Cultural Conflict

Introduction and Question
An issue that was brought up in the case was how to deal with cultural practices that may be harmful to the patient, yet important to the patient’s culture in terms of treatment and healing. Some cultural practices may not necessarily be harmful to the patient, but may conflict with your own culture or religion. How can you address cases where your own personal beliefs or cultural values are in conflict with those of your patient in such a way that ensures quality patient care without compromising your own ideals?

Discussion
After reading through the cultural competency section of this case the issues of autonomy and patient rights in the context of cultural differences in gender equality and family dynamics stood out as some of the most complicated. When I think of having a female patient from a culture in which communication and decision making is deferred to a senior male in the family, I can imagine feeling pulled in different directions. What if you suspect your patient doesn't agree with the decisions her family has made for her? As a female I feel inclined to promote independence, autonomy and individualism in other women, regardless of their heritage. On the other hand I recognize that this may be interpreted as an imposition or unsolicited opinion better kept to myself. Regardless of whether you have a mother and a son (such as Miguel and his mom) or a husband and a wife (as in my hypothetical situation) ultimately, as a physician you want what is best for your patient as an individual, but need to remember that after they leave your office or the hospital they are returning to their family and their community. There is a balance to be struck between respect of cultural differences and feeling that you, as a physician, have provided the best possible care to your patient, in every sense of the word.

The most important issue here is to address the quality of the translation and also trusting and finding the right skillful translator. Being able to trust the interpreter translations is also important as it can affect your diagnosis and also the patient’s understanding of your diagnosis and treatments. In addition, respecting patient’s culture and religion values is important. Judging the patient based on your own beliefs and culture is bias as it can influence your diagnosis and treatment.

First of all, I think that it is important for physicians to understand their own beliefs before addressing those of others. Taking a good look at yourself will help you better respond to situations that may catch you off guard. In addition, being comfortable with the choices you make and facing adversity associated with these choices may give you a better understanding of how patients may feel. Having said that, there are many situations in which your own beliefs may conflict with those of a patient. Such as the classic example of a Jehovah's Witnesses refusing a blood transfusion that would save their life. In this situation, it would be important for the physician to describe why the treatment is needed and what will happen to the patient if they refuse. The patient must be aware of all the available choices and alternatives so that they can make the most informed decision. This is the physician’s sole responsibility. We cannot make choices for the patient. If they refuse treatment, we must respect that and go on. This is the very core of autonomy.

This is a very real issue and I appreciate you bringing it up. It is also a very touchy situation. I think it is important for the physician to make sure the woman agrees with the health decisions being made for her. In order to do this, I think the woman needs to be spoken to alone in a very tactful manner. You could express to her that you respect her husband's/family’s decision, but that SHE is your patient and you want to make sure she is taken care of in the best way possible. The most important issue is getting the woman alone. This may be difficult. In addition, I think the physician would have to be prepared that the woman may not want to make her own decisions

While I don't agree with certain cultural beliefs that men are superior to and in control of women, I have found that this happens way too often and I must learn to bite my tongue. In the past few days I've had several encounters with couples of different cultural backgrounds in which the wife didn’t speak much English. I felt that the situation was awkward and I wondered if there were some things that these wives wanted to say but couldn't?

Just today at a well child check up I was trying so hard to understand what the kid was saying until it dawned on me that it wasn’t English. His father explained to me that he was saying pumpkin in Korean. I then asked the father if he was teaching the child English as well and he said no. I started to feel sorry for the kid because he has no choice in the matter. It really bothered me but all I could do was smile and pleasantly accept his beliefs...

Everything discussed is relevant to not only the practice of medicine but the way in which we humans interact with one another on a daily basis. Fully comprehending another individual’s experience can be a very difficult undertaking. However, taking pride in genuinely attempting to understand the values of others makes this task more achievable. Those individuals whose intent it is to do good regardless of what the situation entails have already figured out that while barriers may exist, hurdling these obstacles is possible.

I was at the gas station today in Hopewell, a small county south of Richmond. As I’m about done filling up, this guy next to me started up a conversation. He first greets me, “howdy”. I responded back with a simple “doing well, you?”. Expecting that to be the end of our few words together, he took me for a swing. He asked me whether I liked my beat up Subaru and as the conversation proceeded he was curious to know of my ancestry. As I described my parents’ Indian upbringing and the struggles they endured coming here, I observed his demeanor and I could genuinely tell he was interested to hear what I had to say. For about 10 minutes we talked about so many different things. From his love of cars, to our shared love of baseball, to how happy he is to be a father, it is a conversation which will be etched in my mind for a long time. There was no particular algorithm he followed. He just genuinely viewed this as an opportunity to connect with another human being. In my mind this man will affect many people in a positive way because he communicated, listened and was genuine in his approach.

