Cross Cultural Medicine at Home and Abroad 2007

1
Cross Cultural Medicine at Home and Abroad 2007

• Gregory Juckett, MD, MPH
• Associate Professor of Family Medicine
• West Virginia University
• gjuckett_at_hsc.wvu.edu

2
America is Changing

• Global Village We now live in multi-cultural,
  multi-ethnic societies both at home and abroad
• By 2050, almost half of U.S. population will be
  comprised of minorities
• Todays Tossed salad vs. Yesterdays Melting
  Pot
• U.S. minority populations are quite diverse and
  not limited to urban areas

3
What is Culture?

• Beliefs and behaviors that are learned and shared
  by members of a group
• World view of a culture may have a profound
  effect on healthcare e.g. fatalism
• Cultural Competence (knowledge, awareness,
  respect for other cultures) is now an necessary
  clinical goal for which we should strive
• Cultural Sensitivity/Humility caring awareness
  which tries to avoid giving offense to those of
  another culture (achievable)
• Importance of R-E-S-P-E-C-T

4
Cross Cultural Terms

• Stereotyping (bad) the mistaken assumption that
  everyone in a given culture is alikeclosed to
  exceptions (ending point)
• Generalizing (ok) awareness of cultural
  normsopen to educational, generational
  differences (starting point)
• Ethnocentrism the usually unconscious conviction
  that ones own culture should be the normthis is
  almost a universal human trait
• Racism the misguided belief that ones own
  race/ethnicity is superior to that of others
• Discrimination treating people differently due
  to prejudice may be unconscious you people

5
Remember that every person is unique
6
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
7
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
8
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
9
Cultural Dynamics Influencing the Clinical
Encounter
Scott Cottrell
10
The Cross Cultural Interview Exam

• Developing Trust (view this as an investment of
  time that pays you back later) and listening to
  patient
• Eliciting pertinent history always ask
  (non-judgmentally) what alternative therapies
  your patient is using and what providers have
  they already seen (hierarchy of care)
• Understanding how the illness is viewed ( its
  meaning) and acknowledging differences in
  worldview
• Culturally Sensitive Physical Examination
• Explaining diagnosis to patient and family in
  understandable terms
• Negotiating treatment plan and follow-up have
  patient repeat your instructions and have them
  written down (if patient or family member is
  literate) Teach-Back

Knowledge of language and culture Effectiveness
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LEARN Model for Cross Cultural Interview

• Listen to the patient and the family's concepts
  of the illness.
• Explain your medical diagnosis in understandable
  terms.
• Acknowledge differences (and similarities) in
  cultural perspectives.
• Recommend your diagnostic and therapeutic
  approaches.
• Negotiate all areas of care.
• Reference A teaching framework for
  cross-cultural health care.
• Application in family practice.
• West J Med. 1983 Dec139(6)934-8.

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ETHNICS Mnemonic a framework for culturally
appropriate care

• Explanation why do you have this problem?
• Treatment what have you tried for it?
• Healers who else have you sought help from?
• Negotiation how best do you think I can help
  you?
• Intervention this is what I think needs to be
  done.
• Collaboration how can we work together on this?
• Spirituality what role does spirituality play in
  this?

Kobylarz, Heath, Like. The Etnics Mnemonic A
Clinical Tool for Ethnogeriatric Education. J Am
Geriatr Soc 2002 50 1582-89
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The Spirit Catches You and You Fall Down by
Anne Fadiman

• Poignant story about a Hmong refugee child from
  Laos with intractable epilepsy
• Clash of Hmong-U.S. health care cultures with
  difficult consequences for all involved
• Asks what questions could have led to better
  cross cultural understanding?
• Should be required reading in medical schools

14
Kleinman Cross Cultural Interview

• What do you call the problem?
• What do you think has caused the problem?
• Why do you think it started when it did?
• What do you think the illness does? How does it
  work?
• How severe is the sickness? Will it have a long
  or short course?
• What kind of treatment do you think is necessary?
  What are the most important results you hope to
  receive from this treatment?
• What are the chief problems the sickness has
  caused?
• What do you fear most about the sickness?
• Adapted from Kleinman A, Eisenberg L., Good B.
• Culture, Illness and Care Clinical Lessons from
  Anthropologic and Cross-Cultural Research
• Annals of Internal Medicine 1978 88 251-258.
• Always ask about alternative therapies, herbs
  and supplements the
• patient may be usingif you dont ask, the
  patient is unlikely to volunteer
• this information.

