In the Clinic: The Importance of a Culture Understanding of Illnesses and Healing

"Everything is subjective," says my tenth grade teacher (He goes on to say, "However, everything you learn behind the walls of this school is fact, and you will be tested on how well you memorize these facts every other Friday.")

His words came back to me when I was studying medicine in antiquity, where the healers worked in the shadows of a statue of some god or chanted and prayed to some deity. I'm sure you've all heard of weird and sometimes distasteful treatments. Like drilling holes into people's skulls to relieve them of a headache. Or eating the testicles of your enemy to gain his strength. While some of these were extreme, you've got to admit that they would not have prevailed for hundreds of years if it didn't work somehow.

Medicine and how successful it is relies primarily on public perception. If people trusted the shamans who told them leaving their sick and elderly behind to fend for themselves was the right thing to do to ward away illness, they would. If people believed that spirits were the cause of epilepsy, they will rely solely on their prayers to the gods for treatment. If people believe that science works, wouldn't they be more willing to take all those weirdly named pills the good doctor, with his fancy stethoscope, prescribed?

Unfortunately in the Western world, where I live, there comes the assumption that everyone believes in science. Medical students are taught that when a clot that is formed somewhere else in the body travels through the blood stream to the brain, the brain is deprived of oxygen and can lead to death of brain tissues, a situation known as a stroke. They are not told that strokes are caused by malevolent spirits or by excessive pressure of the brain on the skull, as some cultures may believe. What, then, does one do when one encounters a person or a group of persons who believe there is a non-scientific explanation to a disease? Do we tell them they're wrong? Do we impress on them our knowledge and insist that we are superior?

The health professionals that deal with patients on a daily basis, namely doctors and nurses, are not trained to understand the beliefs of other cultures. Education of the cultures of other people should be allotted to the anthropologists, archaeologists, and tribal buffs of the world. To suggest that we include such worldly studies in the syllabi of medical schools, nursing schools, and training programs is impractical. But to emphasize the importance of the caregiver's understanding of his or her patients' beliefs is not.

A health professional is guaranteed to encounter a different culture sometime in his or her career. Such an encounter could be as simple as receiving a gift from a thankful patient to something as frustrating as convincing a stubborn, non-English-speaking patient to undergo surgery for a life-threatening condition. Such encounters can shake both the professional and the patient to the core.

In a 2005 study done in the US, patients of all races and ethnicities were asked questions about their perceived quality of care.

Patients reported a more positive experience when they believed that their providers:
Showed sensitivity to Complimentary and Alternative Medicine (CAM)
Were willing to incorporate CAM into treatment plans
Had ethnic concordance with the patient
Included family in healthcare discussions and planning
Accepted the role of spirituality (by allowing the patient's ministry to be included in treatment and by respecting spiritual preferences)
Took a humanistic approach (by showing sensitivity to patients' needs for privacy, by making eye contact, by using non-technical and thorough explanations, and by treating patients as equals)
Elicited information from patient (and not making assumptions about health beliefs and education)

Patients felt providers could've improved by:
Not making assumptions about insurance due to the patient's race or ethnicity
Accepting and equally prioritizing patients receiving a broad spectrum of insurance plans.
Taking the time to understand the patient’s understanding of the health concern.
Assuming the patient is an equal partner who is interested in his/her health.
Using resources to address language barriers (obtain interpreters, bilingual staff, or translated materials).
Taking time to explain the illness from a medical perspective but consider it part of a larger understanding that also includes the patient’s perspective (by paying attention to the patient’s subjective experiences and to the patient’s understandings of disease etiology)

In response to this study, the L-E-A-R-N model was created to help medical students in particular to provide culturally competent care:
Listen with sympathy and understanding to the patient's perception of the condition.
Explain your perceptions of the problem and what would be your strategy for treatment.
Acknowledge and discuss the differences and similarities between your perspectives.
Recommend treatment while remembering what you have learned about the patient's cultural parameters
Negotiate agreement. Make sure you understand the patient's perspective so that you can ensure the treatment plan fits his or her cultural framework.

Everyone views life through a unique cultural lens shaped by experience, background, and education. It is understandably hard to reshape the lens to match what another individual has and see life through his or her eyes. However, that does not mean we can't try.

Resources and sites of interest:
Anne Fadiman's The Spirit Catches You and You Fall Down: A Hmong child, Her American Doctors, and the Collision of Two Cultures
Transcultural Care
Stardust - Glow

Transformed Illness - Diabetes

The class discussion I participated in a few weeks ago was about the evolving role of the physician, and this soon led to a discussion about the moral issues that comes with "healing." We depend so heavily on the physician's ability to heal that we don't notice most of the time, "treatments" are actually used to support life. To what extent should that support go? This is where all those medical ethics and moral conflicts come in. Oftentimes, we mistaken longevity for cure, and people go ecstatic over these instances. But as the professor said, there is no magic bullet.

