Culture, Race, and Hierarchy

Full text

COMMENTARY
Culture, Race, and Hierarchy
Mary-Jo DelVecchio Good
Published online: 6 April 2013
Springer Science+Business Media New York 2013
I read these essays with immense appreciation for the creative construction of
reflective analyses, elaborated through conversation between ethnographers and
academic physicians, as designed and realized by the special issue’s editors,
Elizabeth Carpenter-Song and Sarah Willen, and their collaborating authors. I also
appreciate the authors’ frankness in critical reflection, exposing, and puzzling over
the conflicts and ‘‘pitfalls’’ in the pedagogical interventions discussed and their rise
to the challenge set by Willen, drawing on George Devereux, to ‘‘lift the hood.’’ I
approach my commentary having spent decades studying the culture of medicine in
its many guises, at times through observations and surveys but mostly through
conversations with physicians across the globe from highly diverse institutional and
societal settings. I have published with some of these physicians representing a
conversation internal to our projects, most recently in Shattering Culture,American
Medicine Responds to Cultural Diversity (Good et al. 2011b), for which Willen and
Hannah are contributors and co-editors and Bullon and Carpenter-Song contributors.
I have often engaged collaborating physicians who were also subjects of my
research in jointly authored essays, for instance on psychiatry, oncology, end-of-life
research primary care, HIV in Africa, maternal and child health, global health, and
medical education. A few examples of essays in which I drew in my clinician
collaborator-subjects as co-authors include ‘‘American Oncology and the Discourse
on Hope’’ (1990); ‘‘Oncology and Narrative Time’’ (1994); ‘‘Conversations with
Oncologists’’ (1995); ‘‘Clinical Realities and Moral Dilemmas’’ (1999); ‘‘Physicians
Narratives at the End of Life’’ (2004); ‘‘The Culture of Medicine and Disparities in
Healthcare by Race, Ethnicity and Social Class’’ (2003,2004); and ‘‘Communi-
cation Barriers among Physicians in Care at the End of Life’’ (2012). As primary
author, my voice most often dominated as I wove the clinicians’ voices into the text.
What is refreshing and unique in this issue of Culture, Medicine, and Psychiatry are
M.-J. D. Good (&)
Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
e-mail: maryjo_good@hms.harvard.edu
123
Cult Med Psychiatry (2013) 37:390–397
DOI 10.1007/s11013-013-9308-0

the critical conversations, as well as reflective analyses on pedagogical projects, that
are carried on not through jointly authored essays, but rather via independent
contributions in which disciplinary voices speak to each other through the volume’s
structure of paired essays. As readers, we too can engage in an expansive discourse
across the disciplinary and positional divide as we interpret the emergent links
within each pair of positional essays. Thus, we come to a dominant theme
throughout: the often unexplicated ‘‘under the hood’’ or silent discourse on race,
hierarchy, and privilege, and the pedagogical difficulties in addressing these issues
directly in medical educational settings.
Pair One: Teaching Cultural Sensitivity or Cultural Competence
Sarah Willen and Antonio Bullon set the pace with their paired essays on an
ethnographic study that began with Willen’s observations of a required cultural
sensitivity course for a (highly multicultural) group of psychiatry residents in which
she not only attended the course sessions, but also interviewed at length the
residents and the two faculty psychiatrists who were its committed teachers. In
puzzling over the course’s limitations with residents and faculty (Willen et al.
2010), she was drawn to George Devereux’s warning that, as she puts it, ‘‘if
unacknowledged, unspoken and unconscious influences have the capacity to torpedo
interaction.’’ This warning helps her make sense of the strong emotional reactions of
residents, including one who claimed the course each week would open ‘‘a big huge
gaping wound.’’ In framing the residents’ reactions through a lens of transference
and counter-transference, Willen links the ‘‘gaping wound’’ imagery to the
awkwardness of race talk that invades social spaces in American society. Is the
awkwardness perhaps related to the exceptional diversity among participants?
Emotions exploded in particular in a session led by an African-American
psychiatrist, who presented four cases that illustrated the depth of American racism
and ‘‘horrendous health disparities’’ of those not ‘‘relatively privileged.’’ Willen
ends with reflections on key recommendations drawn from residents: ‘‘safe spaces,’’
collegial experiential learning, robust and nuanced concepts of culture, and
avoidance by faculty of assumptions about residents and their cultural interest and
knowledge. I ask: what is a safe space in today’s American health care institutions?
Personally, the residents’ comments amuse me since they echo those of
psychiatry residents and medical students from a much earlier era at the University
of California, Davis in the late 1970s and early 1980s, where I was at times forced to
teach dreaded courses on race and ethnicity along with an anthropologist (my
Midwestern Mennonite husband) and a male psychiatrist (who was Mexican-Italian-
American but could barely speak a word of Spanish). Only when we devised courses
in collaboration with medical students, psychology graduate students, and
psychiatry and family medicine residents did I feel some satisfaction with the
pedagogical experience and ‘‘safe’’ from derision. My recommendation for all
medical education on culture is make it collaborative and seductively elective!
Antonio Bullon’s response to Sarah Willen’s paper is remarkable for its frank
honesty and personal insight. Upon moving from Peru to the U.S. for residency
Cult Med Psychiatry (2013) 37:390–397 391
123

