Medicine & Culture

Culture & Health

All ancient and modern cultures and societies had developed “health beliefs” to explain what causes illness, how it should be cured or treated, and who or what should be involved in the process. Although, “culture” is a term that appears frequently in the medical literature, it is typically used to denote “non-western” cultures. It is generally assumed, but not proved, that western industrialized societies, such as the USA, England, France etc., have principally the same view on diagnosis and treatment of illness, and at least similar rules for maintaining health, except maybe the “French Paradox”.

The book Medicine & Culture was published first 1988, again 1995, and is still in print. This book compares and contrasts the attitude of physicians and patients in England, France, the USA and in Germany. This is not a book concerning different health systems, but rather a book concerning the fact how differently physicians and patients in these countries use diagnoses and therapies, and how, frequently unexpressed ideologies, thereby participates.
To the layman at least, the differences are at worst scary and at best provide a dramatic illustration of how little medical care is really “evidence-based” and how much medical care depends upon fundamental assumptions about the body and disease which are not based on clinical research or outcomes data.
Lynn Payer gets straight, that these assumptions drastically differentiate between countries, and that, what is by agreement recognized as diagnosis or therapy in one country, it is regarded in another country quite often as "malpractice".
The book is delightfully easy to read yet has many important things to say.

Many people are surely unaware of how little diagnosis and treatment is evidence-based. They will find Medicine & Culture a true eye-opener – whether they live in the United States or anywhere else.

Most of what follows are therefore quotations from Medicine & Culture, so that Lynn Payer can speak in her own words.

The big picture which emerges from this book is, that doctors in the four countries practice medicine very differently because their national culture, history and medical training are fundamentally different.

Introduction

In the introduction to the 1995 edition Payer wrote:

“British, Canadian and American specialists in genitourinary oncology were asked how they personally would want to be treated if they had cancers. For locally advanced bladder cancer, 92% of American and Canadian specialists wanted radical surgery, compared to only 30% of British specialists. In the case of localized prostate cancer, 79% of the American specialists, 61% of the Canadian specialists, and only 4% of the British specialists wanted radical surgery.”

“Patients and doctors in England and America, while often taking opposite sides on the issue of whether it is better to do something or nothing, tend to see disease as something that comes from the outside. By contrast, Continental doctors and patients are more likely to emphasize weaknesses of particular organs or imbalances between various organs and/or systems.”

“French doctors will diagnose vague symptoms as spasmophilia or something to do with the liver; German doctors will explain it as due to the heart, low blood pressure, or vasovegetative dystonia; the British will see it as a mood disorder such as depression; and Americans are likely to search for a viral or allergic cause.
What doctors don’t know, they attribute to a virus, or when a condition doesn’t respond to treatment, they attribute it to a virus…America has an overall virus mentality. ”

“This ‘can-do’ attitude is as much a characteristic of American medicine as it is of the American character in general.”

“American medicine is aggressive partly because doctors are trained to be aggressive but also because many patients equate aggressive with better.”

“The same clinical trials that will be interpreted cautiously in England are often touted in the United States as definitive proof that treatment works.”

“When psychiatrists from six countries tried to agree on who was dangerous, the overall level of agreement was under 50% for three-quarters of the cases considered, and the psychiatrists did not agree any more among themselves than did non-psychiatrists.”

Diseases & Doctors

"A belief in the terrain also undoubtedly plays a role in the fact that fewer invasive procedures are used in intensive care units in France than in the United States - with patients doing equally well in both countries."

"West Germans use about six times the amount of heart drugs, per capita, as do the French and English."

"'Herzinsuffizienz' really has no translation into English because it would not be considered a disease in England, France, or America. German doctors often translate it as 'cardiac insufficiency'."

"By far the strongest philosophical movement in Britain has been that of the empiricists. 'But because it ought to work doesn't mean it does ... The data are more important than the hypothesis' This respect for factual details explains why the British have been the chief proponents of the randomized, controlled trial in medical research."

Summary

“Not all French doctors are Cartesian, not all German doctors authoritarian romantics, not all English doctors kindly but paternalistic, not all American doctors aggressive. As with most caricatures, these pictures may be distorted, but they are based on truths found in the overall practices of each country.”

No doubt some of the many examples given by Lynn Payer are now out of date, but many differences surely remain. We are deeply indebted to Payer for making us aware of the different medical cultures, and we deeply regret that she will not be around to keep us informed.

"Actually there are substantial cultural differences concerning the choice of pharmaceuticals or cures or the choice of certain operation methods, despite the international exchange of knowledge and experiences. One finds more to this topic in the book of Lynn Payer 'Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France'"
[ Volker Koellner, University Hospital Carl Gustav Carus, Dresden, 1999]