A Call for a Dual Culture Change

As a general pediatrician for over 30 years the focus of my practice keeps changing to comply with emerging demands; sometimes precipitated by “new morbidities” other by economic and institutional changes, this time it is by the increased awareness of the impact that social determinants and adverse childhood events have on health outcomes of children and in our communities. Only that this time what needs to change is different; it is not about learning to manage newly described conditions or incorporating electronic medical record technologies, or new disease classifications, it is about a “dual culture change”, in us as practitioners and also in what families expect to get at the clinic [1].

Culture refers to the “cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notion of time, acquired by a group of people in the course of generations through individual and group striving.” “Culture consists of patterns, explicit and implicit, of and for behavior acquired and transmitted by symbols, constituting the distinctive achievement of human groups”; “the sum of total of the learned behavior of a group of people that are generally considered to be the tradition of that people and are transmitted from generation to generation”. If we belief that we are what we learn then it is true that “the ideas, meanings, beliefs and values that people learn as members of society determines human nature [2].”

New and continuous encounters always shape our reactions and new conventions, schedules and values advance. Some encounters quietly penetrate tight examples of conduct while others we receive through cognizant choice. This pruning process helps us choose what influences our common behavior; this process requires constant vigilance and analytic observation [2]. The cumulative scientific evidence of the role of social determinants on our health, the demonstrated impact of “toxic stress” on brain development, the pervasive exposure - personal or vicariously - to violence is gradually shifting the attention we are giving to emotional and behavioral health in primary care. DSM-V diagnoses have made it to the “top 10 list” in our clinics.

The “culture” in which we receive training and currently practice under represents values and norms that guide our professional behaviors and emphasizes beliefs and attitudes that are in disconnect with the environment and realities that our patients live in.

To properly address the emotional, behavioral and developmental impact that adverse childhood experiences have in children we need to be intentional about it through early developmental screening, prompt referrals to early intervention; offer integration of behavioral health in primary care in a medical home environment and develop multiple collaborative strategies with other community providers.

We must be deliberate in creating a culture that emphasizes strengths not deficiencies and problems, a culture that gives importance to patient narratives, where we use open-ended questions and create safer environments more conducive to listening rather than controlling conversations for the sake of keeping up with time efficiencies. A culture that promotes resilience, one that offers comprehensive programs that support protective factors and family strengths.

The challenges are many: to move to a person and family centered approach while we comply with certifications, Joint Commission requirements, meaningful use, ICD-10 nomenclature and numerous other quality improvement initiatives and mandatory processes. Sometimes this parallel processes are in conflict and creates a “background noise” that challenges anyone’s altruism and sense of professional satisfaction.

Primary care practice needs to evolve into a new culture that is intentional in its efforts to impact what our patients and families need from health care and in turn come to expect as the new norm.

This new awareness of the effects of trauma begs a transformation of our primary care practices, a dual culture change comprised of values, beliefs, norms, symbols, traditions and practices that we need to pass on to next generations to achieve better health outcomes than the ones we are seeing in our communities.