Why Does Culture and Context Matter for Care That Aims for Quality and Impact?

I am pleased to comment on Dr. Periyakoil’s contribution that advances the vital need to acknowledge, encompass, and catalyze approaches to achieve a sensitivity and capacity to care for persons whose social and mental model backgrounds may differ dramatically from the professional provider. Raising the topic of cultural awareness and diverse populations has the tendency to elicit top of mind classifications as well as unconscious biases/thinking models that come from defined categories of experience and beliefs. This reaction commentary to the article by Periyakoil is intended to affirm the reason it is an inflection period in society to commit to culturally effective care that engages not only as an individual patient focus and also that of the ecosystem of the community in which older diverse persons live and receive formal health and/or medical care. Besides being an appropriate intention of providing quality care, there is more than ever an aligned “business case,” as indicated in the author’s article. Whether it is the topic of “aging,” obesity, opioid addiction, mental or community health, or social determinants, these areas engender a fair degree of complex reactions. As a result, until a degree of urgency occurs in politics or policy/ payment, these evergreen matters do not receive an amplified focus. I contend that the matter of aging and diverse population emerges more visibly today (even though many have long championed these topics with modest or negligible uptake) and is due to sheer population growth along with institutional environmental policy shifts in today’s healthcare landscape. There are at least three factors that shape current change: payment stressors (volume and expense), payment consequences (eg, readmission penalties and outcome measurement instead of institutional care transactions), and policy changes of payment for added community services vs solely reimbursement of medical services (ie, The CHRONIC Care Act of 2018). Furthermore, the importance of culture as a professional care concept and as a key clinical component of accurate diagnosis and management has been designated by the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual, the “bible” for those in mental health. The framing has changed from a “simple list of culture-bound syndromes” to “cultural concepts of distress,” enabling and advancing greater fluency in various idioms of distress. In 2017, the APA noted that “many persons from racial/minority groups are less likely to receive mental healthcare”; of seven noted barriers, four of the issues related to culture. Clinical work in Montreal, Canada, by McGill University’s Division of Social and Transcultural Psychiatry incorporates an interdisciplinary approach with input from anthropologists, translators, and community “cultural brokers” who help provide the background to cultural meaning and behaviors. This approach to better care is helpful specifically here in the mental health arena, but its relevance to more somatic health conditions is inferred. Dr. Andrew Ryder of Concordia University, and connected to McGill’s program, notes that clinicians who will be effective in the future will possess an assessment skill that is “informed curiosity,” knowing possibilities while remaining openly and authentically curious so that the clinician would be less apt to assume and act upon before acquiring a fuller understanding of the patient.