Can there be any doubt that our health care systems in North America are in the process of breaking down?  An amazing array of pressures is pushing the systems past the mere overhaul stage into major transformations—into something new and different. We need our systems to change. Too many people are not receiving the care they need. Too many healthcare workers (our wounded healers) have been hurt by our systems’ uncontrolled and topsy-turvy growth, and by a huge range of past practices that helped when they were first put in place but are now at the heart of what most needs to change. Even with the best of intentions, the slash, hack and burn approaches to improvement have not worked. To create the kind of systems we all want, we need to let go of what we have already created—even though there have been many successes. We need to see and understand our health care systems as whole entities, be prepared to build different sets of alliances and relationships, and, most importantly, reflect upon and learn the lessons from our past. Only then will we be truly able to create new systems that really work.

In this essay, we will begin to describe the core dynamics that lie at the heart of health care.  We will present a model (The Four Cultures of Health Care) which provides a new framework for understanding the complexities of contemporary health care systems, and perhaps generate new ideas about how we can come together to heal the people and the system of which we are all a part. To begin this discovery process, we will start with what lies at the core of health care: anxiety.

Health Care and Anxiety

Illness and the ultimate threat of death have forever been great sources of anxiety. With our ability to reflect on the end of life, we long for an existence that is long and comfortable, even joyful and certainly free from pain or suffering. Instead, we find ourselves living a temporary life in a world that is filled with pain and suffering. Health care resides at the heart of this existential dilemma, for in our search for health, joy and freedom from injury and illness, we seek some relief from the fears and anxiety that seem to be inherent in the human condition.

Fear and anxiety are justified. We don’t have to go very far back in history (nor do we have to travel very far in our contemporary world) to discover a profoundly frightening world. Within the last seven hundred years, which is a brief moment in the scale of human history, we have witnessed the ravaging epidemic of the Black Death. Our societies continually confront life-threatening diseases, such as leprosy, bubonic plague and smallpox. We have seen massive injuries and fatalities caused by warfare, and multiple illnesses resulting directly from malnutrition, environmental pollution and unhealthy living conditions. While life expectancy is increasing in many parts of the world, life remains short and cheap in most societies, and the threat of massive epidemics, terrorist attacks, global environmental disasters, and nuclear holocausts continue to yield insecurity and the need for some type of psychological shelter from the storm.

For most people, the experience of illness begins with a personal awareness of change in body feeling. A sense of not being myself. If this sense of dis-ease with the body continues to operate, anxiety increases and eventually people self-label or are labeled by others as ill. It is generally recognized that this person needs to be healed. During most of the 20^th Century this meant focusing on the person’s body and curing the disease or condition. We are coming to recognize in the 21^st Century that healing the body and healing the person are not identical and do not even necessarily go hand in hand.

Healing someone involves a process of restoring the person’s lost sense of wholeness, connected-ness and control. This healing process and the resolution of the anxiety that is inherent to it lies at the heart of our health care system. We believe that this pervasive anxiety lies at the center of much of what has been created, both good and bad, in health care. Understanding how culture and anxiety interact contributes much to understanding why healthcare functions the way it does. We examine the nature of culture itself, how our organizing structures have acted to contain pain, and finally how culture and anxiety interact to create four core health care cultures.

The Nature of Culture

Culture plays an important role in shaping people and the structures they create.[i] In this book we will look at culture’s impact on health care where it plays a major role in defining patterns of thinking, feeling and acting about the nature and scope of illness. We will also examine healing strategies and the management of our anxiety about illness and death.

Culture comes in many forms and influences health care in many different ways. From a very broad perspective, culture refers to the profound differences that are to be found in the ways that societies in our world operate. This is often called culture with a big “C”: Culture. From this very broad perspective, Culture impacts on health care in three profound ways. First, Culture dictates interpretations of the nature and cause of illness and injury. Cultural interpretations regulate whether someone who is identified as ill can be among others or will be isolated, whether the sick will be considered foul or acceptable, and whether they are to be pitied or censured. In many African and some Asian countries, for instance, people with AIDS have a life-threatening disease that threatens their entire communities. People with AIDS are separated into special treatment centers and isolated from friends and family for the rest of their lives. This obviously is also the case now with the global invasion of COVID-19.  In some countries both AIDS and COVID-19 are being considered serious disease but are now “taken for granted” and do not warrant quarantine. People take medications, get vaccinated and continue to function normally.

Culture impacts on health care in a second way. Culture helps to identify specific behaviors and specific reactions to things that are important in society. In health care the focus is on pain and illness. When should one tough out the pain? When can we stay home, take to our bed, or sip chicken soup? Furthermore, a culture provides a set of norms and values that influence how people seek care, and accept medical interventions. Third, a culture suggests specific models of care. Should health care be community-based, with family members and friends gathering around one’s bed? Should it instead be physician-centered or patient-centered?

There is yet another way in which the term, culture, can be used. We call this culture with a small “c”: culture. This notion of culture describes differences among people and institutions that operate within a specific society. These are smaller differences; yet, they also impact in a profound way on the ways in which health care systems. We focus in this book on culture with the small “c.”

