Each year, the University of Pennsylvania sponsors a series of events throughout its campus focusing on a central theme chosen by faculty, staff and students. The focal point of the 2014-2015 academic year is Health.
The Year of Health was chosen, in part, because of the national focus on health-care issues. But closer to campus, the theme acknowledges and celebrates the upcoming 250th anniversary of the Perelman School of Medicine. In keeping with this theme, all incoming freshmen were required to read Anne Fadiman's The Spirit Catches You and You Fall Down. The book – which was the focus of a recent University panel discussion – explores the story of the Lees, Hmong refugees from Laos who immigrated to California. Their daughter, Lia, begins to have seizures as an infant. The doctors at the clinic where they bring Lia diagnose her with severe epilepsy. The Hmong know the illness as quag dab peg (the spirit catches you and you fall down).
The Lees spoke no English, a significant barrier in and of itself, but, as one physician in the book noted, “The language barrier was the most obvious problem, but not the most important. The biggest problem was the cultural difference.”
Indeed, while Lia’s physicians tried to treat her with medication, her parents preferred a combination of Western medicine and folk remedies to coax her wandering soul back into her body. Foua, Lia’s mother, does not give her prescribed medicine because she does not understand what the doctor has told her, but, even more important, it goes against the Hmong culture of using plants, herbs and rituals to treat illnesses. As a result, despite the best intentions of everyone involved, cultural differences and miscommunication led to tragedy.
Cultural differences can make a significant impact on many levels, but especially in medicine; a disconnect between patient and provider can result in poor outcomes. At the panel discussion, Beth Linker, PhD, director of Penn’s Health and Societies Program, noted that in times of stress, “people retreat to a comfortable place, the center of their own culture. Lia’s parents became more Hmong while her doctors became more medical, more rational.” Clearly each person’s own identity – where we come from – influences how we react with others, the way we look at the world. The Spirit Catches You and You Fall Down was published 15 years ago but its lessons are enduring: we shouldn’t use our cultures to judge others.
Giang Nguyen, MD, of Penn Family Medicine and Community Health, who came to this country from Vietnam with his family in the 1970s, has found that many immigrants constantly go back and forth between worlds and cultures. He spoke of a relative who has Alzheimer’s and is in a nursing home. He said his aunts believe spirits play a role in the disease. “Does the fact that they believe there might be spirits involved change the fact that my aunt is in a nursing home? No. But if you completely dismiss [the family’s beliefs], do you lose a partner in arranging her care?”
Because Penn Medicine cares for such a diverse population of patients, cultural competency is – and needs to be – an integral part of care. Asking about a patient’s cultural and religious beliefs – and their potential impact on care – is a standard part of every initial assessment upon admission. In the Clinical Practices of the University of Pennsylvania, the ambulatory care component of Penn Medicine, this question is asked of all new patients and those who haven’t been seen in more than a year.
To overcome the language barrier, all UPHS hospitals offer translation services around the clock. Its inner-city locations offer access to more than 200 languages, over the phone or in person. A recent Philadelphia Inquirer article noted that in the past seven months alone, patients required interpreters for 52 languages at the Hospital of the University of Pennsylvania.
Students at the Perelman School of Medicine learn about cultural competency early in their medical careers. Doctoring 1A (Introduction to Medicine and Society), which all students take their first semester, examines the influence of social and cultural forces on doctoring relationships. Subsequent “Doctoring” courses throughout the first three years “revisit various elements of the first course while new ones are introduced,” said Horace Delisser, MD, associate dean for Inclusion and Diversity. “There is a lot of discussion around these issues. Students use their collective experiences to arrive at an understanding.”
Medical students can also gain real-life experience by volunteering at one of Penn’s many community clinics that serve immigrant, minority and disadvantaged groups, such as Puentes de Salud or the United Communities Clinic.
Overall, the goal is to teach students “ways of engaging with patients and approaching these situations,” he continued. “‘How do I begin the conversation? How do I ensure we’re hearing each other?’ We want students to think about these issues and learn.”