Health care in a globalised world: is there more than one type of patient?

Clinical care guidelines for collecting and using information on the cultural heritage of patients are needed

We cannot escape globalism or its consequences for medical practice. The article by Morgan and colleagues in this issue of the Journal1 could not have been better timed to initiate a debate about diversity and Western medical paradigms. The authors examined how often and why the cultural heritage of patients — a broad field encompassing ethnic background and national heritage, their religious, cultural and socio‐economic diversity — was cited during medical handovers and in electronic records in a Perth hospital. Aboriginality was mentioned by clinicians much more frequently than other backgrounds. The interpretation and implications of their findings are complex and challenging.

Western health practice is built on scientific evidence about the known, rationalising or debating the uncertain, and clarifying by investigation the unknown. Increasingly heterogeneous patient encounters challenge relying only on scientific evidence about the knowns, as conventional evidence gathering rarely focuses on translational elements (phase 4 clinical research).2,3 New approaches are therefore emerging, such as standardising, coding and classifying heterogeneity (eg, taxonomies), broadening the evidence base, and developing local solutions based on post‐trial evidence.4,5

Understanding the permutations of how scientific tools are applied is itself an art. The main scientific purpose of the doctor–patient interaction is to extract information on health and disease phenotypes from manifestations such as symptoms, signs, and diagnostic correlates of tissue and organ function.4,5 In this context, the only reason a clinician might need to specifically ask about ethnic background would be to gain phenotypic information needed for evidence‐based care. Ethnic phenotypes may be seen as risk factors in disease processes — for example, in cardiovascular disease — although apparently confirmatory data and genetic inferences may be affected by biases or unknown factors, so that the evidence base for assessing ethnicity in clinical practice is tentative.6,7,8 There are nonetheless limited but well defined evidence‐based reasons for acquiring information on ethnic phenotypes when treating certain diseases, and these will undoubtedly increase with time.

The importance of a patient's cultural background for medical practice

Phase 4 studies have indicated that acting on clinical trial‐derived evidence does not achieve the expected outcomes unless the findings have been validated at the community level.2,9 In organised programs with this aim, the art of medical practice becomes evident when assessing non‐phenotypic factors such as rapport, compliance, trust, satisfaction, behavioural change, and personal psychology. Cultural heritage adds greater challenges to doctor–patient communication, including interpreting non‐verbal cues and other cultural differences. Subjectivity and biases are often expressed in clinical care; for example, could over‐reporting underlie recent political discussions about poor Aboriginal health? Nevertheless, routinely obtaining details about ethnic background for informing the art of medical care must be distinguished from using this information clinically, as its significance for disease and management taxonomies is uncertain. Conversely, cultural information other than ethnicity can also influence clinical management, and requires thoughtful extraction and communication.

It is unclear how and by whom such information should be collected, and how often it should be updated. Resolving these questions would be advanced by integrating cultural heritage and related information in a scientific sense, particularly by compartmentalising the process in taxonomies. The process must be defined to ensure accuracy, maintain standards, and guarantee that patients providing information in good faith are not disadvantaged by their doing so.

Towards clinical guidelines for recording cultural heritage

A cultural heritage taxonomy could guide understanding of the various relevant processes and form the basis for clinical guidelines. Information on the socio‐cultural background of patients is routinely obtained when taking a clinical history (Box, A). In solo practice, subjectivity is more likely than in multidisciplinary care, where greater consensus is required. The judicious handling of cultural information can shape health worker–patient relationships, and standards are needed for a unified approach. Medical teaching and health policies deliver the scientific basis for collecting this information with the aim of ensuring that factors which impede optimal health care are identified and addressed. A classification of cultural disadvantages in medical care, complementing health management taxonomies, will be developed with experience across a range of health care settings (Box, B). Finally, subjectivity influences decision making in practice. In theory, domains that might define the taxonomy of cultural influences could include any non‐disease factor that affects outcomes, such as ethnic background (including known genetic associations), socio‐economic and geographic factors, language and culture, social supports, mental health, and medical literacy (Box, C). Corroborating subjective claims and resolving questions in contentious areas, such as ethnic background, are among the challenges for the future.

A cultural heritage taxonomy could support a model of care in which a multidisciplinary team documents and responds to disadvantages or differences that could negatively affect health care. Funding these services would be a political issue influenced by public sentiment. While investigating the role of cultural heritage in medical practice is noble, social attitudes will affect our ability to act upon the outcomes of clinician‐driven studies, and doctors will require a political voice to advocate policies regarding socio‐cultural factors.

In summary, information about cultural heritage is regularly collected during the routine care of patients, but its use is subject to the discretion and biases of practitioners. In multidisciplinary care, a consensus process is required, and we applaud the many examples of optimal health care delivered in socio‐culturally diverse settings. However, comprehensively extending such optimal care requires standards that counter political and societal influences that can reduce its effectiveness (eg, affirmative action creating generic policies for a group at the government level, individual biases from past experiences, resident status of the patient, socio‐cultural miscommunications).

The ideal model of universal health care includes a cultural heritage taxonomy that helps practitioners respond to the diversity of their patients. Without reaching consensus on how and why we collect such information, publications such as the excellent article by Morgan and colleagues1 will remain isolated. Advocacy bodies, including the Royal Australasian College of Physicians (RACP), the Australian Medical Association (AMA), local, state and federal health bodies, as well as administrators and research institutes, could establish pathways for lobbying and deliver a taxonomy for health systems that has broad appeal. It is exciting to see the sprouting of new health science branches for guiding the development of an objective balance in what is currently a highly subjective area of health care.

Box – Flow chart highlighting current patterns of use of information about cultural background, and a theoretical framework for the future

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