Cultural Humility: A Paradigm Shift ThroughGlobal Engagement Experiences
Towards a New Paradigm for Understanding Cultural ...
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In order to reach the best health outcomes, physicians must communicate effectively across cultures and strive to integrate patients’ cultural healing traditions and the allopathic care of the mainstream medical establishment. The integrative approach towards the treatment of culturally diverse patients has already shown initial success in Merced, California, where Hmong shamans work closely in the hospital with medical doctors [5]. While in allopathic medicine the therapeutic relationship between physician and patient may play a minor role in comparison to the goals of diagnosis and treatment [8], the therapeutic relationship represents a central focus of alternative medicines, including cultural healing traditions [9]. Due to this emphasis that non-allopathic approaches place on the therapeutic relationship, current efforts at cross-cultural medicine like the tuberculosis questions from the Tena Hospital in Ecuador [Figure 3] are not sufficient. Towards a New Paradigm for Understanding Cultural Competence in Medicine Joshua R. Niska Barrett, The Honors College at Arizona State University, Tempe, AZ. Background The U.S. medical system has only begun to define the range of diverse acceptable practices and understandings in medicine. Currently, two quite different groups of medical practitioners co-exist: 1. Mainstream medical practice: Western, allopathic, peer-reviewed, or evidence-based. 2. Traditional, Complementary, and Alternative Medicine (TCAM): Practices not in the mainstream of the American medical establishment, including cultural, traditional, indigenous, and alternative medicines [1]. Thesis Shamanism and Allopathy? Once physicians have a clear grasp of the best strategies by which to communicate with patients of different cultural backgrounds, they can approach how to integrate allopathic medicine and cultural healing traditions. The physician guiding our tour of the hospital told us the hospital staff must honor cultural beliefs regarding snakebites, such as a ban against pregnant women in the presence of snake bitten people; regional cultural belief asserts that if a snake bitten person sees a pregnant woman, the snake bitten person will experience tremendous swelling. We saw an elderly woman who a snake had bitten. She waited to come to the hospital for more than a week after the bite occurred and her leg became terribly infected. She sat in the crowded hospital room with minimal anesthesia while a nurse cut necrotic, infected skin off her ankles and feet. The nurse bandaged the wounds, and we left the room before I could see whether the staff sent her into surgery. The old woman was clearly native, and I could not help but wonder whether she had waited to come to the hospital because she was relying on shamanistic medicine [alone]. Judging by the advanced nature of her wounds, utilizing the hospital was clearly her last ditch effort. Case Studies Figure 2. Visual analog scale used in interviewing the Quichua [6]. Today we conducted our first census interview. The questionnaire we filled out was the existing questionnaire Dr. DeWalt has previously used because we are still in the process of revising and adding questions. We still have not figured out how to ask opinion questions, so we [again] tested the visual analog scale on the woman we interviewed. She did not grasp it any more than Mama Carmen and still rated everything nearly identical despite her preferences that were apparent in conversation. The most interesting encounter of the day was an impromptu interview with Mama Carmen. We were trying to figure out how to survey the community’s opinion of the various medical services available to them. Dr. DeWalt has experience in surveying communities, and she thought a visual analog scale [Figure 2] might work with the Quichua. In order to test the method before adding it to the questionnaire, we asked Mama Carmen to answer some questions for us. When comparing yachaj [shamans], pharmacists, nurses, doctors, and curanderas [folk healers], she simply told us that they were all great and placed an “X” directly between “muy malo” and “muy bueno” on our linear scale. She also rated all of them ten on a one-to-ten scale. However, when we probed deeper for whom she would [actually] see for help when ill, we received a wealth of opinion through conversation and narrative. Journal entries from fieldwork in Ecuador. The manners in which people assert opinions regarding medical care differ across cultures. Tolerance and “cultural competence” alone will