We specifically propose that there are key cultures that operate within health care systems. Each of these cultures has much to say about what counts as a symptom of illness and about when to consult family members, lay practitioners, healers, or traditional health care professionals with regard to an illness or injury. Each of these health care cultures offers specific hypotheses regarding the reasons for disease. We are strongly influenced by these small “c” cultures in forming our own assumptions about what caused illness or injury: A microbe? Breaking a social taboo? Negative thinking? Stress? We are impacted by these cultures also in the treatment modalities being used to address the illness: Clean Water legislation? Open heart surgery? A shift in body energies? A new diet? More equitable and responsive reimbursement procedures?

We believe that each of four health care cultures exists in contemporary North American society because each has successfully influenced the formation and maintenance of our attitudes and expectations regarding health care facilities and resources. Which facilities and resources are deemed most appropriate for a specific illness or injury? Which roles should specific people take in the health care enterprise: patient, healer, physician, clinician, family member of a sick person, and so forth.

At either the big or small “c” level, C/culture is a collective programming of the mind that distinguishes members of one group or category of people from another. This can be at the level of nations and it can also be applied to four key cultures charged with the task of healing people and maintaining a system of health care. This collective programming can lead to increased efficiency and understanding among members of a specific culture. It can also be a source of wounding among those people who do not belong to the dominant culture(s) and among those people who attempt to cross the chasm that forms between competing cultures.

Culture and Anxiety

Culture provides a container. It establishes roles, rules, attitudes, behaviors and practices. In terms of the illness experience it describes ways for people to begin feeling safer after they have experienced themselves as vulnerable, unsure or threatened. Many people, for instance, feel comfortable and comforted when they place themselves in the hands of a physician. The patient can depend on the physician’s allegiance to the Hippocratic oath and the pledge to do no harm.

Culture places boundaries around the illness experience. It provides predictability. Culture says that when you take on the sick role you are not alone. There are specific people to see. There are tests to be performed. There is assurance that you are a long way from dying. Culture provides meaning. In some parts of the world illness and injury are expected to be an opportunity for transcendence and personal growth. In North America and many other technologically dominated societies it is something to be endured and gotten past as soon as possible. We know that the illness or injury will soon pass or heal, because he has faith in medical technology. In all these ways, culture helps to manage anxiety.

Psychologists tell us that when we become anxious, we tend to regress to a more primitive state of mind and feeling. We become more like we were as children. In particular, we are likely to become dependent, and look forward to being taken care of by a person who in certain respects is superior to us. This anxiety and resulting dependency often serves us well. Our anxiety encourages us to seek help. It provides an incentive for us to turn to other people, to rely on their expertise or at least their caring attitude, and to recognize our own need for change.

Yet, anxiety is also a source of major problems with regard to health care. Anxiety not only keeps people from addressing major health-related problems in their lives, it also contributes to the wounding of healers and blocks the fundamental changes required in our contemporary health care delivery systems. As we come to understand the nature and effect of anxiety in health care, we will begin to unravel many of the Gordian knots associated with our current health care crisis.

The Anxiety of Health Care

Taking care of people who are ill or injured of body or spirit is a difficult task, given the elusive and often complex nature of the difficulties that befall people. We are confused. We come wanting health care that is aimed at addressing a possible illness or injury. Perhaps unconsciously, we also want help in dealing with the anxiety inherently associated with our difficulties. When we enter our family doctor’s office for our annual checkup, we simultaneously feel anxious and reassured. There is always the haunting presence in each of us that something, yet not known, is terribly wrong. TV shows and movies about the unanticipated disease exacerbate these fears of the unknown. Yet, each of us somehow knows that we will be taken care of in a professional and thoughtful manner by a health care provider.

Like many other people, each of us knows that we have found the most competent and most sensitive physician in the world, and that we are in good hands. Irrational anxiety intermingles with regressive dependency. This ambivalence resides at the heart of our contemporary health care enterprises and the cultures in which these health care enterprises are embedded. The cultures of health care make us feel vulnerable, yet, at the same time, enable us, as patients, to feel that we can, in some sense, rely on and become dependent on other people with certain competencies and a certain enlightened or altruistic interest in our personal welfare.

What is the core business of the health care field? Yes, of course, illness, injury and patient care. But this does not give us adequate insights to the range of passionate and contradictory reactions that are a confounding part of discussions about changing health care systems and services. Underneath lies ambivalence, vulnerability and dependency. Below this is anxiety and it comes from many places. Obviously, the threatening nature associated with any illness or injury, be it ever so mild, offers one very important source of anxiety.

Anxiety is manifest for the ill or injured person and other people in life because this illness or injury in some basic way threatens this person’s life or at least her sense of being invulnerable to external, environmental forces. In particular, the presence of illness and injury calls into question some of our most cherished beliefs regarding the power of rationality and knowledge. This is especially the case in many contemporary societies that have become increasingly dependent on technology. While these high technology societies retain their myth that nature can be subordinated to human will, members of these societies become frightened because they are reminded of their mortality and their limitations in an infinite expanse of time and space.

