Unit 8Section 1 Cross-CulturalExercise 1 Communication Barriers Across Cultures

Clinical correlate #1 Cultural Sensitivity

This section explores some examples of how cultural differences affect families and health decisions. Cultural differences may reveal themselves dramatically as a 'complete clash', due to a confrontation between indigenous values and non-assimilated health beliefs. They may also be intergenerational, disrupting families due to conflicting values, which in turn relate to different degrees of assimilation within the family. Furthermore, they may be defined as ‘internal’ cultural differences, relating to minorities and disadvantaged populations, or to controversial topics and gender politics.

The book The Spirit Catches You and You Fall Down by Anne Fadiman contrasts the perspectives of the patient's family and her caregivers...

Chapter 3, p. 20-31 In the excerpts below, you will be introduced to Lia and her family. The Lee’s are Hmong people living in Merced, California, and Anne Fadiman’s book documents the cultural conflict between Hmong and Western perspectives on illness. Lia’s story in particular, reveals the intensity of the clash between cultures, and at one point protective services place the child into foster care because of non-compliance. The following paragraph describes the Lees' explanatory model of epilepsy: “When Lia was about three months old, her older sister Yer slammed the front door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her arms jerked over her head, and she fainted. The Lees had little doubt what happened. Despite the careful installation of Lia’s soul during the hu pluig ceremony, the noise of the door had been so profoundly frightening that her soul had fled her body and become lost.”

You can read more about the way in which Fadiman sets up the cultural differences in the opening of her book: http://www.spiritcatchesyou.com/bookdescription.htm and http://www.spiritcatchesyou.com/bookexcerpt.htm

Later, when Lia’s epilepsy gains in intensity, the Lees take their daughter to the emergency room and thus enter into the conflict, the basis of which is simply described: “Dan [the family practice resident] had no way of knowing that Foua and Nao Kao had already diagnosed their daughter’s problem as the illness where the spirit catches you and you fall down. Foua and Nao Kao had no way of knowing that Dan had diagnosed it as epilepsy. Each had accurately noted the same symptoms, but Dan would have been surprised to hear that they were caused by soul loss, and Lia's parents would have been surprised to hear that they were caused by an electrochemical storm inside their daughter’s head that had been stirred up by the misfiring of aberrant brain cells.” (p. 28)

Lia was admitted to the hospital and underwent numerous tests and procedures. Fadiman writes: "Foua and Nao Kao signed “Authorization for and Consent to surgery or Special Diagnostic or Therapeutic Procedures” forms, each several hundred words long…It is not known whether anyone attempted to translate them, or, if so, how 'Your physician has requested a brain scan utilizing computerized tomography' was rendered in Hmong.” Lia was discharged from her first hospitalization on anticonvulsants, but many hospitalizations ensued. During one confrontation with Dan, “[Lia’s] mother informed him that she didn’t think you should ever have to give medicine forever…Dan recalled, 'I remember that I was just watching them and they looked very resolute, like, you know, we are doing what we think is right….the other thing that was different about them was that they seemed to accept things that to me were major catastrophes as part of the normal flow of life. For them the crisis was the treatment, not the epilepsy.'”

In chapter 5, we learn about the difficulties the Lees have with thei daughter"s antiepileptic medications, which initially are prescribed: "Take as directed,' and the doctors also have no way on knowing what doses Lia is in fact taking.

In chapter 6, Fadiman outlines the many ways in which doctors mishandled their encounters with Hmong patients: addressing the English speaker in the family rather than the patriarch, introducing themselves by their first names, allowing too much direct eye contact. But she also describes how maddening and appalling their refusal to follow medical advice could be. In one case, a girl and her family refused salpingectomy to resolve an ectopic pregnancy, stating that she’d rather die than lose a tube that could compromise her future fertility. The girl actually left the emergency room. In another case, a woman decides to have her breech birth at home—only when the baby gets stuck does she finally reverse her decision. At that time it is too late too save the baby. Finally, Fadiman explores at length the conflict between doctors and the Hmong (pages 75 to 77). She finds one doctor who stands out as having the largest Hmong practice of the community. He is not particularly admired by his colleagues as a clinician. “When I asked him why he was so popular, he was to offer no explanation other than “Maybe I talk slower than the other doctors.’ His patients have no problem explaining. Every Hmong I asked said exactly the same thing: ‘Dr. Fife doesn’t cut.” On the whole that was true. Dr. Fife generally did not perform episiotomies on Hmong women, though he did not know why they didn’t want them, never having asked. He avoided caesarian sections whenever possible, and he had particularly endeared himself to his Hmong patients by handing them their babies’ placentas in plastic bags whenever they request them though he had no idea what the did with them and said he had never been curious….When I asked him why he didn’t force his Hmong patients to comply with conventional American medical practices, he shrugged and said, “It’s their body.” (76-77)

Study Questions

1. Imagine that you were Lia’s parents during their numerous visits to the Emergency Department. What types of barriers did the family face when trying to have their daughter treated? What barriers and challenges did the medical teams face? In what ways could these difficult encounters have been improved to allow better medical care for Lia?

2. In Lia’s case, her parents later refuse to give her medication to suppress seizures. Lia is taken away from her parents by social services for a period of time, as her parents are viewed as “unfit.” What consequences to Lia does this action have? Who is at fault: the parents for non-adherence or the social services for depriving a child of her parents?

3. What is your response to the non-compliance of Lia’s parents with her medications? To the young women who risk their own lives or the lives of their babies by not wanting to be ‘cut?'

4. Fadiman writes about negative physician attitudes, quoting one instance as follows: “‘I am totally disgusted by their breeding rate,’ said Robert Small, an obstetrician who is well known for his clinical proficiency, his unapologetic contempt for the Hmong, and his propensity for mixed metaphors. ‘The Hmong breed like flies as if the golden goose of welfare will continue to lay eggs forever.’” Tie this statement to Peter Selwyn’s segment about the staff attitudes towards him for taking care of drug-seeking patients like Betty in Unit 5.

5. What do you think of Dr. Fife’s philosophy? Why does Anne Fadiman make so much out of the fact that Dr. Fife is not interested in the reasons his patients might have for their choices? What about the statement, “It’s their body.” Do you agree or disagree with this justification?