of culture.

One example of this is that well-intended, “culturally competent” physicians may ascribe patient behavior to their cultural identity while overlooking more pragmatic concerns—for example, attributing noncompliance to cultural beliefs when financial difficulties may be the cause. Clinicians are at risk for overlooking individual differences, seeing cultures as static and unchanging and seeing social groups as strictly separated from one another in a world where “information technology and globalization have permitted people to accumulate cultural influences beyond immediate surroundings.”

Aggarwal suggests that clinicians draw a “cultural formulation” approach from ethnogeriatrics and cultural psychiatry (a subfield of anthropology). This is a four-part understanding of doctor-patient relationships that incorporates the patients’ understanding of cultural identity, illness, social networks, and the medical system. In this framework, rather than assuming that the individual’s ethnic, national, linguistic, or religious affiliation is the main determinant of their identity, the patient is able to prioritize other affiliations like veteran status, age, or sexual identity. In multicultural societies, individuals’ cultural explanations are influenced by a variety of factors such as acculturation, place in the larger family, and personal history.

The cultural formulation approach is a very patient-centered approach, particularly useful with older adults given the variety of cultural explanations of aging and illness. Asking patients how the patient and those around him or her understand the illness—asking the patient how he or she understands the cause and diagnosis—is one way to avoid misunderstandings. Particularly relevant for the older adult population is the psychosocial environment of the patient. Familial organizations and expectations vary tremendously, so the effect of the illness on the patient’s social and familial roles also will vary considerably….this based not only on ethnic or social identity, but on individual circumstance.

Perhaps most provocatively, Aggarwal urges clinicians to consider “cultural elements of the clinician-patient relationship” by recognizing the role of culture in the doctor’s own perception of others, regardless of his or her own ethnic, racia,l or other social identity. As contemporary anthropologists would argue, culture isn’t just an influence on minority or immigrant populations. Culture frames how people make sense of the world and understand their role in it.

Aggarwal presents two case studies with older adults. In contrast to previous cultural competency models that emphasize the cultural influence on minority groups, the first of these two cases shows how this approach is also beneficial with white, middle-class patients. By considering the role of the patient’s own cultural background on his understanding of his stroke and resultant difficulties, the clinician was able to improve compliance and patient self-care by tending to the patient’s sense of family identity and desire for self-reliance and autonomy. The second case is an example of introducing dietary changes and Alzheimer’s treatment to a 71-year-old woman who migrated from India who drew on existing social networks and community support.

These cases, and the article as a whole, point to a few ways that the treatment of older adults can benefit by an improved understanding of culture. The cultural worlds of baby boomers, their parents’ generation, and their children’s generation vary tremendously. Ideas of what it means to age, to be independent, and to talk about illness differ accordingly. Remembering that all people have some sort of cultural perspective that may be vastly different from those of other families and peers, is scientifically sound and clinically useful.

Articles cited (click for links):

Aggarwal, Neil Krishan, (2010). “Reassessing Cultural Evaluations in Geriatrics: Insights from Cultural Psychiatry.” Journal of the American Geriatrics Society 58(11): 2191-2196.

Kleinman A, Benson P (2006) Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. Public Library of Science: Medicine 3(10).

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