A second source of anxiety is that associated with the emotionally laden nature of illness and injury. We are frightened because illness and injury bring out a huge range of emotions in ourselves and in those who may be taking care of us. The very dependency that is fostered by illness and injury, and the anxiety associated with illness and injury, becomes a source of further anxiety and fear. This irrationality and reliance on other people and belief systems would have been fully acceptable in previous eras. It stands in stark contrast, however, for most of us from the seemingly rational and orderly lives we envision at the start of the Twenty-First Century. Illness and injury throw a wrench in the works, and we are frightened when standing at the abyss of emotions that illness and injury reveals about ourselves as well as those we love. Much like falling in love, we fall into illness and injury.[ii] We must live with the consequence of the accompanying feelings.

This sense that the world has become irrational when a patient is faced with illness or injury is contagious, especially in the turbulent world of contemporary health care. As Lucia Sommers has noted, professionals are supposed to deal with anxiety by not thinking of it as anxiety.[iii] They are instead to think of this as a condition of uncertainty. A health care professional relieves their anxiety by gaining greater clarity and, in particular, greater certainty with regard to the challenge they are facing. There is little clarity or certainty, however, in the contemporary world of health care. Health care workers are faced with complexity, uncertainty and turbulence in the organizations of which they are members. Policies change in unpredictable ways. Funding is undependable. A climate of anxiety is fostered and each person who lives as a patient or works as a health care professional in this climate is infected by it and becomes a carrier of the anxiety to infect yet other members of the health care institution.

A third source of anxiety is pain and an attendant experience, suffering. A parallel can again be drawn between love and (in this case) pain: “Like love, [pain] belongs to the most basic human experiences that make us who we are. Perhaps pain is most like love in that it comes and goes of its own accord, as if obeying laws from whose knowledge we remain almost totally shut out. Yet our lack of knowledge continues to recede. Every year—now sometimes every month—researchers uncover new details about the secret life pain leads within us.”[iv] Even with our increasing capacity to manage and even eliminate pain, it remains a particularly frightening and often perplexing state of the human condition.

Oddly enough, pain and anxiety are not topics with which many of the administrative and political parts of the health care system are familiar. Administrators, computer systems people, politicians, insurance agents and many others are content to leave these concepts to their medical colleagues for understanding and action. There is, thus, a profound and reoccurring disconnection between pain and anxiety, on the one hand, and the formulation of organizational policies, procedures and priorities, on the other hand.  In failing to connect with pain and anxiety, non- medical members of the health care community risk acting bluntly and blindly. They do not understand a crucial determinant of their tasks and responsibilities. And their assumption that the hands-on practitioners are in fact knowledgeable about the role of anxiety and pain has often been proven wrong.

The Meaning of Pain and Suffering

This third source of anxiety—pain—is particularly important as we seek to identify the forces in health care that wound both the healer and patient. One can conceive of pain in dynamic triangulated interaction with anxiety and culture.

PAIN

                                    ANXIETY                  CULTURE

As pain increases so does anxiety. As anxiety increases, the culture of an organization becomes more powerful, for there is greater need to address and somehow reduce the anxiety. Anxiety is, in turn, often reduced by a culture when it finds an appropriate and acceptable way in which to make the pain meaningful and the resultant anxiety in some way justified or at least understandable. Thus, pain becomes a key ingredient in the creation of culture in health care systems and anxiety becomes a key motivator for the formation of culture.

This dynamic triangulated system works pretty well when the culture can readily assign meaning and justification to the pain. We run into trouble, however, when it is hard for a culture to assign meaning or justification to the experience of pain. This is the case in 21^st Century North American health care. Pain has taken on a different meaning—or, in fact, lost all meaning—in contemporary Western societies. This shift has brought new pressures to bear upon those who assume the role of healer. Even though and perhaps because we are increasingly able to reduce or eliminate pain, our society has lost its capacity to find any meaning in pain.

In past times, in our own and other societies, pain was a given. It was a regular part of life, as experienced by most people in most societies. Being a basic part of life, people assigned it a particular meaning, ranging from God’s punishment to a sign of one’s union with and perhaps even special status with regard to God. Pain has always had meaning for people and is often defined in religious or spiritual term. The experience of pain, and the accompanying pursuit of pain’s meaning, moves the concerns of the patient beyond medical puzzles and problems into medical dilemmas and ultimately existential and spiritual mysteries regarding the meaning of pain, suffering—and life.

Yet, today, our Western, industrial, technocratic world has succeeded in persuading us that pain is simply and entirely a medical problem. All we have to do is take an aspirin, get a shot, knock ourselves out with a drug, or take Prozac or a tranquilizer We have successfully reduced the occurrence of pain, yet have failed miserably in our attempts to hold pain within a meaningful social context. “The meaning of pain,” observes Morris, “seems a non-issue as long as medicine can provide its reassuring explanations and magical cures. When cures repeatedly fail, however, or when the explanations patently fall flat, we must confront once again—with renewed seriousness, even desperation—the ever-implicit question of meaning.”[v]

For Morris, “meaning” seems to refer to not just the cause of the pain, but the importance assigned to this pain and the message that is inherent in the pain as it relates to the failings, successes, destiny or importance of the person who is experiencing the pain. This is his key message. We may know more today about the cause of pain, but no longer know much about the meaning that is assigned to this pain by the individual patient or that is assigned by the society in which this patient constructs her sense of self.

