When culture and medicine collide

When culture and medicine collide – Knowledge of cultural differences needed

Julie A. Brow

As new immigrants flock to the United States each year, it becomes more challenging and important for health care professionals to be sensitive to cultural and religious traditions different from their own while still providing optimal care for these patients. Confounding the influx of unfamiliar cultures is the relative lack of knowledge among medical professionals about other cultural groups. This can, at best, lead to misunderstanding and, at worst, compromise the care and treatment of a patient. Dentists and dental assistants must work together to ensure that patients feel understood and respected, and must also understand their own roles and limitations in patient care when the patient’s culture or religion collides with standard medical practices.

Listening makes a difference

Although, as a dental assistant you are not permitted to function without supervision, it is within your scope of practice to treat all patients with compassion and empathy. Part of being compassionate is being an attentive listener. One of the most common complaints of patients is that no one listens to them anymore. By listening to patients, you can learn valuable information that can alleviate cultural conflicts that may arise over the course of treatment, and thus be powerful partners in optimizing patient care.

Sometimes listening is not enough and other tools must be employed. There are instances when patients will cite religious reasons for not having a procedure done, but those reasons may turn out to be erroneous and show a lack of understanding of their own religious doctrine. It is important to be respectful and nonjudgmental when confronted with this possibility and ask if the dentist might be able to speak with the minister or other religious leader on the patient’s behalf. (1) However, according to Myrtle Flight, CMA, MEd, JD, it is not ethical or lawful for any health care professional to try to coerce a patient to undergo a procedure. “It is up to the patient to decide,” she says.

Education is key to understanding

Another key component to providing good patient care to a culturally diverse population is being proactive and learning as much as possible about the cultural heritage, beliefs and customs of patients. You can take classes offered at a local community college or perform searches on the World Wide Web. (2)

The misunderstanding of other customs can create a breach of the trust that is needed between a patient and dentist for effective care. For example, Korean- and Mexican-Americans often withhold information from a sick family member about the prognosis. They do not want to further burden their loved ones with negative information. Another example is the perception of the origin of illness among some Native American tribes. They believe that illness comes from an evil spirit and therefore needs to be driven away by a traditional tribal healer. A seemingly harmless refusal of a small gift from a recent Japanese immigrant or an Alaskan native is considered an insult and can have profound repercussions. According to a report conducted by the Hastings Center, “Failing to recognize such important cultural influences on seeking, understanding, or complying with recommended treatment may result in inadequate care, causing key ethical problems.” (2)

Jan Chase-Nelson, Certified Medical Assistant, of Pediatric Partners in Fremont, Neb., discovered first hand how ignorance about the culture of the Mexican community that her clinic serves can lead to misunderstandings and compromised care. “I took a 10-week course, Spanish for Medical Professionals, that covered not just the language, but the culture as well.

She also notes that in Mexico, a prescription is not needed to get medication and so the idea of bringing their prescription to the pharmacist in order to get the needed medicine is foreign to them. She often has to explain to them how it works here.

When there is a language barrier as well as a cultural barrier, sometimes it’s better to refer patients to another office where one of the staff members speaks the patients’ native language, particularly if patients do not bring an interpreter with I them. In the future, Chase-Nelson believes that more medical professionals will need to be bilingual.

Conflicts can still arise

Even with sharpened listening skills and knowledge of the cultural background of patients, conflicts can arise. “In the case of a child,” explains Flight, “the courts can override the religious beliefs of the parent. Although both sides would be given the chance to present their cases, if it can be shown that a treatment is in the best interests of the child, the court can rule against the parent. If the parent refuses to comply with the court order, charges of child abuse or medical neglect can be filed. However, it’s never quite as simple as this.”

Seeking the legal route is not the only choice or even the best choice. Many times, conflicts can be resolved by paying attention to body language and tone of voice, by seeking the other person’s perspective and by using conflict management or mediation skills.

