Nov 20, 2011

Lessons In Cultural Competency

I'm white.

I mean, really white. Scandinavian mostly, a little Irish and Scottish, and part Sicilian. Not Sicilian enough to give me the gorgeous olive skin of my relatives, rather, just enough to turn my eyes brown and leave me with the fair and freckled skin of generations of peoples who have never seen the sun. When it comes to those "race" boxes on standardized forms, I only get to check "White" or "Caucasian." There's really nothing else there.

But, I can switch fairly fluently between English and Spanish in the exam room. I've begrudgingly completed the "cultural competency" courses of medical school and as required by my employer. I tell myself that I'm open to other cultures, I enjoy experiencing things different than what I'm used to. I really did consider myself culturally competent, at least for a white chick.

But this month, I've had a few situations that were new to me, and showed me far more culture and much less competency than I had ever seen with any of the informational videos provided by the HR department. It turns out that understanding, and respecting, another culture that is much different than your own is very difficult, especially when a pregnancy and child is involved. And sometimes that a new culture is a lot of fun, and it's a privilege to join it, at least for a little while.

Lesson #1: Las Mujeres
I come into the room to say hello to a new patient. She is ready to push, but I can't see her. There is not a word of English, and at least twenty people in the room, all female.
"Excuse me, excuse me." I jostle through the crowd. I say hello, and introduce myself, and ask, in Spanish, if she wants everyone in the room for delivery? I'm expecting most to leave, but instead, they all circle the bed, and are ready to help her push.
Who are all these people? I start to get a little irritated as they touch my delivery instruments "No, please, those are sterile", and bump me as they crowd around the bed (hello, please give the doctor some space!). But I come to find out that in this patient's culture, all of the females she loves are here for delivery. The dad is nowhere to be found, but this patient's mother, grandmother, great-grandmother, multiple tias (aunts), sisters, nieces, and even her own young daughter are here, ready for her delivery. In this culture, birthing is women's work, and all the women are here to work.
The mother cries "No, no puedo" when told to push. The tias respond with a chorus of "Si! Se puedes!" And so it goes on, until this baby- a girl- delivers, and all the women crowd over to the warmer to see the new nina, the new addition to their family.
I smile, for the small reason that they are now in the pediatrician's way instead of mine, but for the bigger reason that this is an enviable culture. I'm not even sure if I have close relationships with half as many women as this girl had at her bedside supporting her for delivery. They all were there, and knew what to do, how to support her and love her during this significant event in all of their lives. Se puedes, indeed.

Lesson #2: A Native American Preemie
There was a patient who came to our clinic from the Indian Reservation, with the complaint of bleeding. She bled off and on, and eventually went into labor, and delivered a twenty week-old nonviable baby. These are very sad situations, and we have people and programs at the hospital set up to help families cope with this. However, this family wasn't interested in the bonding time offered, or even seeing their baby. That baby needed to be out of the room as soon as possible, as it is bad luck to be around anyone who is dying, and particularly the spirit of a dying child that could affect future fertility. I came around the nurses station a few minutes later and looked suspiciously at a mound of blankets in a metal bassinette. Was that...? One of the nurses picked up the blankets, and gave them to me to hold. It was the baby, the smallest one I had ever held, with an irregular, slow heartbeart visibly fluttering under tiny ribs, with small hands and wispy eyelashes. I touched his forehead gently and pulled my hand back, startled, as I felt how cold it was. The longer that baby was cold, the more slowed-down his metabolic processes would be, and the longer he would hover somewhere in between a heartbeat and inevitable death. I wrapped him up in a swaddle and tucked him under my sweater, holding him close to my chest, sitting at the nurses station for about forty five minutes, until I couldn't see a heartbeat any longer.
And here is the cultural difference that I struggled with: His parents weren't wrong. To me it seemed wrong, to let their baby die cold and alone, but that's only because of my own learned customs of love, grief, and healing. It seemed like the right thing to do to me to bridge the gap for this baby between this earth and wherever these little ones go to, but just because I felt that was right doesn't mean his parents were wrong.

