Culture is an active, dynamic, and complex process of the way people interact and behave in the world. Culture encompasses the concepts, beliefs, values (including nurturing of children), and standards of behavior, language, and dress attributable to people that give order to their experiences in the world, offer sense and purpose to their interactions with others, and provide meaning for their lives. The growing diversity of the United States requires that health care workers make an attempt to understand the impact of health, illness, and treatment on the patient and family from their perspective. This requires open-ended questions, such as: “What worries (concerns) you the most about your child’s illness?” and “What do you think has caused your child’s illness?” These can facilitate a discussion of parents’ thoughts and feelings about the illness and its causes. Addressing concepts and beliefs about how one interacts with health professionals as well as the family’s spiritual and religious approach to health and health care from a cultural perspective allows the pediatrician, patient, and family to incorporate differences in perspectives, values, or beliefs into the care plan. Significant conflicts may arise because religious or cultural practices may lead to the possibility of child abuse and neglect. In this circumstance, the pediatrician is required by law to report the suspected child abuse and neglect to the appropriate social service authorities (see Chapter 22).
Complementary and alternative medicine (CAM) practices constitute a part of the broad cultural perspective. Therapeutic modalities for CAM include biochemical, lifestyle, biomechanical, and bioenergetic treatments, as well as homeopathy. It is estimated that 20% to 30% of all children and 50% to 75% of adolescents use CAM. Of children with chronic illness, 30% to 70% use CAM therapies, especially for asthma and cystic fibrosis. Only 30% to 60% of children and families tell their physicians about their use of CAM. Some modalities may be effective, whereas others may be ineffective or even dangerous.
Society provides a profession with economic, political, and social rewards. Professions have specialized knowledge and the potential to maintain a monopoly on power and control, remaining relatively autonomous. The profession’s autonomy can be limited by societal needs. A profession exists as long as it fulfills its responsibilities for the social good.
Today the activities of medical professionals are subject to explicit public rules of accountability. Governmental and other authorities grant limited autonomy to the professional organizations and their membership. City and municipal government departments of public health establish and implement health standards and regulations. At the state level, boards of registration in medicine establish the criteria for obtaining and revoking medical licenses. The federal government regulates the standards of services, including Medicare, Medicaid, and the Food and Drug Administration. The Department of Health and Human Services regulates physician behavior in conducting research with the goal of protecting human subjects. The Health Care Quality Improvement Act of 1986 authorized the federal government to establish the National Practitioner Data Bank, which contains information about physicians (and other health care practitioners) who have been disciplined by a state licensing board, professional society, hospital, or health plan or named in medical malpractice judgments or settlements. Hospitals are required to review information in this data bank every 2 years as part of clinician recredentialing. There are accrediting agencies for medical schools, such as the Liaison Committee on Medical Education (LCME), and postgraduate training, such as the Accreditation Council for Graduate Medical Education (ACGME). The ACGME includes committees that review subspecialty training programs.
Historically the most privileged professions have depended on their legitimacy for serving the public interest. The public trust of physicians is based on the physician’s commitment to altruism. Many medical schools include variations on the traditional Hippocratic Oath as part of the commencement ceremonies as a recognition of a physician’s responsibility to put the interest of others ahead of self-interest.