Sociology ETDs

Publication Date

Summer 7-31-2017

Abstract

PURPOSE: At the turn of the 21st century, the concept of cultural competence in medicine became a strategy to address cultural diversity and widening health and healthcare inequities. Cultural competence combines the tenets of patient-centered care, with an emphasis on the social and cultural factors that affect the quality of medical services, treatment decisions, and health outcomes. Substantively, this dissertation answers core questions about the parameters of cultural competence in medicine. Theoretically, it considers the jurisdictional terrain of the medical profession and its changing nature concerning the adoption of cultural competence. The overarching research question is how, why, and with what consequence did the medical profession integrate cultural competence?

METHODS: I analyzed the conceptualization, operationalization, and implementation of cultural competence. I conducted semi-structured interviews with 14 key policy actors from four major organizations concerned with U.S. medical education to examine the conceptualization of the cultural competence mandate passed in 2000. Using discourse analysis, I analyzed 89 articles published in the Journal of the American Medical Association (JAMA) to assess the diverse operationalization of cultural competence within the medical profession. Moreover, I conducted a comparative case study analysis on data from a larger NIH-founded research team studying biased decision-making using mixed-methods to assess the implementation of cultural competence. We conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 students at 15 diverse public and private medicals schools. We also led focus groups with an additional 196 third and fourth-year medical students. These three empirical chapters provide a cross-sectional snapshot of the medical profession’s legal, workplace, and professionalization jurisdictional claim to cultural competence.

RESULTS: The first empirical chapter demonstrates that the conceptualization of cultural competence is a moving target. Cultural competence was conceptualized as being integral to the identity of the 21st-centuryprovider, but the standards, mission, approach, and policy effect has expanded. In the second study, three themes capture the tensions with implementing cultural competence into the practice of medicine. Culturally competent providers provide appropriate health information and make culturally-appropriate medical decisions, but such practices are constrained by the biomedical structure and culture of medicine. Finally, in the third chapter, the implementation of cultural competency varies widely among the fifteen medical schools. Three themes capture the manner in which schools incorporated cultural competence, but the medical school structure limits the ability for integration. This dissertation shows that the medical profession’s jurisdictional claim to the legal aspect of cultural competence was poorly constructed, the profession’s jurisdictional claim in the workplace was limited by the culture of medicine, and their jurisdictional claim in professionalization was restricted by the current education structure.

DISCUSSION: The medical profession’s adoption of cultural competence potentially changes the work performed by medical providers. However, cultural competence has yet to be integrated enough to modify the actual work performed by providers. The jurisdictional claim to cultural competence is an example of what I call a surface jurisdictional claim. The vagueness of the cultural competence mandate allows the profession to adopt cultural competence without specifying or providing a uniform definition or approach. The practice of cultural competence through providers’ behaviors is limited given that the biomedical framework not only structures the clinical encounter but also structures the culture of medicine. Additionally, the training of cultural competence is further restricted within an education system that operates under a didactic knowledge-based framework. The adoption of cultural competence may not be possible unless the underlying assumptions of the biomedical model are further critiqued and analyzed. Additionally, adopting cultural competence at the provider level is insufficient; it requires a modification at the systems level beyond a public claim to addressing health disparities and improving the quality of care that places the onus on medical providers.

Degree Name

Sociology

Level of Degree

Doctoral

Department Name

Sociology

First Committee Member (Chair)

Dr. Kristin Barker

Second Committee Member

Dr. Nancy Lopez

Third Committee Member

Dr. Jessica Goodkind

Fourth Committee Member

Dr. Andrew Sussman

Project Sponsors

RWJF Center for Health Policy; Andrew W. Mellon Foundation

Keywords

Cultural Competence, Cultural Competency, Medical Profession, Sociology of Professions, Jurisdictional Claims, Healthcare Delivery System, Medicine

Language

English

Document Type

Dissertation

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