Ideological struggle in your local medical practice

On being misidentified while the nurse takes your blood pressure.

The medical centre I go to has, as far as I can tell, hardly any New Zealand-born staff. Maybe none. I don’t ask anyone where they’re from, of course, but most are Indian or Chinese. And, as far as I’ve seen, everyone gets along well out of common courtesy and mutual respect.

People of diverse backgrounds are the healthcare providers and the patients in my neighbourhood. But a draft document from the Medical Council says that the “design and operation [of public healthcare services] continue to privilege or advantage people who align with the ‘norms’ of [UK and western European settlers], and disadvantage others who do not.”

The Chinese nurse taking my blood pressure is too busy to discuss that statement, and so I don’t know what she thinks about it. But the Medical Council of NZ knows what she ought to think, and it insists that the Indian GP should challenge her if she unintentionally discriminates against me.

Its draft “Statement on Cultural Competence and Cultural Safety” begins with the obvious – “Aotearoa New Zealand has a culturally diverse population” – but leaps ahead to assert: “Some dimensions of identity result in power and privilege whereas others result in underprivilege, which can lead to discrimination or marginalisation”. No scientific grounds are given for that statement, and anyway it’s simply ungrammatical: it uses an abstract noun – identity – as if it were a thing with “dimensions” that can “result in power”. Unfortunately, such poor writing gets a pass in some university courses.

Discrimination does of course happen, and fortunately there’s a law against it. Providers can’t refuse a person healthcare on the grounds of their race or nationality. And yet healthcare isn’t provided equally to all throughout society. But this draft statement cites neither law nor scientific evidence as its authority. It does mention “recertification”, however, which looks to me like an implied threat to de-register doctors who don’t comply.

The Medical Council’s role is “to protect you by ensuring doctors are competent and fit to practise”. Its draft Statement on Cultural Competence and Cultural Safety reads as if written by an undergraduate sociology student, however, and not by a physician, nor by anyone qualified to advise us what to do or think.

A good intention behind it is that people of different cultures, abilities, financial circumstances, etc. should be treated fairly and respectfully. We should all strive to make sure that happens. But the Medical Council’s document adds two troubling features.

Qualified and trained medical professionals are doing their best to care for our health and to do so ethically. But the draft statement is unethically bossy. It uses the word “must” five times, and the phrase “you should” also five times.

For example: “You must actively acknowledge and address your own power, privilege, biases, attitudes and assumptions that may affect the quality of care you provide.”

But it’s not made clear what actions would qualify as “actively acknowledging and addressing”. Do busy doctors have to record in their diaries, or even on patients’ records, those moments of privilege, bias or cultural assumptions that crept in and must be scheduled for correction?

I believe that my GP does respect the background and circumstances of each individual she sees. In future, however, she should undertake a deliberate process of “continuous improvement” (a phrase taken from management textbooks), as apparently she can’t be good enough. This means compulsory “self-reflection, learning, [and] assessment” which is meant “to build your cultural competence and ensure you provide culturally safe care”.

“You should make every effort to recognise your patients’ and colleagues’ cultural worldviews and adjust your practice accordingly”, and yet you must “avoid making assumptions about an individual based on their cultural identity.”

How does my doctor “recognise” my cultural worldview and yet “avoid making assumptions” about me? Should I write an essay for her about my “worldview” and my “cultural identity” to correct any bias?

Dear doctor, I was born in New Zealand, not Europe, so please don’t classify me as “European”. And don’t assume that I follow the rugby nor that I drink beer while minding the bbq.

Surely she has better things to do.

My poor doctor will have to walk a tightrope – if she takes the Medical Council seriously – as she’ll never know whether she’s getting it right. At any time someone could challenge her about an unintentional deviation from the Statement on Cultural Competence and Cultural Safety.

That brings me to the next troubling aspect of the document. It goes beyond requiring the basic civility of respecting one another’s cultures. It demands an inner ideological struggle. Every medical practitioner must undertake a continuous programme of self-reflection. If she finds any gaps in her own cultural knowledge (and we all have them), then she is “required to identify and address these gaps in [her] recertification activities”.

The GP is expected to question her own biases and her privilege continuously in order to be recertified.

She has to identify biases in herself and in her colleagues – and even in the entire health system. “You should be prepared to challenge the bias of individual colleagues and systemic bias within the health system”. This includes challenging “unintentional discrimination by other health professionals, colleagues, patients, or their whānau/family members”.

She should identify and challenge offences that others weren’t aware they were committing.

If my GP fails to do so, could she fail her recertification?

Under such conditions, everyone is watching everyone else for the slightest deviation from non-discriminatory and equitable day-to-day behaviours. No one knows what that ideal set of practices actually is, however, because “there is no single fixed or right way to belong to a particular cultural group.”

You’re already screwed, as anyone anytime can accuse you of an offence you didn’t mean to give. And then you’ll have to undergo an ideological struggle session in order to be recertified. Yes, I’m afraid it does resemble Chairman Mao’s Cultural Revolution. Read Jung Chang’s Wild Swans.

No one’s safe in this world of regulated “cultural safety” because everyone lacks complete “competence” in the many cultures of diverse people. No one knows enough about every other culture, hence everyone fears being accused.

Everyone is guilty until proven innocent. But no one can be innocent!

The Machiavellian response, then, is to pre-emptively accuse others of “unintentional discrimination”, as offence becomes the best form of defence. Always be on the side of the accusers, because then you’re uncovering discrimination. The programme that was intended to question power creates new ways to use and abuse power. Everyone clams up because the clinic becomes an unsafe workplace, patrolled by cultural-safety watchdogs – if too many takes this stuff seriously.

Call me “privileged” if you want, but all I need is my repeat prescription and a Covid jab, thanks all the same. Challenging the system can wait for another day. In the meantime, I’ll just tolerate the occasional incorrect assumption, like the time I was misgendered, because we’re all learning.