by Betty Farley
Prior to the last several years of global expansion, expectations were that if you chose to come to America, you should feel privileged to be here. You were expected to learn the English language and to immerse yourself into the culture. This assimilation of any and all cultures was the driving force behind America as the melting pot. With the ability to transplant large populations from around the world at a moments notice, this assimilation is no longer a practical expectation. Partial assimilation may still be the ultimate goal when welcoming immigrants to America, but fully absorbing first generation immigrants into our culture or mores is not always desirable or acceptable to them. It is a price some are not willing to pay. Even when desirable, a true blending into the American culture can easily take a generation to accomplish. Unfortunately, for Lia Lee that wait was too long. As evidenced in the book, The Spirit Catches You and You Fall Down, Lia’s parents were not willing to discard their Hmong core beliefs for the privilege of living in America or having their daughter treated with only western medicine. Most of the medical community that this family came in contact with was not even aware of those core beliefs. They certainly did not take those beliefs into consideration in their treatment of Lia and the family. The medical community must acknowledge and take into consideration these global cultures when training physicians and when treating patients. Those two aspects along with continuity of care are all integral parts of the excellent health care America could and should offer to all its inhabitants.
Working at Children’s Hospital made me aware of obstacles to optimum care that were being experienced in all aspects of patient care and were not being addressed in formal training. With a greater than 50% indigent population, there were quite often multiple barriers to compliance with medications and treatment plans. Attempts to overcome these barriers had to be flexible and creative. Social workers took an active but inconsistent role in educating pharmacists and physicians in some of these methods. In the book, it is a social worker who made the most effort to work within the Hmong culture to impact the care of Lia. Flexibility and creativity were sadly lacking in the physician’s attempts to treat her. Language and cultural barriers must be addressed as they are presented. Individuals may not want to emulate nor even understand the culture of America just because they reside here. As described in the book, the Hmong had maintained their culture through several displacements from various countries, and these beliefs were not dependent upon where they ended up living. These beliefs remained steadfast through generations. As no one should expect every individual in America to be fully assimilated into the culture, no one should expect medical schools to address specifics of multiple cultures and train physicians in those specifics. However, developing respect and empathy along with understanding and acceptance of the culture, mores and core beliefs driving an individual needs to be incorporated into their training.
When treating patients, physicians must take in all aspects of the individual, not just labs and symptoms that they then fit into a mold before making a diagnosis or treatment plan. Treat the individual, not just the illness. If trained to have sensitivity to cultures that may impact the care of the individual, they can provide better care. The understanding of these cultural differences may be the defining factor in compliance to a prescribed treatment plan and good outcomes for the patient. Lia and her family did not receive that sensitivity nor was the reality of their existence taken into consideration when presented with treatment plans. If optimum treatment of the patient requires a team approach such as the inclusion of a social worker or an interpreter, then that is the avenue that should be pursued. Lia’s social worker knew the family as no one else did, but was not considered an integral part of the patient’s care by the physicians. As physicians treat immigrants, especially first generation immigrants, the physicians must not assume they have been fully assimilated into the American culture. Every effort needs to be made to understand any influences that can impact the desired treatment plan and be flexible enough to adapt when necessary.
Language and culture are not the only barriers to excellent health care. Having been a frequent visitor to the emergency room with my daughter, I know the importance of continuity of care for a chronically ill patient. The emergency room is not an optimal choice for care for a chronic illness. You rarely get the same physician and each physician has his/her own beliefs and methods of practice. More often than not, we left the emergency room frustrated, upset and confused because we could not get physicians to listen to what we knew about her illness. Obviously, Lia’s parents felt these same emotions. To consider dealing with these situations with a lack of formal education, an inability to understand the language and a culture that defines core beliefs that are totally foreign to the physician, is incomprehensible. With some empathy, physicians might have recognized that these barriers were dramatic for Lia’s parents and would predictably have a negative impact on the desired treatment plan. Only after we found a primary care physician who was willing to take responsibility for managing the treatment of my daughter did her care become optimal. That optimal care only came about after a couple of years of treating my daughter and getting to know how her illness presented under different circumstances. Unfortunately for Lia, that continuity of care was lacking and negatively impacted her treatment and her life. The outcome could have been different for Lia.
Although total assimilation of all immigrants would make it easier to treat patients, it is not a practical nor desirable outcome. You cannot strip an individual of his core beliefs if the individual does not want to change. Lia’s siblings tried total immersion into American culture, but eventually converted to a blending of their Hmong cultural beliefs and the cultural beliefs of America. That is the essence of a true melting pot. Since total assimilation of all immigrants is not going to happen, the medical community must search for some answers on how to approach this shrinking world. It is a daunting task the schools face in preparing physicians for a career that demands so much. The schools must incorporate some aspect of practical training to develop the physician for practice in the global community we all live in. They must develop empathy and cultural understanding. The practicing physicians must police their community to insure that all aspects of treatment for the patient are being met, including continuity of care. They must also assist in making sure that the institution of medicine continues to develop in a manner that will enable all who approach asking for care to receive the best the field can offer.