Saturday, June 8, 2013

Culture and Medical Care

It is now 25 years since Lynn Payer wrote “Medicine and Culture: Varieties of Treatment in the United States, England, West Germany and France”.  Published in 1988, Ms. Payer’s book imparts a message that should be repeated frequently.  The message is that medicine is cultural and not only scientific.  Despite the fact that different countries have the same results as measured by mortality rates, the care differs significantly in the types and quantities of drugs used, in the kinds and numbers of operations performed and even in the definitions of what is “within normal limits” and what requires treatment.  She made the observation that these differences in the approach to illness can be explained by differences in culture and values ingrained over hundreds of years. 

Ms. Payer wrote this book while she lived as an American in Paris, working as the health and science reporter for an American newspaper.  She had lived her whole life in the US, having been born in Kansas and had then spent 8 years in Paris working and writing.  Ms. Payer died too soon in 2001 at the age of 56 from breast cancer. 

I find myself picking up and re-reading her book from time to time to get inspired by the simplicity of her message and the profound implications of what she had observed.  So much of medical decision making is cultural and values driven.  Even though medicine has a scientific backbone, the way the science is used by doctors and patients alike, is based on values and trust.  Culture is important because therapeutics must be based on a trust bond between health professional and patient.  That trust bond is built by understanding and communicating values and cultural norms in a way that reflects respect for and autonomy of the person in need.  If you don’t understand and accept the differences of people in the four western democracies that Ms. Payer describes in her book, you cannot understand and accept the differences in people from far more diverse cultures.  In order to be effective in truly touching that person in need and foster healing, a health professional must meet that person on their terms.  That holds true for all cultures around the world and also holds true for differences in cultural norms in different regions of the United States.  It even holds true for different subcultures related to schooling, profession, and socioeconomic status. 

A recent case in point at my company Accolade brought all this to mind.  A young woman from an English speaking country was transferred to the United States by her company.  This brilliant scientist found herself in the exciting yet daunting position of gaining a promotion but also having to move to a new culture.  Language was not an issue however changing cultures can still be quite difficult.  Her Health Assistant at Accolade had been helping her intermittently with understanding her health benefits and her health plan as this was totally foreign to her since her move to the US.  This stress was taken to a new level when she became ill and was admitted to the hospital.  In the hospital, the cultural challenges intensified.  She was told that she had to have a procedure and that without the procedure, treatment could not be initiated.  She then asked what the complication rate of the procedure was and was told that she would do fine, and that the complication rate was only 1 in 100.  As she was in a teaching hospital, the message was given by a doctor in training, a resident, and the doctors appeared to her to change on a daily basis.  She felt alone, frightened, and even in danger.  For a scientist used to working with quality parameters of 1 in 250,000, 1 in 100 seemed barbaric.  She interpreted this as meaning that since a doctor in training, who was not very well trained, was going to do this procedure they expected it to be much riskier than it had to be.  They also told her that she was too sick to be discharged from the hospital and that she either had to have the procedure or just get sicker.  She had no options.
She felt like a prisoner.  She felt as though there was no one on her side.  At that point her Accolade Health Assistant®, Kate, was the only person she could turn to.  The patient was speaking to Kate, who she was starting to trust, on a daily basis.  Kate, understood that she did not have all the expertise in that young woman’s cultural background that she needed so she turned to another Accolade employee, Mary, who is not usually on the front lines with people in need, but who came from the same region of the same country as this young woman.  Mary immediately coached Kate on communication norms that would help to build trust. Subsequent phone calls reflected that cultural intelligence in communication.  After a few calls, that trust bond was strengthened in order to help this young woman through her illness. Mary also began to talk with her on the phone creating more trust for the entire team at Accolade.
The end result was a patient who felt supported and empowered and who was able to subsequently be transferred to another hospital in order to have a fresh start in building trust with a new medical staff in order to move therapy forward.  It did turn out in the new hospital that the previous well known teaching hospital had been giving her medication in doses that was toxic to her liver.  That toxic effect was reversed and she started to improve. 

I think about all this and wonder if evidence based guidelines which are purely based on science, and not on culture or values, leave out a critical point.  I wonder if the push for productivity that forces doctors and nurses to spend less time finding out the values and cultures of the people in need sitting in front of them will ultimately lead to worse care.  I wonder if we can maintain and even improve our ability to effectively treat people in a way that values them as autonomous independent people when we seem to be pushing in the opposite direction, even with the best of intentions to try to build a more sustainable system from a cost perspective.  Ultimately, medicine is personal with one person touching another in a way that is intimate, honorable, and respectful of all that the person in need is as a fellow human being.  We should accept nothing less as health professionals or as patients.