not yield the best medical outcomes for patients. Attempts at cross-cultural communication should not become stereotyping. Every patient possesses a unique perspective on health. Focus should not be upon categorization and so-called integration. Rather, physicians need to identify good medicine that will improve the health of patients [10]. Good medicine is different for each patient. By communicating effectively with patients and their cultural healers and striving to include the patients’ own healing traditions, physicians can provide the best possible care to all patients. REFERENCES 1. Bodeker G, Kronenenberg F. A public health agenda for traditional, complementary, and alternative medicine. Am J Public Health 2002 Oct;92:1582–1591. 2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998; 280:1569–1575. 3. Blecher MB. Alternative medicine on pins and needles no more: Acupuncturists and others get mainstream nod. Crain’s Chicago Business. January 27, 1997, p 4. 4. Cultural competence education. Association of American Medical Colleges; 2005. p. 1. 5. Brown PL. A doctor for disease, a shaman for the soul. New York Times. Sep 20, 2009. A20. 6. Lehti A, Hammarström A, Mattsson B. Recognition of depression in people of different cultures: a qualitative study. BMC Family Practice 2009:10(53). 7. Karasz A. Development of valid subtypes of depression in primary care settings. a preliminary study using an explanatory model approach. The Journal of Nervous and Mental Disease 2008:196(4):289-296. 8. Snyderman R, Weil A. Integrative medicine, bringing medicine back to its roots. Arch Intern Med 2002;162:395–397. 9. Astin JA. Why patients use alternative medicine: results of a national study. J AMA 1998;279:1548–1553. 10. Ernst E. Disentangling Integrative Medicine. Mayo Clin Proc. 2004 Apr;79(4):565-6. Note: The image in Figure 1 is from www.holistic-urbanite.com. The image in Figure 2 is from http://www.stonybrookmedicalcenter.org. Steps Toward Cultural Competence Conclusions The results from surveying the Quichua parallel the findings of a recent study on the diagnosis of depression in people of different cultures. The study suggests, during interactions with minority patients, “dialogue about patients’ illness narratives and social context are crucial” [6]. The same study indicated the need for physicians to truly understand the social and cultural context of their patient rather than to generalize based upon the culture of the patient. For example, several physicians in the study incorrectly reported a “suffering woman” of Middle Eastern descent. In the end, the physicians made the correct diagnosis despite their biased observations [6]; however, other studies discuss misdiagnosis due to misconceptions regarding Middle Eastern culture [7]. After our conversation with Bartolo, we made a house call in which Dr. Agosta was to collaborate with him. The patient was a young boy with a fever and four ulcers on his left leg. The ulcers started a week ago when the boy thought he was bitten by bugs. In the U.S., Dr. Agosta would give oral antibiotics and topical antifungal in order to treat the ulcers. However, [after discussion regarding how to approach the boy’s treatment], Bartolo treated the boy using natural remedies. Bartolo collected leaves of aji del monte, yagu caspi, caballo kiwa, veneno leaf, chilco, and chilluayusa, which acts as a painkiller and fever reducer. He also used the pulp from the chilco stem. In a plantain leaf, the six ingredients were mashed, mixed, and cooked. After cleansing the ulcers with the juice of leaves called mountain soap, Bartolo applied the cooked juices of the plants he picked, while the boy held his foot over a large leaf. Later, he will give the boy the powder of the six plants he picked to apply to his ulcers. Bartolo will also make churiyuyu tea, of which the boy will take a teaspoon three times a day. The boy was [initially] very hesitant to show us his sores. When first asked how he was doing, he responded that he was fine and had nothing beneath the bandage on his leg. However, after Bartolo [spoke to him, he] removed the bandage from his leg, [and] the boy opened up to us. […] Walking is painful for him. The school year is ending at his high school, and he is missing exams, because he cannot make it to school with his ulcers. The boy may even be held back because he is missing all of his exams. Dr. David M. Eisenberg of Harvard Medical School reports 42% of people in the U.S. use medical practices outside the mainstream [2]. Researchers at Oxford estimates 80% usage of TCAM i n developing nations, [1]. Additionally, the utilization of non- allopathic medicine grows at a rate near 30% per year [3]. Efforts to understand diverse healing modalities and cultures have led the American Association of Medical Colleges to establish guidelines for “cultural competence education” [4]. Cultural competence describes efforts towards understanding diverse cultures. Such education may neglect differences in communication and the potential for the integration of healing modalities across cultures. Researchers from Arizona State University explored this issue further in an indigenous Quichua community at the Andes and Amazon Field School in Ecuador. Figure 1. Herbal remedies used by TCAM practitioners. Cultural clash with allopathic medicine. Physicians need patients to arrive at the hospital early in the disease process. Treatment with the shaman and physician. Efforts to integrate can include both cultural and mainstream medicine. Both physician and shaman work together. Dr. Agosta examines the boy’s leg [left]. Bartolo applied a plant mixture to the sore [right]. Figure 3. Tuberculosis questions in both Spanish and Quichua at the Tena Hospital in Ecuador. Do you have a cough today? How long have you had a cough? Do you have phlegm or a sore throat? The young child’s ulcers soon healed. He returned to school and passed his exams, moving on to the next grade. ACKNOWLEDGEMENTS: Thank you to Dr. Jane Maienschein for her guidance and support. Without the efforts of the Andes and Amazon Field School, Barrett Honors College, and Santo Urco Community, this project would not have been possible. Drs. Ted Humphrey and Janet Burke of the Barrett Honors College, along with Dr. Tod Swanson of the Andes and Amazon Field School, facilitated my experience. Thank you also to my fiancé, Emily Cole, for her help with revisions and continual encouragement and support throughout my research project.
Transcript of Towards a New Paradigm for Understanding Cultural ...
In order to reach the best healthoutcomes, physicians mustcommunicate effectively acrosscultures and strive to integratepatients’ cultural healing traditionsand the allopathic care of themainstream medical establishment.
The integrative approach towards thetreatment of culturally diverse patients hasalready shown initial success in Merced,California, where Hmong shamans workclosely in the hospital with medical doctors[5].
While in allopathic medicine thetherapeutic relationship between physicianand patient may play a minor role incomparison to the goals of diagnosis andtreatment [8], the therapeutic relationshiprepresents a central focus of alternativemedicines, including cultural healingtraditions [9].
Due to this emphasis that non-allopathicapproaches place on the therapeuticrelationship, current efforts at cross-culturalmedicine like the tuberculosis questionsfrom the Tena Hospital in Ecuador [Figure 3]are not sufficient.
Towards a New Paradigm for Understanding Cultural Competence in MedicineJoshua R. Niska
Barrett, The Honors College at Arizona State University, Tempe, AZ.
Background
The U.S. medical system has only begun todefine the range of diverse acceptablepractices and understandings in medicine.
Currently, two quite different groups of medicalpractitioners co-exist:
1. Mainstream medical practice: Western,allopathic, peer-reviewed, or evidence-based.
2. Traditional, Complementary, and AlternativeMedicine (TCAM): Practices not in themainstream of the American medicalestablishment, including cultural, traditional,indigenous, and alternative medicines [1].
Thesis Shamanism and Allopathy?
Once physicians have a clear grasp of the beststrategies by which to communicate withpatients of different cultural backgrounds, theycan approach how to integrate allopathicmedicine and cultural healing traditions.
The physician guiding our tour of the hospital told us thehospital staff must honor cultural beliefs regarding snakebites,such as a ban against pregnant women in the presence ofsnake bitten people; regional cultural belief asserts that if asnake bitten person sees a pregnant woman, the snake bittenperson will experience tremendous swelling. We saw an elderlywoman who a snake had bitten. She waited to come to thehospital for more than a week after the bite occurred and herleg became terribly infected. She sat in the crowded hospitalroom with minimal anesthesia while a nurse cut necrotic,infected skin off her ankles and feet. The nurse bandaged thewounds, and we left the room before I could see whether thestaff sent her into surgery. The old woman was clearly native,and I could not help but wonder whether she had waited tocome to the hospital because she was relying on shamanisticmedicine [alone]. Judging by the advanced nature of herwounds, utilizing the hospital was clearly her last ditch effort.
