Cultural Sensitivity

A delightful couple, pregnant with their first child, came to the office to interview me, to help them decide if I was the right pediatrician for their baby. We had a lovely chat and I felt that I was doing well. At the very end, they asked a question. “Do you have many Asian patients? Do you find you have to ask questions a different way with them or that you have to take a different approach?“ I took these questions as an inquiry about my level of cultural sensitivity. I had a long answer. For the record, though, these people looked by their facial features to be of Asian ancestry; the last name appeared to be of Japanese origin.

“It’s the Bay Area, “ I replied. “What are the odds?“ They agreed it was pretty likely that I had some Asian patients. This was the beginning of my reply.

I told them I took care of a group of about 8 or 10 families from Mongolia. They all live near each other because only a couple of them speak any English at all, and the language barrier is substantial. Taking care of them has sometimes been a challenge. there are no patient-education materials available in Mongolian. AT&T has available translators via telephone in dozens and dozens of languages, but Mongolian is not among them. I called UNICEF at the United Nations in New York. They did send people to Mongolia, but they had no patient information. Same story when I contacted the World Health Organization in Geneva, Switzerland. At one point I had a polite exchange of emails with the Minister of Health in Ulan Bator, Mongolia. He or the person composing the emails under his direction and signing his name, had good English-Language skills. His office had no written materials on child health in Mongolian. These families are Asian. Am I culturally sensitive with them? Probably not. Since communication is so difficult, we need every extemporaneous sign language technique we can come up with just to convey information.  So cultural sensitivity is not helped by a language barrier. I take care of these Asian patients, but do I take care of them differently? Yes, I suppose so, but it’s not because of a cultural divide.

I’m reminded of a classmate in medical school. When he was 14, his parents and he joined many others on a small boat headed blindly from Vietnam out into the South China Sea. Obviously they made it, and he’s now a fine surgeon. What should I know to deal with his family in a Vietnamese-friendly way? Are Koreans different?  What about Malaysians of Chinese descent?

When I was in business, there were no courses that were required, but everyone knew that Japanese investors and businessmen expected certain salesmanship behaviors when they were entertained in New York. In Japan, a completely different set of rules applied. It wasn’t called cultural awareness, it was called good business. In Hong Kong, it was often thought best not to mention that you’d just had a successful series of meetings in Tokyo.

So what was this nice couple asking me? If I had other patients who, by their visible bodily characteristics, appeared to be of Asian descent? Nearly half the human race is of Asian descent. Were they asking if I treated my patients of Japanese descent as if they were Japanese? I don’t know. How many generations of their family have been born in the United States?

I take care of a nice family, for example, with a hyphenated last name. They are all American citizens. They say that they are Brazilian. When their kids were born, I encouraged the parents to speak only Portuguese to them at home. The mother’s ancestors were from Portugal. She looks like a European might. The father’s ancestors were Chinese. He looks Asian. The kids are…adorable. Is this an Asian family? I don’t think even the father’s parents speak much Chinese, back in Brazil. How Asian to you have to be to qualify for a checkbox of ethnic identity? How Asian to you have to look?

No institution with which I have been associated over the last 20 years or so has failed to offer--actually require, I think--a course of some sort in cultural sensitivity. As demanded, I have wasted valuable hours in these courses. In one, the head of a fabulous Spanish-language health clinic gave a presentation on cultural awareness doctors should have to the Latino community. Assuming that language wasn’t a barrier, what could I do with that? Ask a proud Ecuadorian if they identify more with Mexicans than with Americans? Ask someone from Spain if they relate better to a Dominican than a Californian? Will I learn about the distinctions of all those who speak Spanish in a short course or lecture on cultural sensitivity?

I have a family from Yemen. Devout Muslims, they appreciate that I never extend my hand to the mother. I try to be respectful and to the point. I don’t even close the exam-room door when I see their kids and the father isn’t with them.

I think that doctors--people in general--look fake when they try to be someone they’re not. I also think that doctors can be particularly culturally insensitive. But I think it’s cynical political correctness to require learning cultural sensitivity. What they really need to learn is just sensitivity.

If physicians are going to be culturally sensitive, they must first spend enough time with the patient to listen. Maybe they can take a course on reading body language and eye contact, tone of voice or listening skills. Maybe they can learn to interrupt just a little bit less. This would go a really long way towards sensitivity to what a patient really needs. I don't think it's helpful to put on an air of paternalistic cosmopolitanism—like an anachronistic white man's burden—that says to patients that overeducated well-to-do Americans can feel inappropriately self-confident about learning in an hour what patients have taken a lifetime to master.

It's nice if you and your auto mechanic grew up in the same neighborhood. But it's a lot nicer if you find a mechanic who treats you well, listens to your complaint, and actually fixes your car. Which one would you choose?  The one that shares your background/language/heritage or the one who listens to you, does a great job, and doesn't rip you off?

Medical management (and this applies equally to corporate management) shows astounding hubris to impose an unsupported belief that patients will perceive as a better experience a visit with a doctor who has memorized a few facts about your grandparents' country of origin. Whether the patient is from Mongolia or Malaysia, Brazil or Burundi, I don't pretend to be something I'm not. If doctors could spend more time, could simply have more empathy, listen to their patients and think about what it's like to live a day in their shoes, cultural sensitivity would just be sensitivity.




The photograph from my collection is by Keith Carter and is titled, "George Washington."

Giving Thanks

Dear father and mother, I know
I cannot your kindness repay,
But I hope as the older I grow
I may learn your commands and obey.
You loved me before I could tell
Who it was that so tenderly smiled,
And now that I know it so well,
I should be a dutiful child.
 --from a sampler by Fanny Kitson Newman, London 1832, age 6.  Yes, 6.

