The CAM in UME Project
http://www.caminume.ca
Culture and CAM
CAMpod Section: Foundations for CAM
Author: Michael Epstein, PhD & Joseph Schnurr, MD, MA
Institution: University of Saskatchewan
Creation Date: April 16, 2007
Revision Date: May 18, 2007
Synonyms and Related Terms: Ethnoculture, organizational culture , occupational culture
Descriptors: Culture; Decision-making
This document provides a succinct overview of the basic concepts and principles associated with the topic
of Culture in the context of health care generally, and as it pertains to complementary and alternative
medicine (CAM) in particular. The main body of the Pod is divided into two parts. Part A provides
an overview of some key concepts pertaining to culture as it relates to health care in general. Part B
addresses the topic of culture as it relates to CAM in particular. In the event that the fundamentals of
culture are already covered in the existing curriculum, the reader may wish to skip directly to Part B. This
Pod is intended to be used as a teaching aid for undergraduate medical education by providing
instructors with a synopsis of factual information, as well as ideas for student discussion around the
points contained within. Instructors can use the points and references to generate their own curriculum
materials. Particularly useful references on this topic are also identified in the CAMPod. Other related
teaching/learning resources or CAMpods that are available in the CAM in UME Digital Resource Repository
are hyperlinked to the document.
1.
Purpose
This CAMPod is intended to explore the concept of culture as it applies to clinical decisions pertaining to
health care in general, and to CAM in particular, and to identify implications for undergraduate medical
education. Part A (culture and health care) contains definitions of culture, subculture, and some related
concepts. Part B (culture and CAM) explores the cultural beliefs and behaviours associated with CAM.
Section 3.1 includes a few discussion questions that can be used to help students and faculty gain an
appreciation for some of the cultural issues that arise in health care generally and in complementary and
integrative medicine in particular. The appendices contain discussions of: the relationship between
occupational culture and personality (section 3.3); occupational culture and beliefs regarding CAM
(section 3.4); and cultural assumptions regarding health and health care (section 3.5).
1.1
Rationale for including this topic in UME
Cultural sensitivity. Physicians and patients will both tend to interpret comments in the context of their
own culturally specific belief systems. If the cultural background of the patient and the physician are
different, then they will therefore tend to misunderstand each other. Awareness of this phenomenon may
enable physicians to develop culturally sensitive strategies for interacting with patients, thus enhancing
many elements of the therapeutic relationship, including trust, disclosure, decision-making, and
compliance. (The term “cultural safety” is increasingly being used to underscore the importance of
reflective self-awareness on the part of practitioners in their interactions with patients (Browne et al,
2005)).
Impact of culture on behaviour. Socio-cultural factors underlie and shape all human behaviour. Attempts
to change one’s own behavior, as well as that of patients and colleagues, are generally futile unless the
underlying cultural issues are addressed.
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Multidisciplinary health care teams. Each health profession can be viewed as having a different
occupational subculture, with its own unique set of beliefs, values and assumptions. Effective
communication thus requires an appreciation of one’s own cultural background and how it may differ
from those of other health care professions.
Cultural context of CAM. In order to understand a given CAM system or intervention, and to appreciate
the ways in which it may differ from conventional health interventions, it may be helpful to understand its
cultural context, including its underlying belief system, and its culturally-specific concepts, principles,
practices and social structures.
CAM as occupational culture. The view of CAM systems as distinct occupational cultures can be useful in
promoting understanding of CAM systems, and in facilitating effective communication between CAM
practitioners and conventional health professionals.
1.2
Key CAM Competencies
The information in this CAMPod will contribute to enhancing CanMEDS competencies in the roles of
Communicator, Collaborator, Health Advocate, and Scholar. It will also contribute to meeting
CAM-focused educational objectives from the list of core CAM competencies for undergraduate medical
education available at http://www.caminume.ca/documents/competencies.pdf.
PART A: CULTURE AND HEALTH CARE
2.
Overview
2.1(a) Definitions and terminology
For present purposes, culture can be defined as:
the integrated pattern of human behavior that includes thoughts, communications,
actions, customs, beliefs, values and institutions of a racial, ethnic, religious,
occupational, organizational or social group. (adapted from Cross et al, 1989)
Three levels of culture. In his classic book Organizational Culture, Schein (1997) identifies three levels at
which culture can be described.