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Applying Kleinman Questions and LEARN
Center for the Health Professions
Information
Example
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Applying Kleinman Questions and LEARN
Example
Information
Center for the Health Professions
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Applying Kleinman Questions and LEARN
Information
Example
Center for the Health Professions
18
Cross Cultural Interview

• Establishing trust (and understanding each other)
  may take much more timeoften mistrust is
  inherent
• Eye contact issues may be avoided among less
  Westernized Asians (unless of equal
  status/gender)
• Personal space/Touch issues (low touch)
• Gender issues and casual touch
• Facial expressions/Body Language e.g. smiling as
  embarrassment instead of happiness
• Time and Punctuality Agrarian rubber time vs.
  Industrial time

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Interpreter Pitfalls Family or Friends

• Limits scope of inquiry unlikely to share
  intimate or embarrassing details (family
  violence, sex, mental illness)
• Lack of training medical terminology may be
  either misunderstood or mistranslated out of
  embarrassment
• No confidentiality guarantee
• Sometimes family member has a personal agenda
• Better to use trained medical interpreters if
  available but if unavailable must recognize the
  limitations
• Try to speak directly to the patient, not to the
  interpreter

20
Name Conventions

• Best to use formal title (especially with older
  patients) until given permission to be
  informalnever assume its ok
• Chinese and SE Asian names are usually written
  and pronounced backward Surname precedes given
  name if not already U.S. acculturated e.g.
  Xumiao is Dr. Xu. Married women usually dont
  take their husbands name.
• Latino names complex surnames usual (fathers
  name precedes mothers) e.g. Senorita Maria
  Sanchez Rodriguez becomes Senora Maria Sanchez de
  Gutierrez (usually Senora Gutierrez) after she
  marries Senor Gutierrezmothers name is usually
  dropped some Latinas just retain their maiden
  name however or adopt U.S. customs
• Marias children will go by Gutierrez- Sanchez
• Don and Dona indicate respect for older Hispanic
  patients
• If in doubt, just ask How do you wish to be
  addressed?

21
Language and Body Language Signals

• Embarrassment or respect prevents the asking of
  many necessary questions
• Patients will say they understand when they
  really have no clueinstead have them repeat what
  you want them to do
• Nodding vigorously may indicate respectful
  attention but not agreement or understanding!!!
• Dont confuse Indian head wagging with
  disagreement! It means I hear what youre
  saying.
• Speak slowly and simply but not loudly (unless
  your patient really is deaf!) Short sentences!
• Eye Contact in non-western cultures may indicate
  disrespect of authority and/or sexual interest
• Avoid idioms and dont use negative queries You
  dont or you wouldnt mind if)

22
Culturally Appropriate Gestures

• Beckoning should not be with index finger
  (S. America, Asia) since this is either
  reserved for dogs or considered very rude.
  Instead the palm of the hand should be held down
  and all fingers used
• Displaying your feet is insulting in Asia never
  touch anyone with your feet
• Patting a child on the head is an insult in SE
  Asia since the head, as the seat of the soul, is
  sacred
• Thumbs up sign is the same as the U.S. middle
  finger in Iran

23
Reciprocity and Gifts

• In many cultures, it is required to demonstrate
  ones gratitude with a gift and its refusal may
  well cause offense
• However, gifts are often offered to ensure best
  possible care for the patient (a soft bribe for
  the care-giver!)
• If gift is inappropriate (e.g. money), suggest
  an alternative (such as food) that could be
  shared with staff

24
Giving Bad News

• In many other cultures, it is customary to first
  inform the family and let them decide if and when
  the patient should be informedviolates U.S.
  HIPAA regulations
• Anger against the provider is often expressed if
  this custom isnt followed as it is felt that
  giving someone a bad prognosis not only takes
  away any hope but also becomes a self-fulfilling
  prophecy.
• At least in the U.S., ask the patient how they
  would like their family involved. Explain to the
  family that informing the patient first is the
  standard U.S. practice