training, Bullon became a ‘‘designated minority’’ and ‘‘the other’’ which intrigued
him, and as a social justice activist and new graduate from psychiatry residency, he
was asked to teach a ‘‘culture course’’ in partnership with two colleagues who were
also recent residency graduates and social activists with college educations in the
humanities. Bullon describes how after putting together ‘‘the course of their
dreams’’ they would have liked to have had as residents, they were dismayed by
‘‘the lukewarm responses of many residents year after year.’’ Although Bullon looks
for sources of difficulty and suggests ways such a course might be improved to
make it more relevant to residents’ immediate concerns, the three faculty members
were influenced by the civil rights era and perspectives on social justice and were
‘‘very different from the generation of young physicians we were training.’’
Although trained to de-escalate angry patients, he writes, ‘‘we had no models in how
to defuse tension between doctors after a heated discussion about race and
privilege.’’ I empathize with his argument for training in conflict resolution and
negotiation skills as I reflect on my own past experiences. However, I disagree with
his recommendations that older clinicians should teach such a course and that
experience is the solution, as I recall 36 years of observing and being engaged in the
missteps of clinical and social science faculty, young and old, who end up having to
teach cultural competence courses. The authors of these paired essays lead us to ask
if it is not precisely the heated debates, transferences, and counter transferences
generating emotional distress and anxiety that should be the essence of such
courses, in which part of learning about ‘‘culture and race and privilege’’ involves
speaking about that which is normally unvoiced and sometimes arguing very loudly
about it. Is learning space not safe space but rather anxious space and at times hot
space? Can one tolerate this heat while erasing negative consequences of the
hierarchy of power? Might not managing relationships with fellow residents who
intensely and emotionally disagree and experience ‘‘cultural sensitivity cases’’
differently simply be part of learning to be a culturally competent psychiatrist in
American society?
Pair Two: Residency Research Training Collaboration
The next pair of essays, Carpenter-Song and Whitley’s ‘‘Behind the Scenes of a
Research and Training Collaboration: Power, Privilege, and the Hidden Transcript
of Race’’ and Malik’s ‘‘A Collaboration Between a Historically Black University
(HBU) and an Ivy League Psychiatric Research Center: A Psychiatrist’s Reflections
of the Impact on Residency Training,’’ delve deeply into the issues of ‘‘assumptions
and perspectives on race and identity’’ as well as organizational culture, disciplinary
divides, and deeply felt and difficult to discuss inequalities of privilege.
I was struck again by the authors’ reflective openness in talking about the ‘‘under
the hood’’ or ‘‘behind the scenes’’ difficulties of collaboration between a rich Ivy
League University (ILU) and rural bastion of white privilege, and an urban, HBU.
When the authors write about the hostility of senior psychiatry faculty who
dismissed the Ivy League anthropologist-researchers ‘‘with contempt’’—asking,
‘‘how could we as non-clinicians understand anything about mental illness? What
392 Cult Med Psychiatry (2013) 37:390–397
123

