Diversity

Introduction and Question
Diversity can be a beautiful asset. However, I can imagine that it can backfire in medicine in cases where a physician does not have the appropriate resources or does not understand or is unaware of another culture that he/she is dealing with.


 * 1) As physicians (on an individual and on a public policy level), how can we increase our awareness of our patient population.  In other words, how can we overcome our biases and be more culturally competent?
 * 2) Do you think that increasing diversity in Medical school directly correlates with improved patient care?
 * 3) Just curious if anyone has been abroad and seen a practice with a homogeneous patient population?  How is medicine different in your point of view from a diverse patient population care?

Discussion
In response to the second question:

To a certain degree increasing diversity in med school would correlate with improved patient care, but in my opinion, it really comes down to the individual and whether they are open-minded or not. If they are, they’ll be able to empathize and see varying points of view from their patients (regardless of race, ethnicity etc), and thus be able to provide better care. I know that it is only natural for individuals to be able to relate better to others of the same nationality, but the key is to be a good listener and put one’s views and beliefs aside when treating patients. At the root of this, we are all human, and common ground should be able to be reached regardless of race or ethnicity.

I think, being able to accept cultural treatments that are different from western medicine is hard, but very for patient doctor relationships. However, I had this situation when primary caretaker of a child grandmother( spoke English) refused used asthma treatment believing that she can do it with herbal treatment...that child was in ED getting intubated for asthma attack every several months. She just refused to use western medicine regardless of poor child status...what do you do in situation like this? Do you report her to a social service or respect her cultural believes?

In the case previously mentioned, I would clearly explain to the grandmother (especially since she speaks English) that for the future health and well-being of her child, she needed to be given nebulizing treatment. Regardless of grandmother's views of western medicine, I would treat the child. I'd also tell her that if she wanted to continue her herbal treatment, then that would be fine too, but not without nebulizing/bronchodilating/steroid treatments. That way, hopefully a compromise would be reached, the child would get better, and grandma would not feel as if she turned her back on her own cultural beliefs (eg herbal treatments).

Might be an off-topic question, but what are your takes on complementary alternative medicine? A lot of CAM is based on healing practices in different cultures (eg traditional chinese medicine). Do you think that one day some of the techniques and beliefs in this field might be able to be merged with allopathic medicine?

To respond to the 2nd question about a DIRECT connection b/w diversity among medical students and improved patient care, I would agree that there is a potential connection but that it is not "direct." As previously said, it depends on one's willingness to appreciate other cultures and care to understand them more so than simply having significant multicultural exposure. That said, I believe that if a doctor was only exposed to a very homogeneous population in training, it would likely be more challenging for that physician to understand cultural barriers in future practice, but not mutually exclusive.

I just had a thought. Wouldn't it be great as part of our cultural competency training to take advantage of the diversity in our own class? I think it could be a really fun project during first year or something to have groups of students present highlights of their own culture to the class. I'm sure everybody has a good story from childhood or about family that would help the rest of us gain insight into that culture. I feel that cultural issues are such a hard thing to "study" but very enjoyable to learn--especially through story-telling.

This sounds like a very difficult situation.

I think the goal of respecting the patient's cultural beliefs is to hopefully foster a relationship of trust and understanding that is beneficial to the patient (and for that matter rewarding to the doctor). In a trusting doctor/patient relationship some  negotiating of treatment options is common, so that while the illness/disease is being adequately addressed, the patients beliefs are respected. It does not sound like that kind of relationship exists here. Did the grandmother seek out a western doctor? If she did, on some level she must have wanted the input of western medicine in taking care of the child. It would be interesting to find out at what point this relationship failed and maybe why now she is so against western style therapies. The other thing that might be considered is that despite the repeated intubations, the grandmother is unwilling to try another approach. This might be a signal that her concern is not focused on the child, but maybe on some other self-serving motives (like my way is better than yours). Ultimately, I think anytime the health of a minor is in danger you should enlist all the resources you can to protect the child. This might include calling social services, but this may not be the worst thing. Social services can do home visits and may be able to look more closely at the grandmothers motivations/beliefs. Social services may also serve as a third party to help negotiate a relationship that is clearly failing the patient.

Not to interrupt the flow of conversation going on here but I thought this was an excellent thought on having competency training where groups of students present highlights of their own culture to the class. I do encourage you to work on that and maybe help your professors to conduct such a project and see how it goes. While the learning comes from the books and experts and patients, some of the most valuable lessons (like here) we learn are from our peers. Highly encourage you to go for it.

