Caring for Patients from Different Cultures

Geri-Ann Galanti

• Publisher: University of Pennsylvania Press
• Year: 2014
• ISBN:
  9780812290271
• Edition: 5
• Topic: Medicine
• Subtopic: Caregiving

Healthcare providers in the American medical system may find that patients from different cultures bring unfamiliar expectations, anxieties, and needs into the examination room. To provide optimal care for all patients, it is important to see differences from the patient's perspective and to work with patients from a range of demographics. Caring for Patients from Different Cultures has been a vital resource for nurses and physicians for more than twenty years, offering hundreds of case studies that illustrate crosscultural conflicts or misunderstandings as well as examples of culturally competent health care.Now in its fifth edition, Caring for Patients from Different Cultures covers a wide range of topics, including birth, end of life, communication, traditional medicine, mental health, pain, religion, and multicultural staff challenges. This edition includes more than sixty new cases with an expanded appendix, introduces a new chapter on improving adherence, and updates the concluding chapter with examples of changes various hospitals have made to accommodate cultural differences. Grounded in concepts from the fields of cultural diversity and medical anthropology, Caring for Patients from Different Cultures provides healthcare workers with a frame of reference for understanding cultural differences and sound alternatives for providing the best possible care to multicultural communities.

Chapter 1

Basic Concepts

If the United States is a melting pot, the cultural stew still has a lot of lumps.

Introduction

What happens when an Iranian doctor and a Filipino nurse treat a Mexican patient? When a Navajo patient calls a medicine man to the hospital? Or when an Anglo nurse refuses to take orders from a Japanese doctor? Generally, the result is confusion and conflict, unless they all have some understanding of cultural differences.

The goal of the medical system is to provide optimal care for all patients. In a multiethnic society, this goal can be accomplished only if the health care providers understand such things as why Asian patients rarely ask for pain medication whereas patients from Mediterranean countries seem to need it for the slightest discomfort; why Middle Easterners will not allow a male physician to examine their women; and that coin rubbing is an Asian form of medical treatment, not a form of child abuse.

Disparities in Health Care

The health care system in the United States has been in a state of crisis for some time. An obvious problem is the cost and apportionment of medical care. Over the last decade or so, much attention has been paid to the health care disparities that exist in this country. According to the National Conference of State Legislatures (2013), infants born to African American women are 1.5 to 3 times more likely to die than those born to women of other races/ethnicities; American Indian and Alaska Native infants die from SIDS at nearly 2.5 times the rate of white infants; African American men are more than twice as likely to die from prostate cancer than whites; Hispanic women are more than 1.5 times as likely to be diagnosed with cervical cancer; African Americans, American Indians, and Alaska Natives are twice as likely to have diabetes as white individuals; and diabetes rates among Hispanics are 1.5 times higher than those for whites.

Such disparities result from multiple factors including poverty, inadequate access to care, and poor quality of care. A study by Hasnain-Wynia and colleagues (2007) found that minority patients tend to receive care from lower-quality hospitals. The gap was particularly large in terms of patient counseling. This finding underscores the need for better communication.

One way to improve health outcomes is to improve patient adherence to health care provider recommendations. Essential to adherence is trust; if the patient trusts the provider, he or she is more likely to follow recommendations; if not, then not. Good communication is a key to developing trust. And understanding the patients’ perspective—often influenced by their culture—can go a long way toward achieving a positive outcome. Thus, this book looks at ways in which health care providers can improve communication and enhance trust through more culturally sensitive care.

Cultural Competence

This book addresses the cultural differences that can create conflicts and misunderstandings and that may result in inferior medical care. The goal is to help the reader achieve cultural competence. It begins with understanding your own culture and biases, becoming sensitive to the cultures of others, and appreciating the differences. The next step involves acquiring knowledge and understanding of other cultures, especially their values and beliefs. The final step is to apply that knowledge. Culturally competent health care will lead to greater patient satisfaction, improved clinical outcomes, and greater cost efficiency. Note that throughout the book, I use the terms “cultural competence” and “cultural sensitivity” somewhat interchangeably. It should also be acknowledge that cultural competence is a journey, not an end point.