was the point of such ‘‘soft research’’? ‘‘How could we dare to critique psychiatry?’’
(ms p 12)—I too felt discomfort, empathizing to my core as the authors described
their own discomfort. The essay builds, illustrating the difficulties of getting
residents at the HBU to buy into the research training experiences offered by this
collaboration. What emerges is not only a clash of institutional cultures, but the
American ‘‘gaping wound’’ of differences of race, and disparities of privilege. Were
the senior HBU psychiatrists perhaps voicing something else when they questioned
the ‘‘right’’ of the white Ivy League anthropologists to enter their psychiatric turf?
This difficult and uncomfortable story unfolds as the authors explore issues of
privilege and race, hierarchy and authority, and the cultural differences between
these two educational institutions—‘‘all this to say that things that are easy at [the
ILU] and …taken for granted—are often problematic at [the HBU].’’ Furthermore,
issues of race, as they are experienced in the context of our interactions with
one another, are not made explicit. We have never, as a team, come together to
discuss our perspectives on race and our lived experiences of coming from
diverse backgrounds. Instead race only explicitly enters into the collaboration
as part of the official transcript of our research and training efforts. Yet hidden
dynamics of power and privilege shape day to day interactions among
members of the Collaboration. (p. 21 ms)
Mansoor Malik, the training director of the psychiatry residency program at the
HBU, was a psychiatry fellow at the ILU following his residency training first in the
United Kingdom and then at a Philadelphia hospital in the U.S. He writes directly
about his own ethnicity and minority status, noting that he is an immigrant physician
from Pakistan and a member of the Ahmadiyya, a minority Muslim sect persecuted
in Pakistan (and elsewhere in the Muslim world). He notes that ‘‘cultural
competency has assumed an ever increasing role in our curriculum’’ and that ‘‘we
take care to select residents that are sympathetic and possibly committed to reducing
racial disparities in mental health.’’ His goal is the collaborative program goal—to
build research capacity in minority and in particular African-American mental
health. His view of the influence of the summer training program on residents is
somewhat startling. He notes,
perceiving that the introduction of anthropological methods of inquiry was
uncovering the latent anxieties about power sharing and hierarchy within the
residency program, we initiated a regular confidential process group. …the
residents have come to appreciate anthropological methods and theory that
place disparities research in the context of social justice and promote a
sophisticated understanding of ‘culture’ and its role in disparities. (p. 8 ms)
As a bridging figure between the two institutions, and perhaps between black and
white America as immigrants are at times able to do, Malik identifies negative
aspects of the culture of hierarchy between senior faculty and residents at the HBU
and introduces the uncomfortable challenges it poses for the research training
collaboration. While not going as far ‘‘under the hood’’ as the Ivy League
anthropologists, his essay sets forth warnings to entrenched hierarchies to step aside
and let new researchers grow.
Cult Med Psychiatry (2013) 37:390–397 393
123

Pair Three: Patrolling Your Blind Spots and A Safe Place to Speak
Seth Hannah, Elizabeth Carpenter-Song, and Roxana Llerena-Quinn offer com-
mentary on a faculty development course to reduce bias. As Roxana notes in her
essay, the course in its third iteration replaced one that, in my experience, was
driven by the 1960s generation grounded in social justice and civil rights. The
pedagogical strategy of this course, Hannah and Carpenter-Song tell us, is
promoting self-awareness and introspection and creating safe spaces in which to
speak without blame or criticism to reduce bias. Llerena-Quinn highlights the
importance of reducing bias and disparities in treatment in line with the agenda set
forth in the Institute of Medicine’s ‘‘Unequal Treatment’’ (2003) and national
policies at the National Institutes of Health, as well as local policies to reduce health
disparities by reducing disparities in medical care and treatment that may be caused
by bias and prejudice. Hannah and Carpenter-Song attended the twelve meetings of
the course and had informal conversations with participants and instructors as well
as formal interviews with three instructors and five participants. Through interviews
and their own observations, the ethnographers ‘‘lift the hood,’’ exploring the
motivation and responses of participants and the philosophy of the course founders.
Llerena-Quinn, one of the course instructors and developers, welcomes the feedback
and again sends out a clarion call for a commitment to social justice and reduction in
disparities. She argues for cultural sensitivity and knowledge as well and for cultural
competence in the widest sense, despairing at supervisors who dismiss those who
are too poor to be well served. Llerena-Quinn draws on the movements against
disparities and inequalities in mental health care—calling attention to ‘‘Culture
Matters’’ in reducing disparities and ‘‘Unequal Treatment.’’
This pair of essays presents a positive and contemporary intervention, one that
can perhaps be improved given the newness of the course format. Yet the course
was a success. Why? The course is voluntary! Faculty who join for the twelve
sessions are committed to introspection in a safe space and are interested in culture
and reducing blind-spot bias, or what the authors note is now referred to as ‘‘ethical
self fashioning.’’ The detailed ethnographic description of the course, its highly
successful small group discussions, its over-all agenda, and the participants’
positive responses show that the small group method achieved the instructors’
pedagogical goals. The authors note a steadfast commitment to social justice and
reducing health disparities by minimizing bias and exploring one’s own negative
bias and cultural identities. All three authors argue for a more robust link between a
focus on the micro-aspects of the self and macro structural concerns.
What a marked contrast this pair of essays is to the discomfort generated in the
Willen and Bullon essays on the residency training course. What are the essential
differences between this faculty seminar and the residency seminar? My own
reflections are shaped in part by a short stint in an earlier version of the course,
which was established many years ago by one of the faculty leaders of the New
Pathway revolution in medical education at Harvard Medical School. Dan
Goodenough, a highly esteemed and popular professor with students and faculty,
offered a course on racism and self-awareness designed to reduce racism and bias.
The ideological core of the course was a commitment to social justice, civil rights,
394 Cult Med Psychiatry (2013) 37:390–397
123