25
African-American and African Immigrant Culture

• Historically the largest U.S. minority but
  recently replaced by Hispanics (some
  African-Americans are also Hispanic)
• 12.3 U.S. population22 live in poverty and
  life expectancy 5.9 y less (2x stroke death, 36
  B w/ HTN vs. in young black men 15-34) Health Care Inequity
  and Race
• Most are long term U.S. residents but immigration
  from Caribbean and African countries is
  increasing (immigrants have better life
  expectancies than native blacks!)
• Mistrust of white institutions common place (and
  sometimes historically justified e.g. Tuskegee
  syphilis experiments)reluctance to donate organs
  
• Conspiracy theories regarding HIV, birth control
  common in some areas

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African-American Folk Conditions

• Falling Out stress-related collapse (inability
  to move but normal senses) preceded by
  dizzinessmay be confused w/ stroke
• Bad blood suggests blood contamination,
  usually by syphilis (or other STI)
• Slang terms miseries pains, low blood
  anemia, sugar diabetes
• High blood while this is may be slang for HBP,
  it may also refer to hot, thick blood that
  rises in the body for extended periods and its
  treatment involves cooling and thinning the blood
• High-pertension episodic but temporary
  shooting up of blood to the head which then
  resolves (over 3.3 x as likely to be non-adherent
  as a patient who believed in biomedical
  hypertension) MMWR Oct 12, 1990 39
  (40) 701-704

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The Why and How of Non-Adherence

• A 65 year old African American woman with
  hypertension is noted to have a BP of 180/105 on
  follow up even though she had been well
  controlled on the last visit. When asked if she
  was still taking her medicine, she responded
  Those things are supposed to lower the blood,
  arent they? So I just cut them in half and only
  took them for another week , then threw them
  away.
• Why did she stop taking her medicine after being
  told that the pills were working well?
• Adapted from Culture and the Clinical
  EncounterRena Gropper

28
Hypertension Control in Blacks

• More sodium sensitive than white population
• Thiazides are good first-line therapy
• Long-acting calcium channel blockers also helpful
  for hypertension
• Beta-blockers may be less effective than in white
  population
• Blacks and Asians have 3- 4x greater risk of
  angioedema from ACE Inhibitors compared to whites
• Controversy over race-specific marketing of
  pharmaceuticals

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Hispanic or Latino Culture

• Now the largest, fastest growing U.S.minority
  (12.5)not just in S.W. USA, NYC, and Florida
• Many nationalities and subcultures Mexican,
  Puerto Rican, Cuban, Brazilian, Guatemalan,
  Colombian
• Machismo vs. Marianismo dominant male culture
  women traditionally submissive
• The Importance of Balance in Health Cold/Hot
  Duality similar to the Yin/Yang of Asian Medicine

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Issues in Latino Medicine

• Confianza/Personalismo necessary trust or
  rapport should be established prior to the
  medical part of the interview
• Some Latinos resent Americans for usurping the
  name of both continentsthey are Central or South
  Americans whereas Gringos are North Americans
• Personal space is less, sometimes resulting in a
  dance where the gringo retreats (and therefore
  is perceived as being cold)
• Being a little fat gordito is often perceived
  as healthy While MexicanAmericans have up to 5x
  as much type 2 diabetes mellitus as non-Hispanic
  whitesstill the risk of coronary death is lower
  (The Latino Paradox)
• More relaxed concept of timepeople are more
  important than schedules

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Latino Folk Medical Diagnoses

• Mal de ojo (evil eye)
• Empacho (GI blockade from overeating)
• Susto (magically induced fright w/ soul loss)
• Mal puesto (unnatural illness due to sorcery)
• Ataque de nervios (anxiety attack)
• Frio de la matriz (frozen womb)
• Caida de la mollera (fallen fontanelle)
• Fatiga (shortness of breathnot just fatigue)

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Case Study Upside Down Baby

• A nurse visiting a Mexican family was shocked to
  see a baby being suspended upside down over a
  bowl of steaming water and it appeared as though
  the babys head was about to be dipped in.
• What should she do?
• Dx Caida de la mollera (fallen fontanelle)
• Sx irritability, diarrhea (r/o dehydration)
• Adapted from Culture and the Clinical
  EncounterRena Gropper