1

Sometimes, however, even the best of intentions can go awry. Carolyn, an American physician, was part of a medical team that flew to an Islamic Arab nation to operate on a member of the royal family. Interestingly, one of the reasons the patient wanted American doctors to perform the surgery was that he wanted doctors who could be impartial and do what was medically indicated regardless of the loyalty they might feel toward him. For example, if he wanted something to drink while intubated—a medically unwise action—his own personal doctors would find it difficult to refuse his requests; American physicians would have no trouble doing so. In addition, his doctors did not want him to experience even the slightest discomfort, and would overmedicate and sedate him for even the most minor procedure, such as changing bed sheets. In any case, Carolyn was concerned that she show respect for Islamic traditions, and had one of the flight attendants on the plane show her how to properly cover her head. On her second day in the country, she went to the mall to buy an abaya, a traditional, loose, robe-like garment worn over the clothing by many Arab women. After receiving a dirty look from the guard at the mall, she quickly took it out of her shopping bag and put it on. From there, she went to the hospital to see the patient in the ICU, joining the male physicians on their rounds. When she walked in wearing her abaya and headscarf, she was stopped by a royal advisor. He didn’t want her wearing that kind of dress: “In here, dress like a professional.” The patient was paying millions of dollars to bring in a western team to do his surgery; he wanted western doctors, not women in traditional dress. She quickly changed into a white coat, to the approval of the royal advisor. The lesson here is clear; rules may exist, but they are often specific to a situation. You may have every intention of following the rules, only to find that they don’t apply to that situation. Always expect to be surprised.

2

As indicated earlier, cultural competence is something we continually strive for, rather than attain. I was reminded of this when I was a speaker at a conference in the South. The setting was lunch in the grand ballroom. There were over 100 people in the room. Salads sat waiting at every plate. My presentation was over; I was hungry. I waited several minutes for people to begin eating. No one did. Finally, I asked one of my hosts if there was some reason no one was eating. He was rather nonresponsive, and I was starving, so I began to eat. No one else followed suit. A few minutes later, a member of the clergy came to the podium and said grace. Then, everyone picked up their fork and began to eat. What I hadn’t considered was that people in the South tend to be more religious than those in the West Coast urban center where I live. Apparently, my host hadn’t wanted to embarrass me by pointing out my ignorance when I asked about eating. I wish he had. Sometimes we forget that there can be cultural differences even within our own culture. And no matter how much we think we know, we can still make mistakes.

Asking the Right Questions: The 4 C’s of Culture

Culturally competent care is essentially patient-centered care. Effective communication is vital. Although the case studies used in this book focus on a variety of ethnic groups, the principles of cultural competence should be applied to all patients. The key factor in achieving cultural competence is learning to ask the right questions to elicit an understanding of the patient’s point of view. A number of mnemonics have been developed to help practitioners remember what questions to ask. A simple one, which I developed with physicians Stuart Slavin and Alice Kuo, is called “The 4 C’s of Culture.” It was inspired by “The 8 Questions” proposed by Arthur Kleinman and his colleagues (1978).

The first C is for “Call,” as in What do you call your problem? This is to remind the clinician to ask, “What do you think is wrong?” (You wouldn’t want to literally ask someone “What do you call your problem?”) It’s a way to get at the patient’s perception of the problem. This is an important question because the same symptoms may have very different meanings in different cultures and may result in barriers to adherence. For example, among the Hmong, epilepsy is referred to as “the spirit catches you, and you fall down.” Seeing epilepsy as spirit possession (which has some positive connotations for the possessed; after all, a powerful spirit is within you) is very different from seeing it as a disruption of the electrical signals in the brain. This should lead to a very different doctor-patient conversation and might help explain why a Hmong patient may be less anxious than the physician to stop the seizures. For an excellent example of what can happen when caring, competent physicians do not understand the patient’s perspective, see Anne Fadiman’s 1997 book The Spirit Catches You and You Fall Down. Understanding the patient’s point of view can help the health care provider deal with potential barriers to adherence and improve the patient-practitioner relationship.

