Doctor Meets Patient: The Effect of Cultural Memory on the Medical Interview. Sarah May Fauzi. University of Texas at Arlington

Transcription

1 Doctor Meets Patient: The Effect of Cultural Memory on the Medical Interview Sarah May Fauzi University of Texas at Arlington Introduction This paper explores the effect of memory on the medical interview. The medical interview typically consists of two participants: the patient and the health care provider. Each of these participants or interlocutors brings their own cultural beliefs to the medical interview. These beliefs can be constructed by their culture, religion, or societal norms. Previous Research This section will examine research studies that have addressed different causes of misunderstandings in the medical interview including cultural memory, religious/spiritual memory and societal memory. Cultural Memory Studies have shown that a patient s culture will affect the way they perceive their body, illness, and disease. This is also true for the providers as their own families and communities have also helped to shape these cultural beliefs within them. Each participant in the medical interview brings with them the culture in which they were raised. At times, differing cultural beliefs can have an adverse effect on the care that one receives. For example, a project in Tanzania designed to provide care for children suffering from malaria within the first 24 hours of the onset of fever met its own obstacles. The women in the region could not distinguish an ordinary fever from

2 malaria. In this case the cultural knowledge about disease and symptomatology significantly influenced the outcomes of these pediatric patients (Kamat 2945). Studies in the East Asian region have found similar problems with cultural knowledge of both symptomatology and treatment. Many of these cultures focus on the balance of the yin and yang. Manifested in the medicinal sense as hot and cold. Illnesses can both be brought on and cured through hot and cold remedies (Gould-Martin 39, Jenkins 1052, Sich 68). When patients bring these beliefs with them to the Western medical setting, misunderstandings can occur that affect both the diagnosis of the patient and adherence to the treatment prescribed if the health care providers do not work to integrate the cultural memory of the patient into the medical interview. Spiritual/Religious Memory Patients not only bring their native culture with them to the medical interview, they also bring their religious beliefs. Recently, an immigrant from Afghanistan sought treatment for cancer in the United States. When his doctor explained to him that his surgery had been less than successful and the cancer remained the patient was encouraged to seek chemotherapy treatment to eliminate the remaining cancerous cells. But Mohammad Kochi, a devout Muslim, believed that the intravenous treatment would affect his preparation for prayer and so he rejected the treatment outright without offering explanation to the provider. Had Mohammad explained to the provider why he was hesitant to take the intravenous treatment, he would have known that there are oral alternatives to the chemotherapy that would not have interfered with his religion. For

3 Mohammad Kochi, it was too late. He passed away from cancer before his family communicated his objections to the provider (Underwood and Adler 1). In her book, The Spirit Catches You and You Fall Down, Anne Fadiman described the case of Lia Lee, a your Hmong immigrant who suffered from epilepsy. Her parents refused to treat the seizures, attributing them to spiritual causes and consistently rejecting the medications and treatments prescribed by the physicians. For this young girl, the battle between the hospital and her family resulted in not only separation from her parents, but also led to a massive seizure that put her in a vegetative state that she still remains in today. Social Memory Each participant also brings social and linguistic memory to the medical interview. On the part of the patient, this memory tells them when it is respectful and permissible to ask questions and offer statements. Many cultures view the health care provider as an authority figure who should not be questioned or challenged. Linguistic research has shown that even patients sharing a native language and culture with the provider will have problems with misunderstandings and find it difficult to ask questions. The providers also bring their social memory to the medical interview as a part of their training which instructs the providers on when to ask questions and what point to simply offer information to the patient. Physician Preparedness A study by Weismann in 2005 examined the preparedness of physicians to handle the unique challenges that immigrant patients bring to the medical interview. In the study,

4 25% of physicians stated that they were not prepared to provide care for patients with health beliefs that were at odds with the Western medical system. In addition, 24% said that they lacked the skills to identify relevant cultural customs that impact medical care. These statistics are daunting when you consider what they mean for a patient entering the intercultural medical interview. Not only do the physicians fell unprepared to deal with the differing health beliefs that patients bring to the interview, almost a quarter of them do not know how to recognize and draw out these differences between themselves and the patients. 25% of the physicians also reported a lack of preparation for treating new immigrants with 20% unprepared to treat patients whose religious beliefs affect treatment and 26% unprepared to treat patients who use alternative or complimentary medicine. The issues of religion and alternative medicine strongly correlate with what medical anthropologists have been discovering among different cultures immigrating to the U.S. They retain string dependence upon alternative medicinal treatments and, as seen in the review of previous research, religion can be a life or death issue for many patients. The final issue facing physicians and immigrant patients is the patients mistrust of the U.S. medical system. 28% of physicians said they were unprepared to deal with such a mistrust of the system, which many patients bring to their clinics and hospitals. There is still a lot of work for the medical community to do in catching up with the changes in the American population. Examples from Data Though a patient does not have to come from another country to have cultural beliefs that differ from their providers, the research considered here involves only

