In this essay Bob Simpson considers the cultural diversity of NHS doctors, offering the image of the doctor as tightrope walker.
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The Covid-19 crisis has rendered many things differently visible. What became apparent to many outside of the UK’s National Health Service (NHS), however, was something that had been there all along, namely the extraordinary diversity that is now part of the fabric of NHS provision. This multicultural alliance was core to NHS effectiveness and viability before its Covid response and will be afterwards [Beans on Toast, 2019]. In 2019, a House of Commons briefing reported that NHS staff were drawn from over 100 nationalities with ethnic minorities making up 12.5% of the workforce [Baker 2019]. Among doctors, 26% are non-British, with roughly half of these coming from South Asia. In as much as there has been outside interest in overseas doctors in the NHS it has mostly been in terms of workforce, recruitment and immigration or how their medical education and qualifications might be mapped from one country to another [Mckimm & Wilkinson, 2015; Michalski, Farhan, Motschall, Vach, & Boeker, 2017; Valero-sanchez, Mckimm, & Green, 2017]. Where cultural diversity has entered the conversation it has tended to focus on patient diversity rather than that of doctors themselves [for example see Napier et al, 2014, also see Mattingly, 2018, Kleinman, 1981]. However, it is not just that the patients of the NHS who are, to use Vertovec’s term, ‘super-diverse’ [Vertovec, 2007], the supply side is too.
What I explore here goes beyond managing the facts of this diversity per se to consider the pragmatics of difference: what does the evident cultural diversity of NHS doctors really mean when it comes to patient care, treatment and outcomes? In technical terms, the answer to this question is simple: it doesn’t mean anything because the transparent, rule-governed, reproducible, evidence-based practical competences of medical diagnosis and treatment lie outwith questions of culture and are, or should be, wholly devoid of the agent’s background. However, when aspects of clinical practice of a more opaque, reason-governed, experience-based and subjective kind are considered, the answers are not quite so straightforward. Here we begin to move away from the technicalities of clinical competence to consider what happens when doctor and patient begin to step into and out of one another’s stories. Medical anthropologists have long pointed out that patients bring with them diverse ideas about the body, the mind, causality, illness, morality, and death, but what of those that doctors themselves bring? To get us into the frame let us begin with an example.
Some years ago, a GP friend of mine described a predicament he and his colleges were facing. An Egyptian trainee was recruited to their practice. As a devout Maronite Christian, one of the first things the trainee did as he made himself at home in his consulting room was to place a large picture of the Madonna and child on the wall behind his desk. The practice was split. There were those who would like to see the picture taken down – the consulting room should be a secular space and private beliefs and values should not be allowed to intrude lest they cause offence to patients of other faiths and otherwise distract from the rational authority that underpins medicine. Others felt that it was quite acceptable and indeed reassuring for patients to be able to situate the doctor in terms of culture and religion. The point is not whether the image should be there for all to see nor about the place of religious belief in medicine per se but the more fundamental fact that for the trainee there are a set of foundational assumptions that we might think of as ontological, that is, to do with a sense of what it means to be, both as one who acts intentionally and as one who is acted upon amidst the intentions of others. Moreover, these assumptions are in play whether the image is there or not. Similarly, turbans and other head coverings, crucifixes, wedding rings, hair length, ear-rings, styles of dress and other signifiers all suggest that no doctor comes to her/his practice from nowhere. Basically, it is not only patients who need to feel comfortable in their skins, but doctors too. An important corollary of what is often coined ‘person-centred medicine’ (i.e. approaches which recognise the importance of the patient’s biography, stories and cultural understandings in diagnosis) is that the doctor as a person is also fundamental to the realisation of medicine’s therapeutic objectives frame [see Boutin-Foster et al 2008].
To point out this fact is to do no more than re-state something obvious and fundamental but often overlooked about the therapeutic relationship in medical practice. This relationship builds on the interaction between two people and develops in accordance with the intellectual and emotional capacities of each. As such, it is impossible to divorce from the ontological assumptions about what it means to be a person that each brings into play when exploring symptoms and causes and then deciding on optimal treatments. In the present day, this relationship also unfolds in settings which are plural and complex. Classical notions of the ‘sick role’ give way to more heterogeneous notions of patiency or what it is to be a patient and how this might be negotiated from case to case. And, as is true of any domain in which human social and cultural variability needs to be factored into technical expertise, a plurality of distinct styles of interaction will emerge, none necessarily wrong, and many perhaps equally good. The challenge is just how to integrate these within medical practice as a whole.
