Working effectively with those of various cultures

April 9, 2010

In my years of medical practice, I have learned how to approach patients with an appreciation for diversity.

As a young Puerto Rican girl growing up in the 1950s in the South Bronx, I experienced the pain associated with discrimination and stereotyping. In my neighborhood at that time, the white population was dwindling and the Latino population growing. My dad was a minister and held a second job to help pay the bills; my mom stayed home to take care of my two brothers, two sisters, and me. Money was scarce, and when any family member needed healthcare, my parents had to figure out how to pay for it and where to find a doctor. Few physicians had practices in the South Bronx. When one of us had to go to the clinic, we all went, because there was no money for a babysitter.

I remember one occasion when my mother was ill and we all went with her to the clinic. Although we were well-behaved, there was still an audible bustling as five children under the age of 10 followed their mother into the sterile-looking waiting room. An 8-year-old sensitive girl, I couldn't ignore the withering looks from the office staff upon our arrival. Taking up six seats in the small waiting room also was an embarrassment, but the alternative of foregoing healthcare was not an option.

SEEK OUT THE PATIENT'S POINT OF VIEW

This approach has served me well as a physician. For me, every healthcare encounter is a cultural encounter. In my years of medical practice, I have learned how to approach patients with an appreciation for diversity. In my clinical activities, I understand why patients bring their children into the office and the exam room with them, and I share this background with my colleagues. I discuss with them the pitfalls to effective communication that can occur when using children as interpreters. I work at being conscious of my patients' socioeconomic backgrounds, health literacy levels, and language preferences. I've learned to seek my patients' explanations of how their cultural beliefs and practices affect their lives and health status. Every patient is a "culture of one."

ASK OPEN-ENDED QUESTIONS, AND EXPECT THE UNEXPECTED

During my first year of internship, I admitted a very anemic African-American woman for her third hospitalization of the past year. She was seen as a clinical enigma by my gastroenterology and hematology colleagues, who thus far had been unable to identify the source of her anemia.

She was symptomatic once again and had a very low blood count. To effectively treat her, I knew I needed a fresh perspective that would not to be influenced by preconceived notions, medically or culturally. So I began by asking an open-ended question: "Tell me what a day in your life is like." Surprised by the question, but pleased to share her story, she began reciting the details of a typical day. It was quite mundane until she said, ". . .and then I felt like enjoying a pinch of starch, so I stuck some in the corner of my mouth." Of course this led to a series of more specific questions, and I learned that she regularly ingested a box of laundry starch a day for as long as she could remember. She explained that this practice was something she had learned from her mother and grandmother in Georgia, where it was a cultural habit to consume various picas (non-food stuffs) such as red clay and starch.

There it was, the information we needed. Eating large amounts of laundry starch blocks the body's absorption of iron, which could cause the anemia. Although I also grew up with my own brand of cultural legacies and home remedies, I was unfamiliar with this practice and typically would not have asked my patients about it. But my personal experiences already had transformed me into an advocate for culturally and linguistically appropriate healthcare standards and to seek my patients' explanations about their conditions.

I understand the necessity of practicing self-awareness every day and how important it is to ask myself how my life experiences are affecting this interaction. Am I making assumptions? Have I created a respectful relationship and allowed my patient to share information that may be affecting his or her heath and subsequent treatment? Does my patient nodding at me when I'm speaking mean that he or she understands, or is it simply a sign of respect?

In every interaction I have with my colleagues, I make a conscious effort to be aware of my own perceptions. I am pleased to be one of the executive sponsors of our network's cultural competency strategic plan and implementation team that advocates for cross-cultural healthcare approaches among all clinical providers. Knowing that I'm delivering the highest quality of care to every patient, regardless of race, ethnicity, religion, gender, age, or English proficiency, makes me feel as if I am fulfilling the meaning of my dream of being a good and kind doctor.

The author would like to acknowledge Cherry Woodburn, MPA, owner, Borderless Thinking LLC, for her substantive input and assistance in crafting this article, and Judy Natale Sabino, MPH, diversity/cultural liaison, for her assistance with the sidebar on the CLAS program.

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