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."

The Power of Slow Medicine

I discovered the power of slowness even while being rushed to see more patients faster. Luckily, I have a good way with most children, and they aren't usually scared of me. But there's no practical way of examining a child within a minute of walking in the room. Like the rest of us, children get territorial about their personal space, and will be upset if you violate their boundaries. So the key to a cooperative examination is getting the child to invite me to share their space with them. This takes time and patience. I will often use a prop of some sort, such as my tie or a toy or stuffed animal to engage the child and get them to reach out to me. It's a subtle dance which can take more than a few minutes, especially for anxious children. The first part of my definition is literal: slow visits.

Slow visits allow the patient or parent to ask all their questions, to get comfortable with the surroundings. In medicine, there's something known as the 'doorknob question.' The patient is in the room with the doctor, and their visit is finished, and just as the doctor turns the knob to leave the room, the patient asks a really important question like, 'Oh, and doc, should I be worried about this chest pain I keep having?' I think there would be fewer doorknob questions if doctors weren't always reaching for doorknobs. The removal of time pressure in the visit allows the patient to express their anxiety, and gradually open up about important issues. It also allows them to explain complex related problems, like family or financial situations that might have an important impact on whether they will be able to take their medicine or follow the doctor's advice.

The goal would not be simply providing the minimal acceptable level of care. Having an expert doctor who knows who you are is like having a chef who knows how to take advantage of that local seasonal produce. It takes more skill to cook something fresh than to heat something in the microwave. Having uninterrupted access to your physician can keep you from unnecessary treatments and save your insurance company money.

When I see a sick child, I have a luxury that I didn't have when working in a busy clinic. In the clinic, it wasn't clear when or if the parent could bring the child back. So to be safe, we would sometimes prescribe medication on the assumption that the diagnosis would eventually require it. Because my current patients have open access to me, I will often choose not to treat the child at all. I tell the parents to call me right away if the child gets worse. If I don't hear from them, I'll call the next day to check up on the child. Often, my patient will get better on their own and won't need any medication at all. This system only works because when parents call, they talk directly to me. I know the situation and can evaluate the need for treatment at that time. If it were a doctor covering for me, this might be a problem. Either the covering doctor would be extra cautious and prescribe medication or possibly not take it as seriously because they wouldn't know the whole history. If the parent is even more removed from the doctor, by calling a call center, they often can only get a response by selling the person answering the phone on how awfully sick their child is.

About two months ago, I got a call one Sunday from a mother of two preschoolers. Both had fever and seemed to be in pain. I met them at my office, opened the office for them and treated them. I was later told by their insurer that Sunday visits aren't a covered service. The person I spoke to on the phone in the claims department suggested that I do what most practices would do on Sunday--send them to the emergency room. It didn't seem to matter that the ER would be way more expensive, slower, and scarier.

I wonder if slower, more customized, more personal care would end up costing less. I think there might be fewer tests, fewer ER visits, fewer prescriptions, better compliance with the doctor's advice, and a lot more medical problems might be caught early. That could result in better health outcomes, lower cost of care, and more satisfied patients. I suspect there aren't enough doctors who practice this way to do the research to prove it.

I practice slow medicine.

Next Post: Slow Medicine and the Telephone Paradox

Slow Medicine

What is Slow Medicine?

Berkeley, California is the epicenter in America of the Slow Food movement. It has gradually developed over the past 20 years or so as a response to Fast Food.

The idea, I think, is that food should be very fresh, as local as possible, as organic as possible, and prepared just before serving. Michael Pollan has written a lot about these ideas in his books about food. Alice Waters has written cookbooks that emphasize these priorities and has a fabulous restaurant here that puts the concepts into practice.

I think it's time for a similar revolution in medical care. So I'm inventing the term Slow Medicine.

At business school, I first learned of the existence of Hamburger University, near Chicago. One of my smartest professors would often go and teach a course there. What he taught was Industrial Production, ways of ensuring the consistency and high quality of the final product, produced in the most economical and fastest way. Hamburger U. is run by McDonald's, and is where they send most of their best managers for training, and where they develop new systems for service. McDonald's makes great products--delicious food that's fast and inexpensive, and can almost always be counted on to be consistent in quality whether ordered in Berkeley or Brooklyn.

A few years ago, I had the honor to serve on a panel discussion about the quality of medical care. On the panel were health plan administrators, state health officials, insurance plan managers, a few professors of health policy and medical practice, and me. (I met one of the professors in the hotel elevator, and introduced myself. He asked what I did, and I said that I was a primary care doctor. He huffed and said that he didn't understand why they invited me, since he was an expert on primary care and head of the department of primary care at a major medical school. I asked him politely if he took care of patients. He said he didn't, except for the 3 weeks a year he has to supervise medical residents in their clinic. Though he was invited, I presume, as the expert in 'primary care,' I was the only practicing doctor.) The organizers went around the room, and I learned a lot! What is called 'quality' as it applies to medical care is really a code word meaning consistency, efficiency, and the lowest acceptable standard of care at the lowest average cost. In the back of my mind rang familiar echoes of chain restaurant strategy and Hamburger U. When it was my turn, I pointed out that this is not at all what my patients would think of if they were asked about the quality of their medical care. The view of patients on medical quality just didn't matter. The quality debates occurring at the moment are dominated by healthcare institutions and insurers. They want consistent, if minimal, results for the least cost.

This industrial model of the provision of medical care is everywhere in America. Because doctors are paid per visit (just as with sweatshop workers, it's called piecework), there's a lot of pressure on them to do as many visits as possible per day. That's why when we see our doctors (me, too) we sometimes get 10 minutes or less. In order to provide minimal standards of consistent results (quality), the medical assistant might have us fill out a questionnaire first or give us a lab form. Chances are that the doctor doesn't know us, our issues or questions, or our concerns. I have been to doctors where I was told that I can only ask about one problem. Another problem is another visit. In what I'm calling the industrial model, patients are the raw materials and payment is the factory output.

The people that run our healthcare companies and institutions are generally nice people with families like the rest of us. They know what good medical care is and they want it, too. But the qualities we all really want are difficult to measure and hard to define. We all want a doctor who knows us and cares about us, and tries to do their best for us. But what we get is Fast Medicine.

Do you want fries with that?

Next Post: Why Slow Medicine might actually work.