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 Knowledgeable and Empowered Parent

Last night I went over to the home of a couple of my patients to drop something off.  The dad greeted me at the door and said that his daughter had something for me.  The 7-year-old gave me the picture above.  Impressed as I was, I asked her why she chose this subject.  “Because we were really sick!  You could have made us feel better.”  But I didn’t know anything about it.  Her parents had never called.

Much of what I write about could be called parenting.  Hopefully, the cases I describe are instructive in some way.  It’s logical that a first-time parent will learn more new information than a more experienced parent, who have seen and experienced so much.

Indeed, part of my Slow Medicine practice model (described in parts 1, and 2) is taking the time not just to engage with the child but also the parents.  I want to make the parents feel like an essential part of the health apparatus applied to their child.  In what I call the ‘factory model’ of medical care currently being practiced, patients are nameless widgets whose crucial function is to be passively processed as quickly as possible.  Above all, they can’t be allowed to slow the velocity of throughput.  I want to take the time to explain things to parents, describe my approach to the problem and what the options are as I see them.

Over time, however, I have discovered an unexpected aspect of this method.  Empowered families feel empowered.  Strangely, this hadn’t occurred to me right away.  I did realize that from the payer’s point of view (the insurance company), it was an absurd and obvious false economy to push patients to be seen as quickly as possible.  Though it might cut insurance expenses this month or this quarter, over time each patient would have to come in again and again for their one or several problems.  Teaching them to manage their own care better will save both patient and insurer a lot of real money.  Keeping patients out of ERs would save even more.  This post, however, isn’t about the counterproductive financial incentives of our dysfunctional system, and the ways it doesn’t work.  This post is about the system I came up with, and how it does work.  I want to be up-front about the economics, however, and get that out of the way.  Like every primary-care physician, I am paid per visit.  No visit means no pay.  It may be true that if you give a man a fish you feed him for a day but if you teach him to fish you feed him for a lifetime.  Still, it seems strange to run a fish store with a tuition-free fishing academy.

(As an aside, when I was in Business School a few decades ago, piecework was considered so obsolete and ineffective a model of employee compensation that it wasn’t really covered.  I couldn’t have guessed that one day I’d be living the dream.)

In The Telephone Paradox, I note my experience of changing people’s behavior just by answering the phone.  Not so much but what I say, but just by picking up.  As parents came to believe that they really could reach me directly at any time, nights or holidays, they actually called less.  They came to see that since they could always call if the child got worse, they could wait and see for a moment.  Given the opportunity, many of those sick children did get better on their own, and so the parent never actually called the doctor.

My practice is populated by a very diverse group of families.  Many of the nurses at the nearby hospital bring their children to me, along with many of the physicians.  They all know lots of things that I don’t know.  As the parents in non-medical fields become more educated and empowered, by me and by their own experience, they too make a lot of their own treatment and diagnostic decisions.

‘This is what I wanted!’ I sometimes have to remind myself.  A group of smart, independent-thinking, empowered parents who can handle a lot of routine medical issues.

The problem is, they don’t come to the office.  When the children get sick, these parents are rightly self-assured that they can handle it.  They were carefully instructed by me about the method and purpose of treatment, and what to watch for.  Besides, they know they can call me at any time.  I’ll always see their child the same day, even if it’s at night or I have to come to their home.

As it turns out, I’m not sure this is really ideal.  I worry about parents being a little too confident, and missing some important aspect of the child’s condition.

I also worry more about missing patterns of illness that I might pick up over time, by seeing when or how often certain symptoms were happening.  In the case of Tammy, her horrible rash kept appearing on Mondays, a day after visiting grandma.  There are many medical problems that are identified by pattern-matching, and like a pixelated picture, more data produces a clearer image. 
Surprisingly often, I see a child in the office with the following dialog.

“It’s nice to see you.  How have things been going?”
“Great,” says the parent.  “She’s been really healthy.”
“I’m glad to hear it.  So what brings you in today?
“Well, she’s been coughing a lot at night.”
“For how many nights?”
“I don’t know exactly.  Maybe 4 or 5 months.”

There are important, unspoken—and mostly unstudied—aspects to medical care and the doctor-patient interaction.  Her parents may have been right in deciding that they knew how to handle the illness and I wouldn’t have changed anything.  But for children (and this is true for many people of all ages), going to the doctor helps to make them feel better.  I think it’s one of the reasons that people sometimes complain when the doctor never examined them or listened to their heart, even if they are there for an unrelated problem.  I think there’s a real therapeutic value in physical touch and just listening attentively to the patient’s complaint.  So although her parents may have been precisely right about the appropriate therapeutic intervention, and maybe I couldn’t have made the child get better sooner.  But they didn’t see that maybe I could have made her feel better sooner.

Perhaps this is why doctors and nurses bring their kids to me.  I may not know more, but I’m the doctor, and that gives them permission to be mom and dad.

Slow Medicine: The Telephone Paradox

When I tell other doctors that my patients have my home phone number, they simply don't believe me. I tell them that calls to my office in the evening and on weekends or holidays get automatically routed to my cellphone or home phone. There is no answering service or triage nurse.

I set this up because the job of the answering service (this is one of the selling points they use for doctors) is to minimize the number of calls they put through. They seem to be measuring their effectiveness by how impenetrable a barrier they are for the patients. When your child is sick, if you want to talk to a doctor—forget the possibility of talking to your doctor—you have to sell the person answering the phone on how desperate your situation is, but not so desperate that they tell you to go to the emergency room. I want to get those calls, and want to know what's going on with your kid.

But my colleagues don't believe it. They tell me that if they let patients call them at home, they would get calls through the night about trivial things. They would suffer and their patients wouldn't benefit. I used to work for a big group practice, and this seemed a reasonable summary of my experience, too. So nobody actually tried it.

Here's what I found. The more I gave out my home number, the fewer calls I got. When I opened my own practice, I could actually program the office phone to direct all the calls automatically. Patients didn't even need my home number, they could get me at home any time. I got almost no calls. In the last 2 years, I have been awakened by phone calls just 6 or 7 times. In each of these cases, I got out of bed, got dressed and either made a housecall then or met the family in the emergency room. So those few calls were well justified.

As I thought more about this paradox, I realized that the general population of doctors had become so convinced of the universality of their experience, that they didn't attempt to repeat my experiment. I think there's an interpretation that isn't so mysterious.

First, in my Slow Medicine practice, everybody knows me. They see the same doctor with every visit and talk to me with every phone call. This leads to a humanization of the doctor as more (and less) than a BMW with a white coat who barely makes eye contact in the five minutes he spends with you, forgetting your name. So I suspect people are more respectful of my private time, the way we all are with our own friends and family. They all know that when they call at night, they won't get an anonymous shift-worker at a call center.

Second, Slow Medicine is all about access to the doctor. Once the parent is convinced they really can get a hold of me anytime, they are more willing to try and handle minor problems on their own. The thinking, I suspect, is that if the child gets worse, they can always call then. That results in perceptive parents carefully observing their sick children. If they get worried, if it gets a little too much for them to feel comfortable with, they can always call me at that time. So parents handle a lot more on their own, I think. In this way, there is another paradox. The fewer calls I get, the more empowered and self-reliant the parents feel. They know I'm there to back them up, so they might be willing to take a few steps on their own.

I believe that the ability to get in touch with your child's personal doctor in a crisis is often very beneficial to the quality and continuity of their care. Besides, if you have confidence in your doctor, and can get your doctor on the phone, then you'll have confidence in the phone advice you get. It's logical that this confidence is itself reassuring, even without actually making the call. This paradox helps me sleep better. And maybe the parents of my patients, too.

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.