Jun 15, 2015

Interview Transcript

Interviewer: Things to keep in mind when working with Hispanic immigrant populations. Next on The Scope Radio.

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Interviewer: In medical school we learn how to heal, but one thing we don't learn is how a person's culture might play a role in the approach to their treatment. Dr. David Gontrum is a family practitioner, and a large portion of his patients are immigrants from Central and South America.

Many of these patients' attitudes, feelings, and beliefs towards life and health care are culturally different, and it can be a challenge to bridge these cultural differences to deliver effective medical recommendations and health care. So Dr. Gontrum, what type of patient population do you mostly work with in your practice?

Dr. Gontrum: The defining characteristic of our patient population is low income. Over the years, that's evolved increasingly to a Hispanic, mostly Spanish-speaking population.

Interviewer: Is there a specific event or presentation where you first became aware of how someone in this demographic or in this culture might approach health care differently than someone who you've known that's American?

Dr. Gontrum: I think the most common experience that I have on an almost day-to-day basis, which I am aware of the difference between my priorities and what appear to be the priorities of my patients, childhood tooth decay. The most common chronic illness right now in the United States among children under one is early childhood caries. Fortunately, this is an easily-prevented disease. One of the simplest measures is to simply discontinue using a bottle early in life and usually by the time of first tooth eruption.

What I've discovered over many years is that again and again the mothers bring these children back at 18 months, 20 months, and 2 years, and these children are still using a bottle. What I've realized over time is that their concerns about the child crying and the shame that they would feel from the rest of their family about their child being unhappy or appearing to be unhappy trumps any long-term concerns about childhood tooth decay.

Interviewer: Was there a specific moment where you kind of had an 'aha' moment where you realized that maybe it was a cultural difference where mothers were very interested in soothing their child and soothing their baby, even while you were giving recommendations to not continue bottle feeding?

Dr. Gontrum: You know, I'll admit I continue to struggle with this one because I feel my responsibility remains with the overall health of the child in the long term. The moment I think I recognized that is one of my partners said to me, "You know, for this culture, like many other cultures, the highest priority is to avoid shame." I thought about that from the perspective of the mother in a close family and it's 2:00 in the morning and everybody's sleeping in the same room, and as this child cries because you've taken away their bottle, the shame they must feel amongst their family would be much greater than their fear of something that's somewhat intangible and distant into the future, and really, it's a leap of faith to believe me rather than to pay heed to their family who is sitting in the room and looking at this mother and making her feel like a bad mother because she's just made her child cry.

Those are two very different perspectives; one immediate and one more long-term. How is it for me to say what really is the best, though I struggle with this daily because I continue to feel that they can do both, and I try to approach that in both and try to help them find ways to not feel shame when they may do something that causes the child to cry. What I usually say is, "You may have a choice, which is to have the child cry now or have the child cry and wake up later when they have tooth decay in the middle of the night in pain."

Interviewer: Was there any training along the way that you had or any specific education that helped with these cultural barrier issues?

Dr. Gontrum: For me, my training goes back to a lot of prior experiences with travel and working in different cultures. I think it's hard to learn specific things about individual cultures because the danger is oversimplification, and the danger is when you try to come up with specific themes, you often, again, oversimplify rather than really try to understand the individual.

I guess there are certain themes that do stand out for the Hispanic culture, but I would say these are very broad and difficult to pin down, in part because trying to identify Hispanic culture as one culture is, again, an oversimplification. Even in our practice, we have everything from poor migrants from rural Mexico who've had little more than maybe a second or third grade education, to very urban educated South Americans, for example, who have an entirely different Hispanic background and share oftentimes very little in common with this other group of patients.

Interviewer: What specific strategies have you employed to try to cross cultural barriers?

Dr. Gontrum: I guess the primary strategy I employ with almost every patient is both respect in an effort to try to hear what they're telling me, and humility about my own biases toward their explanations. I find usually that if I approach their concerns with humility, I'm generally most able to bridge some of the cultural barriers.

With that said, I think there are some themes in cultural differences, particularly with our Hispanic community, mostly which comes from rural or Mexico. That is a tremendous value in the sense of the family and that the respect for one another in a family sort of trumps almost any other priority. If I keep that in mind as well as the tremendous value that this culture places on respect for authority and the need for kindness and politeness from one person to another, I find I make much more of an effort with my Hispanic patients to demonstrate warmth and care and kindness because that appears to be so important for them to be able to hear any recommendation or concern. It is a distinction from the larger culture in which we live.

Interviewer: I really like that answer. So if you could give one piece of advice to the medical student listening to this in dealing with another culture that they might be uncomfortable with, what would that piece of advice be?

Dr. Gontrum: Maintain humility. I think the most important, and this, I think, goes particularly for medical students and the medical profession in general, we are often to blame for a lack of humility in most of what we do. We have to have confidence in our decisions and confidence in our approach. That's why we can lend strength in difficult situations, but I think we have to remember that we might also be wrong and we might also have not heard what the patient is really saying. To keep that always in the back of our mind and approach patients with kindness foremost, I think we're most likely to be able to help them.

Interviewer: Any other points that you would like to make that we could ask a question to get across?

Dr. Gontrum: Yeah, I would like to add something. I'd like to say that, again, it's been an incredible privilege and opportunity to take care of a non-English speaking patient population, in part because it teaches you so much more about yourself and about your own culture than you would ever have an opportunity to learn if you didn't have that experience.

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