33
Hispanic Folk Medicine
HOT
COLD

• Hypertension
• Diabetes mellitus
• GERD and PUD
• Pregnancy
• Sore throat/Infection
• Susto
• Mal de Ojo
• Bilis

• URI colds
• Pneumonia
• Menstrual cramps
• Colic
• Headache
• Cancer
• Frio de la Matriz
• Empacho

Key Distinction of natural vs. supernatural
causation Mal natural vs. Mal puesto
34
Vitamins Stopped

• A Puerto Rican family brought in their 4 month
  old with diaper rash. After a prescription was
  written, the nurse-practitioner asked if any more
  vitamin drops were needed. Ive not used up the
  drops from before. As you can see, my baby has a
  rash so I stopped giving them to him. I try to
  take good care of my baby
• Why were the drops discontinued?
• Another example is a Latinas reluctance to take
  iron supplements during her pregnancy
• Adapted from Culture and the Clinical
  EncounterRena Gropper

35
Hypertension a hot condition

• Hot etiology thick blood, caused by susto (fear)
  or corajes (anger)
• May be viewed as a temporary rather than
  long-term conditiontherefore patients may not
  adhere to long-term therapy
• Cool treatments lemon juice, passion flower tea,
  zapote blanco
• Hot diseases are always treated with cool
  remedies and vice versa but what constitutes
  hot or cold varies by cultural tradition

36
Peruvian Healing
Curandero--Brujo
Curandero Herbalist
sapo
cuyes
37
Asian Culture

• Third largest U.S. minority (3.6) but multiple
  nationalities Chinese, Japanese, Korean, Hmong,
  Vietnamese, Thai, Cambodian, Filipino (many
  differences)
• Hierarchical family structure
• Poverty is still a problem for many Asians
  although there is usually a strong family
  commitment to work, education and advancement
• Accommodation rather than assertiveness valued
  yes may really mean no in some instances (you may
  also be told what your patient thinks you want to
  hear)
• Face (personal honor) issues very important so
  be sensitive to thisalways provide a
  face-saving way out

38
The Stigma of Mental Illness

• Stigma of mental illness is often
  devastatingviewed as a disgrace to the Asian
  family and seldom discussed
• Somatization is therefore common and depression
  must be suspected early and dealt with tactfully
  as an imbalance
• Mental illness often presents with physical
  complaints!
• Counseling viewed by many Asians as suitable only
  for the hopelessly mentally illunlikely to
  follow through
• Multiple Asian culture bound psychiatric
  presentations Amok (violence w/ dissociation),
  Hwa-byung (suppressed anger w/ abdominal fullness
  or mass), Tajin kyofusho (intense fear of being
  offensive e.g. imaginary body odor), Latah
  (hypersensitivity to fright with trance-like
  behavior)

39
Chinese and Asian Illnesses

• Wind Illness fear of being cold or exposed to
  wind which would cause of loss of yang
• Shen kui anxiety, panic, sexual complaints
  attributed to semen loss (believed to be
  life-threatening by patient)
• Hwa-Byung (Korea) epigastic pain attributed to
  an abdominal mass that pt believes will result in
  deaththought to be caused by unresolved anger
• Taijin Kyofusho (Japan) pathological fear about
  embarrassing others by an awkward behavior or a
  physical problem such as body odor (social
  phobia)

40
Health Care Concerns for Asians

• A loud tone of voice (or a friendly slap on the
  back) may be misinterpreted by some Asians as
  showing hostility
• Correcting or even joking about a personal
  mistake in a public setting may cause intolerable
  loss of face
• The left hand is often used for personal hygiene
  and is considered uncleanif medical samples or
  business cards are offered with the left hand,
  they may be discarded.
• Ice water is often refused (upsets hot/cold
  balance)warm or hot water preferred, esp. during
  Chinese sitting month after delivery
• Avoiding Foot Contact feet are unclean and
  should not come in contact with another or be
  elevated/in view shoes should be removed before
  entering homes

41
The Bruised Baby

• A Vietnamese mother brought in an infant girl for
  acute respiratory infection manifested by cough
  and fever. Physical examination also showed
  numerous bruises on her chest and back.
• When the childs mother was asked about these,
  she became embarrassed and changed the subject.
  When the matter was pressed further, the mother
  attributed these bruises to the grandmother.
• What should be done?

