My medical education has been a long journey to this point — a journey filled with many obstacles and detours resulting in moments of self-reflection and personal growth. One of the most important detours on my journey led to me being relocated to Riverside University Health System (RUHS) for a longitudinal care assignment. Also known as “County,” RUHS provides necessary primary care to patients without insurance and houses a trauma center, psychiatric inpatient treatment facility and much more.
I was excited to start my assignment there because of the patient population. I had previously been at a clinic where the patient population consisted of middle-class and affluent patients who always had insurance. I knew that RUHS was the place where people without insurance would go for care. I was hoping that this relocation would provide me with the experience of actually making a difference and contributing to the health care team.
One of the reasons that I initially chose to pursue medicine as a career was because I wished to provide care to one of the largest subsets of the population here in southern California: Latinos. Being Latina and speaking Spanish, I have always felt a special connection to the people living here and have considered serving them in the future as a physician. Although I knew that the Latino population, not to mention Asian, Middle Eastern, and many other subsets of people, is underserved and underrepresented in medicine, it was not until I began my assignment at County that I truly began to realize the magnitude of the problems that patients — regardless of race or ethnicity — face in obtaining competent health care.
My observations of the blatant disparities in health care accessibility and quality remind me of topics covered in my medical school’s public health course. In particular, cultural competency and health care access have been circulating in my mind as I reflect on my longitudinal assignment and other volunteer experiences. I have realized that it is impossible for me to grasp the nuances and diversity of each cultural background, especially those about which I know nothing. The concept of cultural humility has challenged me to be more open-minded about other cultures’ traditions and health beliefs. Before this experience, I would get frustrated when the best course of medical management seemed so obvious to me but not to my patients. I have had to learn to see beyond my own thoughts and accept that each patient has a unique set of life circumstances that will influence decision-making.
While rounding on patients on the inpatient internal medicine wards recently, Dr. Tom Nguyen, my attending, commented, “Asian patients are the hardest; they want to stay alive.”
He was referring to how the patient’s family members were trying everything to keep their loved one alive. I had learned about the different approaches to elder care in Asian cultures in my public health classes, but it was not until I was actually in the hospital that I experienced it. It was quite a scene: the elderly Asian patient looking like the bed could swallow his frail, thin body whole with a countenance reflecting a mixture of gratitude and tiredness while his family members patiently gathered around him.
When caring for a patient of Asian descent, it is customary for the physician to not talk directly to the patient but instead to one of the patient’s children when explaining the patient’s prognosis and potential next steps in treatment. The commitment that Asian family members have to their elders and their willingness to do almost anything to keep their loved ones alive are, perhaps, unrivaled by other cultures in my experience. My opinion did not appear to be mine alone; Dr. Nguyen also offered the same insight. In the case of this particular patient, who had encephalopathy, the family members decided to continue all life-saving measures even though the time that these measures would buy them with their loved one would be unappreciated from an outsider’s perspective.
In light of this new approach to understanding the perspectives of such a diverse patient population, I have tried to become aware of differences in beliefs. It is sometimes difficult to balance what I know to be effective health care management with approaching patients in a culturally respectful way. Specifically, it is challenging to apply the idea of cultural humility in order to continue learning about different cultures while at the same time learning as much about medicine as possible.
Approaches to patient care differ within the Latino community as well. My parents are Salvadoran, but it has been important for me to become aware of specific aspects of Mexican culture and health care. At County, I have estimated that the patient population in the internal medicine clinic is approximately eighty to eighty-five percent Latino; of those, many are from Mexico.
One encounter I had with a Mexican patient centered on insulin. The gentleman had decided in an earlier visit that he did not want to take insulin because he believed it would harm him. Instead, he tried to improve his diabetes with diet modification. I interviewed him in Spanish about his food choices, what he was eating, why he was worried about taking insulin and whether he would be willing try it.
Though I was previously unaware of the many holistic approaches to medicine that he described, we established rapport in talking about things that are common across many Latino cultures. The common ground we established obviously put him at ease by letting him express his frustration and experiences. All the while, I learned about his cultural beliefs as applied to healing and more specifically, to medicine.
Now that I am in my third year of medical school, I have started to see how health care disparities can have significant impacts on the management and prevention of disease. It is my hope that as the culture of medicine changes ever so slowly more physicians will be aware of the disparities and develop cultural humility to better serve their patient populations.