Kindliness is next to godliness.

Withdrawing life support is always difficult. When patients and health professionals are from different ethnic backgrounds, value systems that form the basis for such decisions may conflict. Many cultural groups do not place the same emphasis on patient autonomy and self-determination that Western society does and find the idea of terminating life support offensive. Although physicians should never assume patients will respond in a particular way because of their ethnic background, issues of life support should be discussed in a culturally sensitive way. African-American, Chinese, Jewish, Iranian, Filipino, Mexican-American, and Korean patients were surveyed about their views on life support. The findings reported here, although not meant to be definitive, should add to health professionals'' understanding about diverse beliefs around life-and-death issues. By becoming aware of this diversity of beliefs, health professionals can avoid the damage to the physician-patient relationship caused by conflicting value systems.     

Letter to my doctor

Considerable attention is now being given to ethical conflicts raised by such issues as the disclosure of diagnosis and prognosis, the role of the family in making medical decisions, and the withholding or withdrawing of treatment of terminally ill patients. Already complicated, these issues take on added complexity in contexts where medical professionals and patients have differing cultural beliefs and practices. Ethical dilemmas that develop in multicultural settings have been largely unaddressed. Through the analysis of a case involving the hospital admission and death of a Chinese woman with metastatic lung cancer, we examine some of these dilemmas and their effect on the patient, family, and physicians. Many issues were raised by this case regarding the relationships among ethnic background, bioethics, and medical care.     

Use of traditional health practices by Southeast Asian refugees in a primary care clinic.

To determine the prevalence of use of traditional health practices among different ethnic groups of Southeast Asian refugees after their arrival in the United States, we conducted a convenience sample of 80 Cambodian, Lao, Mien, and ethnic Chinese patients (20 each) attending the University of Washington Refugee Clinic for a new or follow-up visit. Interpreters administered a questionnaire that dealt with demographics, medical complaints, traditional health practices, health beliefs, and attitudes toward Western practitioners. In all, 46 (58%) patients had used one or more traditional health practices, but the prevalence varied by ethnic group. Coining and massage were used by all groups except the Mien, whereas moxibustion and healing ceremonies were performed almost exclusively by the Mien. Traditional health practices were used for a variety of symptoms and, in 78% of reported uses, patients reported alleviation of symptoms. The use of traditional health practices is common among Southeast Asian refugees. Clinicians who care for this population should be aware of these practices because they may supersede treatments prescribed by physicians or leave cutaneous stigmata that may be confused with disease or physical abuse. Good patient care may necessitate the use or tolerance of both Western and traditional modalities in many Southeast Asian refugees.     

The Relationship between Cultural Anxiety and Ethnic Essentialism: The Mediating Role of an Endorsement of Multicultural Ideology

Many studies have explored the social consequences of ethnic essentialism in recent decades. In addition, a few studies have focused on the impact of perceived cultural context on ethnic essentialism. However, it is not clear why perceived cultural context can lead to changes in ethnic essentialism. In the present study, we hypothesized that the cultural anxiety of ethnic minorities may trigger a strong endorsement of and support for a multicultural ideology, thereby affecting beliefs about ethnic groups. To address the issue, 226 Tibetan and 102 Hui college students from Mainland China completed our questionnaires. The results across the two samples showed that (1) cultural anxiety was positively associated with both the endorsement of a multicultural ideology and ethnic essentialism, (2) cultural anxiety and the endorsement of a multicultural ideology positively predicted ethnic essentialism after controlling for demographic variables, and (3) cultural anxiety had both a direct effect on ethnic essentialism and an indirect effect on ethnic essentialism through the endorsement of a multicultural ideology. Our findings suggest that when ethnic minorities experience cultural anxiety, they might endorse a multicultural ideology and adopt essentialism to affirm their ethnic identities.     

Use of traditional and modern health services by Laotian refugees.

Although refugee health care emerged as a special interest in the United States following the influx of almost a million Southeast Asians since 1975, few studies have been done of the influence of refugee traditions on the use of Western medical services. The illness patterns, medical beliefs, and health care behavior of a Southeast Asian refugee group, the Mien from Laos are described in this study. A cohort of 119 Mien refugees living in Richmond, California, was observed for a 6-month period. In-home interviews were undertaken about all episodes of ill health, including treatment and health care decisions. This study shows that the Mien integrate traditional healing beliefs and practices with the use of American health services. Such findings are important because the increasing cultural diversity in the United States, particularly in Western states, necessitates that health care professionals understand the importance of cultural factors for access to and the use of health care by all patients including refugees and other immigrant groups.     