redressing prejudice and inequalities for minorities, and affirmative action. At the
time we spoke about the poor, minorities, and inequalities rather than disparities.
We were a multicultural group of faculty members, but only one of us was African
American, a highly esteemed surgeon. We anthropologists soon excused ourselves
from yet one more evening we could not spare given an overload of nighttime
seminar obligations, but the respect Dan held for others, and faculty for him, was
extraordinary. This was a 60s generation course in its ideology and leadership. The
participants and those who returned and collaborated in various versions of the
course were enchanted with the safe space for hard talk that Dan and his colleagues
created.
The contrasts with the residency course are curious. Dan’s course, much like the
one Hannah, Carpenter-Song, and Llerena-Quinn describe, was elective; the
psychiatry residency course was not. The faculty courses were collaborative and
small group based and focused on the self in a 60s sort of way, and the residency
course was not. The faculty course was a place where young and old and junior and
senior faculty met to speak about themselves, and the residency course was not.
Dan’s course, and perhaps this course too, was playful; it was time for faculty
imagination to play out. The residency course was also initially for the faculty a
time for imagination to play out, but the residents were not in a space to relish the
intellectual play. One wonders what vulnerabilities made it so hard for them to
enjoy and engage what their young faculty found so interesting? Perhaps third year
residents are not worthy of such a course? Perhaps the rule of law rather than
education is what matters?
Pair Four: The Canadians and Working with Culture Seminar
The Canadians in Montreal have their own fascinating cultural modalities for
teaching clinical cultural psychiatry, where diversity is the message. Authors
Jaswant Guzder and Ce
´cile Rousseau, cultural psychiatrists, offer a fine essay on the
‘‘Diversity of Voices’’ in their summer seminars on Working with Culture.
Psychiatrist Laurence Kirmayer comments on their ‘‘distinctive pedagogical values
and orientations.’’ The Working with Culture Seminar, which takes place as part of
a month long program in Social and Transcultural Psychiatry, is case based and uses
an all-encompassing biopsychosocial model. The case however holds the center,
and the conversation Rousseau and Guzder seek to create interweaves the voices of
seminar teachers and participants who engage each other in a zone of ‘‘cultural
safety.’’ Discussing therapist–client relationships and therapeutic process is at the
core of their agenda, and cultural competency training is incorporated into the whole
model. The course sounds like summer intellectual fun, engaging, bonding, and
conversing about ‘‘uncertainty and non-closure’’ in therapeutic work. The
‘‘universal and culturally specific are woven through the seminars’’ (p. 11 ms)
even as specific modes of therapeutic engagement are taught by visiting faculty.
Guzder and Rousseau hope the seminars will provide a place for critical thinking
and the emergence of new ideas useful in structuring clinical training experiences
and managing local cultural challenges.
Cult Med Psychiatry (2013) 37:390–397 395
123

