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A Difficult Birth: Navigating Language and Cultural Differences - Reflections by Marc Tunzi
Poor Ana. While she and her baby received state-of-the-art treatment in many ways, her care really didn't go so well in others-and it's not exactly over yet
No-one in this case - patient, family, or staff-did anything particularly wrong, but many of them certainly could have done a number of things "more right." What makes this case challenging is the fact that those involved probably thought they were doing the right thing.
Ana and her husband assuredly wished to stay in the U.S. and wanted their baby to be born here and become a U.S. citizen. Avoiding prenatal care was simply one aspect of avoiding any kind of "official institution" that might increase the risk of job loss or deportation. Like many who have immigrated to the U.S. in search of a better life (nearly all of our families at some point ), they were willing to make sacrifices to secure their future.
Ana was probably born and raised in a small, rural Oaxacan village, where she never went to school and which she never left before coming to the U.S. Like many of my own Oaxacan patients, she may be very bright-just uneducated. Personally, I like to think of education as a "reverse onion" with layers added on as we learn more; larger layers can only be added on if the smaller and intermediate layers have been built up first. It is impossible to teach anyone anything new if the learner does not have the foundation on which to understand it. Ana had probably never seen a physician nor been in a hospital anywhere before the day she arrived bleeding and in pain at East Valley. C-section? NICU? Can you imagine even trying to obtain informed consent from her with such a combination of language, education, and experience barriers?
But to suggest that she "doesn't seem really to care about her baby" is another thing. Without knowing for sure whether people from her particular Mixteco culture are generally a little stoic-many of my Oaxacan patients are-we can assume that she must have been incredibly frightened. Most likely, she was also acutely depressed, wondering what this meant for her personal future, her baby's future, her relationship with her husband, etc.
The staff at East Valley took care of Ana in the same way, with the same standard, that they would take care of anyone. They followed a very traditional physician-centered, Western medical model, doing what they thought was best. What else could they do? They couldn't talk directly with Ana and there was no obvious surrogate decision-maker; they had to do what they believed was in Ana's and her baby's best interests. The staff's shortcoming was not in their initial emergency care; it was in what followed.
There are two commonly used clinical approaches to cases with cultural conflicts or misunderstandings. One is the LEARN pneumonic 1:
Listen to your patient's perspective (and remember that
sometimes you have to elicit it actively
The other is a standard set of questions meant to engage and "draw out" a patient's understanding of what is going on 2:
What do you think has caused your problem (or illness
or circumstance or situation)?
The first step in using either of these approaches, however, is to recognize the disconnect between doctor and patient or between health care team and family to begin with. It is impossible to see things from someone else's different perspective if you don't actually see that the perspective is different.
And that's what the staff failed to do here. Like most of my own errors, the staff's shortcomings were not acts of commission but acts of omission. It was not what they did; it was what they failed to do.
An analysis of this case from the "principles" approach of Beauchamp and Childress3 would focus primarily on a failure of the principle of respect for autonomy, honoring an individual's right to control his or her own body and health care decision making. The East Valley staff did not appear to obtain informed consent from Ana or her husband at any step of her or their infant's treatment. Staff may have provided information, and Ana and her husband may have signed consents, but even if they did, it was assuredly an automatic process. It is not clear that independent, thoughtful decision making based on real dialogue between the healthcare team and the patient and family took place. The other three major medial ethics principles-beneficence (doing good), nonmaleficence (avoiding harm), and justice-also apply, but less strongly.
Should the staff have known better? If this were the first time they had encountered such a case, maybe not. I've made similar mistakes; I suspect we all have. The East Valley staff did what they knew, and several of them made true extra efforts. Let's hope Ana taught them well for the next time. And let's also hope that they've shared their new-found knowledge and skills with those who are caring for Ana and her baby now.
1Berlin E, Fowkes W. A Teaching Framework
for Cross-Cultural Health Care: Application in Family Practice.
Western Journal of Medicine, 1983; 139:934-938.
MARC TUNZI, M.D., is associate director of the Family Medicine
Residency Program at Natividad Medical Center, Salinas, Calif.,
and is associate clinical professor of family and community
medicine at the University of California, San Francisco, School
of Medicine. After graduating from Santa Clara University, he
received his medical degree from the University of California,
San Diego, School of Medicine and completed a family medicine
residency with the University of California, San Francisco,
Fresno-Central San Joaquin Valley Medical Education Program.
He holds a Certificate in Health Care Ethics from the University
of Washington and has served on the Natividad Medical Center
Bioethics Committee for fifteen years.