Preventive attitudes,beliefs, and practices of physicians in fee-for-service and health maintenance organization settings.

To identify the self-reported differences in preventive practices, attitudes, and beliefs of physicians practicing in fee-for-service (FFS) and health maintenance organization (HMO) settings, we surveyed a 100% sample of primary care physicians practicing in a large, urban, closed-panel HMO and a random sample of physicians, in the same county, who were in an FFS practice. The FFS physicians were more likely to consider behavioral risk factors important than were HMO physicians, and they were more likely to ask their patients about behavioral risk factors. Fee-for-service physicians were more likely than HMO physicians to use continuing medical education courses to upgrade their skills in modifying behavioral risk factors. There was little difference in the self-reported proportion of patients with specific behavioral risks in the FFS and HMO practices. Also, both groups were comparable in their perception of their ability to do behavioral counseling and their perceived success in such counseling. We conclude that FFS physicians are more likely to have positive preventive beliefs, attitudes, and practices than are HMO physicians.     

Ethnic Elders and American Health Care—A Physician's Perspective

The aging process is a fugue composed of innumerable themes; the theme of “ethnicity” is by far one of its more dominant. Due to the increasing incidence of chronic, progressive infirmity and acute, catastrophic illness, the elderly are thrust into direct contact with the health care systems of their society. The experiences of ethnic elders in American health care situations are fraught with conflict and mutual dissatisfaction with the physician-patient relationship. Both providers and consumers of health care services harbor differing culture-bound perceptions of health, illness and the healing process; these cultural beliefs define personal and professional needs and expectations and notions of how those needs are to be met by others. Both physicians and patients can enhance their communication and their compassion for one another by acknowledgment of cultural differences and by increased willingness to interpret motives and behavior within native context.It behooves us in medicine to examine the cultural traditions underlying our own attitudes, beliefs and values about the aged in a universal sense, as well as in a culturally specific sense, that we may gain insight that will be helpful in serving elderly persons more effectively, and in solving some of the problems inherent in the aging process.     

Beliefs Matter: Cultural Beliefs and the Use of Cervical Cancer-Screening Tests

In this article we examine the influence of cultural beliefs on behavior or, more specifically, beliefs about cervical cancer risk factors and the use of Pap exams. Individual Latinas' (Hispanic women) holding of beliefs similar to Latinas' generally (cultural consonance) did not significantly influence their use of Pap exams. Rather, structural factors such as medical insurance, age, marital status, education, and language acculturation explained Latinas' use of this medical service. However, when Latinas held beliefs similar to those of Anglo women, then they were significantly more likely to have had a Pap exam within the past two years. Latinas whose beliefs were closer to those of physicians were significantly less likely to have had the exam recently. Arriving at these findings involved both ethnographic interviews and survey research. That these beliefs proved to be significant influences on behavior suggests not only the important ways that beliefs matter but that ethnographic methods for examining those beliefs also matter. [ Latinas and cervical cancer, Pap exams, culture and behavior, ethnography and survey research ]     

Informed Consent in Cross-cultural Perspective: Clinical Research in the Tibetan Autonomous Region, PRC

Procedures of Informed Consent are considered a high priority for international biomedical research. However, informed consent protocols are not necessarily transferable across cultural, national or ethnic groups. Recent debates identify the need for balancing ethical universals with practical and local conditions and paying attention to questions of cultural competence when it comes to the Informed Consent process for clinical biomedical research. This article reports on the results of a two-year effort to establish a culturally appropriate Informed Consent process for biomedical research in the Tibet Autonomous Region in the People's Republic of China. A team of Tibetan and American researchers, physicians, health professionals and medical anthropologists conducted the research. The Informed Consent was specifically for undertaking a triple-blind, double placebo-controlled randomized clinical trial of a Tibetan medicine compared with Misoprostol for reducing postpartum blood loss. The findings suggest greater need for flexibility and cooperation in establishing Informed Consent protocols across cultures and nations.     

The role of birds in the culture of the Ndebele people of Zimbabwe

Msimanga, A. 2000. The role of birds in the culture of the Ndebele people of Zimbabwe. Ostrich 71 (1 & 2): 22–24.

The Ndebele people of western Zimbabwe uphold some beliefs and practices relating to birds and these are either shared with other ethnic groups or unique to them. Some areas of interaction include the naming of birds, taboos, folk stories and songs as well as food and medicine. The changes in the lifestyle of the Ndebele resulting from industrialisation and urbanisation have had corresponding effects on attitudes towards cultural beliefs and this is affecting birdlife and indeed all biodiversity. It is suggested that where possible those beliefs and practices that impact positively on birdlife be identified and promoted for purposes of conservation and sustainable utilisation.     

