Ten weird things GR - UNT Health Science Center · Ten weird things about Western medicine ... “physical” intervention like meds or herbs, ... (voodoo, rootwork, demon possession)

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Ten weird things about Western medicine

John Z Sadler MDDaniel W. Foster Professor of Medical EthicsDistinguished Teaching ProfessorProfessor of Psychiatry & Clinical SciencesUT [email protected]


OverviewI. Why 10 and why Western medicine?II. Why cultural understanding is importantimportantIII. Cultural competenceIV. The Ten and examplesV. Conclusion

Why 10 and Why Western med?

Why 10?A nice round number – “completeness of order”What fits in the time availableMost importantly, these are the ones the anthropology literature has most commonly identified as ones which are relatively idiosyncratic to our culture

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Why 10 and Why Western med?Why Western medicine?

“Culture” is the summary of our taken-for-grantedbeliefs, attitudes, behaviors, and worldviews - what is real, what is important, how and why things work, what is meaningful

Everyone has oneEveryone has oneNormative - Mine is normal and yours is “weird”Pervasive/encompassing - Bound up with ordinary daily practices – what we eat, how we think, when we sleep, what is OK to do.

When we encounter a patient who is culturally-different, we need to be able to step outside our own cultural assumptions in order to understand others’The “ten weird things” are reference points for cultural differences.

Why 10 and Why Western med?

Why Western medicine?Example: A Mexican-American woman appears embarrassed when you approach and counsel her for consent for approach and counsel her for consent for a needed surgery. Why?

Why cultural understanding is important to medical practice

Some basic nomenclature:CultureEthnicity: name for a group with an identity as a people: Cajuns, Jews, Navajos, WASPsIdiom of distress: a culturally-specific variety Idiom of distress: a culturally-specific variety of illness experience & expression – “nervous breakdowns” “heart attacks” “mal de ojo” “Ghost sickness”Acculturation: the degree an ethnic adapts or fits into a host culture

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Some basic nomenclature:Behavioral vs. ideological ethnicity: behavioral ethnics persist in the ways of their original culture, ideological ethnics value their original culture but have adapted to the host culture.p

Jazz musician Dizzy Gillespie – an “ideological ethnic”


2002 IOM report: reviewed high-quality studies about racial/ethnic disparities in health care

Hispanic/African American patients 2 – 3x more likely to experience “major” difficulty in accessing specialty careHispanic and African-American physicians are 2-3x

lik l t id t more likely to provide care to poorOverall: minorities less likely to

Receive needed servicesDiagnostic/therapeutic procedures

Diseases implicated: cancer, cardiovascular disease, HIV/AIDS, diabetes, and mental illnesses

Institute of Medicine- National Academy of Sciences. 2002. Unequal Treatment: What healthcare providers need to know about racial and ethnic disparities in healthcare. Washington, DC: IOM.


Cultural (mis)understanding related to health disparities

One of many factors implicated in IOM report.“Poor communication” among MD’s and culturally different patients (Betancourt 2003)culturally different patients (Betancourt 2003)

Poor compliance/adherenceUnclear communication with patient about side effects/toxicitiesDismissal of “idioms of distress” from ethnicsIgnoring of the coincident use of folk remediesIneffective use of translation services

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Cultural Competence

“Cultural Competence”Emerging trend in medical educationEmerging requirement in accreditationCultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring service delivery to meet patients’ social, cultural, and linguistic needs.

Betancourt J.R. et al.Betancourt J.R. et al. Defining Cultural Competence: A Practical Framework for Addressing Racial/Ethnic Disparities in Health and Health Care. Public Health Reports 118: 293- 302, 2003.

Cultural Competence

“Cultural Competence”Basic elements

Translation services and skillsTraining for translatorsTraining for translatorsSensitivity to nuance, gesture, idiomKeep queries shortDon’t shout


Cultural Competence


Adapting clinical services to be ethnically-friendly

Non-isolation of familiesHours fitting the communitie(s)Multilingual signageMultilingual, low-literacy written materials“health care navigator” – aides familiar to/member of the ethnic group


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Cultural Competence


Community tailoringEngagement of community in the care missionEngagement of community in the care missionIdentification of problem areasAccounting for social/political/geographic variables


Cultural Competence


Education and accountabilityEducation efforts on culturally-sensitive careEducation efforts on culturally sensitive careClinician performance assessmentsSystem performance assessments



However, current conceptions of “cultural competence” overlook or minimize the role of our own cultural assumptions and biases based in Western scientific medicine.DSM-IV-TR: Recommends specifying cultural variations p y gon disorders, but acknowledge the impossibility of doing so for every ethnocultural variation of every disorder (APA 2000)Understanding our own cultural assumptions frees us to listen to different assumptions and belief systems

Allows us to avoid making cultural assumptions or stereotyping ethnics

For this lecture, I will introduce a “weird thing about Western medicine” with a cultural-clinical example.

