Cultural issues can curtail compliance, satisfaction
Language, different beliefs present barriers to care
A Hmong woman came to the emergency department suffering from a massive cerebral hemorrhage. An immigrant from Thailand, she had had many children as well as two abortions. While the doctor treating her focused on broken blood vessels as a cause and craniotomy as a treatment to relieve pressure on the brain, the woman’s family had another explanation.
She had considered aborting her current pregnancy. The soul of her unborn baby the same soul as in the previous abortions was angry at having been rejected, her relatives said. The doctor performed the craniotomy and discovered trophoblastic tissue, or tissue from a developing fetus in a pregnancy that went awry. The tissue became an embolism that had traveled to the brain.
For Kathie Culhane-Pera, MD, MA, the family practice physician who encountered this unusual case, it presented yet another lesson that the spiritual and even supernatural worlds of patients can coexist with the biomedical model of medicine. Culhane-Pera has learned not only the spoken language of her Hmong and Latino patients, but she has adapted to their unique perspectives on medical care.
Multicultural sensitivity is of growing concern in health care. Physicians are under pressure to conform to standard treatment and preventive care guidelines. But to attain good clinical outcomes and performance measurement, they must convince patients to seek the recommended tests or take the prescribed medication.
The physician’s cultural awareness may impact a patient’s adherence to treatment advice, satisfaction with care, and loyalty toward the physician, say experts in multicultural medical care.
"Physicians focus on disease, a pathological problem, and patients focus on illness, how does this impact on their lives their physical, spiritual, and psychosocial lives," says Culhane-Pera, director of cross-cultural and international family medicine at St. Paul (MN) Ramsey Medical Center.
Culhane-Pera believes it is important for her not to be dismissive of patients’ belief systems, however unscientific they may seem. Her patients accept the Western medicine, as long as it isn’t presented in direct conflict with their own expectations of care.
Centers around the country offer language interpretation and multicultural education. But Susan Black, MD, FAAFP, a family practice physician in Lowell, MA, and vice president of the Kansas City, MO-based American Academy of Family Physicians, has viewed a new medical world through her work with immigrants from Southeast Asia and Latin countries. (For multicultural resources, see sourcekit, p. 91.)
"Be soft and gentle as you learn from experience," she advises. "It’s going to take a lot of experience. Your patients will teach you a lot if you let them."
Language presents a common and basic barrier to care of people from different cultural backgrounds. Minimally, physicians need access to interpreters. Increasingly, they also can access patient education materials in a wide range of languages.
Physicians should be cautious about whom they choose as interpreters, advises Julia Puebla Fortier, director of Resources for Cross-Cultural Health Care, a nonprofit information center based in Silver Spring, MD. Just pulling in anyone who happens to speak the language isn’t acceptable, she says.
"You have people interpreting who say kidney when they mean liver," she says. "It can be downright dangerous if physicians are relying on someone whose skills they don’t know."
A number of organizations offer trained interpreters, courses for health care professionals, or referrals. (For contact information, see sourcekit, p. 91.)
In addition to enhancing patient compliance, offering language services can enhance patient satisfaction. Culhane-Pera’s center is known in the community as "La Clinica" the Spanish-speaking clinic. All staff members are bilingual in Spanish or Hmong, the two major languages; language classes are offered on site every Tuesday.
"To have providers speak the language makes a huge difference," Culhane-Pera says. "If patients get to tell their story, if they have someone listen, that’s a major aspect of satisfaction as well as healing."
In patient satisfaction surveys, patients cite the language services as a major advantage for the practice.
Yet cultures differ in more than just language. Their words reflect the vastly disparate ways they view life, health, and death.
"Patients who come from many different cultures see the body functioning in a variety of ways," says Culhane-Pera. "All ethnic groups that have come from an intact society have their own ideas about how the body works."
Different cultures may have words that don’t even translate directly. For example, when Latin parents complain that a baby has empacho, they are referring to an intestinal upset they believe is caused by changes in formula or food.
To Culhane-Pera, the likely culprit may be lactose intolerance. She presents her perspective and proposes the treatment (perhaps a special formula), yet remains sensitive to the perspective of the parents. In many cases, they may be able to fit the biomedical treatment into their traditional world views.
Black has learned that noncompliance often has cultural roots. For example, she has Portuguese diabetic patients who need to lose weight and will not comply with their diets. The reason: Their husbands prefer them to be heavy.
"I’m going to have a battle unless I can get the husband in to talk to him also, so that’s what I do now," she says.
Being aware of cultural issues isn’t the same as stereotyping, stresses John Hawk, president of COMSORT, a Baltimore firm specializing in physician-patient communication that offers resources through its Center for Multicultural Medical Information.
"What we need to do is to raise awareness, alerting physicians to take some time and ask a few questions in a nonjudgmental way about healing traditions," he says.
"If the person they’re seeing is newly immigrated to this country, what was the health system like in that country?" he says. "Maybe the person has no idea about how to access this system."
In fact, knowing what questions to ask may be more important than taking a crash course in one particular culture, suggests Puebla Fortier. (For a sample list of culturally sensitive questions, see box, at left.)
Some issues contribute to noncompliance
Physicians also need to be sensitive to issues that could lead to noncompliance. "What about a Laotian who believes Western medicine is too strong, that it has too much heat’?" says Hawk. "If the physician is aware of that, it can be discussed."
Ultimately, multicultural sensitivity is about better communication among physicians and patients, particularly when there may be barriers to care. Some physicians cross that divide by learning more about traditional healing practices or alternative medicine and integrating those alongside biomedical treatments.
"I see traditional treatments helping people with their illnesses and their suffering," says Culhane-Pera. "It doesn’t just get at the physical health but spiritual health and social health."
For more information about multicultural issues in health care, contact:
Center for Multicultural Medical Information at COMSORT, 2300 N. Charles St., Suite 200, Baltimore, MD 21218. Telephone: (410) 467-1100. Fax: (410) 467-1196.
This firm specializes in physician-patient communication and has expanded into multicultural issues, including a CME self-study program. COMSORT provides geographical mapping based on U.S. Census data that can tell medical groups about pockets of ethnic populations within their service areas. It also creates patient education and provider fact sheets using in-language focus groups of patients from the target ethnic group. COMSORT also has developed some multilingual patient education information for certain pharmaceutical firms.
Cross-Cultural Health Care Program, 1200 12th Ave. S., Seattle, WA 98144. Telephone: (206) 326-4161.
This center affiliated with Pacific Medical Clinics in Seattle offers cultural competency training and assessment, interpreter training as well as assistance integrating interpreter services into a medical organization, and translations of patient education and other health care materials. The center also offers health care profiles detailing the common beliefs and practices of 12 ethnic minority groups.
Resources for Cross-Cultural Health Care, 8915 Sudbury Rd., Silver Spring, MD 20901. Telephone: (301) 588-6051. Internet: http://www.diversityrx. org
This organization publishes a quarterly newsletter, offers conferences, and maintains an Internet Web page on model programs, legal and policy issues, and referral services for culturally appropriate health care. The center responds to questions over the phone and also provides referrals for cultural competency training, interpreter services, and related issues.
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