Medicine Reconciling evidence-based practice and cultural competence

[Dannnnnnnnnn]

Over the past few decades we have seen a tremendous rise in the support for evidence-based practice, the three-pronged ideal that requires medical practice to make use of research evidence, clinician expertise and client preference.

Simultaneously, we have seen a rise in the understanding of the need for cultural competence. We are beginning to understand how differently people view, encode and respond to certain situations and suggestions based on their cultural background (if you're interested in a review of this topic, albeit through a psychological lens, there is a great paper out there entitled "Culture, mind, and the brain: current evidence and future directions," by Kitayama & Uskul). As a result, the view that clinical practice should approach some scenarios differently with individuals of varied backgrounds is growing in prevalence.

On the surface, this does not appear problematic: navigation of cultural issues could be seen as one aspect of client preference, and most clinicians would tell you that they consider themselves both culturally competent and advocates of evidence-based practice. In practice, however, the two ideals often conflict. One of the more respected advocates of transcultural psychiatry, Laurence Kirmayer, says this:

On the one hand, the EBP movement has emphasized the routine need for a standardization of clinical practice that might ensure that only empirically supported treatments are adopted and promoted to address the mental health needs of the world. On the other hand, the multiculturalism movement has emphasized the routine need for a diversification of clinical practice that might accommodate the increasing ethnoracial and cultural heterogeneity within the U.S. population as well as retain relevance for a globalized world. The fundamental challenge that remains is how to accommodate nontrivial cultural divergences in psychosocial experience using narrowly prescriptive clinical practices and approaches.

http://journals.sagepub.com/doi/pdf/10.1177/1363461514568239

How, then, do we progress, assuming that both of these are necessary movements?

 

[bontshow]

In practice, however, the two ideals often conflict

In what way?

 

[Dannnnnnnnnn]

In what way?

Kirmayer touches on it in the quote, but I'll expand.

What we want in evidence-based practice is standardised practice. We want our actions to fit within strict constraints of how a method should be used in order to ensure that we're conducting ourself in a way that is supported by evidence. This is because of the strict conditions within research evidence is actually relevant and its conclusions generalisable. In psychometric testing in particular there is strict regulation of the way you explain things, the way tests are conducted and the way you interact with the client more generally to ensure the validity of the results. It's especially important in this setting due to its focus on comparing client results to norms, but it is, however, still important in other settings as well.

However, the more we learn about culture's influence, the more we realise that a "one size fits all" approach is improper in many circumstances. Acting in a way that is culturally competent often results in a need to diverge from the "script" to ensure we're taking into account the client's unique background and ideals, and not dismissing the different ways that they view and respond to phenomena.

Strictly following an evidence-based method may disadvantage individuals of non-western cultural backgrounds, but diverging from this may also put the validity of results at risk. In essence, the way we currently do things is not overly conducive to both evidence-based practice and cultural competence.

The ideal solution is to create research-based methods for individuals of different cultural backgrounds, but is that realistic? Because of how diverse, changeable and amalgamated an individual's "culture" is, there really is no way to reliably and meaningfully categorise people - which is obviously necessary for this method to work.

My area is primarily mental health/neurological assessment so anything I write will be viewed through that lens, but I'm interested in hearing about examples in other settings as well.

 

[bontshow]

What we want in evidence-based practice is standardised practice

I've carefully read through both your posts and still find it difficult to conceptualise where the two clash. Maybe you're speaking too generally and theoretically, and the solutions will become obvious when considering each actual scenario

 

[grumbleguts]

The Pirahã people of Sth America, live their lives and speak there language entirely according to levels of evidence.

The Pirahã use suffixes that communicate levels of observed experience, which is a category lacking in English grammar. One such suffix, -xáagahá, means that the speaker actually observed the event in question. I am paraphrasing here because I don't speak the language but:

"Where's Bob?"
"Bob wentxáagahá fishing."
Meaning I actually saw Bob go fishing with my own eyes.

However they have another suffix if someone told them that they saw Bob go fishing and another again if a further level of removal than that. Thus if a person cannot produce someone who actually has empirical evidence of an event then that event did not, in their belief, take place.

 

[Frank Bunn]

After I was in a vehicle accident in New Zealand the ambo was conducting a verbal neurological assessment on me. He asked who the Prime Minister of New Zealand was. I felt fine but I had to tell him I had no idea. I could have told him most of the Australian cabinet.

I reckon any time you hook a machine to someone or make physical observations such as pulse, pupils, muscle reflex etc then it's fairly objective. But when you interact with the person such as by asking them questions then the results are skewed by the prior experiences of both the questioner and the subject. Culture is just one of the differences of experience but there are many such as age, sex, intelligence, language, environment, educational background. I don't think there's an answer to it. It's just a fact of life that that sort of dealing with people is not pure science and you can't always draw conclusive results from the tests and experiments.