American Psychiatric Association 2000. Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text Revision. Washington DC: American Psychiatric Press.

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Example 1Navajo ghost sickness

A 56 year-old Navajo male presents to the clinic with his family, who say he has been y, y“confused” for a week, having “nightmares” of “punishment”. He admits to having visions of dead relatives chiding him and says he has bouts of “suffocation, fainting, and dizziness.” His family says he has “ghost sickness”.


1. The basic unit of sickness is the individual.

Doctors seeing only individuals may not elicit the full context or problem, and thereby miss the diagnosis.Many cultures, and perhaps the majority of people of the world by population, view illness as embedded in the family community and/or societyfamily, community, and/or society.Causes of illness can be social and/or moral, often requiring a social or moral intervention by the involved community.Navajo Ghost Sickness – a richly intergenerational syndrome where a living family member is punished for past wrongdoing by ancestors. Treatment requires a traditional Navajo healer.

Ethics corollary: just because a treatment isn’t biomedical doesn’t mean you can’t recommend it


Example 2A southeast Asian woman is very pleasant to the doctor, but her English-doctor, but her Englishspeaking daughter says she never takes her high blood pressure medicine.

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2. One can need treatment without being sick.

Taking medicine when you feel well can easily be understood as strange.A prime reason for nonadherence A prime reason for nonadherence (noncompliance) among behavioral ethnics.In Western medicine, one can have disease without illness

Illness: the lived experience of sicknessDisease: disturbance in internal physiological functionExample of illness without disease: hypochondriasisExample of disease without illness: hypertension

Ethics corollary: Negligence can include neglecting culturally-sensitive care


Example 3An Iraqi refugee is annoyed by his doctor’s counseling session about counseling session about proper wound care.


3. Egalitarian doctor-patient relationshipsFor many cultures, physicians are expected to be “authoritarian” and tell people what to do.The physician who tries to share or shirk decision-making with the patient/family may be seen as wimpy or incompetentor incompetent.These ethnics may experience typical informed-consent and treatment negotiation procedures as annoying, anxiety- provoking, or intrusive.Ethics corollary: “Bridge the gap” between Western medicine and folk care. Take a treatment history including folk treatments. Get a sense of how the ethnic dealt with/responded to the folk healer. Adapt your doctor-patient style according to your findings.

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Example 4Mrs. Chang, a traditional Chinese (mainland) woman, complains of fatigue and weakness which she calls weakness which she calls “neurasthenia”. She resists her doctor’s formulation of the problem as “depression” and, with embarrassment, shakes her head “no” to the discussion of an antidepressant medication.


4. “Mental” and “physical” illnessesMind-body dualism is a curiosity of the West.Many ethnics make no distinction between mental and physical illnesses: illnesses may require a “physical” intervention like meds or herbs, as well as eq i e sociomo al changes in patient famil and/o require sociomoral changes in patient, family, and/or

community.Not understanding this can lead to noncompliance or seeking of folk care unbeknownst to you.Ethics corollary: Don’t be anal about making the patient adapt to biomedical understandings. Ask her about Chinese medicine. Ask her about coming to a Western physician and what she expected.


Example 5Mr. Y, a 44 year-old man, has been to several doctors for depression, which he says he “deserves” because of his “sins”. He is a fundamentalist Christian man whose wife has Christian man whose wife has left him after their son was killed in an auto accident that was the patient’s fault. He believes he is being “punished by God” because of his “carelessness.” Antidepressant pharmacotherapy has failed to help him.

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5. Illness is secular.For many cultures, including ones in the U.S., illness is caused by nonbiological factors like:

Immoral conductMagic or supernatural forces (voodoo, rootwork, demon possession)Family disturbances of various sortsFamily disturbances of various sortsFailures of religious faith or practiceRetribution and penitent guilt (as in Mr. Y)

Many ethnics “hedge their bets” and seek both biomedical and folk healers - you better know what the folk healer is doing!Ethics corollary: Western clinicians are trained in dealing with pathological guilt (guilt not justified by reality) and not trained in treating penitent guilt (guilt as a result of a wrong actually committed). Know when you’re over your head and refer to a suitable religious or spiritual healer or counselor.