I like courtesy. Manners, at their core, are culturally-filtered actions that confirm the empathic nature of human interaction. OK, I'll try to put that another way. When I hold a door open for someone, and they walk through, it's nice if they say thank you. Superficially, it would be considered plain good manners. But at a deeper level, the person is acknowledging that I did something that took thought and effort, that I delayed my own journey by a little bit to make theirs a little easier. They get that I didn't have to hold the door.
Yes, it bugs me when I do this and somebody walks through the door without a glance or word, as if it were my job. And by the way, that's not enough. As if all of us haven't had our shares of thankless jobs or ungrateful bosses/ employers/ clients/ customers, getting paid does not take the place of simple, empathic, courtesy. We should thank people for a job well done.

How do we teach this kind of behavior to children?

This is a much more complicated question than parenting books would have you believe. The complication results from the understanding that each child brings to these interactions their own social programming and intuition, governed by a wide variety of influences from brain chemistry to sibling birth order. As with my perspective on parenting in general, there is no one right answer.

That being said, there are clear wrong answers. The parent who punishes the child for what is perceived as bad manners does not effectively teach the child to be polite. They may indeed condition the behavior they desire. We can indeed physically intimidate most children to get them to perform whatever tricks we have in mind for them to do. It changes a behavior without teaching any knowledge or understanding that can be applied to different situations when the threat isn't there.

For those of us who didn't go to Dartmouth in the early 1960s, an instructive documentary film provides a glimpse of a typical hazing ritual that culminates in the repetition of the phrase, "thank you sir, may I have another?" I advise all parents of college-bound children to obtain a copy and study it, in private.

Children, I believe, are a lot smarter than we often give them credit for being. They usually know--or eventually find out--when we're lying to them. It is particularly insidious to make them lie for us. That's a great way to teach them what dishonesty is and how casually we employ it.

So it continues to bother me when it unfolds in my office. One of the very least favorite things I have to do in my job is perform a painful procedure. Whether it's giving a shot or taking out a splinter, draining an infection or just finding out where it hurts, I don't look forward to it. Kids, of course, are not usually trying to repress their feelings, and are often refreshingly open about how they feel about the unpleasant activity. No good parent wants to see their child in pain and no good doctor wants to cause it. So why is it that many parents make their child say thank you as they are leaving the office?

It's fine to remind your child to say thank you after getting a lollipop. Maybe they need a little coaching to ask for one with a please. But being grateful for a shot is too much like thank you sir, may I have another.
It's true that courtesy becomes a habit and rote repetition will reinforce the habit you'd like your child to acquire. But it's the empathic foundation of manners that will actually make them into courteous people. We need to teach that. Here are some of the ways to do it.

1. 
   Notice them being good. It never ceases to surprise me how often children will occupy themselves quietly while a parent and I engage in important but incomprehensible conversation, and the parent doesn't notice! I really try to thank the child for helping by letting us talk about things. I tell them how great it is that they put away the blocks, or looked at the book. If there is one universal failure of parents, this is it. Like the parents of Fanny Newman, we simply expect excellent behavior. How is that different from our ungrateful boss, who simply expects our superior work product as the norm and neither notices nor rewards it? Why do parents expect their kids to do stuff without thanks? So much of what I do with behavior is managing rational expectations. You made the decision to have children and if you expected them to thank you for the privilege, your goals need to be adjusted. Seriously. If you want them to be speaking to you when you're old, you need to start right now. I have nothing against assigning them duties around the house—but if these chores get done, you still need to say thank you. Every single time. Even if it's a uniformed doorman who opens the door for you, thanking him says so much—especially if you're with your child. We need to re-train ourselves to see what's right in front of us, the child who's doing something right. And don't wait around for the kid to be doing everything right. I promise they are doing lots of things right, so don't let a day go by without thanking them for something real.
   
   
   
2. 
   Point out to them when somebody is helping them (or you). Though shopping and getting around in general can be quite an inconvenient hassle with a child, every parent's life is filled with the kindness of strangers who give up their seat on the bus, hold one of the grocery bags, or otherwise lend a hand when it's obviously needed. You might thank the person, but did you explain it to your child? Did you say it really helped us when that lady gave us her cart. That's why I said 'thank you'?
   
   
   
3. 
   Tell them how it makes you feel. Every child wants to please their parent, and they want to learn how other people do it, too. So when it's you that gets thanked for bringing over a pie, don't miss the opportunity. Tell your child that it made you feel good when you were thanked for it. You might be shocked how often your child will notice things to thank you for once you explain how this works.
   
   
   
4. 
   Don't force them to give thanks for stuff that hurts. It's not courtesy, it's counterproductive Dickensian brutality that will just teach them that these basic expressions and words are meaningless. So in #1 above, when you thank them for something, it's got to be something they know is honest. Thanking them for being 12 or for doing something you made them do (like getting shots) is not going to leave a helpful impression on an intelligent child of nearly any age.
   
   

Thanks for reading.







By the way, I found the full(?) text of the poem.  I haven't been able to find an author, so if anybody knows who wrote it, please share.

  My father, my mother, I know,
    I cannot your kindness repay;
  But I hope that, as older I grow,
    I shall learn your commands to obey.

  You loved me before I could tell
    Who it was that so tenderly smiled;
  But now that I know it so well,
    I  should be a dutiful child.

  I am sorry that ever I should
    Be naughty and give you a pain;
  I hope I shall learn to be good,
    And so never grieve you again.

  But, for fear that I should dare
    From all your commands to depart,
  Whenever I'm saying my prayer
    I'll ask for a dutiful heart.

I suppose this says a lot about the way that children were looked upon 200 years ago.  There's a lot about it that makes me uncomfortable.