If our culture no longer assigns any meaning to the pain that we experience, then it becomes particularly important that health care professionals do a good job of eliminating the meaningless pain that we do experience. The culture of health care thus is no longer in the business of giving pain and anxiety some meaning and justification. The culture of health care is now in the business of eliminating all pain, otherwise, anxiety will rage untamed in the lives of both the patient and healer. While contemporary health care professionals may conceive of their job as primarily curing the presenting medical problem, we, as patients, are first and foremost interested in getting rid of the pain and suffering. When pain is not eliminated then both the patient and the healer feels the anxiety. Both remain wounded and unattended by anyone who is not anxious.

For most health care professionals, pain is nothing more than a sensation, a symptom, a biochemical puzzle, whereas for the patient the pain is the central experience of their illness or injury. As Cassell, a physician, notes “the relief of suffering, it would appear, is considered one of the primary ends of medicine by patients and lay persons, but not by the medical profession.”[vi] When health care professionals can not eliminate pain, and when they can provide no answers to their patients when asked why they must suffer and why they must die, then these professionals experience themselves as not doing an adequate job and their competencies are being challenged. Pain that is not alleviated (and suffering and death as mysteries that can’t be explained) becomes a source of anxiety for not only the patient but also the attending physician, nurse or therapist. The healer is repeatedly wounded in a health care system that ignores the interplay between pain, anxiety and culture.

Organizational Culture: The Container of Anxiety

We base our analysis of health care cultures in this book on this fundamental interplay between the experience of pain, the containment of anxiety, and the formation of organizational cultures. This interplay was carefully and persuasively documented more than forty years ago by Isabel Menzies, who wrote about ways in which nurses in an English hospital cope with the pain and anxiety that is inevitably associated with issues of health, illness, and injury—issues of life and death.[vii] Menzies noted how the hospital in which nurses worked helped to ameliorate pain and protect the nurses from anxiety. She suggested that a health care organization is primarily in the business of reducing pain and the attendant anxiety and that on a daily basis all other functions of the organization are secondary to this pain and anxiety-reduction function.

It is specifically the culture of the organization that serves as the primary vehicle for addressing the nurses’ anxiety and stress associated with ameliorating the pain. The culture of an organization is highly resistant to change precisely because it directly threatens the informal system that has been established in the organization to help those working in it to confront the anxiety and make sense of the pain inherent in health care. Menzies’ observations have been reaffirmed in many other organizational settings. Anxiety and pain are to be found in most contemporary organizations and efforts to reduce this pain and anxiety are of prominent importance. Hospitals and other health care systems, however, may be particularly saturated with pain and anxiety, given the unique problems they confront.  It was not coincidental that Izabel Menzies, in studying a health care institution, was among the first to identify pain and anxiety as central issues in organizational life.

Somehow a hospital, or any other institution that must address the issues of pain and that is inclined to evoke anxiety among its employees and customers, must discover or construct a culture that creates a context for the pain and contains the anxiety. At the same time this institution must addresses the realistic, daily needs of both its employees and customers. How exactly does pain and anxiety get addressed in organizations? Menzies suggested that pain and anxiety are addressed through the social defense system, which is a pattern of interpersonal and group relationships that exists in the organization. Other organizational theorists and researchers similarly suggest that the rituals, routines, stories, and norms (implicit values) of the organization help members of the organization manage pain and anxiety inside the organization. Yet, these rituals, routines, stories and norms are not a random assortment of activities. Rather, they cluster together and form a single, coherent dimension of the organization. This single, coherent dimension is known as the culture (small “c”) of the organization.

Isabel Menzies proposed that health care workers create the culture of a health care institution to contain anxiety. These institutions are to be neutral containers with the ability to absorb anxiety. But what happens when the container is cracked or acts in ways that intensify pain and anxiety—as seems to be the case in contemporary health care? What happens when pain is introduced into this equation, as it must be when we are considering organizations that tend to people who are ill, injured or even dying. A tripartite dynamic is created.

As pain increases, anxiety also increases for both the patient and those attending the patient. Culture is then created which helps to reduce the anxiety and provide comfort or reassurance if it is successful. As Edgar Schein has noted, the culture of an organization is the residue of the organization’s success in confronting varying conditions in the world.[viii] To the extent that a health care organization is adaptive in responding to and reducing pervasive anxiety associated with pain, then the existing culture of this organization will deepen and become increasingly resistant to challenge or change.

