Sunday, April 12, 2015

Cultural Awareness in Medicine

FLASHBACK SERIES: Blog posts written during my medical school days at Pacific Northwest University - College of Osteopathic Medicine

by Kim Ha Wadsworth, OMS I

Being an immigrant from Vietnam, I have grown up straddling the American culture and the Vietnamese traditions and customs. I have experienced at firsthand the distrust toward Western Medicine, the aversion to surgical interventions and non-herbal medications, and the tendency to wait until the last possible moment to see a physician. It is with this background that I was able to advocate for my parents and my oldest brother, all of whom faced illnesses that ended in their premature deaths. I explained the medical information with intimate cultural awareness, which also required speaking in their native language in order to clear up misunderstandings of doctor’s comments. Even with these experiences, I still feel that I need to learn more about communicating effectively and respectfully with this culture in order to gain trust, shift perceptions about the health care system, and encourage early intervention in order to attain the best patient outcomes.

When I lived in Monterey County, CA, I recognized the inequality between the rich and the poor. I started to gain exposure to the underserved community through volunteering at a free clinic in Seaside and subsequently at a Federally Qualified Health Center in Salinas, serving predominantly under- and uninsured migrant workers in the agricultural industry. I observed that patient outcomes in this population are influenced not only by socioeconomic factors but more importantly by la familia, folk cures, and emotional perceptions. It was critically important to develop a trust relationship through being attentive, listening, and showing genuine concern. Moreover, these patients are more expressive in their native language. I took Medical Spanish and conversational Spanish in order to improve my communication skills with this population. In Yakima, I continue to learn cultural humility through my volunteer work with Union Gospel Mission Free Medical Clinic and PNWU collaborations with Yakima Valley Memorial Hospital.

In conducting a culturally sensitive patient encounter, I would use the mnemonic R-E-S-P-E-C-T to recall the important factors:

1.   Respect
  • Use formal address until invited to do otherwise.
  • Allow more time for cross-cultural visits: showing interest, listening, and giving adequate time to the patient in order to establish respect and build trust.
  • Note that intrusive questions by some patients may be a way of determining if they can trust the physician.
2.   Explanatory model
  • Explore the patient’s beliefs and understand the holistic philosophy of mind, body and spirit.
  • Possible questions include, “What do you think may be the reason you have this problem?” “What kind of medicine, home remedies, or other treatments have you tried for this illness?” and “Have you sought any advice from alternate or folk healers, friends, or other people who are no doctors for help with your problems?”  If you don’t ask, they probably won’t tell.
3.   Socio-cultural context
  • Culturally relevant instructions result in much better patient adherence. Non-adherence may be due to medication side effects, poverty, depression, lack of understanding, or conflict with traditional therapies.
  • In communication, try not to rely on family/friends as interpreters if possible.
4.   Power differential
  • Acknowledge the power differential in the patient-doctor relationship. Take a less dominant role, enabling better understanding of the patients’ cultural perspective (especially their experiences or perceptions with discrimination in a predominately white society).
  • Recognize that hesitation (or discomfort) is often indicative of “hitting an invisible cultural wall.”
5.   Empathy
  • Validate the patients’ concerns (avoid their feeling of being judged unfairly).
  • Recognize that folk beliefs encompass the idea that good health is a state of equilibrium between hot and cold principles and that illnesses result from biological, spiritual, emotional and environmental imbalances as well as an imbalance with supernatural power.
  • Be aware that body language is just as important as spoken language.
6.   Concerns
  • Understand what elicits fears in the patient.
  • Be aware of common beliefs, for example in the Hispanic culture: Mollera Caida (fallen fontanel), Empacho, Mal de Ojo (evel eye), and Susto (fright).
7.   Therapeutic alliance
  • Negotiate your treatment plans, acknowledging cultural differences.
  • Collaboration is key, not only with the patient, but also with family members, other health care team members, healers and community resources.
  • Try to find options that will be mutually acceptable to you and your patient and that incorporate the patient’s beliefs rather that contradicting them.
  • Miscommunication between the patient and provider can then often lead to misdiagnosis, confusion related to treatment options, and incorrect prescription of medications. Ask the patient to repeat—in their own words—your instructions to them rather than ask “Do you understand?”