Archive for February 2011

About the Culture of Medicine & Physicians

February 11, 2011

In the initial blog (Jan 24, 2011) I asserted that culture, the basic tenet that informs who the individual is and how he/she behaves, has received little attention as to which of its factors influence or determine how physicians understand the desirability or lack of desirability in adopting the EHR. I also argue that principally, though overlooked, the lack of adoption of EHR by physicians has much to do with deep professional cultural values ingrained within a broader context of societal values in relation to health and health care.

I propose that a cultural framework that explores the customs, languages, and belief systems that have informed physicians in the U.S., particularly during the last century, is most appropriate to understand why or why not physicians would adopt EHR. A word of caution, although it is important to be curious about the values and attributes of a particular cultural group, there is an inherent risk of generalizing these values and attributes to everyone who shares aspects of that culture. This sort of stereotyping should be avoided.

The question then is, what is culture and where does it meet medicine?

Culture can be asserted as a universal whole, a creation of people that in turn informs those people as to who they are. It can be succinctly defined as “all the shared, learned knowledge that people in a society hold.”[1] It can also be defined as, “an integrated pattern of human behavior including thought, communication, ways of interacting, roles and relationships, and expected behaviors, beliefs, values, practices and customs.”[2] Culture is also “the bearer of human wisdom that includes a wealth of human behaviors, beliefs, attitudes, values and experiences of immense worth.”[3]

The assumption is that the individual is often the authority and sole representative of his/her cultural experience. This assumption is of most importance in health care because of the ways in which we interpret and perceive health and illness and our choices in providing and seeking care are informed (defined and influenced) by our culture. Since medicine is a cultural construct, a creation of people, the approach to the universal culture and medical culture is that people are constantly creating, negotiating, revisiting, internalizing, and externalizing their culture, a culture that is always a process and never a thing. [4] On the other hand, medicine informs some of those people, physicians in particular, to define and lead the construct of medicine.

Medicine is also a profession that imprints character. Throughout all epochs, physicians have constructed a corporative collectivity, more or less admired or chastised, but always cohesive in its control of their profession and trade. [5] In all cases this evolution has occurred within the historical and cultural context of each epoch, utilizing the knowledge available at each epoch, two things from which no society or group will ever be able to escape.[6],[7],[8],[9]

The profession of medicine as the epitome of a profession; an occupation which has assumed a dominant position in a division of labor, has gained full control over the determination of the substance of its own work.[10] The profession claims to be the most reliable authority on the nature of the reality it deals with. It deals with the problems people bring to the profession, develops its own independent conception of those problems and tries to manage both the clients and the problems in its own way.

Medicine is not merely one of the major professions of our time; it alone has developed a systematic connection with science and technology. Unlike any other profession, medicine has developed into a very complex division of labor, organizing an increasingly large number of technical and service workers around its central task of diagnosing and treating the ills of mankind. One must not forget that the physician is the preeminent practitioner of medicine, and represents it par excellence.[11] As a matter of fact, the very organization and practice of medicine are themselves cultural.[12]

One must also remember that Biomedicine is the “particular” medicine that the Western world has invented and, as a cultural system, focuses on physicians, its preeminent practitioners. [13],[14]

In exploring this cultural framework, I have reviewed literature to critically analyze prior research studies, reviews of literature, theoretical articles or expert opinions, and case presentations related to cultural determinants that could impact the adoption of the electronic health record by physicians.[15] Most of the literature reviewed recognizes multiple barriers for the physician’s lack of fully embracing EHRs. Repeatedly, it appears that basic organizational, economic, and financial factors are the prime reasons why the adoption of EHR is not greater in the U.S.

There should be no doubt that the costs associated with the adoption of EHR is high and that the “return on investment” is not easy to assess, or at least not clear to most physicians. This is particularly true in the case of physicians in small practices, rural areas, and safety net providers that are already having difficulty maintaining financially sound operations because of the low reimbursement by third party payers and the shrinking pool of self-paid individuals.  On the other hand, economic incentives per se are not a panacea nor easy to implement. As a matter of fact, according to the findings from the Center for Studying Health System Change’s (HSC) 207 site visits to 12 nationally representative metropolitan communities, despite regulatory changes, physicians’ disinterest tempered some hospitals’ enthusiasm in providing financial and other support to physicians. It appears that physicians’ disinterest was rooted in their having to cover all hardware costs and at least 15% of other costs, including the EMR software.[16]