(1) At the first and most superficial level are the physical structures and artifacts of the culture. In the
context of health care, these could include the physical design of hospitals, clinics, offices, waiting rooms,
medical equipment, clothing and attire of health providers and so forth. These physical artifacts embody
the deeper aspects (e.g. values and assumptions) of the culture, provide meaning for patients and health
care providers, and allow the observer to make comparisons (for example, by comparing the physical
artifacts of conventional medicine with those of specific CAM systems).
(2) At the second level are the rituals and behaviours of members of the culture. This includes ways in
which people address each other in verbal and written communication, the way in which clinical
interviews are conducted, the way in which meetings are run, the norms and patterns of conduct at
social events and conferences and so forth.
(3) At the third and deepest level are the patterns of shared beliefs as described above. These cannot be
observed directly, but can be inferred from the artifacts and behaviours at levels one and two. This
approach can be used, for example, to compare and contrast the cultures of conventional and
complementary medicine.
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Ethnocultures refer to patterns of shared beliefs that develop within ethnic groups, and to an ethnic
identity supported by cultural practice, tradition and institutions – for example – Chinese-Canadian
ethnoculture.
Occupational cultures refer to patterns of shared beliefs that develop within an occupation – for example
– medical culture, nursing culture, etc.
Organizational cultures refer to patterns of shared beliefs that develop within work groups and
organizations – for example – the culture of a specific health care team, hospital or health region.
Cultural competence has been defined as a set of congruent behaviors, attitudes, and policies that come
together in a system, agency or among professionals and enable that system, agency or those
professions to work effectively in cross-cultural situations (Cross et al, 1989).
2.2(a) Subcultures in Health Care
Within the culture of health care there exist several occupational sub-cultures, whose members share all
or most of the core premises of the encompassing culture, but who share certain premises that are
specific to the occupation. For example, we may speak of the culture of nursing, the culture of physical
therapy, the culture of naturopathic medicine, and so forth. Medical culture can also be further
subdivided into sub-cultures defined by medical specialty, such as the sub-cultures of surgery, pathology,
cardiology and so forth.
PART B – CULTURE AND CAM
2.1(b) Is CAM a culture?
To what extent can the terms culture and/or subculture be meaningfully and appropriately applied to
CAM in general, and to specific CAM systems? The following points will help shed light on this question:
(1) CAM includes discrete interventions, such as acupuncture and therapeutic touch, as well as
comprehensive systems of health care, such as naturopathic medicine and Traditional Chinese Medicine.
(2) Many CAM systems embody premises concerning health, illness and healing that differ from those of
conventional medicine.
(3) Most prominent definitions of CAM make reference to the ways in which its conceptual foundations
differ from those of conventional medicine, thus leading to a view of CAM as a “medical counter-culture”.
(4) Many CAM systems (such as Traditional Chinese Medicine) embody the concepts, principles and
premises of a specific ethno-cultural society.
For present purposes, it is therefore proposed that CAM in general, and specific CAM systems, generally
meet the definition of culture with sufficient approximation such that the metaphor will be useful in
shedding light on many important aspects of CAM, with useful implications for the practicing physician.
The application of the cultural metaphor to specific aspects of CAM is illustrated in the following
paragraphs.
Culture and validation of CAM. Differences among cultures and subcultures can result in different
approaches to the way in which health care interventions are validated. This in turn may allow us to
understand why certain interventions that are widely accepted within one culture, may be viewed with
suspicion, hostility or ridicule in another culture. Awareness of and sensitivity to these differences with
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respect to validation strategies may help medical students and physicians gain a fuller understanding of
these healing systems. Some documented examples of culturally-based differences in validation of CAM
interventions are outlined in Section 3.3 below.
CAM and conventional medicine as cultures. The language and concepts of culture can function as a
useful metaphor for understanding and describing the relationship between CAM and conventional
medicine. For example, the terms co-existence, cooptation, and systemic integration have been used to
describe three different ways in which CAM and conventional medicine can relate to one another (Tataryn
and Verhoef, 2001). In the terminology of culture, these correspond to the concepts of multiculturalism,
colonialism, and interculturalism respectively. This in turn allows us to apply existing knowledge of these
culture-related concepts to shed light on the relationship of CAM to conventional medicine. For example,
the term colonialism, with all the baggage and connotation that it implies, may be a useful way of
underscoring concerns about CAM therapies being removed from their historical and cultural context, and
“grafted” on to the conventional medical system.