5 patients from cultures outside of the United States. The discourse study conducted also involves patients who have not native speakers of English and in most cases have immigrated to the United States from another country. Of the three types of memory discussed earlier as affecting the medical interview, the research conducted found that two of these were prominent in the Western medical interview: cultural memory and societal/linguistic memory. Below are some examples of discourse that occurred between non-native English speaking patients and native English speaking health care providers. Example 1 Provider: You don t use a Q-tip, do you? Patient: no, no, no Provider: You don t cram it down in there do you? Patient: huh-uh Provider: good, good, good (begins exam) Patient: I don t use Johnson s but I-the-I mean like a what do you say like a swab, ear swab, is that bad? Provider: Nope. It s not bad, we ll be able to rinse that out in no time There are a number of different things at play here that affected this exchange. The health care provider is conducted an ear exam on a patient that has chronic wax buildup that must be washed out every 6 weeks. This is the first time that this patient has seen this particular provider at the clinic. As she begins the exam, she asks the patient if he uses Q-tips to clean out his ears. At first the patient answers no, but then he asks a question that the provider does not hear as she is focused on her exam. He explains that while he does not use Johnson s Q-tips to clean out his ear, he does use cotton swabs. This misunderstanding between the patient and provider was never resolved and the patient s question was never properly answered. This misunderstanding can be related to the cultural or linguistic memory of the patient. Here the problem is with the branding of the

6 cotton swab product that, while widely known to the American population as Q-tips, is known only by its generic name in the country and language of this patient. Example 2 Provider: Do you drink a lot of coffee? Patient: I don t drink coffee, I don t drink caffeine at all..that s why I have to drink an energy drink Provider: That probably has.. Patient: I m really sensitive to caffeine, that s why Provider: I think that has caffeine, excessive amounts and that may have very well contributed to your blood pressure being higher. The source of this misunderstanding is less clear. The lack of the patient s product knowledge is likely due to societal memory, a community that has taught him that energy drinks will keep him awake without the effect of caffeine. Indeed, this misunderstanding could happen no matter what the culture and native language of the patient. Luckily, in this case, the provider was able to assess the possible cause of the patient s high blood pressure and address it in the interview. The provider only looked at the patient s blood pressure when deciding what medication to prescribe for his congestion. The high blood pressure resulted in not only the provider raising the patient s awareness of the caffeine content in energy drinks, but she was also able to choose a medication that would not raise his blood pressure any further. Example 3 Provider: Are you drinking plenty of fluids? Patient: It s just that the water around here is just so cold, I don t know what s wrong with people here Provider: really?..really? Patient: I tell you I just hate- I I put water in the microwave because it is just too cold for me.

7 This is clearly an issue of cultural memory. Many cultures are taught that cold water is bad for the body and are discouraged from drinking it. In this case, the patient was not being adequately hydrated because the water from the tap was cooler than what he was accustomed to drinking. Although he would microwave the water when possible, he was unable to hydrate at work and school when he was away from a water heating source. After thoroughly expressing her surprise that the patient would not drink tap water, the provider went on to explain to the patient that he could substitute tea for water as a means of hydration if he cannot drink the water here. What Can Providers Do? Many of the problems that emerged during this study were due to inattention on the part of the provider. Especially when facing a patient who may be unfamiliar with the American medical system and jargon, providers should be extra attentive to what the patients are saying and the questions that they ask, or do not ask during the medical interview. Providers should ask more open-ended questions to the patients. This encourages dialogue between the patients and providers and eliminates some of the cultural issues with challenging providers and the hesitancy to ask questions. Patients tend to consistently answer in a positive way when asked closed ended questions by the provider such as Do you understand? and Does that make sense? By asking open-ended questions or asking the patients to restate what has been said, the providers can ensure that the patients are leaving with an increased possibility of comprehension.

8 Providers should be aware of cultural differences and the roles that they play. Health care providers should not be expected to study and memorize every cultural belief of every patient that could enter the door, but being aware of the consequences of these differences and having the skills to draw out the patient s beliefs about their own body, health, and illness will go a long way. What Can Patients Do? Patients should ask questions. Do not be afraid to inquire about something that is unclear or bring up symptoms that may seem irrelevant. If there are questions about the treatment regimen, patients should take the time to be sure that they fully comprehend each aspect of their treatment as prescribed by the provider. This leads to the next tip for patients: be informed and take notes. Patients should learn as much as they can about the illness and treatment regimen from their provider and pharmacist. Taking notes of what was said can help the patient to remember every part of their regimen when they get home. Finally, be honest about disbelief or disagreement. The more a patient expresses how something the provider said conflicts with their own cultural beliefs, the better a provider can fully comprehend the patient s illness and treat it effectively Sarah Fauzi

9 Works Cited Fadiman, Anne. The Spirit Catches You and You Fall Down. New York: Farrar, Straus and Giroux. Gould-Martin, Katherine. Hot cold clean poison and dirt: Chinese folk medicinal categories Social Science & Medicine 12.(1978): Jenkins, Christopher, Thao Le, Stephen J. McPhee, Susan Stewart, and Ngoc The Ha. Health care access and preventative care among Vietnamese immigrants: Do traditional beliefs and practices pose barriers? Social Science & Medicine 43.7 (1996): Kamat, Vinay. I thought it was only ordinary fever! cultural knowledge and the micropolitics of therapy seeking for childhood febrile illnesses in Tanzania. Social Science & Medicine 62 (2006): Sich, Dorothea. Traditional concepts and customs on pregnancy, birth and post partum period in rural Korea. Social Science & Medicine 15B (1981): Weismann, Joel S., et al. Resident physicians preparedness to provide cross-cultural care. JAMA (1995):

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