 

[grumbleguts]

After I was in a vehicle accident in New Zealand the ambo was conducting a verbal neurological assessment on me. He asked who the Prime Minister of New Zealand was. I felt fine but I had to tell him I had no idea. I could have told him most of the Australian cabinet.

I reckon any time you hook a machine to someone or make physical observations such as pulse, pupils, muscle reflex etc then it's fairly objective. But when you interact with the person such as by asking them questions then the results are skewed by the prior experiences of both the questioner and the subject. Culture is just one of the differences of experience but there are many such as age, sex, intelligence, language, environment, educational background. I don't think there's an answer to it. It's just a fact of life that that sort of dealing with people is not pure science and you can't always draw conclusive results from the tests and experiments.

He would have passed you with flying colours if you had simply said "Who cares?"

 

[chelseacarlton]

He would have passed you with flying colours if you had simply said "Who cares?"

That's not very nice,my wife is a kiwi and we still discuss politics with friends and family living here and from across the dutch.
Having said that,I don't know the name of the new pencil dicked young earth creationist now running the show.
They're a bloody smart bunch the kiwis and this dufus won't last long,so his name is superfluous.

 

[grumbleguts]

That's not very nice,my wife is a kiwi and we still discuss politics with friends and family living here and from across the dutch.
Having said that,I don't know the name of the new pencil dicked young earth creationist now running the show.
They're a bloody smart bunch the kiwis and this dufus won't last long,so his name is superfluous.

so... the answer remains who cares. And it wouldn't matter what country it was, the answer still remains.... who cares.

 

[chelseacarlton]

so... the answer remains who cares. And it wouldn't matter what country it was, the answer still remains.... who cares.

Yeh ok,but John Key lead them out of an enormous social and economic hole,turning around an abandonment of the homeland to where now more kiwis and internationals are returning and immigrating.
You could attempt to argue that the new pencildick was minister of finance during this period but you'd be kidding yourself.
Who cares!?
Indeed,my folk do!

 

[grumbleguts]

Yeh ok,but John Key lead them out of an enormous social and economic hole,turning around an abandonment of the homeland to where now more kiwis and internationals are returning and immigrating.
You could attempt to argue that the new pencildick was minister of finance during this period but you'd be kidding yourself.
Who cares!?
Indeed,my folk do!

At risk of derailing the thread, I grew up in Tonga and quite possibly have more links to Aotearoa than most people, as I said who cares.

 

[John Who]

Over the past few decades we have seen a tremendous rise in the support for evidence-based practice, the three-pronged ideal that requires medical practice to make use of research evidence, clinician expertise and client preference.

Simultaneously, we have seen a rise in the understanding of the need for cultural competence. We are beginning to understand how differently people view, encode and respond to certain situations and suggestions based on their cultural background (if you're interested in a review of this topic, albeit through a psychological lens, there is a great paper out there entitled "Culture, mind, and the brain: current evidence and future directions," by Kitayama & Uskul). As a result, the view that clinical practice should approach some scenarios differently with individuals of varied backgrounds is growing in prevalence.

On the surface, this does not appear problematic: navigation of cultural issues could be seen as one aspect of client preference, and most clinicians would tell you that they consider themselves both culturally competent and advocates of evidence-based practice. In practice, however, the two ideals often conflict. One of the more respected advocates of transcultural psychiatry, Laurence Kirmayer, says this:

http://journals.sagepub.com/doi/pdf/10.1177/1363461514568239

How, then, do we progress, assuming that both of these are necessary movements?

It’s never going to be a perfect solution. Cultures will clash and individuals will adhere differently to their previous culture(s) and the new culture(s).

There is a genuine degree of difficulty when we’re talking about the realms of psychology/psychiatry, where the DSM criteria may mislead us into thinking someone is delusional wherein fact they may be perfectly fine within the context of their culture/religion. But there is also the issue of learned behaviour of past cultures which is hard for them to change and this can create challenges for the practices of Western medicines/management.

In the health setting for example, I’m a witness to many Asians (particularly the older generation) wanting certain antibiotics because they feel comfortable with their past experiences, even though this may be a second-line or third-line treatment with a current infection.

Anyway, I guess the moral of my story is that it’s never going to be an easy ride dealing with other cultures. It will likely take a lifetime to know all the idiosyncrasies of an individual/culture, and patience/tolerance is really what’s required by the end of the day.

 

[CD Xbow]

I've been looking forward to seeing evidence based management. Rare bird that one.