Educational strategies. Intercultural education and cross-cultural education have been the subject of
considerable research. As a result, there exist well established models of these forms of education, and
these intercultural and cross-cultural strategies could be applied in the education of physicians with
respect to selected complementary healing systems. This could be especially effective for ethno-culturally
specific healing systems such as Traditional Chinese Medicine.
Cultural sensitivity. Because medical students typically now receive some training in the principles and
practice of cultural sensitivity, this training could be appropriately applied to clinical situations involving
selected CAM systems and practices. For example, the principles of cultural sensitivity may be relevant to
a physician in working with a Chinese-Canadian family who may have interest and experience with
Traditional Chinese Medicine. The application of cultural sensitivity principles, however, need not be
limited to ethnocultures. For example, there is evidence that members of the groups known by labels
such as cultural creatives (Ray, 2000), counter-culture (Rosak, 1969) or integral culture (Ray, 1996) now
represent a substantial percentage of the population in the United States (and likely in Canada). These
individuals have a strong preference for lifestyle choices, self care practices, and health care interventions
that are simple, gentle, natural, non-toxic, non-invasive, and environmentally friendly.
Cultural analysis. One powerful component of cultural analysis involves the identification of the core
beliefs, values and assumptions that form the conceptual foundation of the culture. This process of
“assumption surfacing” enables participants to understand the physical manifestations and the rituals and
behaviours associated with the culture. Awareness of these core premises can also provide the basis for
cultural sensitivity and for cross-cultural communication. The methods of cultural analysis may thus be
effective in building integrative communication bridges between medical students and CAM practitioners.
In some medical schools, for example, students have applied some basic techniques of cultural analysis
as part of a group assignment involving site visits, clinical observation, and interviews with CAM
practitioners.
Bridging roles. There is a well established body of literature addressing the development and
effectiveness of boundary-spanning roles (sometimes referred to as culture brokers) which involve the
bridging of two cultures (Schwab et al, 1988). This knowledge of inter-cultural bridging roles can be
useful in helping to understand and resolve communication problems, and could be applied in the context
of building integrative bridges between CAM and conventional medicine. For example, understanding the
culture of biomedicine and the culture(s) of CAM, and how they differ, may help future physicians to build
collaborative and/or integrative bridges between these distinct healing systems (Davis-Floyd and St John,
1999). This kind of shared understanding and cultural sensitivity on the part of physicians, may also
reduce the likelihood of CAM therapies being assimilated , or co-opted (Tataryn and Verhoef, 2001) by
the biomedical culture. Recognition of these differences may also assist curriculum developers and
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instructors in designing CAM-related educational modules to which medical students are likely to be
receptive, and which also avoid the tendency for CAM to be co-opted by the biomedical paradigm.
Cross-cultural communication. Meaningful, effective communication between two or more parties requires
a shared set of premises, definitions, and terminology. Without this foundation of shared understandings,
individuals and groups tend to “talk past each other.” Much of what we experience as stress, conflict, and
“communication problems” in working relationships, is the result of differences in foundational premises,
many of which may be unconscious (i.e. taken for granted). Becoming aware of one’s own cultural
premises is therefore a major step in developing cross-cultural sensitivity. Simple exercises which
encourage students to identify the beliefs, values and assumptions of biomedical culture and of CAM
culture(s) could go a long way towards preparing future physicians for building collaborative bridges and
encouraging effective integration of CAM into health care systems.
3.
Discussion
3.1
Questions for Student Discussion and/or Reflection
CAM in Europe and North America. Many CAM therapies that are widely accepted within the European
Community still lack widespread mainstream acceptance within North America. What are some possible
explanations for this phenomenon?
Cultural analysis of a CAM therapy. Pick a CAM therapy with which you are familiar. Try to identify the
three levels of culture associated with this therapy (i.e. physical artifacts, rituals and behaviours and core
premises).
Cultural context of healing systems. Identify some of the key values and beliefs in traditional Chinese
medicine and show how they fit into the cultural context in which TCM evolved. Now do the same
exercise for biomedicine.
Medical culture. On the basis of your experiences at medical school and your experiences with your
medical profession to date identify some of the elements of each of the three levels of culture associated
with western medicine.
Cultural messages. Below is a list of topics of relevance to health science, health research, and the
practice of medicine. Pick one of these topics and do the following: identify the dominant Canadian
cultural values, beliefs and assumptions regarding this topic. What are the most prominent messages that
you have received (from the media, your teachers, authority figures, peers, etc.) regarding this topic?