3

Another medical anthropologist and I were shadowing a pediatric attending on rounds. A young Mexican boy named Pablo Medina presented with cyclic vomiting. His mother reported that the episodes had occurred in conjunction with specific events. The first was when Pablo saw his dog run over in the street and he watched his father carry the dog’s bloody body into the house. The second was when a friend of the family was shot while he was standing next to him. Just before his most recent admission, his father informed the family that he (dad) was moving back to Mexico. On the day of admission, Pablo’s teacher yelled at him for something he did wrong. His mother was called to pick him up from school for vomiting. My colleague and I both immediately shared a single thought: susto. This is a Hispanic folk disease in which a shock—such as the ones the boy experienced—causes the soul to leave the body. (For more on susto, see Chapter 12.) No one mentioned susto—not the mother, nor the attending, nor the interpreter. My colleague and I wanted to, but as observers, we didn’t feel it was our place to do so. But we left wondering, what if the attending had said something like, “What do you think is wrong with your son?” What if she had answered, “I think he might have susto.” Perhaps the mother didn’t see it that way. But what if she did? Would it have changed the clinical management of the boy’s condition? Probably not. His symptoms were treated successfully. But what might it have done for the relationship between the patient and the physician if the physician had nodded and acknowledged her belief?

We tend to think that everyone respects the knowledge of doctors, but that’s not always the case. What if you had just moved to a foreign country and were diagnosed with soul loss by the traditional healer who was held in high esteem by all the villagers? Would you be impressed with his diagnostic skill, or would you think he’s not very smart and doesn’t really understand what’s going on? Might some of your patients feel the same way?

4

A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

No one is expecting physicians or nurses to work within the health model of their patients, but by showing some respect and understanding for it, they can greatly increase patients’ trust. Finding out and acknowledging patients’ interpretation of what is wrong can aid in that. However, it’s crucial that providers not fall into the trap of focusing only on what the patient thinks the problem is and ignoring other possibilities. Fixating on one possibility can defeat the purpose of making a differential diagnosis.

The second C is for “Cause.” What do you think caused your problem? This gets at the patient’s beliefs regarding the source of the problem. Not everyone believes that disease is caused by germs. In some cultures, it is thought to be caused by upset in body balance, breach of taboo (similar to what is seen in the United States as diseases due to “sin” and punished by God), or spirit possession. Treatment must be appropriate to the cause, or people will not perceive themselves as cured. Doctors thus need to find out what the patient believes caused the problem, and treat that as well. For example, it may sometimes be appropriate to bring in clergy to pray with them if they believe God is punishing them for some transgression.

5

Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman. This case will be discussed again in Chapter 12, with an additional possible solution suggested. [See case #287]

6

Roberto Cruz, a sixty-three-year-old Hispanic male, developed pneumonia two days after surgery to remove a thoracic tumor. Emma, his nurse, asked him was he thought caused him to get the pneumonia. His wife answered for him, saying that he wasn’t wearing socks during the surgery, and that he always gets a cough when exposed to the cold in that way. The patient nodded in agreement. Learning this led Emma to change the way she educated her patients prior to surgery. In the past, she had always told them what to expect—things such as catheter placement for collecting urine and compression devices on the legs to increase circulation. After her experience with Mr. Cruz, she also talked to her patients about temperature management and assessed their need for warming blankets and made sure that every part of the body not being operated on would stay warm and unexposed to the cold. Until this time, she hadn’t realized that temperature could make such a difference to patients. (See Chapter 12 for more information on similar beliefs.) She stated that she hopes that by doing this, she can help relieve some of the anxiety of patients who believe they will become ill due to exposure to cold in the operating room.

The third C is for “Cope.” How do you cope with your condition? This is to remind the practitioner to ask, “What have you done to try to make it better? Whom else have you been to for treatment?” This will give the health care provider important information on the use of alternative healers and treatments. As is discussed in Chapter 12, most people will try home remedies before coming in to the physician; however, few will share such information due to fear of ridicule or chastisement. It’s important that health care providers learn to ask about such remedies in a nonjudgmental way, because the occasional traditional remedy may be dangerous or could lead to a drug interaction with prescribed medications.

7

Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by h...