An example we studied in-depth was diabetes. Prior to the 1920s, diabetics could only hope to live for three years after diagnosis. It was seen as a very serious disease because it targeted mostly children, who unfortunately would never live to adulthood and do things other children could do. In the late 1700s, it was discovered that when evaporating a diabetic's urine, a kind of "brown sugar" was left behind. This led to a sugar-free diet first prescribed in the 1790s to diabetics that soon evolved into a meager 960-calorie diet that was the only treatment for diabetes. In the late 1800s, the idea of "insulin" in the pancreas emerged as a theoretic substance whose absence may lead to diabetes. This was done when a physician took out the pancreas of a dog and found that the dog's urine was sweet, similar to that of diabetics. Then in 1921, a team of Toronto lab researchers isolated the mysterious insulin substance, and the following year, insulin was mass-produced as the miracle cure for diabetes - there are always consequences.

The reason why the treatment caught on so fast was the dramatic before-and-after shots that were published in scientific journals. Here's an example picture:
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Before insulin treatment, a child would be all skin and bones and would be cradled tenderly in their mother's arms. After insulin treatment, the same child would be much rounder, healthier looking, and standing on his own. While there were such instances and extreme differences between before-insulin and after-insulin, in most cases, there really wasn't much a difference between how the child looked. The effect of insulin was therefore exaggerated. The insulin was also heavily advertised as something that can allow your child to live a long and fruitful life - have children, work, and be independent. Just a daily shot of insulin and a well-planned diet was all your child needed to overcome his disease.

Unfortunately, there was another side to this that was rarely shown to the public. True, diabetics were now living to the age of forty, fifty, and having their own kids and living their own lives. But they were still dying of diabetes. What's more is that what was once considered an acute disease, diabetes now became a chronic one, riddled with complications such as kidney failure. Diabetic patients were now living with an extreme dependency on the health care system - they need their insulin shots, they need regular check-ups with their physicians, they need dialysis machines. They aren't the independent, smiling adults whose pharmaceutical companies used to promote the use of insulin treatment. And when the effects of insulin had finally come to light, physicians couldn't go back on treatment. Now that a patient's body is so completely dependent on the outside insulin, taking it away would prove fatal.

And finally, there's the issue with the transmutation of disease. After a decade or so of insulin treatment, physicians began seeing that insulin wasn't working for all patients anymore. Some patients were able to produce their own insulin BUT were still producing sugary urine. Ah, the birth of Diabetes II. When the natural course of diabetes was intervened by insulin, the pre-existing disease evolved into something wholly new.

The reason why diabetes is such an important disease to study is because it is THE modern disease. The history of diabetes, a disease from antiquity, its "cure," and its complications are seen in various other diseases that plague our society today, i.e. heart disease and cancer. As one disease's prominence in a community decreases, life expectancy increases, and thus allowing another disease to take its place. It's a neverending vicious cycle, one that all sparked from the desire to create a new human who can survive what his ancestors could not.

Bittersweet: Diabetes, Insulin, and the Transformation of Illness (2003) by Dr. Chris Feudtner
Stardust - Glow

About this community: Extended

This journal was supposed to be the "serious" companion to bethyb00sh's private journal. As I learned more and more about the history and evolution of medicine and its implications for humanity, I felt the need to express my opinions and my interpretations on the issues that have sprung up throughout the ages and find out what my peers thought of these issues. While I had initially begun to share these posts with my friends, I realized that the posts on serious, broader topics disturbed the flow of my personal journal since these issues aren't personal anymore; they involve the community. So why not create a community for it?

This community is first and foremost an interactive community for the general audiences. It is not a lecture journal where I try to impress on you random bits of history that you have no need for. It is not a scientific journal where you will learn how to make an x-ray machine. Rather, it is a journal where you may learn how the invention of the x-ray affected World War II and how the lessons learned from the x-ray can be applied to the adaptation of 21st century technology. Sure, you may learn a few random historical and scientific facts, but they do not help us understand and see the wider picture. And to truly draw conclusions about ethical issues, such as organ donation and euthanasia, one must read and discuss both sides of issues.

Flashing your knowledge here and there means you have the ability to copy and paste from Wikipedia.

I will be posting often, as often as ideas spring to mind, but I do hope this community will expand large enough so others may post topics that they'd like to discuss/learn more about.

Posts will be organized in the memories according to the topic. Tags will be used to organize themes, content, relevant countries, and year the topic became a major issue.

Therefore, the requirements for posting/commenting in this community are:
+ a brain (functional or not)
+ a computer (or expensive handheld gadget with Wi-Fi)
+ an idea

This post will be used for general questions/comments/suggestions about this community.