I'm very interested in Traditional Chinese Medicine (TCM), as my mom-in-law is a former doctor in China and dad-in-law is a dean at a Chinese medical school. Much of medicine that is practiced today in China is pretty similar to western medicine that we teach and practice here today, but there is also a strong connection to traditional medicine used in the past. TCM focuses on Qi, which basically is the body's internal energy, a force which can be harnessed to help the body heal itself. Herbal remedies are also still a very important part of medicine in China. The thing that really intrigues me about TCM and its current implementation in modern Chinese medicine is the emphasis on preventative medicine -- maintaining health and wellness of all body systems and not waiting until problems become so serious that acute drastic medical intervention is needed. Whereas here we eat ourselves to obesity, shun exercise and then want a magic bullet pill to make it all better. In my view an ounce of prevention is worth of pound of cure. For a little more info in TCM check here: http://www.longevity-center.com/chinese_medicine_history.html

I was surprised to see in the text of the Miguel case mention of the fact that asking the patient about his/her own cultural practices and medical beliefs may result in undermining the "authority" of the physician and cause the patient to lose confidence in the doctor. This seems like a strange statement because, to me, one of the most important parts of patient care is to anticipate and acknowledge differences in people, whether cultural or otherwise. Sincere interest in another person's culture, heritage or background creates a situation where there is a mutual exchange of information, which sounds like the beginning a good doctor/patient relationship.

I think that if you had a practice that served a large community of people from a culture different from your own, you could (and should) really learn about the culture and the language, and be aware of the pitfalls that you may encounter with those patients. Unfortunately, we don’t spend most of our time in that sort of an environment, and many of us wont have that sort of a practice. In a place with as diverse of a patient population as MCV, I think that trying to apply specific cultural details from many different cultures leads to oversimplification, and ultimately may lead to some stereotyping. After all, meeting a patient from Latin America and automatically bringing up "empacho" might be as off-putting for someone as ignorance of it was for the example patient.

This is why I really disagree with the idea that asking the patient about their cultural beliefs undermines ones authority. I think in the real world, being open-minded, non-judgmental, and asking about things we don’t understand -- clarifying issues where there seems to be a disconnect between our perspective and the patient's -- may be the only realistic way to practice cultural competency. I think this sort of fallback technique is bound to lead to putting your foot in your mouth once in a while, like the psychiatrist in the earlier example.. but I’m not sure what else you could do. After all, we can't all be experts in every patient's culture, and even among people from the same culture there will be huge variability in individual's beliefs.

A couple years ago I spent time at a monastery in Nepal with a few monks trained in medicine who had opened up a medical clinic for local villagers. It was in that monastery in Tengboche where I observed an overwhelming peace which to this day still effects my daily mode of thinking. Many of the monks there had been exiled from Tibet during the uprising in 1959 and had migrated across the border to the Everest region in hopes of pursuing “human enlightenment” and helping others in their pursuit. I was particularly surprised on how much emphasis was placed on the mental state of the human being. It was refreshing to see sadness and “emotional suffering” discussed with the same respect and regard as we deal with cancer and other physical illness here in the United States. In my mind someone who suffers with depression should be given the same care as the individual who has just been diagnosed with squamous cell carcinoma of the lung. Both processes eat away at the body; both affect the mind; both can cause significant morbidity and mortality.

My question is: Why do such disparities exist and how can we more effectively address these disparities in hopes of improving care for the mentally ill?

i think it is important to remember that a patient doesn't have to be from the other side of the world, speak a different language, or belong to an unfamiliar faith to challenge our own way of thinking about the practice of medicine. i recently saw a patient with degenerative joint disease in both of her knees who is refusing surgery because she believes that god is going to heal her miraculously. like me, this patient is white, she has lived most of her life in virginia, she is a committed follower of jesus christ, and we both experienced healing of our pancreas in 2001 that is difficult to explain scientifically. in spite of our remarkable similiarities, i struggle to understand (believe?) that god would really tell this woman to reject his provision (curative surgery) and instead lead her to continue sublimating her pain with benzos and opiates.

perhaps it is because we are similar in so many ways that i feel more inclined to dismiss the way that this particular woman feels about her own medical care as backwards and/or irrational. my mental approach to this patient was different than i think it might have been with "miguel" because i was caught off guard, never suspecting that this woman would confront me with something so philosophically "foreign." i hope that we can all remember that even if the patient is "just like us," we may still be challenged by a new/surprising views of the world and it is no less important to seek common ground and work toward a mutually agreeable outcome.

This week at my preceptor we had a conference which involved an ethics session. I wanted to share what we came up with.

Ms. G was a 4 y/o who presented with her mother to the ED three days status post greenstick fracture to the right radius and the bones were undisplaced. The forearm was previously placed in a fiberglass cast which is now wet.The mother initialy requested that the cast be removed because it got wet.The physician indicated that the cast was in good condition and could be dried without first being removed.The mother then demanded that the cast be removed as she deisred to treat the fracture with herbal remedies including hot compresses. A brief ortho consult stated that the cast should be left in place. I know this brings up another point along with cultural competency of parental authority vs. physician authority. I beleive that in pediatrics cases in particular we must listen to the parent/other cultural view but also know that we must adhere to patient care.

Therefore, if our views clash we must remain true to three principles.

If it can NOT be shown that the parental/cultural care is abusive, negligent, or inconsistence with standard of care the parent/cultural care must be provided.

In this case a compromise was agreed upon and the child was splinted so the splint could be removed to apply the herbal remedies. The mothered agreed to bring back the 4 y/o for visits every week to make sure the fracture was healing.

Good communication solved the conflict. But strict adherence to proper patient care provided the correct medicine.

Texts

 * Awakening Hippocrates: A Primer on Health, Poverty, and Global Service
 * Mountains beyond Mountains

Websites
http://www.longevity-center.com/chinese_medicine_history.html

Links to Cases
Back to Miguel or Case studies.