How to practise medicine in a multicultural society
Sabina Dosani gives some practical advice

Begum
You may know a typical Begum. She is an Asian woman suffering from non-specific pains and weakness. When questioned, pains change places. On examination, nothing is apparently wrong. Investigations are normal. Begum comes to casualty with her large extended family who interpret for her, insisting that this is sorted out once and for all. Gynaecologists see Begum and diagnose functional dyspareunia. Perhaps you observed her endoscopy result and were taught about functional dyspepsia. Or perhaps you met her in the professor's neurology outpatient teaching clinic where her numbness disobeyed dermatomes. She visits many different departments and gets increasingly nervous. Doctors become irritated. Students are perplexed. Twenty years ago, someone wrote her up: "The Begum syndrome."1

Stereotypes
It is not just Begum. Alcoholic Paddy turns up in almost every department with a plethora of alcohol related illnesses. Well, he's Irish, isn't he? What do you expect? Or the tired looking African man who must have HIV. Where do stereotypical patterns of illness in ethnic minorities come from?

Ethnocentrism
Ethnocentrism--believing your culture is superior to others--leads to stereotyping. We tend, both socially and clinically, to look at other cultures through our own culture tinted spectacles.

Expressing distress
A man from Haiti has chest pain. You might ask him questions about the position of the pain, its quality, radiation, severity, and timing. In response, he says a voodoo spell has been put on him. When you present your history, the consultant feels irritated. The patient is baffled. Nobody seems to be listening to him. He is treated for his myocardial infarction and referred to psychiatrists.

Is he mad? He is only expressing his distress according to his cultural background. Belief in voodooism is common in Haiti. Members of other cultures have their own culture specific expressions of distress leading to somatisation presentations, fears of black magic being practised against them. Illness is explained by fate, bad karma, or witchcraft.

Asian women like Begum, lonely and cut off from their cultural roots, can only appeal to mostly white doctors in an attempt to communicate what is wrong. They may go to what British medicine considers the wrong department, at the wrong time, with the wrong symptoms. But something is obviously the matter. How can we fulfil our duty of care?

Clerking patients from other cultures
Interpreters

Find out your patient's first language. If you speak the same language clarify terms used by you and your patients. Medical students, doctors, and patients may use an identical word and mean different things. For example, the medical term "section" means a "cut specimen" to a chemical pathologist, a "means of delivering a foetus by incision through the abdominal wall and uterus" to a gynaecologist, and a "legal method of compulsory admission of a patient" to psychiatrists. For a different language, you will need an interpreter. Avoid using patients' families to interpret. They may lack the objectivity expected from dispassionate outsiders. A skilled interpreter should act as a bridge between two cultures, educating us about patients, and patients about British models of health and illness.

However, interpreters may try to hide painful topics. A colleague of mine had difficulties working with an interpreter who was too embarrassed to ask a woman whether she experienced pain during sexual intercourse. Some may be defensive about their culture--for example, hiding the features of mental illness. Coming from a community already stigmatised by racism, it is understandable to try to avoid further stigma from a psychiatric diagnosis. One way of avoiding such potential problems is to meet with interpreters beforehand and explain the purpose of the interview and probable questions. Of course this is impossible in a busy accident and emergency department, but one half hour meeting potentially saves hours of outpatient clinic time over months especially if a bank of interpreters are used regularly.

Confidentiality
Reassure patients that any information will be treated in confidence. An orthodox Jew, for example, is more likely to reveal possible sources of his gastroenteritis if he feel sure his community elders will not hear about his unorthodox eating patterns.

Be especially careful not to breach confidentiality when discussing diagnostic dilemmas with members of your patients' community in an attempt to glean clinically useful information. In many small communities demographic details alone may be enough to identify patients although real names are not used.

Degree of identification with cultural group
Patients may seem to be of a certain ethnic background, but on further questioning it becomes clear that they are second generation immigrants who may not identify with their parents' cultural group.

Assumptions
Assume nothing. Traditional Mormons, Methodists, and Muslims are from religious groups prohibiting alcohol. I have seen delirium tremens in patients from each of these faiths. Do not leave out any routine screening questions for fear of causing offence. Finding a sensitive way of prefacing your questions minimises offence. For example, "I ask everyone this because it is important in trying to find out what is wrong." Aim to strike a balance between overemphasising culture and stereotyping on one hand and insensitivity of cultural influences on the other.

Physical examination
Always use same sex chaperones when examining patients. If possible, select chaperones from the patients' own culture. If interpreters and chaperones are not one and the same explain examination procedures to patients using interpreters beforehand. It is bad enough to have a stranger you cannot understand inserting a finger into your anus. To do this without prior warning and verbal consent constitutes assault.2

Prescribing
Traditional remedies such as Unani and Ayurveda are no longer just the domain of ethnic minorities. Eastern healing arts have enjoyed a renaissance in Britain recently. It is important to find out if patients are using traditional treatments. Many contain substances which can interact with prescribed medication. Traditional healers may recommend food taboos or dietary restrictions potentially affecting drug absorption.

Cytochrome P450 isoenzymes are involved in oxidation of many drugs. Some patients--for example, Hispanics and Nigerians--are more likely to have low levels of these enzymes leading to poor metabolism of these drugs.3

Compliance with medication depends on patients' personalities, attitudes, and beliefs, all of which are influenced by culture.

Ten top tips for practising medicine in a multicultural society

Elicit patients' language, culture, and ethnic group
Beware of cultural stereotypes
Avoid using patients' families as interpreters
Familiarise yourself with expressions of distress used by cultures you commonly encounter
Keep confidentiality
Avoid religious and social taboos
Use same sex chaperones
Remember potential prescribing pitfalls
Allow culture specific rituals--for example, after death
Do not make assumptions

Death
There are some blunders nobody makes. You would not call a Catholic priest if a Jewish patient was dying. However, a female colleague once held out her hand to offer condolences to a man whose wife had just died. The man was an orthodox Jew whose culture forbade him to shake hands with women in case they were menstruating. Although she had meant to offer comfort, her gesture was embarrassing and insensitive at a very inappropriate time.

Another colleague noticed that a bereaved Asian family seemed especially distressed about the way in which their relative had been laid out. The family wanted the paperwork completed quickly despite reassurances from nurses that there was ample time to register the death. By talking to other members of that community he learnt that Muslims often prefer to wash the body themselves. According to Islamic law, burial must take place as soon as possible. These simple facts explained his grieving family's emotion and behaviour.

Begum returns
It is 2am. Begum is back. With abdominal pain. The nurses are anxious that she is dealt with quickly as her extended family is taking up a lot of space in the waiting area. Before she is sent on her way, following a perfunctory examination, routine electrocardiography and subsequent cardiac enzyme tests indicate that she has sustained a myocardial infarction. Symptoms may be somatic metaphors of distress. Others are indicators of underlying pathology. The art of multicultural medicine is about finding the true meaning, regardless of their expressions.


1 Galbraith J. Begin the begum. World Medicine 1980;14 June:77-8.

2 Lin KM, Poland R, Nakaski G (eds). Pyschophparmacology and psychology of ethnicity. Washington DC: APA Press 1993

3 ******** J. A fundamental problem of consent BMJ 310:43-6.


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Sabina Dosani senior house officer in psychiatry, St ******'s Hospital, London
s.dosani@medix-uk.com