Chase-Nelson was able to recognize and defuse potential conflict by seeking to understand the other person’s perspective. Her office always requests Spanish-speaking patients to bring an interpreter, and on one occasion, the interpreter became upset. “A child was brought in for his kindergarten physical and i was asking his parents if the family had had any exposure to TB. I asked if they had been out of the country or if they had had non-US visitors. The interpreter became irritated because she thought I was targeting them as Mexicans. I had to show her that these were routine questions we ask of everyone, regardless of ethnic background. I explained to her that we get businessmen who travel to other countries and may be exposing their children to disease. She calmed down after that,” she says.

It’s not always that simple, though. Conflicts can be multifaceted and laced with deep emotion. Some of that emotion could be yours. The first step in working through conflicts is to take a moment to bring your own emotions under control, it is important to be calm and clear-headed. The next step is to establish the process by which the conflict should be addressed. Patients might just need to blow off steam, they may want a private meeting with the dentist or they may want you to do something for them. The process needs to be established to prevent further escalation of the conflict. Remember the necessity of confidentiality. Avoid addressing a conflict in the hallway. Instead, go into an examination room or offer to speak with patients outside office doors.

Next, ask patients to describe their feelings and their experience of the conflict in a neutral way, while you keep an open mind. Offer your perspective of the problem in a nonjudgmental, neutral way within professional standards of conduct. Remember that it is not your role to try to convince patients to undergo treatment. But, you can listen and you can show that you understand.

Acknowledge patients’ perspectives and help them find options that are acceptable. This may mean talking to a religious leader or, if patients absolutely refuse treatment, helping them to find resources to make their lives more comfortable. Try to be flexible so that creative outcomes are possible; a narrow perception of what options are available for patients can be counterproductive. (3,4) If there is no reasonable resolution using this type of process, it may be more appropriate to refer patients to a medical counselor or, if a child is involved, the physician may choose to seek legal counsel as a last resort.

Health care is a personal profession and often, no matter how prepared you are, it comes down to a matter of trust. “You need to carry yourself in a positive way. People can sense that. Use your instincts. There are always going to be conflicts of opinion whether they are because of religion, HMO coverage, or just personal preference,” advises Teresa Nichols, CMA, Chicago. Trust is the most important aspect of any ongoing relationship, and starts with an open heart and a bent ear.

A PRACTICAL CONFLICT MANAGEMENT PROCESS

(Adapted for health care professionals)

1. Reframe the conflict. Think of it as productive, not destructive. Remember, conflict is inevitable and manageable.

2. This conflict is part of a process that developed over time. Reflect on the situation briefly and address your own feelings, as well as observable facts relevant to the conflict.

3. Arrange the proper place to discuss the situation.

4. Give and request feedback. Invite the person to describe what he or she views are the issues and what those issues mean to him or her. Once the patient is finished, give your perspective of the issues, keeping in mind who and what you are representing. Do not interrupt the other person, and always listen carefully to what he or she says.

5. Brainstorm resolutions to the conflict. Discuss the options and evaluate them. Explore the viable ones.

6. Agree on a plan.

Source: Washington State University (3-4)

Adapted and reprinted from PMA, Jan/Feb 2001, published by the American Association of Medical Assistants, [c] 2001.

REFERENCES

(1.) Cohen C. Prayer as therapy. Hastings Center Report. May/June 2000;30(3): 44-46.

(2.) Roberts L. An office on main street: health care dilemmas in small communities. Hastings Center Report. July/Aug 1999; 29(4):28-37.

(3.) Washington State University. Working through conflict with others. Available at http://www.wsu.edu/~hres/others.htm. Accessed September 7, 2000.

(4.) Washington State University. A practical conflict management process. Available at http://www.wsu.edu/~hres/managing.htm. Accessed September 7, 2000.

Julie A. Brow was employed at the American Society for Clinical Pathologists for three years before becoming a professional writer. She has more than 30 published credits, including publication in the award winning journal, Laboratory Medicine, and a women’s health column covering the relationship between heart disease and race in Access.

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