What do you personally believe about this topic, and how might your personal beliefs differ from the
dominant beliefs in Canadian culture? List of topics: pain, death, body shape, discipline, grief, evidence,
logic, learning, fitness, science, anger, spirituality, knowledge, emotions.
Cultural change. A prominent quantum physicist observed that
A new scientific truth does not triumph by convincing its opponents and making them see
the light, but rather because its opponents eventually die, and a new generation grows
up that is familiar with it (Planck, 2007).
Can you identify a few prominent ideas pertaining to health care and medical practice that have changed
over the past thirty years? How is the content and format of the medical education that you are receiving
today different from that of a physician who went through medical school in the mid 1970s?
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3.2
Readings
3.2.1
Annotated Reading
Schein, E.H. (1997). Organizational Culture and Leadership.. San Francisco, USA: Jossey-Bass.
Ed Schein is a co-founder of the field of organizational behaviour, and a leading expert on the topic of
organizational culture and the implications for management of interdisciplinary teams. This book is a
classic on the topic of organizational culture and is widely used in business schools throughout the world.
Organizational Culture & Leadership, by Edgar H Schein, notes compiled by Ted Nellen,
http://www.tnellen.com/ted/tc/schein.html. Contains a highly detailed outline of Schein’s classic text on
organizational culture.
Capra, F. The Turning Point: Science, Society and the Rising Culture . Bantam, New York, 1981. Fritjof
Capra is a high energy physicist who became interested in the parallels between quantum physics and
eastern religions, most notably Taoism. In this book, he argues that our culture is heavily based upon the
Cartesian-Newtonian world-view, characterized by the premises of objectivism, mechanism, reductionism,
and mind-body dualism. He illustrates the ways in which these premises have become embodied in a
wide spectrum of health related disciplines. He then identifies examples of emerging theory, research and
practice which embody a post-Newtonian world-view (i.e. holistic, organic) and argues that this emerging
world-view may be necessary to complement the Newtonian perspective.
Epstein, MK. Cultures, Stakeholder Groups and Validation Criteria , ROSTR for the CAM in UME project,
March 13, 2006. Contains a succinct overview of the concepts of culture and sub-culture and how these
apply in the context of interdisciplinary collaboration in health care systems. Examines the belief systems
embodied in selected CAM practices. Identifies cultural differences among health disciplines with respect
to the validation of CAM.
3.2.2 Reference List
Browne AJ, Smye VL, Varcoe C, The relevance of postcolonial theoretical perspectives to research in
Aboriginal health, Can J Nurs Res, 2005 Dec;37(4):16-37.
Capra F. The Turning Point: Science, Society, and the Rising Culture . New York, NY: Bantam Books,
1981.
Cross, T, Bazron, B, Dennis, K, & Isaacs, M, Towards A Culturally Competent System of Care, Volume I.
Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center,
1989.
Davis-Floyd R, St John G, From Doctor to Healer: The Transformative Journey , Rutgers University Press,
Piscataway, New Jersey, 1999
Fox, RC. Cultural competence and the culture of medicine, New England Journal of Medicine, Volume
353, Number 13:1316-1319 , 2005.
Hardigan PC and Cohen SR. A Comparison of Learning Styles Among Seven Health Professions:
Implication for Optometric Education. The Internet Journal of Allied Health Sciences and Practice . 2003.
Volume 1 Number 1.
Mead M. Culture and Commitment: A Study of the Generation Gap. Garden City, NY: Doubleday, 1973.
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Planck M, A Science Odyssey, Public Broadcasting Coorporation,
http://www.pbs.org/wgbh/aso/databank/entries/bpplan.html, accessed May 18, 2007.
Ray P, Anderson SR. The Cultural Creatives: How 50 million people are changing the world . New York,
NY: Harmony Books, 2000.
Ray PH. The Rise of Integral Culture. Noetic Sciences Review 1996;Spring:4-15.
Rosak T. The Making of a Counter Culture. New York: Doubleday/Anchor, 1969.
Schein, EH. (1997). Organizational Culture and Leadership. San Francisco, USA: Jossey-Bass.
Schwab B, Drake RE and Burghardt EM. Health care of the chronically mentally Ill: The culture broker
model. Community Mental Health Journal, 24, 3, 174-184, 1988.
Tataryn DJ and Verhoef MJ, Combining conventional, complementary, and alternative health care: a
vision of integration, In: Perspectives on Complementary & Alternative Health Care: A Collection of
Papers Prepared for Health Canada. Ottawa: Health Systems Division, Health Canada, 2001
<www.hc.sc.gc.ca/hppb/health care/cahc/index.html>.