The pain also impacts directly on the culture. While health care professionals are often reluctant to address the troubling issues associated with the meaning of pain, they must eventually confront these issues, even if this confrontation requires, as in the movie The Doctor, that they confront their own pain and mortality. At the same time, patients are trying to make sense of the pain and try to find meaning in the attendant suffering. Together the professionals and patients create additional cultural artifacts. These artifacts include stories, rituals, symbols, language, dress, and decoration of physical space, as well the rights, privileges and responsibilities associated with certain culturally-based roles in the organization. These artifacts give further meaning to the pain and suffering, and to the work of health care professionals. As we note in Chapter Two, these artifacts often cluster and form powerful, coherent images. We call these images the archetypes of health care. These archetypes become particularly powerful and persuasive under conditions of anxiety and pain.

Organizational Anxiety and the Four Cultures of Health Care

Health care organizations must always address the anxiety associated with current or potential pain illness, and injury—and, more generally, the fear of dependency and death. Health care organizations are successful in part, and perhaps in large part, because they can reduce anxiety, or at least provide a context for understanding the meaning or purpose of the pain and anxiety that is experienced by patients, clients, citizens and people working in health care.

In this book we show ways in which organizations have created or embraced cultures that help them address the pain and anxiety that inevitably accompanies the provision of health care. We identify four primary cultures that currently exist in North American health care systems, as well as many other health care systems in our world. These cultures influence the ways in which we interpret the nature and purpose of health care, as well as the ways in which we confront, reduce or find meaning and purpose in the pain and attendant anxiety associated with health care.

In addressing the issue of organizational anxiety, we show, throughout this book, how leadership is a product of and potentially a vehicle for influencing the future character of these four cultures. Through effective leadership that is related to and appropriate to each culture, we are able to help people working in health care and those being served by health care organizations reduce or successfully manage the pain and anxiety they confront.

This mutual interweaving of leadership, culture, pain and anxiety is a partial key to understanding and effectively confronting the challenges associated with the wounding of healers. The current crises, and changes occurring in North American health care, can be effectively addressed if we more fully appreciate the distinctive ways in which each culture addresses problems associated with the pain and anxiety of health care. We begin our task by first introducing our principle cast of characters—the four cultures of health care.

The Professional Culture

Medical, clinical and scientific professionals populate this culture. Most of this culture’s members hold death as the ultimate but inevitable foe. The scientific and medical professions gave over the task of understanding the meaning of life and death many years ago to religious and spiritual practitioners and the alternative culture, while they focused on the disease processes that happen to bodies. In this they have been hugely successful. As a result of the efforts of health care professionals, countless numbers of people have been cured, had their lives extended, and had mobility stabilized if not returned fully to them. Exciting new answers emerge from the problem solving done by the professions that make up this culture. Practices improve. Harmful quackery is questioned and eliminated. A host of competent people labor in richly textured jobs. Health care professionals are proud of the work they do.

In managing pain and anxiety, this culture has very much organized itself around the need to control, at all cost, the experience of death by deferring it as long as possible for themselves and their patients. Pain is to be tolerated. Death is to be resisted and overcome no matter what the cost. Professional practitioners have invented models and organizational structures and put systems in place that try to contain pain and defer death. Nurses have played a particularly active role in establishing these structures.

Pain is a valuable source of diagnostic information. Life is a by-product of the struggle against the death of the body. In this sense, the absence of pain and the continuation of life have no meaning for the professional medical practitioner other than as symbols or signs of success. Death calls into question the very nature of and meaning of life, which is the unexplored aspect of the professional culture’s reality. As long as one is focused on the fight against death, then one never has to confront the purpose of this fight, which has something to do with the purpose of life.

We have effective systems, and successful treatment programs because patients have always come first in the professional culture. People from the professional culture have theories about how to organize for maximum effectiveness that have to do with putting patient care first, which in turn ultimately has to do with the prevention or curtailment of death. The patient comes first because it is through the patient that professional health care providers receive repeated reassurance and all kinds of support for the good job they do in thwarting death. This, paradoxically, becomes the central ingredient in the provider’s own sense of life purpose. Members of the professional culture look for strategies of organizational change that hold the promise of increasing their control over and opportunity to influence the quality of health care they provide. Ultimately, they support organizational changes that enhance their ability to heal people and delay the inevitability of death.

The professional culture has been the dominant culture in health care since early in the history of North American health care. It is now being attacked from all sides and must share power with the other three cultures of contemporary health care. The professional culture finds and takes its meaning primarily from the professional memberships and associations of its members. Members of this culture value technical expertise and specialized technical language. They are fully committed to the preservation of professional autonomy and have established quasi-political governance processes to insure this autonomy. These processes have enabled health care professionals, over the past hundred years, to strongly influence or even dictate the policies, procedures and missions of the health care system. Members of this culture hold assumptions about the dominance of rationality and technically based procedures in hospitals and other health institution.

Health care professionals have the rights and hold the responsibilities associated with physically touching people. This is not a trivial point, for these are among the only people in contemporary society, other than hairdressers, masseurs and a few other members of the touching professions, who hold the power to physically touch another person with whom they are only professionally affiliated. The capacity to touch and comfort may be one of the most powerful and even magical ways in which people help one another in coping with the anxiety associated with physical and psychological pain.