Kirmayer, highlighting Hannah’s concept of hyperdiversity (Hannah 2011; Good
et al. 2011b) to reflect on Canada’s multicultural state, notes that ‘‘for the last
100 years, 15–20 % of Canadians were born outside Canada and that in a sense
everyone is a hyphenated Canadian.’’ He notes how Guzder and Rousseau focus on
collective identities and the larger political dynamics of drawing diverse perspec-
tives from seminar participants (see Bibeau (1997) on multicultural Quebec and the
First Nation of Wasena-Waseya (2008)). He also sees Rousseau and Guzder as
successful, confirming the seminar has created a community of practice that
supports culturally informed and politically aware clinicians, offering a broader role
for clinicians as advocates and partners with patients and community systems.
Perhaps the seminar, which sounds intellectually fun and invigorating, might
enhance the role of traditional therapists, whose cultural and professional authority
may well be eroding in Canada as it is in the United States, where institutional
pressures are leading to compromises in terms of check box psychiatry (Bullon et al.
2011) and financial pressures (Good et al. 2011a,b, p. 22; Hannah et al. 2011).
References
Bibeau, Gilles
1997 Cultural Psychiatry in a Creolizing World: Questions for a New Research Agenda. Transcultural
Psychiatry 34(1): 9–41.
Bullon, Antonio, Mary-Jo DelVecchio Good, and Elizabeth Carpenter-Song
2011 Paper Life: Documentation Practices in the Care of Minority and Low-Income Patients. In
Shattering Culture: American Medicine Responds to Cultural Diversity. Mary-Jo DelVecchio
Good, Sarah S. Willen, Seth Donal Hannah, Ken Vickery, and Lawrence T. Park, eds. New
York: Russell Sage Foundation.
Good, Mary-Jo DelVecchio, Nina M. Gadmer, Patricia Ruopp, Matthew Lakoma, Amy M. Sullivan,
Ellen Redinbaugh, Robert M. Arnold, and Susan D. Block
2004 Narrative Nuances on Good and Bad Deaths: Internists’ Tales from High-Technology Work
Places. Social Science & Medicine 58(5): 939–953.
Good, Mary-Jo DelVecchio, Byron J. Good, Cynthia Schaffer, and Stuart E. Lind
1990 American Oncology and the Discourse on Hope. Culture, Medicine and Psychiatry 14(1): 59–79.
Good, Mary-Jo DelVecchio, Cara James, Byron J. Good, and Anne E. Becker
2003 The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare. In Unequal
Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Brian D. Smedley, Adrienne
Y. Stith, Alan R. Nelson, eds., pp. 594–625. Washington, DC: National Academies Press.
Good, Mary-Jo DelVecchio, Tseunetsugu Munakata, Yasuki Kobayashi, Cheryl Mattingly, and Byron J.
Good
1994 Oncology and Narrative Time. Social Science & Medicine 38(6): 855–862.
Good, Mary-Jo DelVecchio, Esther Mwaikambo, Erastus Amayo, and James M’Imunya Machoki
1999 Clinical Realities and Moral Dilemmas: Contrasting Perspectives from Academic Medicine in
Kenya, Tanzania, and America. Daedalus 128(4): 167–196.
Good, Mary-Jo DelVecchio, Sarah S. Willen, and Seth Donal Hannah
2011a Shattering Culture, An Introduction. In Shattering Culture: American Medicine Responds to
Cultural Diversity. Mary-Jo DelVecchio Good, Sarah S. Willen, Seth Donal Hannah, Ken
Vickery, and Lawrence Taeseng Park, eds., pp. 1–30. New York: Russell Sage Foundation.
Good, Mary-Jo DelVecchio, Sarah S. Willen, Seth Donal Hannah, Ken Vickery, and Lawrence T. Park, eds.
2011b Shattering Culture: American Medicine Responds to Cultural Diversity. New York: Russell Sage
Foundation.
396 Cult Med Psychiatry (2013) 37:390–397
123

Good, Mary Jo DelVecchio, Irene Kuter, Simon Powell, Herbert C. Jr. Hoover, Maria E. Carson, and Rita
Linggood
1995 Medicine on the Edge: Conversations with Oncologists. In Technoscientific Imaginaries:
Conversations, Profiles, and Memoirs. George E. Marcus, ed., pp. 129–152. Chicago: University
of Chicago Press.
Hannah, Seth
2011 Clinical Care in Environments of Hyperdiversity In Shattering Culture: American Medicine
Responds to Cultural Diversity. Mary-Jo DelVecchio Good, Sarah S. Willen, Seth Donal Hannah,
Ken Vickery, and Lawrence T. Park, eds., pp. 35–69. New York: Russell Sage Foundation.
Hannah, Seth Donal, Lawrence Taeseng Park, and Mary-Jo DelVecchio Good
2011 Physicians’ Perspectives on Financial Barriers to Equitable Care. In Shattering Culture:
American Medicine Responds to Cultural Diversity. Mary-Jo DelVecchio Good, Sarah S.
Willen, Seth Donal Hannah, Ken Vickery, and Lawrence Taeseng Park, eds., pp. 217–234. New
York: Russell Sage.
Muhaimin, Amalia, Mary-Jo Delvecchio Good, Yati Soenarto, and Retna Siwi Padmawati
2012 Communication Barriers among Physicians in Care at the End of Life: Experience from a
Postgraduate Residency Training in Java, Indonesia. Asian Bioethics Review 4(2): 102–114.
Tousignant, M., A. Laliberte
´, G. Bibeau, and D. Noe
¨l
2008 Comprendre et agir sur le suicide chez les Premie
`res Nations: Quelques lunes apre
`s l’initiation.
Frontie
`res 21(1): 113–119.
Willen, Sarah S., Antonio Bullon, and Mary-Jo DelVecchio Good
2010 Opening Up a Huge Can of Worms: Reflections on a ‘‘Cultural Sensitivity’’ Course for
Psychiatry Residents. Harvard Review of Psychiatry 18(4): 247–253.
Cult Med Psychiatry (2013) 37:390–397 397
123