Culture As A Vital Sign

cul·ture
/ˈkəlCHər/
noun
the customs, arts, social institutions, and achievements of a particular nation, people, or other social group.

I was a 3rd year medical student in Brooklyn, New York. As an Indian immigrant with physician parents, I had experienced various aspects of healthcare from numerous perspectives.  However, growing up in rural Pennsylvania, my parents’ patient population was much different than my clerkship experiences in Brooklyn. The racial, cultural and linguistic diversity was welcoming.  Even though I was able to speak 3 languages, I didn’t have the opportunity to use them until I was in my OB rotation. Even 22 years later, I still remember the situation so vividly: the clinic, the staff rushing around, me standing there in my short white coat—but most importantly, the patient, a woman in a hijab, the traditional Muslim head covering, standing with her husband.

This woman, an immigrant from Bangladesh, who had recently arrived in this country, entered our OB safety-net clinic for her prenatal care.  The husband conversed with the nurse in his broken English and began to raise his voice. The look of frustration on the patient’s and her husband’s face told me that something just wasn’t right.  I gingerly approached the couple, the woman welcoming my presence since she realized that I looked similar to her/them. 

Although we didn’t speak the same language, between his English and my Hindi coupled with the cultural nuances, the situation became clearer.  This woman, an older woman here in the US to have her baby, was Muslim, as evidenced by her hijab. In Islam, maintaining modesty is an overarching Islamic ethic.  For observant Muslim women, covering up the body is important when they are in the company of males whom they are not related by blood or marriage. On this particular day, there were only male OB residents who were seeing patients.  When the husband tried to explain their concerns and religious restrictions, they were basically given an ultimatum: see the male resident or leave the clinic. Unfortunately, she was given the dreaded label of The Difficult Patient because of her request.

I tried to explain the situation to the nurses and residents—but to no avail.  In her Bengali tongue, which overlapped with my cursory Hindi, she asked me: ‘Can you deliver my baby?’ I explained to her that I was a doctor-in-training, and while I was unable to do so, I would try to help them.  

As I made my way through different staff, nurses and doctors, finally, my concerns were taken seriously. I found that there was a midwife service affiliated with the OB program. I sat down with the couple explaining how the midwives (all women) would now takeover her OB care. To say they were grateful would be an understatement.  The woman’s eyes welled up with tears and she cupped her hands in mine just saying ‘Thank you.’ I still remember feeling satisfied and happy that we had found a resolution so that her obstetric care would not be compromised while respecting her religious beliefs. But I was also concerned, wondering if everything would work out for the couple and their baby.

Fast-forward 2-3 weeks later: I was now on the OB in-service unit.  Back then, there were no duty-hour restrictions, not even for medical students.  Call nights usually were 24-30 hours long. But I didn’t mind. I loved being in the hospital, helping mothers through one of the toughest but most exciting times of their lives.
I truly enjoyed caring for the mother, the long hours of timing contractions, checking cervical dilatation, monitoring blood pressures, while making her comfortable during the laboring process.  Of course, the nurse and obstetrician were in charge, but the benefit of training in a big city was the fact that medical students received so much actual hands-on experience; things I had never learned in thousands of pages of text.

One evening, a laboring woman was getting admitted.  I looked at the name and recognized it being the Muslim woman I had met in the clinic. As I ran over to her room both she and her husband recognized me immediately—and smiled.
I guess I can imagine what it must have been like to be in a foreign country, the customs, culture, language and then see someone, a ‘doctor’ who looks like you, understands your culture and can (almost) converse in your language.  
I introduced myself to the midwife and quickly explained how I knew the patient. The midwife allowed me to stay, allowing me to help the patient deliver a healthy, beautiful term baby.  

To this day, this story sticks with me.  I think while the mother and father thanked me, I really must thank them for what they taught me.  During the preclinical years in medical school, people always tell you that the real learning begins during clinical rotations.  While we learn the pathophysiology of disease, memorize enzymes and dissect cadavers to learn the orientation between bone and muscle, the true art of medicine lies in patient interaction.  

Now as an academic pediatrician, I teach medical students and residents the importance of cultural beliefs as it relates to healthcare. I use what I have learned from my patients to try to educate the health team, including nurses, social workers, and therapists, how culture, religion and language can and will affect the care of the patient.

As the world becomes more diverse and we interact with patients from many different cultures, the awareness of these ideas will become increasingly important.  While we cannot be expected to know every aspect of every cultural group we care for, it is part of our medical exam to ASK. None of my patients/parents have become offended when asking them about their culture, in fact, most are relieved when they perceive that their cultural beliefs are being addressed within the clinical setting.  

This patient also showed me how quick we are to label certain patients as difficult based on our own inherent biases.   The rapidity with which to label patients, while we may think it does no harm, actually may compromise the care of the patient.  As physicians, we increasingly face more demands on our time, it can be easy to forget to take the time to listen to our patient, allowing them to tell us their story.  

To read the complete story as well as the complete anthology, please get a copy of our book The Chronicles of Women in White Coats

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