Cure (amelioration) is highly valued in the professional culture. Prevention is also important. Any nurse or physician would prefer to prevent an illness or injury than treat it; however, professionals must often assign secondary status to prevention. These health care workers are often overwhelmed with the demand for treatment and are usually being paid primarily to cure rather than prevent. This emphasis on cure is intended in part to reduce the anxiety of both providers and patients. When the emphasis on cure is dominant, there is a tendency for members of health care systems to defer or deny issues associated with death and dying and to collude with patients in the avoidance of pain.

The professional culture also highly values competency. This emphasis helps to reduce the anxiety of both providers and patients. This emphasis, unfortunately, also tends to perpetuate the myth of medical infallibility and can block public access to the secrets of the inner temple of professional health care. Members of the professional culture value hierarchy and believe that a clear and stable hierarchy can effectively reduce the anxiety of both providers and patients. This does not mean that the professional culture values bureaucracy—a hallmark of the second, managerial, culture. Members of the professional culture instead value clarity regarding whom is in charge in any given instance. Physicians, nurses and a host of other players in a busy Emergency Room often are dealing with highly chaotic and emotionally charged situations. They value hierarchy from the perspective of identifying power and responsibility so that effective decision making occurs. This emphasis on hierarchy can, in turn, lead to major status differences among health care providers—and is a source of considerable wounding among many members of the health care community.

The Managerial Culture

This culture also brings much that is of value. It builds on the dichotomy between control and chaos. Members of this culture fear their loss of organizational control and are anxious about organizational chaos. They resolutely hold theories about how to organize for maximum effectiveness that have to do with predictability regarding the outcomes of any change effort. They look for continuity and for planned change. Just as members of the professional culture live with the hope of thwarting the physical death of their patients, members of the managerial culture live with the hope of thwarting the death (chaos and unpredictability) of their organization. They look for organizational strategies that will reduce their anxiety regarding organizational chaos and delay the inevitability of organizational decline and death.

Lucia Sommers, who identifies herself as a member of the professional culture, offered a very insightful comment regarding the fear of organizational death among those in the managerial culture:[ix]

If the managerial culture’s function is to preserve the organization, then I think the conflict [between] this culture and the professional culture [concerns] the definition of [organizational] death. I see the professional culture believing the organization must be preserved to fulfill its function, i.e. serving patients well. When it can no longer do this, [the professional culture] has essentially died. Efforts should not be made to preserve a health care organization that now exists primarily to make money or to provide high salaries for administrators of the system.

There is another important artifact of the managerial culture. People from this culture are not allowed to touch patients, but they are allowed and hold the rights and responsibilities to touch the organization and it’s resources, especially money. By touching and controlling the resources, health care managers believe that they can directly benefit their patients as well as society in general. Over the years, health care managers have primarily focused on the provision of resources for the amelioration rather than prevention of illness and injury. These managers have traditionally believed that they could reduce both their own anxiety and the anxiety of their customers (patients) by demonstrating that they could provide healing services at reasonable costs to their customers.

Today, we find a greater emphasis on prevention among some health care managers and in some health care systems. In some instances, this shifting priority is quite real and tangible. Typically, this new emphasis on prevention is occurring because prevention has been found to be more financially viable, under certain conditions, than effective but often costly treatment programs. In other cases, the increasing attention to prevention is more a matter of rhetoric and appearance than a sign of real shifts in attention. Prevention is often added to the vocabulary of health care managers and the plans of health care systems they administer primarily in order to make their services appear more attractive.

The same is often true of alternative health care options that are covered to attract members. These alternative health care options are usually inexpensive, even though they have often not been proven to be effective. By contrast, health care managers often refuse coverage of bone marrow transplants for cancer treatment because this treatment modality hasn’t been sufficiently proven. One suspects that expense, rather than patient welfare, is the real reason for refusal of coverage for many bone-marrow transplants.

We would suggest that prevention still has being given secondary attention in most sectors of the managerial culture, despite the rhetoric and verbal commitments. Furthermore, we propose that when an emphasis on prevention does occur, this shift in priorities might tend to reduce the anxiety of the managers, but it is not likely to reduce the anxiety of those who are receiving health care services. They are accustomed to treatment plans and dependency on health care professionals. Prevention requires a shift in responsibility back to the patient. This is not very reassuring for most patients. Thus, the rhetoric of prevention might not even be an effective marketing strategy.

Members of the managerial culture have also traditionally valued access. In the past, this emphasis on access helped reduce the anxiety experienced by both manager and clients. Managers could count the number of patients being served and take pride in the provision of maximum service at minimum cost. Citizens could feel assured that treatment was at hand if they needed it. Today, this assurance is no longer warranted. Neither Americans, who confront problems about access, nor Canadian, who confront the problem of long waiting lists, can trust that they will receive adequate treatment unless they are wealthy. Health care managers also no longer can feel comfortable in counting numbers of patients served. They now must take costs more fully into account and often seek less rather than more patient-contact. When access is valued, it is sometimes presented in a very condescending manner on the part of the health care managers: “be glad you’re getting something!”

