Sopheak’s a 12-year old girl with end-stage congestive heart failure due to rheumatic heart disease. She’s been on pressors in the intensive care unit. Our hope is to get her stable enough to go home but we haven’t been unsuccessful – her prognosis is a few days at most. The Buddhist cardiologist shares this with her parents. “Your daughter is very sick. She may die. But she can be saved with a heart transplant. In Australia, they do heart transplants very safely but they cost a lot of money.” The parents ask, “Will she have a normal life afterwards?” “Oh yes. She can get married. She can have children. You’ll be grandparents.” When I went to find the parents after rounds, the nurse told me they left to return to their village to plant vegetables. They were eager to raise money for the transplant, a medically unrealistic and financially impossible task. Sadly Sopheak died alone. We want to gain cultural competence - the ability to understand, communicate with and effectively interact with people across cultures. But we run up against these differences in culture and worldview and honestly don’t know how to respond. So what are some steps to help. Learn more about culture: And we have to start with our own. Lynn Payer, a New York Times health editor wrote, “While living in Europe, I was struck by the differences between US and European medicine. Why did the French talk about their livers all the time? Why did the Germans blame their hearts for their fatigue? Why did the British operate so much less than the Americans? Why did my French friends become upset when I said I had a virus?” Consider that drug doses have varied ten to twenty times in strength from country to country. Low blood pressure has been treated with eighty-five different medications and hydrotherapy in Germany. Mastectomy rates have been three times higher in New England than in England. American rates for coronary bypass have been twenty-eight times that of some European countries. Doctors in different countries diagnosed different causes of death even when shown the identical information. (Payer, Lynn. Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France. Henry Holt & Co, 1996) Why these differences? There are certainly many facets to this. But we can’t ignore that they reflect differing values intrinsic in our practice of medicine… and in us. Some countries value thought; they pay for consults. In America, we pay for procedures because we value action. Americans and Koreans spend a lot of money changing the physical form of our bodies. Other cultures spend money to try to preserve it. These choices are an expression of values within our specific worldview. So the first step is recognizing we all carry deep cultural biases. Try to pull out what the main values in play are in a given situation. If you are not sure, you can ask. Let’s get back to the case. What do you think is my main value? No one should die alone, especially a child. Also there are some thoughts about autonomy, transparency, informed decision-making and medical paternalism. But I honestly had no idea what the cardiologist was thinking so I found him and asked. He said we should not cause suffering. This is a key tenet of Buddhism. Sharing about a daughter’s impending death creates suffering in the patient, her parents and himself. Learn to speak the language: Resist the temptation to use bilingual relative who is sitting with the patient. We all know the pitfalls of doing that especially around sensitive topics. Learning to speak the language is much preferred since so much lost in translation. We can also understand more about a culture by understanding their language. If you are planning on making a long-term impact in a culture or community, I’d encourage you to make this investment in language. And if you cannot, use a trained interpreter. Ask questions with an attitude of learning: We often hear how certain groups hold to a specific set of beliefs such as not telling a parent of their cancer or never speaking about death. It’s helpful to understand how our thinking may be different from others. But not all people act, believe or hold values in line with the stereotypes we have of their cultures. So don’t assume; don’t stereotype. It’s best to ask; best to individualize your care to your patient. I asked the cardiologist why he said what he did to Sopheak’s parents. What is our role as providers in this situation? He said his role or our role as healthcare providers is to give hope, allow parents to feel like they are doing something to help, and remove them from a difficult situation. I could see how what he said to the parents fulfilled these goals. It still rubbed me the wrong way, violating many of my own values. But I was able to see how they were in line with his and perhaps in cultural alignment with Sopheak’s family as well. Maybe in what he said, they understood Sopheak’s death was imminent and were being given permission as it were to say goodbye and leave. Involve them in their solution: “What do you think are the next steps?” This engages them, builds relationship, develops ownership and the solution best fits the patient’s culture, values and available resources. Coming from an individualistic culture, we tend to see solutions coming from the patient alone. But we need to careful not to develop a treatment plan around our own biases. Many people are from community-oriented cultures where decisions are made by families and their larger communities. We can ask the patient and her parents how they make decisions. Is their larger family involved, a community leader or spiritual advisor? We want decisions to be contextualized. We don’t want to remove people from their natural support systems. If the parents want to be helpful, we could suggest ways at the bedside to keep their daughter comfortable – tell her stories, sing, wet her lips, help reposition her. Make the time they have left meaningful and significant in culturally appropriate ways. Ultimately cultural humility isn’t about what we know. We will never have all the answers. But it’s recognizing our own biases and limitations, of being able to set them aside and learning to walk in another’s shoes. It is becoming all things to all people so that by all possible means we might save some. We do all this for the sake of the gospel, that we and they may share in its blessings. 1 Corinthians 9:22-23.
Cultural Humility in Healthcare