Example 6A Japanese-American internal medicine resident is frantic when she hears that her mother has been declared mother has been declared brain-dead after a tragic auto accident. She insists that the doctors retain the mother on life support until she can arrive from the other side of the country.


6. People with beating hearts can be dead.

What constitutes death varies significantly from culture to culture, or even from religion to religion.Biomedically brain-dead patients can been seen as alive by ethnics who consider the heartbeat as the core of life --> big trouble on the unit!big trouble on the unit!Ethics corollary: Common source of ethics consultations around brain death – mixed messages about brain death and being “really” dead – confusing to families

A young doctor informs the family that the patient is brain-dead and then asks permission to withdraw the patient from the breathing machine. The family says no!Another young doctor tells a family that, as they wished, they will keep the brain-dead patient alive on the machines until the organs are procured.Brain death is “really” dead and is the law of the land.

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Example 7An African-American man with “sugar” has stopped taking his oral taking his oral hypoglycemic agent. He says it “doesn’t work.”


7. You have to take medicine even after you feel better.

Even Westerners have trouble with this one.Many ethnics do not understand the rudimentaries of biomedical drugs’ modes of action so stopping medicine afte o feel action, so stopping medicine after you feel better seems the logical thing to do.Educate and predict relapse in case of nonadherence!Ethics corollary: This is an occasion where a self-disclosure can be useful – like when you failed to take the full 10-day course of antibiotics as prescribed.


Example 8You have recruited a multigenerational Asian family to participate in a study concerning a rare genetic disease running in genetic disease running in the family. Your primary contact has been a middle-aged man who arranged for the visit and whom you assumed was the family spokesperson. The family curiously fails to appear for their followup visit.

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8. Elderly parents of adult patients are irrelevant to medical decisions.

Many ethnicities defer important family decisions to the elders of the family.Exclude Granny at your patients’, and possibly your, peril.Ethics corollary: The law may require the patient to sign a consent form, but does not forbid family members from doing so (also).


Example 9A Mexican-American man complains of stuffy nose, intermittent fever, sneezing, cough and describes malaise cough, and describes malaise. You diagnose a viral URI and encourage him to drink plenty of fluids, take Tylenol, and rest. The next day you see him in the clinic waiting room before his appointment with a colleague.


9. Some illnesses don’t require a medicine.Many cultures come to doctors (healers) with the expectation and entitlement to some active treatment, like pill-taking, provision of an incantation, or physical manipulation by the healer.If o don’t gi e them a pill to take the ma think If you don’t give them a pill to take, they may think you are incompetent or even dangerous.Ethics corollary: Become practiced at prescribing good over-the-counter medications for URIs and the like. You can write them on a prescription pad form and hand out to the patient – neither deceiving them with placebos nor recommending useless treatment.

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Example 10A 70 year-old Asian woman stopped taking her hypertensive medication hypertensive medication after she became dizzy and fainted at home.


10. Diseases and their treatments are universal and essential

Universal: occurring everywhere over the worldEssential: presenting in the same basic way everywhereMany exceptions to disease essentialism and universalismuniversalism

Pharmacokinetics vary from ethnicity to ethnicity, indeed a recent review indicated a trend that Caucasians require higher doses, on average, than non-Caucasians.Disease incidence/presentation commonly varies by ethnicityClassic example – sickle cell trait – a disease in the USA, a protective advantage in malaria-endemic areas of Africa

Ethics corollary: Assuming patients are “like you” is a good starting point, but don’t stop there.


ConclusionCulturally-sensitive care requires a knowledge of cultural variation, but also how Western biomedical culture how Western biomedical culture structures how we think about disease, health, and treatment.

Questions - discussion

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Selected ReferencesBeach MC et al. The role and relationship of cultural competence and patient-centeredness in health care quality. New York: The Commonwealth Fund, 2006.Betancourt J et al. Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund, 2003. Goode T et al. The evidence base for cultural and linguistic competence in health care. New York: The Commonwealth Fund, 2006.Johnson JA. Predictability of the effects of race or ethnicity on pharmacokinetics of drugs. International Journal of Clinical Pharmacology and Therapeutics. 38: 52-60, 2000.Kleinman A. Rethinking psychiatry: from cultural category to personal experience. New York: The Free Press. 1988.Lock M, Gordon D. Biomedicine examined. Boston: Kluwer, 1988.Sadler JZ. Values and psychiatric diagnosis. Oxford: Oxford University Press, 2005

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Ten weird things GR - UNT Health Science Center · Ten weird things about Western medicine ... “physical” intervention like meds or herbs, ... (voodoo, rootwork, demon possession)