Accountability is also valued by the managerial culture. This emphasis is intended to reduce anxiety for both manager and clients. Taken to the extreme, however, this emphasis on accountability can produce a bean counter mentality. Furthermore, for many members of the managerial culture, accountability primarily relates to another managerial value, namely profit (in the United States) or efficiency in the use of tax dollars (Canada). This emphasis on profit and efficiency, in turn, is intended to reduce only the anxiety of managers.

Patients typically could care less about profit and, in fact, often take great offense when they discover that their illness, injury or health is a source of profit for another person or institution. The managerial culture’s emphasis on profit creates a climate of indifference when taken to an extreme, People in the managerial culture sometimes lose touch with the real reason for engaging in the business of health care. A dominant concern for profit leads eventually to indifference about the primary customer: the patient. Many people from the management culture, including accountants, information services technicians, insurance agents, and members of the human resource staff, have little contact with patients.

The Advocacy Culture

Representatives of this culture view their world primarily through the prisms of revolution, war and peace. This is the orienting dichotomy of the advocacy culture. We propose that advocates are primarily anxious about disruption in the social system. Just as members of the managerial culture are fearful of organizational chaos, advocates are fearful of societal chaos. In the United States, advocates try to thwart societal disruption by placing a great deal of emphasis on individual rights. They defend the rights of the underdog, ensuring that each citizen receives his rightful access to health care services.

In devoting their primary attention to individual rights, American advocates are sometimes inclined to forget or downplay the other half of the equation: collective responsibility. In their attempts to avoid the death of their society, advocates often fail to recognize the responsibility that all members of society must assume in sustaining this society. On the other hand, advocates provide an invaluable role to the social systems they serve by seeking compromise and by ensuring that there is equitable distribution of those resources that are most central to the pursuit of life, liberty and the pursuit of happiness.

Members of the advocacy culture find meaning primarily in the establishment of equitable and egalitarian policies and procedures for the distribution and use of health care resources within the system. Members of this culture firmly hold assumptions about how to organize for maximum effectiveness. They emphasize negotiation and compromise, the establishment of solid power bases, the forging of alliances, and the provision of convincing evidence for their point of view. Any organizational strategy that is to be accepted by this culture must address the anxiety associated with social disruption and must take into account politically based strategies. As in the case of the alternative culture, the advocacy culture has served usually as a counterpoint to the managerial culture, and to a somewhat lesser extent to the professional culture.

Members of the advocacy culture tend to value both confrontation and compromise. They encourage fair bargaining among constituencies with vested interests that are inherently in opposition. These conflicting constituencies may be management and staff, or, at a broader level, the healthcare institution and potential health care consumers. Advocates tend to hold assumptions about the ultimate role of power and the frequent need for outside mediation in a viable health care system. People from this culture have the authority to touch the whole of the health care system through social policy development.

Historically, prevention has been of primary concern to advocates. Beginning with the attempts to clean up city streets and continuing through the recent efforts to clean up our global environment, the attention of most advocates has been focused on prevention rather than amelioration. Prevention is intended to reduce anxiety for both advocates and citizens. Anxiety is also reduced through this culture’s emphasis on access. Political rhetoric tends to dominate the advocacy culture and this rhetoric sometimes substitutes for tangible improvement in the health care system. When misdirected, this rhetoric also can lead to a proliferation of health care legislation and policies.

Advocates value electability, which specifically reduces the advocate’s own anxiety. A climate of expedience is created when the advocacy culture is taken to an extreme and when this emphasis on electability moves to the forefront. Eventually members of the advocacy culture may begin to do anything and say anything to get elected or appointed. People who take this culture and its values to an extreme can forget why they got into the health care arena in the first place. The electorate, whether this be the voting public, members of a union, or representatives of a community association, collude through their skepticism and cynicism. Trust is lost and with it an ability to easily take actions that are meaningful. The media treat advocacy as a political game, ignoring the importance of the outcomes. Politics becomes personality.

The Alternative Culture

Members of the alternative culture tend to view health care as a process for sustaining and enhancing life rather than deferring death. This perspective is represented in the old Chinese tradition of paying a physician for every day of health and not paying the physician when one gets ill. Unlike members of the professional culture, those who are most aligned with the alternative culture tend to think of disease in direct contrast with the well-lived life. The alternative perspective concerns not the fact that death is inevitable—but that dis-ease inevitably comes with a life that is out of balance.

Members of this culture are most afraid of being seen as quacks or judged crazy, wicked or foolish. They spend a considerable amount of time thinking about the meaning of life and often devote themselves to alternative health care precisely because of this life commitment. Therefore, when their work is criticized or discounted, they are particularly wounded. What if there is no spirituality? What if these models of health are found to be inadequate? Voice, confidence, and credibility are important. Members of the alternative culture often find themselves on the defensive. They are often being defined by what they oppose rather than by what they support.

A Christian Scientist doesn’t go to a doctor. A vegetarian doesn’t eat meat. Where does the Christian Scientist go for healing? What does a vegetarian like to eat? Sometimes, in an effort to gain credibility and public acknowledgment, alternative health care practitioners become organizationally conservative. They establish rigid dogma, practice guidelines, licensing laws and bureaucratic structures. Furthermore, they tend to become just as intolerant of traditional practitioners and practitioners of other alternative practices as members of the professional culture are of alternative beliefs and practices.