Case Studies
Figure 2. Visual analog scale used in interviewing the Quichua [6].
Today we conducted our first census interview. Thequestionnaire we filled out was the existing questionnaire Dr.DeWalt has previously used because we are still in the processof revising and adding questions. We still have not figured outhow to ask opinion questions, so we [again] tested the visualanalog scale on the woman we interviewed. She did not graspit any more than Mama Carmen and still rated everythingnearly identical despite her preferences that were apparent inconversation.
The most interesting encounter of the day was an impromptuinterview with Mama Carmen. We were trying to figure out howto survey the community’s opinion of the various medicalservices available to them. Dr. DeWalt has experience insurveying communities, and she thought a visual analog scale[Figure 2] might work with the Quichua. In order to test themethod before adding it to the questionnaire, we asked MamaCarmen to answer some questions for us. When comparingyachaj [shamans], pharmacists, nurses, doctors, and curanderas[folk healers], she simply told us that they were all great andplaced an “X” directly between “muy malo” and “muy bueno” onour linear scale. She also rated all of them ten on a one-to-tenscale. However, when we probed deeper for whom she would[actually] see for help when ill, we received a wealth of opinionthrough conversation and narrative.
Journal entries from fieldwork in Ecuador. The manners inwhich people assert opinions regarding medical care differacross cultures.
Tolerance and “cultural competence” alone will not yieldthe best medical outcomes for patients.
Attempts at cross-cultural communication should notbecome stereotyping.
Every patient possesses a unique perspective on health.
Focus should not be upon categorization and so-calledintegration. Rather, physicians need to identify goodmedicine that will improve the health of patients [10].
Good medicine is different for each patient.
By communicating effectively with patients and theircultural healers and striving to include the patients’ ownhealing traditions, physicians can provide the best possiblecare to all patients.
REFERENCES1. Bodeker G, Kronenenberg F. A public health agenda for traditional, complementary, and
alternative medicine. Am J Public Health 2002 Oct;92:1582–1591.2. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States,
1990–1997: results of a follow-up national survey. JAMA. 1998; 280:1569–1575.3. Blecher MB. Alternative medicine on pins and needles no more: Acupuncturists and others get
mainstream nod. Crain’s Chicago Business. January 27, 1997, p 4.4. Cultural competence education. Association of American Medical Colleges; 2005. p. 1.5. Brown PL. A doctor for disease, a shaman for the soul. New York Times. Sep 20, 2009. A20.6. Lehti A, Hammarström A, Mattsson B. Recognition of depression in people of different cultures: a
qualitative study. BMC Family Practice 2009:10(53).7. Karasz A. Development of valid subtypes of depression in primary care settings. a preliminary
study using an explanatory model approach. The Journal of Nervous and Mental Disease2008:196(4):289-296.
8. Snyderman R, Weil A. Integrative medicine, bringing medicine back to its roots. Arch Intern Med2002;162:395–397.
9. Astin JA. Why patients use alternative medicine: results of a national study. J AMA1998;279:1548–1553.
10. Ernst E. Disentangling Integrative Medicine. Mayo Clin Proc. 2004 Apr;79(4):565-6.
Note: The image in Figure 1 is from www.holistic-urbanite.com. The image in Figure 2 is fromhttp://www.stonybrookmedicalcenter.org.
Steps Toward Cultural Competence
Conclusions
The results from surveying the Quichua parallel the findings of a recent studyon the diagnosis of depression in people of different cultures. The studysuggests, during interactions with minority patients, “dialogue about patients’illness narratives and social context are crucial” [6].