'India Shopping': Indian Grocery Stores and Transnational Configurations of Belonging

The cost of health services within the USA has increased in recent years, limiting access for many Americans. In response, a growing number of Americans are traveling to medical border towns in Mexico to meet their needs. However, many US patients feel uncomfortable traveling to Mexico for healthcare because they are unsure how the system works and believe that Mexico is dangerous, unregulated, unsanitary, and premodern. To reconcile these beliefs with the need for quality medical care, Mexican medical providers appropriate aspects of the US medical system to encourage patronage and alleviate the concerns of patients. This paper examines how some Mexican dentists, pharmacists and physicians in the Mexican border town of Nuevo Progreso have broadened their appeal to American patients by (a) associating their procedures with US biomedical standards, (b) building facilities that shadow US counterparts, and (c) facilitating access to the Mexican medical system.     

Drugs of abuse--opiates.

Treating opiate-dependent patients can be difficult for many physicians because the patients'' life-styles, values, and beliefs differ from those of the physicians. Primary care physicians, however, are often involved in the treatment of the medical complications of opiate abuse, and physicians must often manage a patient''s opiate dependence until appropriate referral to a drug abuse treatment program can be arranged. Treatment is guided by an understanding of the patient''s addictive disease, for which there are specific diagnostic criteria, and an understanding of the pharmacology of opiates of abuse and the medications used in treating opiate dependence. The opiate agonist, methadone, is useful for both detoxification and maintenance. The opiate antagonist, naloxone, is the treatment of choice for opiate overdose, and naltrexone, also an opiate antagonist, is a useful adjunct in subgroups of opiate-dependent patients for preventing relapse. New medications for the treatment of opiate dependence are being developed.     

Effect of Supervised Students' Involvement on Diagnostic Accuracy in Hospitalized Medical Patients �� A Prospective Controlled Study

Background

During internships most medical students engage in history taking and physical examination during evaluation of hospitalized patients. However, the students'' ability for pattern recognition is not as developed as in medical experts and complete history taking is often not repeated by an expert, so important clues may be missed. On the other hand, students'' history taking is usually more extensive than experts'' history taking and medical students discuss their findings with a Supervisor. Thus the effect of student involvement on diagnostic accuracy is unclear. We therefore compared the diagnostic accuracy for patients in the medical emergency department with and without student involvement in the evaluation process.

Methodology/Principal Findings

Patients in the medical emergency department were assigned to evaluation by either a supervised medical student or an emergency department physician. We only included patients who were admitted to our hospital and subsequently cared for by another medical team on the ward. We compared the working diagnosis from the emergency department with the discharge diagnosis. A total of 310 patients included in the study were cared for by 41 medical students and 21 emergency department physicians. The working diagnosis was changed in 22% of the patients evaluated by physicians evaluation and in 10% of the patients evaluated by supervised medical students (p = .006). There was no difference in the expenditures for diagnostic procedures, length of stay in the emergency department or patient comorbidity complexity level.

Conclusion/Significance

Involvement of closely supervised medical students in the evaluation process of hospitalized medical patients leads to an improved diagnostic accuracy compared to evaluation by an emergency department physician alone.     

Medical disclosure and refugees. Telling bad news to Ethiopian patients.

The strong value in American medical practice placed on the disclosure of terminal illness conflicts with the cultural beliefs of many recent refugees and immigrants to the United States, who often consider frank disclosure inappropriate and insensitive. What a terminally ill person wants to hear and how it is told are embedded in culture. For Ethiopians, "bad news" should be told to a family member or close friend of the patient who will divulge information to the patient at appropriate times and places and in a culturally approved and recognized manner. Being sensitive to patients'' worldviews may reduce the frustration and conflict experienced by both refugees and American physicians.     

How Human Household Size Affects the Habitat of Black-and-White Snub-Nosed Monkeys (<Emphasis Type="Italic">Rhinopithecus bieti</Emphasis>) in Hongla Snow Mountain Nature Reserve in Tibet,China

Human impacts on the environment at local or regional scales largely depend on intrinsic characteristics of the population, such as household size, household number, and human population growth. These demographic factors can vary considerably among ethnic groups sharing similar ecological landscapes, yet the role of traditional cultural practices in shaping local environmental impacts is not well known for many parts of the world. We here quantify land-cover changes and their relation to the habitat of the endangered Rhinopithecus bieti in Tibet, in 2 areas populated by different ethnic groups (polyandrous Tibetans and monogamous Naxi) from 1986 to 2006. Results indicate that habitat of the monkey decreased greatly within our study area over the 20-yr period. Polyandrous and monogamous ethnic communities differed in household size, household number, population growth, and per capita and per household land use. The practice of polyandry by ethnic Tibetan appears to have reduced per capita resource consumption by reducing the growth of overall household number and increasing household size, which can mitigate the negative effects of higher human density and population growth on the environment. Ethnic Tibetan may also reduce land impacts by adhering to Buddhist customs and alternative, more sustainable means of livelihood. Accordingly, the protection of traditional cultural resources, such as polyandry and Buddhist beliefs, could be an effective way to aid biodiversity and environmental conservation efforts in this key ecosystem.     

