Cultural Competence at the Bedside

By Damiana Andonova

A clinician will encounter patients from all socio-economic strata, who speak foreign tongues and understand disease in ways that stand apart from the clinician’s own conceptions of disease etiology.

Perhaps they might encounter a Hmong elderly who complains of a heavy heart. What physical exam does one perform? Their spiritual understanding of disease etiology is linked to their soul, as Anne Fadiman eloquently explains in her text, “The Spirit Catches You and You Fall Down”. The proper course of action may not be just a diagnostic test but perhaps a concert of medicine and spiritual tradition.

Perhaps a 20-something Bulgarian mother demands she feeds you bread and honey before being discharged with her newborn after an emergency Cesarean.

Or consider the scenario that I experienced as a young medical observer:
A Chinese woman experiences post-partum depression after completing a traditional post-partum zuo yuezi, or period of confinement after her pregnancy; an Asian practice that is becoming popular in United States as well.

Abraham

For clinicians it may be difficult to negotiate the culture shock that can take place in the doctor’s office. Yet, the academic community’s response to teaching less technical competencies at the bedside usually results in the creation of many inaccessible, didactic texts that, while aimed at helping students learn, actually bring the student farther away from the bedside and leave the student confounded.

To shy away from academic reviews of the literature and copious reading lists that can be offered to shed light on this issue, we share a quick lesson of cultural competence at the bedside.

Harvey Cushing is perhaps, the greatest neurosurgeon of the 20th century. You may recall many eponyms including Cushing’s clip, law, and symphalangism; Cushing’s syndromes I, II, and III; Cushing’s triad, and some other hyphenated syndromes such as Bailey-Cushing syndrome. Of his many accomplishments, a singular quote on the obligations of physicians is memorable,

“A physician is obligated to consider more than a diseased organ, more even than the whole man — he must view the man in his world.”

This is an extremely fallible yet certainly achievable task. If you’ve listened to Dr. Abraham Verghese’s memorable anecdote about the linoleum factory worker (link), you’ll note Sir Joseph Bell performed his obligations to a sound degree.

Cultural competence is very useful tool to gauge how to approach a physical exam and what practical advice to offer to a patient.

Consider this case:
“The Hand Injury”
An uninsured, yet documented immigrant housekeeper visits Cook County Hospital after a serious injury to her hand while cutting an avocado. “The Hand Injury” received proper care and surgery, and is a single parent whose earnings rely on her ability to iron clothes, to wash the dishes by hand, and to vacuum.

Considering her job security is almost zero (private domestic workers can be fired at any time; they receive no mandatory paid or unpaid sick leave), how might treating and advising her as a hand surgery patient be different if she were a high school math teacher? Would it be any different if she were a freelance jewelry artist?

A long review of the literature will simply show that the discussion of cultural competency and sensitivity at the bedside includes awareness of socio-cultural diversity and the social production of disease as well as its implications at the bedside. An article might recommend a semester course in medical anthropology, too. Understanding her background can provide clues as to how to approach her care, and personalize it so that her care is effective, and as the industry prefers, efficient. Being culturally competent will also render “the hand injury” a useless synonym for her name.

The Stanford 25 bedside sessions as well as the Bedside 5 Minute Moment attempts to bring students closer to real patients and help them gauge differences between caring for the textbook patient and a real patient. Working at the bedside, then, brings students closer to the actual patient, and like Cushing says, gives residents a chance to “view the man in his world”.