Practical clinical relevance

Immigration processes have so altered national demographic patterns that most nation states today have plural populations representing distinctive ethnic backgrounds. In 1900, the population of the United States, for example, included only 13 per cent categorized as ethnic minority members. By 1990 that figure was greater than 25 per cent. The percentage is projected to be one-third in 2010, and by mid-century to reach an astonishing 50 per cent. In California, the largest American state, non-Hispanic white Americans are already in a minority.

Ethnic background has been shown empirically to influence epidemiological rates of disease, patterns of access to health care, help-seeking, and patient-doctor interactions, often with negative outcomes such as delayed treatment, misdiagnosis, non-compliance, and treatment failure. Taking ethnicity into account in the provision of services means a variety of things, such as making translators available, putting up signs in several languages, holding clinics at times when working-class patients can attend, and paying attention to differences in cultural meanings and practices. The now popular idea of providing culturally informed and sensitive care is premised on anthropological concepts and methods. Several of these have been elaborated in the literature.

1. The distinctions between illness and disease: for medical anthropologists illness is the patient's experience of symptoms in the context of family, work, and community; disease is the practitioner's model of the pathological process. Help-seeking is usually orientated around the illness experience with respect to what is most at stake for the patient and significant others. Care can founder when the patient's primary concerns with the illness experience conflicts with or is entirely different from the physician's focus on disease. Thus, many patients with chronic pain experience interrogation of the disease process by the sceptical physician as delegitimizing their illness experience. This leads to high rates of dissatisfaction with care among this group of patients. Many so-called 'orphan diseases'—chronic pain, chronic fatigue syndrome, etc.—produce this result. When patients and families are from ethnic minority backgrounds, differences in cultural meanings and practices intensify conflicts between patient and physician models.

2. Medical anthropology sponsors a method to reduce this explanatory gap and thereby to improve clinical relationships. Called the explanatory models' methodology, it involves three steps.

a. Elicitation of patient and family explanatory models of the illness experience and treatment, which can be accomplished by asking the following questions.

• What do you call your problem?

• What course will it take from here on?

• What do you most fear about the illness?

• What kind of treatment do you desire for this illness?

• What do you most fear about the treatment?

b. Presentation of the clinician's explanatory model of the disease process.

c. Negotiation of a mutually acceptable understanding of the clinical problem across patient, family, and physician models. (4)

Closely related to this technique is the development of a mini-ethnography. This is a brief description, based on interviewing the key parties about the impact of family and work context on the illness experience and vice versa. The mini-ethnography and the explanatory models' elicitation generally give rise to patient stories of the illness experience. These illness narratives can be assessed with respect to the chief meanings and practices associated with the condition and its treatment. The illness narrative can be interpreted with respect to core metaphors, culturally particular content, as well as biographical issues with which psychiatrists are more familiar. The influence of cultural categories, values and practices on the illness and treatment can be assessed from this standpoint. (5)

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