AMA Journal of Ethics^®

Central to the work of doctoring is the ability to elicit, interpret, and act upon the stories of patients. Yet these tasks of effective communication and care often fail with patients whose ethnic, socioeconomic, linguistic, gender, or sexual identities differ from those of the physician and the traditional medical establishment. Although efforts to broaden medical curricula often include teaching endeavors that fall under the heading of "cultural competency," few such programs incorporate the lessons of narrative medicine, which employs the reading and writing of narratives to train clinicians to engage more effectively with their patients’ stories [1].

Cultural competency programs often rely on didactics, small group discussion sessions, or even simplistic lists of cultural characteristics to be memorized about various patient populations. Yet teaching understanding and empathy for patients from dissimilar backgrounds is an entirely different sort of activity than teaching pharmacology or physiology and demands a different pedagogy. Few exercises in either cultural competency or narrative medicine place students in direct contact with the communities about which they are learning, the communities outside of the medical institution. Even fewer challenge patient-physician hierarchy in any meaningful way. This article describes a unique educational activity at the intersection of cultural competency and narrative medicine, an activity that seeks to engender greater understanding across ethnic and institutional cultures while addressing issues of story, voice, and power.

At the Columbia University Community Pediatrics Program, which is located within the University’s Division of General Pediatrics in New York City, our cultural competency training program incorporates a service learning component that integrates community service with explicit learning objectives. Our residents participate in educational endeavors with a northern Manhattan (Washington Heights) Dominican American community organization, Alianza Dominicana. Service learning bridges the artificial distance between medical center and community by locating the educational classroom in the community and placing community partners at the level of teachers [2].

Although the service learning component of our curriculum was designed to teach culturally responsive care for patients, it also brought to light cultural misunderstandings between residents and community workers. To address these issues, a monthly reading group using a literary case study was formed as an educational module for pediatric residents and the predominantly Dominican American community-based workers.

Catching the Story but Not Falling Down

Anne Fadiman’s 1997 book, The Spirit Catches You and You Fall Down, is a familiar text in many medical schools, often offered as a cautionary tale of the perils of culturally ineffective care [3]. The story, an account of a Hmong girl’s epilepsy and her community’s interactions with their local medical facility, illustrates the dire consequences of such a "cultural collision."

Of course, the danger of a narrative such as Fadiman’s lies in its being used as a textbook of sorts—a way to learn about a specific community or a specific cultural situation. The gripping text has been critiqued as presenting a simplistic, unidimentional view of culture that has the potential to "catch" the reader and make the reader "fall down" [4], unable to critique the narrative or get beyond its extreme and obvious lessons to recognize that most instances of cultural clashes in care are far more subtle than those depicted. But the methodology by which the Columbia University Community Pediatrics Project used Fadiman’s story and the context in which her story was read allowed participants to "catch the story" and not "fall down." Importantly, residents were neither given the text to read on their own, nor expected to discuss the book solely with other medical practitioners. Rather, the text was a starting point for extensive, self-revelatory and self-reflective discussions with representatives of the community from which most of the residents’ patient population emerges.

The reading group between residents and community workers lasted approximately 1 1/2 hours, and attendance averaged 15 community workers, 2 or 3 residents, and 1 or 2 community pediatrics faculty members. In our particular community context, the text represented a "neutral" culture; no one felt a sense of personal or professional ownership over the Hmong experience. Both community workers and pediatric residents were placed in the position of learners vis-a-vis this unfamiliar culture. Pediatrics faculty and the community-based organization director acted as facilitators. They began the discussion with questions from the text and subsequently allowed the conversation to develop organically, encouraging participants to draw upon personal and professional experiences that illustrated the topics, including birthing practices, cultural miscommunication, use of complementary therapies, and experiences with chronically ill or dying patients.

Qualitative evaluation of the residents and community workers found that all participants believed the activity helped them learn about the importance of recognizing cultural differences. Moreover, community-based workers suggested that the discussions afforded them a good opportunity to understand the medical point of view, including the day-to-day physician realities of long work hours and limited visit times with individual patients. Similarly, the exercise enabled the medical residents to better understand the community’s expectations and their perspectives on hospitals, the practice of medicine, and physicians’ day-to-day activities. Finally, community workers believed that residents would change their attitudes and behaviors in practice after the activity. Consistent with this perception, the medical residents reported a variety of intentions to change their attitudes and behaviors including an intention to be more sensitive to cultural differences and more patient and to recognize their biases and the effect of those biases on caregiving [5].

Reading into Texts, Reading into Culture

Narrative activities such as this reading exercise can help bridge professional and personal cultural gaps. The exercise allowed participants to do what medical sociologist Arthur Frank calls "thinking with stories." In his words, "To think about a story is to reduce it to its content and then analyze that content…. To think with a story is to experience it affecting one’s own life and to find in that effect a certain truth of one’s own life" [6]. Indeed, this program used the reading of a narrative to engender a real sense of community among diverse members of the literary "classroom."

The creation of community within the classroom may not be an automatic occurrence. This activity was designed and conducted with particular awareness of the power discrepancy between physicians and community workers. Discussion leaders paid attention not only to ethnic cultural differences but also to differences in organizational cultures, with the goal of creating a safe space in which the voices of all participants were honored equally. The theoretical foundation of this sort of facilitation draws from Brazilian educator Paolo Freire, whose writing is particularly concerned with recentering the power of the classroom from the teacher to the students [7,8]. It is also consistent with what activist and educator bell hooks calls "transformative pedagogy." In her words, "I enter the classroom with the assumption that we must build ‘community’ in order to create a climate of openness and intellectual rigor…one way to build community in the classroom is to recognize the value of each individual voice" [9].

Critical, self-reflective learning experiences can facilitate increased cultural sensitivity on the part of practitioners. Literature has great potential for encouraging self-reflection, particularly when narrative texts are used as a starting point for increasing mutual understanding among diverse discussants. It has been suggested that the diverse interpretations and perspectives that emerge when discussing a story with others, the very nature of interpretive ambiguity, challenges the "single, authoritative view" of physicians in medicine [10]. The Columbia University Community Pediatrics Program took just such a literary exercise outside the walls of the medical institution and allowed individuals of extremely varied personal and professional backgrounds to establish an emotional and intellectual community, voicing their individual interpretations of a text based on their varied life experiences, creating an environment within which it became possible to better recognize, understand, and appreciate one another.