Lesson #3: An African-American Queen

It's three in the morning. At this point, I'm wondering why I went into obstetrics. There are floors above me filled with sleeping patients, sleeping residents, and yet I am running around the third floor, awake with another laboring patient. This girl is sweet, a 16 year old here with her mother, who is earnestly coaching her daughter's labor. She's ready to push and have a baby girl, so I put my gown and gloves on, and get ready to help her to push.
She doesn't need it. She pushes well, and her mom shouts "That's it! Push hard, baby! Soon we'll hear that queen holler!" And I smile. Not the absent, tired smile I feel like I usually have, but a genuine smile. For a minute, my shoulders relax away from my ears, and I remember why I loved obstetrics. I'm excited for this family. I'm ready to meet this queen, too.
Aftwerards, I congratulate mom, and grandma. As I'm leaving, I can hear grandma on the phone talking to someone, saying "Listen to that baby holler! Speaking of, you should have seen this young woman that delivered her. Not but a baby herself."

Lesson #4: A Somali Refugee
There is a fairly significant Somalian population in Phoenix, a community of refugees. Most tend to be difficult patients- mistrustful of the hospital system and Western medicine, along with a significant language barrier and cultural gap. The roles between men and women are so much different than I could have imagined based on my own experiences. In our house, my mother had a career. My husband changed careers and moved to support mine. I go to work, and he does the dishes. In their house, the husband is the decision-maker. The patients will not answer me, not acknowledge my presence or information, until their husbands are there to communicate directly with me. The mechanics of birth are challenging because of scar tissue left behind from genital mutilation. It's hard to do an exam under the many layers of robes that the patients insist on wearing. They tend to refuse medications, and epidurals, and any procedure outside of the normal vaginal delivery.
Because of all these things, when my Somali patient's baby's heart rate went down, and then came back up, I thought it was a good idea to talk to her about a c-section. She didn't need one now, I explained, it was only that I wanted to talk to her and answer her questions while everything was calm and her baby's heart rate was fine, while I had time to use the translator phone and could explain everything about the consents.
Three hours later, I'm bleary-eyed. I've tried to be sympathetic, and explain things differently. I've tried to sit back and enjoy the melodic rhythm of a language that I don't understand. But I can't. I've spent my night sitting here, instead of in bed, and I have no consent. What it came down to was the patient understood why I was talking to her about it, but said she didn't want surgery. She wanted to be healthy, and babies die every day, so if something happened, she wanted to remain healthy and not intervene for the baby.
No!! I want to scream. This is America! I can almost certainly make BOTH you and your baby healthy, even if you needed an emergency section. But, she didn't believe me. She wouldn't sign the consent, and ultimately, I can't make her. She is deemed mentally competent, and able to make decisions for herself and her unborn child.
In the end, after my shift had ended and my friend had taken over for the day, the baby's heart rate went down, and she watched them stay down- for ten minutes- as she and an attending tried to cut through genital scar tissue to deliver the baby as fast as possible vaginally, since the patient was still refusing the operating room. My hours of trying to consent her were wasted, she had more of a wound that she would have with a simple cesarean, and her baby was in the NICU.
Did it make sense to me? No. Was I angry, and worried for her and her baby? Yes. But I had to leave this situation with these frustrating conclusions, and realize that maybe that was what she wanted, because she was a culture so different than mine.

These are the real stories of cultural competence. I watched the required videos from human resources, but I didn't learn what these situations taught me- that cultures are so different. Sometimes it's fun, and sometimes its horrifying, but the "competence" isn't learning to manipulate situations to fit your own culture. It is learning to recognize other cultures and try to accept them, to try to bridge a gap for yourself in between your beliefs and these new ones, where you understand a little bit more than you did before the interaction.

As I sit here with my afternoon coffee, reflecting on these interactions, I reach for a butter spritz cookie- my grandmother's recipe- to have with my coffee. No reason other than it's 3 pm, and that's what Swedes do.

As I head for the cookie jar, I smile. At least I am competent in one culture.

1 comment:

  1. What an excellent reflection - honest, accurate, and, as always, compassionate. Not bad for a lil white doc.