Monday, February 16, 2009

Week Seven Online Challenge

This week's online challenge is more of an assignment. We haven't assigned much reading this week in the hope that you'll be able to read a little bit on line.

Visit and read about one of the four following ethnic groups: Karen, Hmong, Somali, and Oromo. Choose a group you're not familiar with. Think about how family structure or culture-specific health issues might influence your interaction with such a patient. What would be different about your ED interaction with a patient from one of these groups? What additional resources would you need? Would your approach to care differ? If you can't think of a reply that is specific to the ED, post an interesting fact from what you read to educate the rest of us about a new culture.

Also, if you are not familiar with The Spirit Catches You and You Fall Down, by Anne Fadiman, here is a case (set in the ER) from that book that you will benefit from reading. (Click HERE!)

Finally, if you have time for some additional reading, consider following links to two other articles I found interesting during my own preparation for this week.

Conceptions of Pain Among Somali Women. Finnström B, Söderhamn O. J Adv Nurs. 2006 May;54(4):418-25.

Principlism vs. Narrative Ethics. McCarthy J. Med Humanit.
2003 Dec;29(2):65-71.


  1. From the readings on the expectations of Oromos, I suppose one thing I would do is prescribe something for them regardless of their reason for the visit. This is due to their expectations of getting a medication every time they visit with a physician. I had a similar experience while doing some international work, actually. The population that I was taking care of expected something for every visit, so regardless of the medical problem I would always give them a medication even if it was just multivitamins. Without this they often felt like they were being insulted or not taken seriously.

  2. It sounds like the Karen might see an American ED as a rude and uncomfortable environment. The cultural profile states that the Karen find directness, loud speech, etc. rude, and I can't imagine a place where they would find more of it than in the ED.
    The profile also states that the Karen make decisions in groups, often with an intermediary, and are not always forthcoming with their needs or wishes (presumably in an effort to avoid confrontation). All of this could make the process of information gathering and quick decision making in the ED quite difficult. The ED physician would benefit from having knowledge about the Karen culture, and should definitely avoid becoming angry or confrontational with a patient s/he might mistakenly consider "difficult". It might be a good idea to involve a family member or friend in the decision making process, or to explicitly state the cultural barrier and explain your needs to the patient (if possible).

  3. Bryce has a point and it doesn't even just apply to the Oromos. Many patients want a "commodity" when they see their doctor. This can be a prescription, a cast, an injection, a lab slip. But they want something. Often times, giving them discharge instructions and handouts can be that thing, but frequently, they want "more." Giving them a vitamin can often be the solution.

  4. I decided to read about Ethiopian culture instead of the four identified as I am considering adoption from Ethiopia and take any chance I can to learn more. Thomas, I hope this is OK.

    One of the bits of information provided about Ethiopian culture is that women do not think that C-sections are safe. Ethiopian women living in the US think that American doctors resort to C-Sections for conditions that they consider within the normal variances to be expected. The article also mentioned that many Ethiopian women remain at home until well into labor in an attempt to avoid an unwanted C-section.

    I can imagine a situation where an ED doc encounters a woman in need of a C-section who has waited as long as she could until arriving at the hospital. The doc might assume that a C-section would be an acceptable decision for this patient and be puzzled and frustrated by any resistance to that course of action. Especially in the ED and with a patient who has waited until the last minute to seek care, the physician will benefit from understanding the patient's pre-dispositions against C-Section.

    The physician might want to utilize an interpreter or someone familiar with Ethiopian traditions to help explain the need for a C-section. It might be possible to contact the woman's OB (as pre-natal care is accepted in this community). The physician might also need to consider whether the patient can continue labor or complete the delivery without a C-section, even if this is the preferred outcome for the physician.

  5. On the other topic: I actually read McCarthy's article on Narrativism in the Philosophy of Medicine class last quarter. I wrote my final paper on this topic, considering whether I thought narrative rose to the level of moral theory (I do not), what I thought it could not do successfully (be the primary source of information for diagnosis) and what I thought it was good at (fostering communication, honoring cultural differences without relying on stereotypes, treating the patient as an individual, not an illness and improving collaboration amongst the care team).

    I do not know if it's OK to post my paper (or how to do it, even if I thought it was OK). So, I will send it to Thomas and he can post it if he deems appropriate. I would welcome anyone's interest in giving it a look, as well as any comments readers might want to make.

  6. From the article on the Hmong culture, I found several aspects of their culture which I could see clashing with the culture of an American ER:

    - it is inappropriate for males to be too close to females while conversing
    - social services (including medicine) are provided within clans rather than by state or federal society
    - Hmong women may not seek prenatal care until the pregnancy is visibly evident (for fear of evil spirits causing an abortion)
    - patients may feel the need to die at home, rather than at the hospital or SNF

    As for how my approach to care would differ, it would be nice to have someone on staff who knows a little bit about the culture (or perhaps a family member who can act as an intermediary) b/c I could see myself stepping on toes all over the place...

  7. The care difference between different ethnic groups would be difficult in certain circumstances in the emergency department. First it is important to treat the physical emergency which in most cases will be similar between different cultures. It is important to also when possible work within the cultural norms. The cultures may be less open to communication, have a certain family member lead, or place different respect to different members of the group. These are important to keep in mind for patient atonomy and cooperation of the patient. Medicine is a team sport, understanding different culutres will better inable the teamwork to proceed.

  8. In reading about Somali women, I thought about research that has shown that women and minorities receive less analgesia for pain in the ED. I am worried that Somali attitudes towards pain and suspicion of Western health care can seriously impede treatment of pain for Somali patients. Since Seattle is one of the cities where large numbers of Somalian people have relocated, I think it would be in the best interest of providers here to become familiar with Somali attitudes towards pain, especially how they believe it is best to be stoic about it, even for small children. I think it would also be important to be familiar with quality interpreters through which providers can express their concern for the patient and their desire to treat the patient, including the patient's pain.

  9. In the ED, we often need the assistance from interpreters. One thing I find very interesting in the field of interpreting is that various dialects exist and that it may be difficult to effectively communicate despite having an interpreter present. From “the words used for parts of the body vary in different dialects, so an Oromo interpreter may not know the right term to use with a particular woman.”

  10. The Karen people find it disrespectful to touch someone one the head, sustain direct eye contact, and normally do not shake hands (but do in dealing with Western culture). These are small "culture bumps" that I would commit without even thinking about it. A translator who knew a little bit about appropriate culture customs would be very helpful in establishing trust and respect in a relationship with a Karen patient. Also general awareness of this information is helpful because I'm sure these aren't the only people that would find these Western customs a bit overbearing.

  11. I found the Somali culture's beliefs about suicide to be interesting. This came up in the "interaction with medical examiner" section. In particular, what interested me was when an autopsy has to be done by law for particular potential causes of death like suicide, violent crimes, etc...and how frowned up performing autopsy is among Somalians. The answers this article gave about how to handle such situations were insufficient in my opinion. I would like to know more about how to deal with situations when you are bound by law to do something that is contrary to cultural beliefs. What can you do besides just saying "it's the law".

  12. Between Ethnomed and research studies listed on Pubmed, Refugees of any of these ethinicities are at higher risk for PTSD and other mental health disorders. The most unique thing about it is the symptoms we use to diagnosis are not symptoms they have words for, so diagnosis is extremely difficult. Usually the symptoms are presented in physical symptoms and are missed.

    Also in Somalian culture, there are many gender issues that we do not have in American. Like a a male is not supposed to be touched by a woman or a woman by a man, however as you can imagine this could be very difficult in an emergency setting.