Growing up, the most common question people would ask me was, “What are you?” As a younger child I was always confused. I’m American. I’m Texan. I’m human? Eventually I figured out what they meant was “What race are you?”
You see, I am the proud product of a union many refer to as only-in-America. My mother is a Chinese-Indonesian and my father fled the Iranian Revolution. However, growing up in Southeast Texas many people assume my brother and I are Hispanic (someone once even asked my mother whose children she was babysitting). In college, my brother and I took two very different approaches to dealing with our unique cultural identity. He became fascinated with our Chinese heritage, became a Chinese language major and spent half his undergraduate education in various parts of China. I, on the other hand, became infatuated with Latin American culture and the Spanish language, eventually spending two summers in Panama and a semester in Chile studying medical Spanish.
The hardest thing I have to explain to others is that though I have a genetic tie to Persian and Chinese culture, I would no more fit-in in Iran or China than Russia or Zimbabwe. I don’t speak Farsi or Chinese, and even though my brother does, he faced rampant discrimination in China for looking different. I grew up listening to country music and going to 5th grade sock-hops. The values that I hold dear are not tied to my ancestry; they are tied to the country my parents chose to raise me in.
Cultural competency, to me, is so much more than skin deep. It is about respecting the context within which each and every person on this planet chooses to exist. Some of my first generation American friends feel very connected to their ancestry; others like me couldn’t imagine calling anywhere but the United States home. Especially in this day and age, we have the means to create our own identity, mixing and matching, sampling from as many, or as few, cultures to create a unique blend all our own. Cultural competency, then, becomes a question of respect. Not just respecting cultures as we traditionally imagine them to include skin tone, food, song/dance, but respecting the micro-cultures we see created around us every day.
As a junior director at St. Vincent’s, I have had the unique opportunity to explore what it takes to be an effective provider in one of the most challenging of environments. Anyone who has spent any amount of time in Galveston knows that even on our island you can find people representing the gambit of humanity. Our population ranges from plastic surgeons at UTMB to people who are still homeless and struggling, three years later, to put their lives back together post Hurricane Ike.
The former group comes from a culture of education. They have spent their entire lives in the pursuit of knowledge and skills. They are no strangers to theoretical principles and revel in understanding how and why things are the way they are. The latter were not as fortunate. They feel confused and abused by the system. They have often times never been asked for their opinion and work hard so that, hopefully, their children will grow up to be the surgeons and engineers living across Broadway. Don’t each of these people come from cultures in their own right? Socioeconomics, in my experience, play as great a role in the patient experience as do traditionally-defined cultural differences. The physicist and the Kroger cashier must be counseled differently, just as a Jehova’s Witness and an agnostic will be counseled differently in certain situations. Yet, the common thread underlying all four encounters is that all four should feel validated and respected by the physician.
Cultural competency at St. Vincent’s means that each and every day our students encounter humanity in its most primitive form. Our job is to provide the highest standard of care to the patients who walk through our doors regardless of race, religion, education, history or favorite color. We, as directors, hope that through their interactions with patients from the most vulnerable and marginalized groups our volunteers will take away that compassion and humility have no boundaries. In our setting, we encourage our students to see the whole individual, not just their disease. What are their barriers to health care? What is coming between the patient and living a life without suffering? Is it transportation? Is it income? Is it education? Sometimes there are things we can do, more often than not we cannot. However, educating a generation of physicians who are sensitive to the plight of patients in times of hardship is the first step in bridging the gap between care of the haves and the have-nots.
As physicians, we are in the unique position of being able to make truly informed decisions regarding health. We have a world of knowledge at our disposal and the training to analyze and employ the latest findings in how we, ourselves, want to be treated. However, the decisions we would make for ourselves are based on our unique experiences and belief system, which may not align with our patient’s decisions.
I had a patient in the TDC during my last rotation who frustrated everyone he came into contact with. He refused his medications, asked for explanations, then did the opposite of staff recommendations and made his nurses and team explain everything to him multiple times. He wasn’t incapable of decision making per se. In hindsight, I think he was scared and attempting to exert even the smallest amount of control over his own fate. I remember particularly well one instance where my intern tried for two hours to convince this patient to take a potassium-lowering drug for what was becoming a life-threatening hyperkalemia. That intern figuratively (and almost literally) talked himself blue but the patient still refused.
What the intern did not realize, and I didn’t realize until the end of that patient’s time on my service, was that his non-compliance was rooted much deeper than “stubbornness.” He came from a culture of mistrust: mistrust of a system which he believed unfairly incarcerated him, mistrust of everyone around him in jail who said they would help him but then took advantage of him, and mistrust in the medical community that had allowed diabetes to steal his eyesight, his legs and now his kidneys. Could we have done anything better? I may never know. I do know that we could have communicated with him more effectively. It took us over a week to allow the patient autonomy in his own medical decision-making and he finally got sent back to his unit without any medical treatments. Prison culture, as it turns out, is just as relevant and important a culture to understand as is understanding the rational behind Asian cultures where the elderly do not want to know their diagnoses, or why Catholics cannot use contraception.
Cultural competency is one thing to conceptualize, and a very different thing indeed to implement. To understand a patient we have to remove ourselves from all of our own constructed identities. We have to enter their world and figure out how to operate within their constraints. The practitioner of cultural competency leaves behind judgment in the pursuit of doing what is right for the patient. We must be perpetual advocates for the patient regardless of what we believe is right. The most important truth is the truths the patient holds near and dear. We must respect that some patients will come from backgrounds that question everything and need to understand why. Others will not take an active role in their health care. Each is a valid decision the physician must respect and work with. I work every day to practice what I preach, and hopefully someday I will be able to provide the level of care I expect and that all of my patients deserve.
Roxanne Radi is a student in the School of Medicine at The University of Texas Medical Branch at Galveston and winner of the 2012 Hector P. Garcia, M.D. Cultural Competence Award.