One thing that comes to mind in this case would be to enlist another family member, or member of that culture, to accompany the grandmother and patient, if possible. This person might become an ally and help modify the grandmother’s opinion of western medicine. What appears to be missing in this case is a further exploration of the grandmother’s prior experiences with western medicine or why she finds lacking in the western medicine approach? This is also a part of cultural competency.

To a certain degree increasing diversity in med school would correlate with improved patient care, but in my opinion, it really comes down to the individual and whether they are open-minded or not. If they are, they’ll be able to empathize and see varying points of view from their patients (regardless of race, ethnicity etc), and thus be able to provide better care. I know that it is only natural for individuals to be able to relate better to others of the same nationality, but the key is to be a good listener and put one’s views and beliefs aside when treating patients. At the root of this, we are all human, and common ground should be able to be reached regardless of race or ethnicity.

I know this is not a political discussion, but while we are discussing barriers to communication and cultural competency, how do you all feel about a presidential election who is a minority, not just by race but by religion (Massachusetts Governor Mitt Romney - mormon). Do you think that he can serve the country without bias? Can we make a correlation to medicine and how physicians serve their patients?

I would have to admit that I am very limited when it comes to understanding the beliefs of different cultures. While there are so many different cultures in the world, it is hard to understand all of them but I think that I could definitely put more effort into educating myself. I suppose experience is also a great way to become educated on these things. It's also really difficult to imagine what people on the other side of the situation are going through. Their frustration in these situations must be incredible! While most mothers are going to be sure that their children seek the appropriate care that they need, adults may not be quite as patient with their own health care needs. Does the communication barrier in medicine cause people to defer medical treatment until the late stages of their disease?

I have an interesting story about culture and translations. When I was in the newborn nursery, there was a mother of a different culture (unfortunately I do not remember her culture) who came to the United States about 6 months before she was due to live with her sister and have her first baby. Her husband stayed back in her home country. After the birth, she would hardly ever hold the baby or change the baby's diaper. Instead she would make her sister do it. No one understood why she wasn't trying to change the baby's diaper and feed the baby, even after multiple attempts at showing her how it is done. There was even talk of not letting her take the baby home.

Luckily, someone knew something about this woman's culture, and it ended up that back in her country, mothers who just give birth are essentially treated like queens. They are waited on hand and foot for one month and don't take care of the baby during this time either.

To make matters worse, english was a second language to her and almost everyone was speaking to her in english. She could get by with english, but I think it would have helped if a translator was used. There was an attempt at getting a doctor in the hospital who spoke this woman's language, but the doctor was on vacation.

I know that in this woman's culture it is perfectly acceptable to not interact much with the baby the first month, but in the United States, that isn't acceptable. Everyone just wanted to make sure that this baby was going to be well cared for since this woman only had her sister here and it was her first child.

In the end, the child was sent home with the mother and mother's sister after many teaching sessions on how to take care of the baby and a 24 observation period that she could take care of the baby. This is just one story that shows how our culture and another culture can collide with a childs safety put at risk. I think a better understanding of this woman's culture and speaking in her language would have helped the situation out from the beginning. Any thoughts?

In response to the first question, I think that if the physician isn't multilingual, than the next best scenario is to find another doctor or staff member who is who can come into the room and help out. It makes it more personal and comfortable than using a phone and you aren't just passing the buck. Also family members are ok, but what if there is something that the patient wants to talk about but doesn't feel comfortable in front of their family member? Also I have run into the same problem as Alison when using a family member to interpret, they just answer the questions without asking the patient.

Regarding the second question, when it comes down to different cultures and treatments for children, especially when it is a life or death situation, I think that if the child isn't going to receive the proper treatment due to a different cultural remedy, then getting social services or the courts involved is the right thing to do. However, if it comes down to that, then maybe the doctor hasn't done a great job at explaining the grave situation and the necessary treatments while expressing cultural understanding.

So far we have talked about pt who are not able to communicate w physicians b/c of language barrier or cultural differences. This week, I had an interesting encounter when pt (an American born) switched her PCP b/c he was a foreign grad and couldn't related to her problems. He believed that his decisions has to be followed w/o questioning and was very inflexible with her treatment. What about that?

One reason a person might defer medical tx until later is a lack of trust. Trust comes from a bond between parties involved whether it be in medicine or anything else. First impressions are very important, at least I have been told. When a patient comes in to see a doctor and that doctor is not able to relate to the patient, there is that emptiness, a gap between a patient and the physician. The patient is not likely to come for a 2nd visit. I can imagine this to be true for fields that have minimal patient contact such as surgery, anesthesiology etc.

To give another example, I believe our class is fairly diverse. On the first day of class, I could already see clicks forming amongst people of different ethnicities and background. I believe that's because one is more likely to approach at least for the first time to a person they can sort of relate to or associate with.

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