Lia Lee was a three-month-old Hmong child with epilepsy whose tragic encounter with Western medicine is chronicled in the book The Spirit Catches You and You Fall Down by Anne Fadiman. Over a period of years, Lia's doctors at a hospital emergency room in Merced, CA, prescribed a vast array of anti-seizure medications for the child. But Lia's parents, Hmong immigrants, who viewed Lia's illness through the lens of their own culture, attributed her epileptic seizures to her "losing her soul."
Their remedies included animal sacrifices and amulets, which they used in conjunction with, and in place of, extensive drug therapies. Despite the best of intentions, this clash of cultures led to numerous deep misunderstandings and, ultimately, the loss of Lia's higher brain functions.
It was a tragedy that serves as an extreme example of what can happen when culture collides with healthcare. It is just such types of misunderstanding that hospitals are taking great strides to prevent by promoting cultural competence, says Dr. Joseph R. Betancourt, program director for multicultural education at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School.
Cultural competence in healthcare describes the ability of systems and professionals to provide high quality care to patients with diverse values, beliefs, and behaviors. This may mean tailoring delivery of services to meet a patient's social, cultural, and linguistic needs. It always involves acknowledging health ideas and practices that may be different from standard Western views.
"Cross-cultural medicine is not about political correctness," says Betancourt. "It is about giving providers the tools they need to give the best possible care, regardless of language or background." As this nation grows increasingly diverse, more healthcare providers are recognizing the need for such tools.
A patient's cultural background may affect his approach to healthcare in myriad ways. It can influence beliefs about treatments or procedures or, as in Lia Lee's case, about illness and its cause. A past experience may create a mistrust of doctors; or a patient may interpret chronic disease as a series of unrelated episodes. Spiritual or religious beliefs can set up numerous barriers, such as an unwillingness to accept blood products, eat certain foods, or be seen by a practitioner of the opposite sex. Some cultures believe that telling a patient about a potential medical risk can interfere with that person's ability to heal. There are also the obvious communication barriers related to language.
Betancourt says it's important to note that these differences aren't exclusively tied to a patient's religion or country of origin. "We all have culture," he explains. "We all have our set of experiences that shape the way we interact with our environment, and this plays out in the exam room."
For instance, people from some backgrounds believe they know when their blood pressure is high and when they should take their medication. But in reality, unless a person's blood pressure is through the roof, it is unlikely to produce symptoms. So, doctors with cultural competency training are learning to ask open-ended questions such as, "How do you understand high blood pressure?"
Doctors need to learn how to build trust with a 64-year-old African American man suffering chest pain who is reluctant to accept treatment because of a relative's poor experience in the hospital. They need to ask patients from China whether they are taking any herbal remedies (which might interfere with prescription drugs). They must also learn how to best deal with the son of an elderly Italian woman with metastatic cancer who wants the diagnosis kept from the patient because it will "kill her."
Even when the situation isn't as extreme as Lia Lee's, language barriers can interfere with treatment at every step, ranging from misunderstandings about the time, date, and location of appointments to the lack of a complete medical history, to upsetting a person's ability to take medications at the recommended intervals.
Fortunately, Boston has been proactive about cross-cultural medicine and leads the country in translation services, Betancourt says. MGH, the Cambridge Health Alliance, Brigham and Women's, Boston Medical Center, and other hospitals "have some of the best interpreter services in the country." In addition, hospitals like MGH have introduced an e-learning program called Quality Interactions that trains doctors, nurses, and healthcare staff in cultural competency and cross-cultural communication. Harvard Medical School now teaches cross-cultural communication to medical students.
Children's Hospital Boston is also committed to cultural awareness. Having recently translated key portions of its website into Spanish, the hospital has also expanded its Diversity and Cultural Competency Council led by physician and researcher Dr. Valerie Ward and director of staffing, Michelle Gordon- Seemore. The council is charged with implementing changes to ensure culturally competent care to a diverse patient population and focuses on retaining a diverse workforce. Ward and her colleagues track patient experiences by race and ethnicity to better understand what leads to satisfaction among culturally diverse populations and to measure any gaps that might occur. The hospital recently received a grant from the Blue Cross Blue Shield Foundation to identify issues important for in-patient satisfaction in culturally diverse populations.
These and other efforts throughout the city leave MGH's Bettancourt optimistic. "I feel very hopeful about how this field is emerging and developing," he says. "All the pieces are in place for us to be a national leader in this issue."