Karma, reincarnation, and medicine: Hindu perspectives on biomedical research

Prior to the completion of the Human Genome Project, bioethicists and other academics debated the impact of this new genetic information on medicine, health care, group identification, and peoples’ lives. A major issue is the potential for unintended and intended adverse consequences to groups and individuals. When conducting research in, for instance, American Indian and Alaskan native (AI/AN) populations, political, cultural, religious and historical issues must be considered. Among African Americans, the Tuskegee Syphilis Experiment is a reminder of racism and discrimination in this country. The goal of the current study is to understand reasons for participating, or not, in genetic research such as the HapMap project and other genetic/medical research from the perspective of the Indian American community in Houston, Texas. In this article, we report on a topic central to this discussion among Indian Americans: karma and reincarnation. Both concepts are important beliefs when considering the body and what should happen to it. Karma and reincarnation are also important considerations in participation in medical and genetic research because, according to karma, what is done to the body can affect future existences and the health of future descendants. Such views of genetic and medical research are culturally mediated. Spiritual beliefs about the body, tissue, and fluids and what happens to them when separated from the body can influence ideas about the utility and acceptability of genetic research and thereby affect the recruitment process. Within this community it is understood that genetic and environmental factors contribute to complex diseases such as diabetes, hypertension, and cancer; and acknowledgment of the significance of environmental stressors in the production of disease. A commitment to service, i.e. “betterment of humanity,” karmic beliefs, and targeting environmental stressors could be prominent avenues for public health campaigns in this population. This study suggests that minority status does not automatically indicate unwillingness to participate in genetic or medical research. Indian Americans were not skeptical about the potential benefits of biomedical research in comparison to other ethnic minority communities in the United States.     

A Systematic Review of Patients’ Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity

Communication difficulties persist between patients and physicians. In order to improve care, patients’ experiences of this communication must be understood. The main objective of this study is to synthesize qualitative studies exploring patients’ experiences in communicating with a primary care physician. A secondary objective is to explore specific factors pertaining to ethnic minority or majority patients and their influence on patients’ experiences of communication. Pertinent health and social sciences electronic databases were searched systematically (PubMed, Cinahl, PsychNet, and IBSS). Fifty-seven articles were included in the review on the basis of being qualitative studies targeting patients’ experiences of communication with a primary care physician. The meta-ethnography method for qualitative studies was used to interpret data and the COREQ checklist was used to evaluate the quality of included studies. Three concepts emerged from analyses: negative experiences, positive experiences, and outcomes of communication. Negative experiences related to being treated with disrespect, experiencing pressure due to time constraints, and feeling helpless due to the dominance of biomedical culture in the medical encounter. Positive experiences are attributed to certain relational skills, technical skills, as well as certain approaches to care privileged by the physician. Outcomes of communication depend on patients’ evaluation of the consultation. Four categories of specific factors exerted mainly a negative influence on consultations for ethnic minorities: language barriers, discrimination, differing values, and acculturation. Ethnic majorities also raised specific factors influencing their experience: differing values and discrimination. Findings of this review are limited by the fact that more than half of the studies did not explore cultural aspects relating to this experience. Future research should address these aspects in more detail. In conclusion, all patients seemed to face additional cultural challenges. Findings provide a foundation for the development of tailored interventions to patients’ preferences, thus ensuring more satisfactory experiences. Health care providers should be sensitive to specific factors (cultural and micro-cultural) during all medical encounters.     

Urban Philippine healers and their contrasting clienteles

This paper is concerned with medical pluralism in a Philippine setting. It reports on results of a study of four indigenous healers and their patients in Cebu City. The city is a modern medical center in the Philippines, with more than 500 practicing physicians. But its indigenous healers also treat numerous patients, and many patients utilize both physicians and healers during the course of an illness. Of the four healers discussed in this paper, two had the largest followings of any healers in the city at the time of the study, the other two had very modest practices. Significant social and medical contrasts between the clienteles of these healers are described in the paper, and the implications of these differences are discussed with respect to decisions people make about their health care in an area with diverse medical resourses.