Let us imagine the doctor as a funambulist, that is, a tightrope walker, who everyday puts one foot precariously in front of the other as they move along a very high wire. Pulling down on one side of the balance bar is the need to ‘lump’ patients and their conditions into types, populations and categories. These constructions are informed by evidence-based medicine, epidemiology, the use of generic medicines and therapies, and other expressions of the reductionist and standardising logic of medical science more generally. In these constructions are to be found the regular patterns and frameworks within which symptoms are to be known, understood and acted upon. Pulling down on the other side, however, is the need to ‘split’ individual persons from received patterns, and to treat each one as a unique, phenomenological intersection of biography and biology. The balancing act is often accomplished naturally and unconsciously but the balancing bar is likely to wobble at the points where the radical openness of human being overflows the explanatory frames into which it is pressed. This situation most commonly occurs when something other than a clinical response is called for; the points at which technical competences give way to cultural scripts concerning basic issues of communication, understanding and empathy in the face of another’s pain and suffering.
Saying that there are competing imperatives in the practice of medicine is hardly novel but the tight-rope analogy brings home two important points. First, the balancing act is not a one-off, once and for all exercise but, on the contrary, has to be managed and adjusted at each new step, that is with each new patient the doctor encounters. Technique and the art of balancing may get better over time but each encounter will require sustained concentration. Conditions may change at any step, mistakes are costly and it is a long way to the ground (here think workplace conflict, complaints of racism, cultural misunderstandings etc). Second, the analogy of tight-rope walking draws attention to the subjective skills of the tight-rope walker in achieving the balance needed at each step. These skills necessarily bring into view a doctor’s own ontological assumptions for consideration. Moroever, these assumptions are mostly hidden from view in the sequential formation of therapeutic relationships, yet they are crucial to the success of this process in settings of plural and heterogeneous encounters. They help the doctor to move safely and effectively, case by case, along the tightrope of medical practice.
In as much as these aspects of diversity have been considered, it has mostly been in terms of cultural competences. What I am suggesting here is a more radical vision which highlights the ontological assumptions that doctors draw on as they daily walk the medical tightrope. Rather than being resisted, ignored or worked around in efforts to improve doctor-patient relations and therapeutic outcomes, the variety of such assumptions in play needs to be recognised, explored and embraced. To do this would mean re-framing them as a starting point for how to deliver medicine effectively in multi-cultural contexts rather than seeing them as a prima facie impediment. A first step in this direction is to recognise the breadth of tight-rope walking skills that are in play in current medical practice. This would require a much greater awareness of the diversity of ontological assumptions brought to the therapeutic relationship, what these are and their consequences for medical outcomes. It would also necessitate a more thoroughgoing recognition that these assumptions do not only feature in the practice of doctors from overseas. Indeed, what may be difficult for doctors who come to this question from the dominant cultural background of UK medicine is to see that they operate with any ontological assumptions at all, as they may never have had to reflect on these. To enable doctors to consider their own ontological assumptions as part of their training would be a necessary primer for how they would then recognise and negotiate the variety of assumptions that their patients bring to a consultation. At its most basic, this would mean tapping into the rich human heritage of how one human being might come to recognise and act to relieve the suffering of another.
Acknowledgements
I am grateful for to Dr Daniel Herron [NIHR University College London Hospitals Biomedical Research Centre], Professor James Wilson, [Department of Philosophy, University College London] and Professor Parashkev Nachev, [Department of Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, University College London] for their comments on earlier drafts of this essay.
References
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Beans On Toast 2019 – Here at Homerton Hospital. The Moonshine Sessions. Towersey Festival. https://www.youtube.com/watch?v=ny2tcNlScDs
Boutin-Foster, C., Foster, J., and L. Konopasek, 2008. Viewpoint: Physician, Know Thyself: The Professional Culture of Medicine as a Framework for Teaching Cultural Competence. Academic Medicine. 83, Issue 1. pp 106-111.
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Mckimm, J and Wilkinson, T 2015 “Doctors on the Move”: Exploring Professionalism in the Light of Cultural Transitions Medical Teacher. 37
Michalski, K., Farhan, N., Motschall, E., Vach, W., and Boeker, M. 2017. Dealing with Foreign Cultural Paradigms: A Systematic Review on Intercultural Challenges of International Medical Graduates. PLoS ONE, 12(7), 1–20.
Napier, A.D. 2014. Culture and Health. Lancet 384 (9954): 1607-39.
Valero-Sanchez, I. 2017 A helping hand for international medical graduates British Medical Journal. 359 j5230.
Vertovec, S. 2007 Super-diversity and its implication. Ethnic and Racial Studies. 30 [6] 1024-1054.
Bob Simpson is an Emeritus Professor of Anthropology at Durham University. His research interests include the anthropology of biomedicine, the biosciences and bioethics. His most recent book is Research as Development: Biomedical Research, Ethics, and Collaboration in Sri Lanka (Cornell University Press 2019 with Salla Sariola). Reach Bob at robert.simpson@durham.ac.uk.