The alternative culture touches communities of believers. Whether this is a Tai Chi club, a group of people dedicated to eating a particular diet, or an institution formed around a set of spiritual beliefs, there is a clear set of beliefs and a community that provides support. As in the case of professional health care providers, alternative practitioners assume the authority to touch people. However, they touch people not only in order to heal their body, but also to heal their soul. They seek to heal the whole person. This authority to touch is given to them by both the individual and the community to which they belong. Prevention and amelioration are equally important. The emphasis on both prevention and amelioration is intended to reduce anxiety for both providers and recipients.

Members of the alternative culture have strong theories about how to organize for maximum effectiveness. These theories often focus on the retention of flexibility and promotion of continuing dialogue and innovation, while also demonstrating thoughtfulness and credibility in a still-skeptical outer world. Members of this culture would welcome a strategy for organizational change—if it helps reduce their anxiety regarding non-acceptance and the ultimate meaningfulness of their work in the life they have chosen to live. This culture has always played a marginal role in the North American health care system. It has been populated by faith healers, herbalists and foreign-trained practitioners of ancient healing arts. Alternative healers have operated spas, provided massage and offered televised instruction regarding new models of health and happiness. Some of these practitioners have been charlatans, while other have been visionaries and insightful innovators.

Alternative healers and their often-controversial methods have usually served as counterpoints to the dominant medical orthodoxy of their time. Alternative medical practices have often been set against those medical practices that are represented in and by the professional culture and, to a varying extent, are also represented in and by the managerial culture. When we move past this theme of contention and anti-establishment opposition, we discover that alternative practitioners find meaning primarily in the creation of programs and activities for comprehensive health care that cross over traditional health care boundaries. Alternative healthcare practitioners also find meaning in fostering the personal and professional growth of all participants in their health care community. They are inclined, in particular, to view their patient as a partner rather than an object of care. Members of the alternative culture hold assumptions about the inherent desire of all men and women to attain and sustain their own personal health and maturity, while helping others in the community become healthier and more mature.

Representatives of the alternative culture seek to alleviate anxiety among those whom they serve. In seeking to fulfill this function they provide a unique understanding and possible treatment of illness, pain, and death. They say: “you are a whole person and you need to understand your dis-ease as part of your spiritual being.” It is assumed in this culture that a patient’s community and support systems can be engaged to make a difference in how the patient copes with illness and creates health. Members of the alternative culture suggest that they can provide competent treatment, for they are skilled in new or very old ways of doing healing work. This culture focuses on empowering each individual to find and understand what illness, death, and pain really mean. Alternative practitioners encourage their patients to listen to their own voices and create their own healing and good health.

Conclusions

If pain and anxiety tend to create culture, then perhaps contemporary health care can best reduce the fear of its patients through bringing together the diverse perspectives that the four cultures offer to health care services. Taken in isolation, each of the four cultures provides a vehicle that is only partially successful in reducing the fears and anxieties of people about their own health. Even when successful, each culture alleviates only the symptoms of the anxiety, not its ultimate source. People are rightfully fearful about any approach to health care that is biased and exclusionary—that does not readily embrace other viable and complimentary perspectives on health care.

Fear and anxiety will only be fully addressed when people feel that they are being fully and freely served with the skills, knowledge, strategies and resources of all members of the health care community, regardless of culture. Unfortunately, health care providers feel wounded—and they are isolating themselves from one another. They are frightened because health care is being transformed. The successes that have come from each culture are being threatened. Members of each of the four cultures attack the people and practices that are part of the other three cultures. The system is being shaken apart. Healers are wounding other healers and they are destroying the health care system they are trying to preserve.

Throughout this book we propose that it is crucial to understand all four of the cultures so that one can operate effectively within and among them. With this knowledge one can also more effectively influence and improve the quality of change that is required in contemporary health care. This book is not about discounting any of the four cultures. It is about an appreciation of the unique features to be found in each culture. When fully appreciated, each culture can become a force for improvement rather than destruction in our health care organizations and systems. Each culture can contribute not to the wounding of healers, but rather to their health and wellbeing.

[i] Geert Hofstede. Cultures and Organizations. New York: McGraw Hill; 1997.

[ii] xxxx, Love and Limerance, xxxxx

[iii] Lucia Sommers. Personal Communication. July 1999.

[iv] Morris (xxxx, p. 1)

[v] Morris (xxxx, pp.l-2)

[vi] Cassell (1991, p. 234)

[vii] Isabel Menzies, “A Case Study in the Functioning of Social Systems as a Defense Against Anxiety: A Report of a Study of the Nursing Service of a General Hospital,” reprinted in Colman and Bexton, Group Relations Reader, GREX: Sausolito, CA, 19xx.

[viii] Edgar H Schein. The Corporate Culture Survival Guide. San Francisco: Jossey-Bass, 1999.

[ix] Lucia Sommers. Personal Communication. July 1999.