Adapted from Culture and the Clinical
EncounterRena Gropper
42
Coining

• Coining is a common Asian healing practice
• Coining is used for conditions associated with
  "wind illness". It is also used with a wide
  variety of febrile illnesses and for stress
  related symptoms (headache, muscle aches and
  pain, and fatigue).
• The practice produces linear petechiae on the
  chest and back which resolve over several days.
• It is believed that the bruises bring out the
  wind illness and that their manifestation
  confirms that the disease was present.

43
Treatment of Wind-Cold
Coining in Cambodia -Debra Coats
44
Herbs
Cupping in China G. Juckett
45
Mongoloid Spots

• Mongoloid spots are common in children from many
  racial backgrounds. Patches of dermal
  melanocytosis are found in the majority of Asian,
  Latino and Black infants. Although they are
  often seen in the lumbosacral /gluteal areas they
  are not limited to those regions.
• Mongoloid Spots need to be distinguished from
  bruises of child abuse. Compared to a bruise they
  are more uniform in skin color, their borders are
  better defined, there is no induration or
  tenderness and they are stable over time.

The Influence of Culture and Pigment on Skin
Conditions in Children-Dinulos and Graham
46
Moxibustion Scars
Sometimes may be confused with physical abuse
(cigarette burns)
Photo by Debra Coats--Cambodia
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10 Rules of Thumb in Cross-Cultural Medicine
SUMMARY

• Allow more time for cross-cultural visits
• Use formal address until invited to do otherwise
• Develop trustnote that intrusive questions by
  some of your patients may be a way of determining
  if they can trust you
• Try not to rely on family/friends as interpreters
  if at all possible
• Ask about the use of cultural therapies and
  herbsif you dont ask, they probably wont tell
• Ask about how the illness began and how the
  patient perceives it
• Hesitation (or discomfort) is often indicative of
  hitting an invisible cultural wall
• Ask the patient to repeatin their own wordsyour
  instructions to them rather than ask Do you
  understand?
• Treat your patients the way they would like to be
  treated not necessarily the way you would like to
  be treated. However you are not obligated to meet
  unreasonable demands
• Negotiate your treatment plans, acknowledging
  cultural differences

Adapted in part from Culture and the Clinical
Encounter by Rena Gropper
48
Benefits of Improving Cross-Cultural Skills

• Better Outcomes much better patient adherence
  results if your instructions are culturally
  relevant non-adherence may be due to medication
  side effects, poverty, depression, lack of
  understanding, conflict w/ traditional therapies
• Improved Access to Care
• Reduce Health Care Disparities
• Awareness of the hazards and benefits facing your
  patients from traditional care givers
• Know what aspects of traditional care can be
  adapted to your healing setting
• Know what needs to be rejected due to danger to
  either spiritual or physical health

49
Books on Cross-Cultural Medicine

• Culture and the Clinical Encounter an
  Intercultural Sensitizer for the Health
  Professions by Rena C. Gropper Intercultural
  Press, Inc., Yarmouth, Maine 1996 (case studies)
• Caring for Patients from Different Cultures
  Case Studies from American Hospitals by Geri-Ann
  Galanti University of Pennsylvania Press,
  Philadelphia 1997
• Cross-Cultural Medicine edited by JudyAnn Bigby
  American College of Physicians, Philadelphia 2003
• Cultural Diversity in Health Illness 6th Ed.
  by Rachel E. Spector Pearson/Prentice Hall, Upper
  Saddle River, New Jersey 2004
• Transcultural Health Care a culturally
  competent approach 2nd Ed., edited by Larry D.
  Purnell, Betty J. Paulanka. F.A. Davis Co.,
  Philadelphia 2003
• Pocket Guide to Cultural Assessment, 2nd Ed., by
  EM Geisler, St. Louis, Mo. Mosby, 1998
• The Spirit Catches You and You Fall Down Anne
  Fadiman