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3.3 Appendix – Occupational culture and personality.
Membership in a given occupational culture is often associated with specific personality traits. In
comparing students within seven different health care professions, for example, Hardigan and Cohen
(2003) found the following differences:
(1) The dominant profile for osteopathic medicine, physician assistant , and dental students was
extrovert-sensory-thinker-judger (ESTJ), meaning they are practical, realistic, with a natural head for
business or mechanics.
(2) The dominant profile for physical and occupational therapy students was extrovert-sensory-feelerjudger (ESFJ), meaning they are warm-hearted, talkative, with a main interest in things that affect
people’s lives.
(3) The dominant profile for pharmacy students was introvert-sensory-thinker-judger (ISTJ), meaning
they are serious, thorough, logical and realistic.
(4) The dominant profile for optometry students was introvert-sensory-feeler-judger (ISFJ), meaning they
rely on facts to make judgments, tend to be organized and offer strong warmth and sympathy.
While there has been little systematic research on personality traits associated with specific CAM
disciplines, it almost certain that different CAM disciplines will have specific personality profiles, and that
these profiles are likely to differ from those of conventional health providers. Understanding and
accommodating these differences will be important in achieving effective communication among patients,
CAM practitioners and conventional health providers.
3.4 Appendix – Cultural differences in the validation of CAM
Major differences exist across cultures and sub-cultures regarding the way that their members validate
health related interventions (including CAM) and by extension, their beliefs regarding CAM in general and
regarding selected CAM therapies for specific conditions. In the following paragraphs, we have tried to
indicate some of the cultures and sub-cultures of greatest interest in this regard, and to provide some
propositions concerning differences in core premises across these sub-cultures. These propositions are
drawn in part from empirical research and in part from careful observation and discussions with members
of these groups over the past twenty years.
Medical and allied health providers. In one recent Canadian study, medical students and pharmacy
students were more likely than students of nursing, physiotherapy and occupational therapy to view
traditional forms of evidence (i.e. clinical trials) as necessary before accepting CAM therapies. Medical
students perceived CAM therapies as less useful than did their student peers in the other health
professions.
Social scientists. As we move across the spectrum from economics to psychology to sociology to
anthropology, the social sciences become less reductionist, and more holistic in terms of their view of
underlying reality, the nature of cause and effect in social systems, and preferences regarding research
methodologies for social systems.
Chronic and acute health care providers. Health providers who are involved in chronic illness tend to
embrace a view of health and health care that is more holistic, multi-factorial, experiential, subjective and
patient-centred than their counterparts in acute care.
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Researchers and practitioners. Researchers tend to value clinical trial data and basic science data above
clinical judgment and experience. With practitioners the reverse is true.
Differences among physicians. Family physicians tend to have a more favorable opinion of CAM than do
specialist physicians.
Allied health providers. Nurses and physical therapists tend to be more favorable toward touch therapies
than do physicians or psychologists
Ethnocultural groups. Members of some ethnocultural groups appear to have a more favorable opinion of
healing systems from their culture of origin than do the general public. For example, Chinese-Canadians
are probably more likely to embrace the principles, concepts and practices of Traditional Chinese
Medicine than are members of the Canadian public at large. Chinese-Canadians may also be more
comfortable with the concept and experience of chi (energy in the body) than the public at large. They
may also be more likely to embrace the test of time in the assessment of indigenous/ ancient healing
systems.
Traditional and emerging cultures. Of the three segments of American culture (traditionalists, modernists
and cultural creatives), the latter are defined by their commitment to environmentalist values, feminist
values, personal growth and spiritual development. These characteristics have been empirically
associated with higher use of CAM among the American public.
3.5 Appendix – Comparative Medicine: Assumptions of Health Care Systems
Our understanding of a specific health care system can be greatly enhanced by identifying its key
assumptions regarding:

The nature and definition of health, illness, healing, pain and suffering;

The validity of complementary and alternative practices and products;

Appropriate validation criteria for health related interventions;

The nature of cause and effect in complex living human systems;

The operational definition of evidence and of evidence-based decision making;

Relative value of basic science, clinical trials, clinical experience and patients’ opinions in decisions
regarding treatment options;

The achievability of scientific certainty through careful systematic research;

The relative value of psychosocial factors and/ or placebo effects in clinical contexts.
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