Yes, Doctor

June 12, 2014

Not long ago I cared for the child of a family from a distant country.  When I walked in, they stood up.  When I walked out, they stood up.  It was like The People’s Court.

They agreed with whatever I said.  Their obsequious nodding whenever I spoke made me feel brilliant.  They treated me as though I knew it all.

The problem was that the family’s insistence on appearing to please me made it such that I could barely tell what was happening with the child.  When it came to deciding on a plan, matters only got worse.  I had to work desperately to dig below the surface of their servile regard for my position.  It was exhausting.

To the provider with a healthy sense of self-importance, this kind of behavior is validating and comfortable.  For the thoughtful provider, this odd imbalance of power is unsettling and potentially dangerous.

Cultural differences between doctor and patient can represent serious challenges to care.  They can work against us and we have to push to insure that the decisions made represent the interests and wishes of the patient.

Sounds like the right thing to do.

But in this case, the encounter was strained.  I have to wonder if I would have been better off acquiescing to their culturally-imposed expectations of paternalism, sizing up the situation and making an authoritarian dictum.  At which point they would have happily nodded and said, ‘yes, doctor.’

The scenario described here has been altered/de-identified/fictionalized/fudged to protect the privacy/dignity of the parent and patient.


{ 5 comments }

Carmen Gonzalez June 12, 2014 at 4:53 pm

Dear Dr. V:

The topic you raise was formally considered regarding Latinos at a recent conference I attended (Latino Health Conference 2014), where Dr. David Acosta from the Univ. of California Davis Health System mentioned common values among Latinos that can often stymy patient-physician communications. While no ethnic group is a monolith, Dr. Acosta noted that there are frequent themes to be on the lookout for:
–Simpatia: denoting an emphasis on politeness and avoidance of disagreement or expressions of doubt;

–Fatalismo: reflecting a belief that individuals can do little to alter their fate, or that thri condition is a result of the will of God;

–Familismo: representing an emphasis on the family over the individual patient;

–Personalismo: a variant of familismo, where personal relationships are given greater weight than institutional ones; doctors building personal connections with patients is welcomed (e.g. shared allegience to sports teams, etc.);

–Respeto: indicating a deference to authority (including doctors);

–Confianza: reflecting a patient’s trust in their healthcare provider borne of the doctor’s respect for the patient’s culture and a personal interest in the patient’s well being.

To overcome the challenges presented by such values, Dr. Acosta recommends two approaches: asking Kleinmann’s Questions; and applying the B.E.L.I.E.F. Model. Basically, these models guide patients through successive questions to determine their thinking process on how they acquired their condition, why it occurred, what their treatment should include, what the important results they hope to achieve are, and what they fear most about their condition. It is this probing that can help the doctor determine the patient’s expalnatory model and provide opportunities for education and behavioral change.

For more info, check out Acosta’s presentation at http://www.healthcarecommunities.org/DesktopModules/Bring2mind/DMX/Download.aspx?portalid=3&EntryId=49465

I wish you well on your next patient encounter and hope you search for the patient’s explanatory construct of their illness.

DrV June 12, 2014 at 6:24 pm

This is beautiful, Carmen. Thank you for such a thorough comment. I’ll need a few hours to process this.

Julian Hinson June 12, 2014 at 5:00 pm

” I have to wonder if I would be better off …paternalism”
Quite the opposite in my opinion. Massive kudos for the cultural sensitivity, but yours may be the only voice that stands to undo generations of paternalistic medicine.

Speaking from experiences in my own west-African culture, where hierarchical norms pervade every social transaction, I believe such paternalistic medicine can be dangerous. In my own family, it allowed patients to more flippantly ignore the advice of their physician, as would a rebellious teenager unaware of the justification for their curfew. Having neither deep knowledge of nor investment in their care, Grandma’s remedies become the failsafe – and the doctors’ sage advice becomes optional.

How to break that cultural barrier? (which I think is the real question your post presents) In my experience, it can only enter the same way that the other lessons have entered, via experience, via storytelling, or via matriarch.

Bobby June 12, 2014 at 5:20 pm

there are many times i wonder…if we spend too much time thinking about adjusting our discourse to meet the needs of the audience or the needs of our own situation. sometimes i wonder if we need the needs of the audience or just spend too much time to make them adjust to the way we want to communicate.

i have no idea what it is like to find the natural balance in this situation…imho…the best physicians are the best listeners…

Ted Leng June 13, 2014 at 12:55 pm

Normally (with all these Press-Ganey worries, the internet and such…) it is quite the opposite. The doctor is trying to be as “agreeable” as possible with the patient for fear of angering them and getting bad reviews.

More like, “Yes, Patient”

You should be so lucky that you finally found a patient that listened to you and valued your opinion over their own agenda and opinions.

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