Cultural Competency in East Asian Medicine: Perspective as a Tool
By William Morris, DAOM, PhD, LAc
Medical education involves the development of cultural competencies. In this discussion, I present the idea of perspective as a tool for navigating complex cultural environments. Hopefully, this article will provide a consideration for coursework in U.S. schools of acupuncture and Chinese medicine.
Skilled reasoning allows for the other points of view, especially for controversial subjects. The ability to articulate another point of view is evidence of that understanding. Good thinkers will actually seek out opposite points of view. Abraham Lincoln,for example, brought his competitors into his cabinet.
There are further reasons to pursue perspective. Hot spots abound in the field of acupuncture and East Asian medicine. Consider specialty groups and the Internet flame wars over a few years ago. Or, the current embattlement from community acupuncture network seeking lower cost training in acupuncture in order to serve the community acupuncture business model. The list is long and can include positions relative to medical ideologies such as the five-element/TCM arguments, economic forces such as insurance, and issues related to power and closure such as licensing, scope and turf concerns between professions.
Point of View
I approach these matters appreciatively and cooperatively. Yet, doing so requires a stance of uncertainty about what I know. A great deal of harm in society is caused by certainty, its correctness and the resulting moral conviction. We only have to look 100 hundred years ago towards the status of women and African-Americans in the world to see the ravages of certainty.
Transformation of the individual and the group requires a change of perspective, whether patients, medical students or the profession in relationship to society. This theory of perspectives leaves space for uncertainty and complexity.
Perspective becomes a useful tool for exploring integrity at individual and collective levels. Perspective allows for complex human systems, and is thus an important feature of cultural competency. The mere act of shifting one's point of view can resolve hot spots among an array of stakeholders. Such a systematic approach allows space for the paradox of opposite views.
Here, I present nine areas of contrast in cultural expression. They are: the personal to group, small to large, tolerance to intolerance for ambiguity, anima to animus, individual to contextual, differences to similarities, static to dynamic, focus upon past to future, and privilege and disadvantage (Martin & Nakayama, 2006; Ting-Toomey & Chung, 2007).
Nine Cultural Axes: The Heart of the Matter
Individual and group needs are valued differently between cultures. Americans often focus on individual rights, where Europeans and Asians negotiate on behalf of the collective. Those who value the individual, attend to primary relationships, nuclear family, regulating of privacy, individual competition, personal competence, direct communication patterns and an independent self. Those who value the collective, attend to extended family and friends, relational harmony, teamwork, group participation, indirect communication patterns and an interdependent self.
Differences in power and status can have a large impact on cultural assumptions. Those seeking large differences in power distribution seek hierarchical organizational with rewards and punishments based on age, rank, status, title, and seniority. Those who value small differences in power seek egalitarian organizations, level power distributions, equal rights and relations, and equitable rewards and punishment related to performance. Military life depends on rank and file hierarchy. Asian culture tends towards hierarchy. Contemporary western culture is exploring egalitarian power structures.
Different cultures vary in their ability to tolerate ambiguity. Those with a high tolerance for ambiguity value uncertainty. They seek out dynamic and changing states, seek high mobility, welcome challenges, encourage risk taking and see conflict as potentially positive. Those with low tolerance for ambiguity see uncertainty as a threat and then reinforce rule-based approaches to problem solving. They seek stability and low mobility, welcome routines, encourage clear procedures and view conflict as negative. We can see these different world views in practitioners who prefer a "scientific" point of view that is filled with repeatable criteria verses knowledge gained from, say, indigenous medical practices that use concepts such as wind.
The anima-animus axis deals with the perspectives of gender. Anima emphasizes flexible sex roles, emphasizes nurturing, allows both genders to take initiative, sees social adjustment as critical, sees "work in order to live," has fluid gender communication and overlapped gendered roles. The anima focuses upon complementary sex roles, emphasizes achievement, takes initiative and sees academic performance as critical, "lives in order to work," sees a "masculine" toughness and a "feminine" softness, and has clear gender roles.
The individual and the context, is similar to individual and groups. Individuals can have needs that differ from the context in which they serve. In addition, the role of the individual impacts their relation with other individuals. The context may be a professional discipline, a city, state or a work team. There are legal, social and purpose-based contexts. Take for example the needs of an individual practitioner as opposed to the needs of the profession at large. Is the decision made to benefit the individual or the group? The win-win of course, benefits both. Is what benefits a practice business model good for the profession? This becomes the question in the Community Acupuncture Network initiative to reduce the amount of education necessary to enter the profession. Is this really in the best long-term interest of the profession? How can we arrive at solutions for all?
Some focus upon differences and similarities. The comfort range for those who seek similarities involve the reinforcement of group rules, they focus upon low mobility, welcome routines, encourage clear procedures and view conflict as negative. In the valuation of differences, decisions and interactions develop from an emphasis on change. This also relates to how individuation takes place through peer phenomena. One individual will align with the group and another will intentionally separate.
There is the range between static and dynamic states in self and other. The person who prefers the static seeks relatively constant cultural and communication patterns. The temporal components and values have long time frames with cultural and communication patterns that shift over time. In dynamic states, change is imminent the culture values a faster temporal order. The bias for a static state will make a process claim "this is moving too fast, we need to slow it down." The dynamically focused culture will urge the process to move more quickly.
Certain cultures focus toward the past while others focus on the future. Past oriented cultures such as those affiliated with East Asian medical practices place value and focus upon traditions. Authority and agency are placed in sources from the past. An example is classical Chinese medicine. A future orientation values emerging trends and new developments. Modern scientific medicine is an example of this value system.
Time is important in some cultures and not in others. Notably, post-industrial societies place more importance on time than indigenous cultures. In terms of experience and the direction of awareness, certain people focus in the moment and others in terms of broad time frames. East Asian culture views time as cyclical while Westerners tend to view time as a straight arrow. Some people emphasize the past while others emphasize the future. Some people approach the moment actively and others passively. Some value the mode of change, while others seek constancy. Some cultures account for time by quantities in terms of the clock and calendar while others account through the quality of experience (Sztompka, 1994).
The axis of privilege and disadvantage is one of the great demarcations in contemporary American culture. Privilege biases towards those who have greater resources: materially, competency, psychosocially and biologically. Similarly, privilege biases resources towards or against those with lesser resources materially, competency, psychosocially, biologically. Privilege and disadvantage can occur at the same time and across the spectrum of class.
These axes of cultural states at the individual and collective levels are often in the background. What may be an apparent issue on the table can be infused with these cultural assumptions. Perspective provides insight and allows for a container large enough to embrace the full range of complexities so that cooperative solutions may be sought.
This article can be used as a cultural competency exercise in medical education programs, where cases or experiences of participants can be analyzed using these criteria. Small groups discuss a cultural problem identifying the cultural axis along which parties are polarizing around an issue. Good critical thinking skills will involve looking at the problem from both points of view. There are also other points of view likely available.
Perspective in cultural competency involves operating as a container for complexity at the individual and social levels. The practice of perspective provides specific tools for dealing with complexity and opposition.
Martin, J. N., & Nakayama, T. K. (2006). Intercultural Communication in Contexts Columbus, OH: McGraw-Hill
Sztompka, P. (1994). The sociology of social change. New York: Blackwell.
Ting-Toomey, S., & Chung, L. C. (2007). Understanding Intercultural Communication. New York: Oxford University Press
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