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Website Resources Cross-Cultural Medicine

• Culture Clues Russian, Latino, Albanian,
  Vietnamese, Korean, African-American information
  sheets http//depts.washington.edu/pfes/cultureclu
  es.html
• EthnoMed Univ. of Washington website with many
  cultural profiles and resources
  
  http//ethnomed.org
• Culture Grams fee for service online information
  by country (limited free information)
  
  http//www.culturegrams.com/
• The Providers Guide to Quality and Culture
  http//erc.msh.org/qualityculture
• Resources for Cross-Cultural Health Care
  http//www.diversityrx.org
• Physician Toolkit Curriculum Univ. of Mass
  Medical School March 2004 http//www.omhrc.gov/ass
  ets/pdf/checked/toolkit.pdf
• Cross Cultural Medicine in American Family
  Physician 12/1/05
• http//www.aafp.org/afp/20051201/2267.html

51
Web-based Interpreter Services (fee involved
for first three)

• Language Line www.languageline.com
  (1-800-628-8486)
• Cyra-Com www.cyracom.net
• American Translators Association www.atanet.org
• Babel Fish (Altavista) translates blocks of text
  http//babelfish.altavista.com/

52
Lost in Translation-1

• Coors put its slogan, "Turn it loose," into
  Spanish, where it was read as
• "Suffer from diarrhea."
• When Gerber started selling baby food in Africa,
  they used the same
• packaging as in the US, with the beautiful baby
  on the label. Later they learned that
• in Africa, companies routinely put pictures on
  the label of what's inside, since many people
  can't read English.
• The name Coca-Cola in China was first rendered as
  Ke-kou-ke-la.
• Unfortunately, the Coke company did not discover
  until after thousands of
• signs had been printed that the phrase means
  "bite the wax tadpole" or "female horse stuffed
  with wax" depending on the dialect. Coke then
  researched 40,000 Chinese characters and found a
  close phonetic equivalent, "ko-kou-ko-le," which
  can be loosely translated as "Happiness in the
  mouth."
• In Taiwan, the translation of the Pepsi slogan
  "Come alive with the Pepsi
• Generation" came out as "Pepsi will bring your
  ancestors back from the
• grave."

53
Lost in Translation-2

• Scandinavian vacuum manufacturer Electrolux used
  the following in an
• American ad campaign "Nothing sucks like an
  Electrolux."
• When General Motors introduced the Chevy Nova in
  South America, it was
• apparently unaware that "no va" means "it won't
  go." After the company
• figured out why it wasn't selling any cars, it
  renamed the car in its Spanish markets
• to the Caribe.
• Ford had a similar problem in Brazil when the
  Pinto flopped. The company
• found out that Punto was Brazilian slang for
  "tiny male genitals." Ford
• pried all the nameplates off and substituted
  Corcel, which means horse.
• When Parker Pen marketed a ballpoint pen in
  Mexico, its ads were supposed
• to say "It won't leak in your pocket and
  embarrass you." However, the
• companies mistakenly thought the Spanish word
  "embarazar" meant embarrass. Instead the ads said
  that "It won't leak in your pocket and make you
  pregnant.
• In Chinese, the Kentucky Fried Chicken slogan
  "finger-lickin' good"

54
Lost in Translation-3

• Chicken-man Frank Perdue's slogan, "It takes a
  tough man to make a tender
• chicken," got terribly mangled in another Spanish
  translation. A photo of
• Perdue with one of his birds appeared on
  billboards all over Mexico with a caption
• that explained "It takes a hard man to make a
  chicken aroused. Or, my personal favorite it
  takes a virile man to make a chicken pregnant.
• Hunt-Wesson introduced its Big John products in
  French Canada as Gros Jos
• before finding out that the phrase, in slang,
  means "big breasts." In this
• case, however, the name problem did not have a
  noticeable effect on sales.
• You are invited to take advantage of the
  chambermaid.from a guest directory in a
  Japanese hotel (1991)
• Japan's second-largest tourist agency was
  mystified when it entered English-speaking
  markets and began receiving requests for unusual
  sex tours. Upon
• finding out why, the owners of Kinki Nippon
  Tourist Company changed its
• name.