International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

CULTURE
Module 2
Kian Preston-Suni, MD

Objectives

1. Understand the connections between culture and health care.

2. Learn to consider an approach to providing patient-centered and respectful care when differences exist between patients, families and their physicians.

Case

A 64-year-old man originally from El Salvador presents to your Emergency Department complaining of fatigue, weakness and weight loss. You perform a history with the assistance of a Spanish interpreter, identifying, along with the above symptoms a vague, persistent abdominal pain and decreased appetite. You note a frail appearing man in no acute distress with scleral icterus. His daughter tells you in English that he’s never been sick and previously worked long hours in a warehouse until two weeks ago when his fatigue and weakness began to prevent him from working. He thought his symptoms were from empacho and visited a sobador for the abdominal pain but found no relief from the treatments provided.

A CT of the abdomen and pelvis shows a pancreatic mass with liver lesions and peritoneal enhancement. When you are about to enter the room, the daughter requests that you explain the findings to her, but not to your patient. You engage the daughter in discussion outside the room. She explains that her father tends to be very fatalistic and think that disease is God’s punishment. She is afraid that if you explain to her father that he has cancer that he will refuse treatment.

Notes

Empacho is a culture-bound syndrome, or folk illness, in which it is believed that food becomes stuck to the stomach or intestines and causes an obstruction. Symptoms may include abdominal pain, bloating, diarrhea, vomiting, or anorexia. It is generally treated with massage, herbal remedies, or dietary changes.

A sobador is an alternative medical provider used in various Latin American cultures to address aches, pains and other complaints. They provide varying combinations of massage, manipulation, creams and herbal remedies.

Discussion Questions

1. Have you encountered patients that seek treatment from traditional healers?

2. How would you address the daughter’s request to not inform the patient of the imaging findings?

Teaching Points

1. Recognizing cultural differences and providing care that is respectful of these differences is important in providing high quality medical care. This often requires humility on the part of the physician. Patient’s attribution of the cause of the disease may lead them to make different choices about types of healers and treatments than a physician might recommend. Healthcare providers should strive to attain cultural humility in order to create an atmosphere of open communication with patients of differing socio-cultural backgrounds.

2. Patient and family requests may differ from what you recognize as “appropriate”. In this case, the family is asking the physician to withhold information from the patient. In the U.S., we tend to value autonomy and choice and believe that the patient’s ability to make informed decisions trumps other priorities. This value may not be shared by patients and families. Some families may believe that shielding the family member from a bad diagnosis is more important to the patient’s overall well-being. This can be difficult for the provider to navigate. Interpreters can aid health care professionals by acting as a “cultural clarifier” in situations like this.

3. Patients may seek care from a combination of formal medical providers and from traditional or alternative sources. Patients may gain some physical or mental relief from suffering from seeing a traditional healer. Health care professionals should encourage patients to share this information openly and receive the information in a way that is free from judgement. Only if the health care professional establishes and open and trusting relationship will they learn what other types of treatment the patient is seeking and then can also assess concerns for treatment interaction and be assured that treatment plans are based on the entire picture.

Practical Questions

1. What resources are available in your hospital when providing care for patients whose cultures are different than your own?

2. How can you approach a patient or family request which differs from you view as acceptable?

Recommended Screening Question(s)

The LA County Health Agency SBDOH workgroup recommends cultural humility and understanding when working with all patients.

Paired Reading

Teal CR, Street RL. Critical elements of culturally competent communication in the medical encounter: a review and model. Soc Sci Med 2009;68:533-43.

Discussion Points from the Reading

1. A culturally competent health care professional has the capacity to recognize and reconcile sociocultural differences between provider and patient to achieve a patient-centered approach to care.
2. The authors describe a model of culturally competent communication with four components: communication repertoire, situational awareness, adaptability, and knowledge of core cultural issues. When using this model, a health care professional whose communication is based in empathy, caring and respect can provide culturally competent care for any patient, regardless of the provider’s specific knowledge of the patient’s culture. Invitation of the patient’s perspective on their symptoms and illness with non-judgmental reactions and follow-up questions are key elements of culturally competent communication.

Additional Readings

1. Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.

2. Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/S0022-3476(00)90043-X

3. Many in Boyle Heights Look to Sobadores for Relief from Pain.
Available from: http://www.boyleheightsbeat.com/many-in-boyle-heights-look-to-sobadores-for-relief-from-pain-754/

4. Fadiman A. The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors and the Collision of Two Cultures. New York: Farrar, Straus, and Giroux; 1997.