It is also true that the majority of practices are finding the transition from a paper-based to an electronic-based medical record difficult even if the physicians and nurses are fully supportive[17]. We should also recognize that the government and industry should clarify its technology objectives, engage the physician community, shape the development of standards and technology certification criteria, and adopt concrete payment systems to promote the adoption of meaningful technology.[18] [19] As an important contrast, other Western countries have been much more successful (despite significantly lower overall national health expenditures) at encouraging the adoption of health information technology by physicians.(20] Data from industrialized nations suggest that a large majority (often more than 90%) of primary care physicians currently use computers in their office practices.

On the other han as technology continues its impact on health care, the adoption of EHRs will depend on the impact of the contextual variables identified. I would argue that the cultural aspects of the physicians’ milieu are mentioned in the literature only casuallyd,. [21] Therefore, specific cultural factors are not usually identified as such and not many specific solutions or incentives are presented from that particular perspective. Each of these cultural factors can be seen as a qualifier to argue for or against adopting the EHRs.

If we could identify cultural factors that influence physicians positively in adopting EHRs, then specific strategies to incentivize physicians could be explored, while factors that could have a negative effect could be modified or minimized. On the other hand, if these factors are not considered it is possible that some of the incentives proposed, or already implemented, might not be effective or could even be counterproductive.

What do you think are these cultural factors?

[1] Loustaunau, M., Sobo, E., (1997) The concept of culture. The cultural context of health, illness, and medicine. (pp. 9-19) Bergin & Garvey

[2] Taylor, T. Cultural Competence: Implications for service

delivery to children with special health needs and their families. An Interdisciplinary Approach: Nutrition Makes the Difference. Childrens Hospital. 1996, USC-UAP, Los Angeles, CA

[3] Nine-Curt, J. (1984) Non-verbal communication in Puerto Rico. Massachusetts; Cambridge.

[4] Stein, H. (1990). American medicine as culture. Westview Press

[5] Loren, S. History of Medicine and of the Medical Profession. Anatole, 1975

[6] Thistlethwaite, J., Spencer, J., Professionalism in Medicine. Radcliff 2008

[7] Hahn, R. (1995). Sickness and healing: An anthropological perspective. Yale University Press

[8] Romanucci, L., Moerman, DE., Tancredi, LR., eds. The Anthropology of Medicine: From Culture to Method. Bergin & Garvey  1997

[9] Crawford, R. Health as a Meaningful Social Practice. Health (London) 2006; 10:401-420

[10] Freidson, E. Profession of Medicine: A study of the Sociology of Applied Knowledge. The University of Chicago Press, 1988

[11] Lupton, D. Medicine as Culture. Sage, 2nd ed., 2003

[12] Stein, H. (1990). American medicine as culture. Westview Press

[13] Lupton, D. Medicine as Culture. Sage, 2nd ed., 2003

[14] Stein, H. (1990). American medicine as culture. Westview Press

[15] Brana, AR., Shaw, D. Cultural Factors that May Impact the adoption of EHRs by Physicians: A Review of Literature. 2008, Un-published monograph developed by this author as part of his field project for his masters in medical informatics.

[16] Grossman, JM., Cohen, G. Issue Brief, Findings from HSC. No 123. September 2008 Center for Studying Health System Change.

[17] Gans, D., Kralewski, J., Hammons, T., Dowd, B. Medical Group’s Adoption of Electronic Health Records and Information Systems. Health Affairs (Millwood-Spring Hope)2005 Sept-Oct;2 4, (5): 1323-1333

[18] Gans, D., Kralewski, J., Hammons, T., Dowd, B. Medical Group’s Adoption of Electronic Health Records and Information Systems. Health Affairs (Millwood-Spring Hope)2005 Sept-Oct;2 4, (5): 1323-1333

[19] Rosenfeld, S. Bernasek, C., Mendelson, D. Medicare’s Next Voyage: Encouraging Physicians to Adopt Health Information Technology. Health Aff (Millwood). 2005 Sept-Oct;24(5):1130-1146

[20] Anderson GF, Frogner BK, Johns RA, Reinhardt UE. Health care spending and use of information technology in OECD countries. Health Aff (Millwood). 2006 May-Jun;25(3):819-31.

[21] Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496