The same study indicated the need for physicians to truly understand thesocial and cultural context of their patient rather than to generalize basedupon the culture of the patient. For example, several physicians in the studyincorrectly reported a “suffering woman” of Middle Eastern descent. In theend, the physicians made the correct diagnosis despite their biasedobservations [6]; however, other studies discuss misdiagnosis due tomisconceptions regarding Middle Eastern culture [7].
After our conversation with Bartolo, we made a house call inwhich Dr. Agosta was to collaborate with him. The patientwas a young boy with a fever and four ulcers on his left leg.The ulcers started a week ago when the boy thought he wasbitten by bugs. In the U.S., Dr. Agosta would give oralantibiotics and topical antifungal in order to treat the ulcers.However, [after discussion regarding how to approach theboy’s treatment], Bartolo treated the boy using naturalremedies. Bartolo collected leaves of aji del monte, yagucaspi, caballo kiwa, veneno leaf, chilco, and chilluayusa,which acts as a painkiller and fever reducer. He also usedthe pulp from the chilco stem. In a plantain leaf, the sixingredients were mashed, mixed, and cooked. Aftercleansing the ulcers with the juice of leaves called mountainsoap, Bartolo applied the cooked juices of the plants hepicked, while the boy held his foot over a large leaf. Later,he will give the boy the powder of the six plants he picked toapply to his ulcers. Bartolo will also make churiyuyu tea, ofwhich the boy will take a teaspoon three times a day.
The boy was [initially] very hesitant to show us his sores.When first asked how he was doing, he responded that hewas fine and had nothing beneath the bandage on his leg.However, after Bartolo [spoke to him, he] removed thebandage from his leg, [and] the boy opened up to us. […]Walking is painful for him. The school year is ending at hishigh school, and he is missing exams, because he cannotmake it to school with his ulcers. The boy may even be heldback because he is missing all of his exams.
Dr. David M. Eisenbergof Harvard MedicalSchool reports 42% ofpeople in the U.S. usemedical practicesoutside themainstream [2].
Researchers at Oxfordestimates 80% usage ofTCAM i n developingnations, [1].
Additionally, theutilization of non-allopathic medicinegrows at a rate near30% per year [3].
Efforts to understand diverse healing modalitiesand cultures have led the American Associationof Medical Colleges to establish guidelines for“cultural competence education” [4].
Cultural competence describes efforts towardsunderstanding diverse cultures.
Such education may neglect differences incommunication and the potential for theintegration of healing modalities across cultures.
Researchers from Arizona State Universityexplored this issue further in an indigenousQuichua community at the Andes and AmazonField School in Ecuador.
Figure 1. Herbalremedies used by
TCAM practitioners.
Cultural clash with allopathic medicine. Physicians needpatients to arrive at the hospital early in the disease process.
Treatment with the shaman and physician. Efforts to integratecan include both cultural and mainstream medicine.
Both physicianand shamanwork together.Dr. Agostaexamines theboy’s leg [left].Bartoloapplied aplant mixtureto the sore[right].
Figure 3. Tuberculosis questionsin both Spanish and Quichua atthe Tena Hospital inEcuador. Do you have a coughtoday? How long have youhad a cough? Do you havephlegm or a sore throat?
The young child’s ulcers soon healed. Hereturned to school and passed his exams,moving on to the next grade.
ACKNOWLEDGEMENTS: Thank you to Dr. Jane Maienschein for her guidance and support. Without the efforts of the Andes and Amazon Field School, Barrett Honors College, and Santo Urco Community, this project would not have been possible. Drs. Ted Humphrey and JanetBurke of the Barrett Honors College, along with Dr. Tod Swanson of the Andes and Amazon Field School, facilitated my experience. Thank you also to my fiancé, Emily Cole, for her help with revisions and continual encouragement and support throughout my research project.
