Is cultural aspect important in medicine?

What is culture?

*jing jing* This is what I understand by reading the lecture note. Sets of ideas, concepts, rules, meanings, beliefs, custom, knowledge, morals, capabilities, habits, skills, and art will be relfected by action or our actual practices or daily performance. This is called as CULTURE.

What role does the cultural aspect play in medicine? Should it be taken into account when we, the doctors, give a treatment to the patient or give an education to the community about the prevention of a disease or promoting health?

Scenario 1:

When i'm very sick, I will go to the clinic to see a doctor. The doctor will usually use less than 5 min to take an anamnesis. If go to GMC, they will finish taking anamnesis and physical anamnesis within 5 min.

Hmm...lets think: A patient, named Pak A, with acute attack of asthma.What does a doctor usually ask and do? maybe as usual: apa keluhan utama? sejak kapan? ada bunyi ngik ngik? pernah ada sesak nafas kayak gi ni? if yes, sejak kapan? apa yang meringankan dan memberatkan sesak nafas? ada allergy terhadap apa-apa? and ask other questions in order to rule out other disease, like CHF, COPD. Then the doctor will auscultate. I think this is what a GP will ask n do, in the reality (sorry, if I am wrong). They will finish doing these within 10 minutes.

BUT my question is: Are those questions sufficient for you to treat a patient with chronic disease? If you do what I mention above only, do you think the patient can control the asthma well?

So, how about the cultural aspect? In order to help a patient to control asthma, do we need to explore the patient's perspective on asthma?

Different people have different perspective on an issue/problem/health-illness. A patient may see "asthma" as an acute and temporary disease in which they just need to take reliever (like salbutamol), but don't need to take corticosteroid; A patient may feel ashamed of using a medication due to the stigma; A patient may care about the side effect of corticosteroid, such as weight gain. Most of the  female patients will care about that; A patient may think in this way: I don't have asthma attack for a month. So I can go jogging/ marching/ dancing!! These perspectives contribute to asthma exacerbation. Besides that, how about the socioeconomic status of the patient? Is the patient having financial problem in buying medication?

By reading these, do you think that exploring emic perspectives is important in order to treat a patient, especially those with chronic disease?

Scenario 2:

The mentawai community may consult a sikerei whenever they are sick. A sikerei is a person consulted by people for any illness. His technique involves magical power to resist and prevent illness.

If you are a GP in that community, you encounter that people rather consult a sikerei than going to your clinic to consult you, what you will do?

In my opinion, in this situation, we should know the concept of how the sikerei treat the patients, the community's belief, perspective of illness, how long does this belief have been inherited in that community, how much does a sikerei charge the patient, the education level and socioeconomic status of the community, etc

Scenario 3:

If you want to organize a campaign of smoking cessation, what will you do?

emphasizing on how to stop smoking, explaining the impact of smoking on health? by the way, before you promote the way of smoking cessation, do you explore the reason why a smoker smoke? do they ever try to stop smoking? what kind of smoker are they? From what age do they start smoking?

A smoker can be an in-control smoker (they will smoke in certain situations only), confirmed smoker (always smoke, with no control in smoking), contrite smoker ( they regret and actively trying to extricate themselves from smoking), etc. According Johnson et. al., 2003, multiple dimensions constituted the youth's smoking identities: their smoking behavior and experiences; their awareness of the role smoking plays in their lives; their aspirations with regard to smoking; and the degree to which the social construction of "smoker/nonsmoker" had been accepted, rejected, or integrated into their lives. Few questions have been raised: do smokers not see themselves as smokers and therefore deny the need for cessation programmes? A good example is given in Johnson et.al, 2003. There were some in-control smokers describing themselves as non-smokers who happened to smoke in certain situation. Note "non-smokers"! They don't see them as smokers! That is one of the reasons why the tobacco control initiatives yield such a low participation and success rates.

Therefore, insight into varied non-smoking identities and the different ways they position themselves contribute to improve tobacco education programs based on social influence models. Besides that, we can see that a one-size-fits-all approach to smoking cessation may not work well. A more tailored approach that responds to and incorporates the range of identities may yield a more promising successful results in tobacco controlling programme.

In conclusion,

there are a lot of diversities of the perception of health-illness and health seeking behavior, depends on the ethnic group, socioeconomic status, knowlege, habituation, religion or beliefs of the community. Due to these factors, doctors and patients will usually have different perception on a disease or problem. So, to be an ideal doctor, we should have these: knowledge, skill, experience, ability to integrate patient's beliefs, values, experience and views to the mangement or daily medical practice (prevention, promotion, treatment, rehabilitation).

Wait a minute! How should we collect the data in order to know the cultural aspects of the patients?

There are two ways: 1) quantitative (questionaires, self-reported data); 2) qualitative ( observation, chatting with patients, in-dept interview, prolong anamnesis, narrative inquiry)

When two people of different cultural background communicate, this is called as cross cultural communication. In this kind of communication, we should:

1. avoid ethnocentrism (seeing his/her own culture to judge practices by other culture)
2. avoild chauvinism (seeing his/her own culture as the best culture for people to adapt to)
3. avoid stereotyping (seeing the negative practices as done by all the people in the ethnic group)

Reference:
1. Dr. Retna Siwi Padmawati. Lecture: Cultural aspects in medicine.
2. Dr. Retna Siwi Padmawati. Practical session: Narrative Writing.
3. Johnson J.L., Lovato C.Y., Maggi S., Ratner P.A., Shoveller J., Baillie L., et. al. Smoking and Adolescence: Narratives of Identity. Wiley Periodicals, Inc. Research In Nursing and Health 2003; 26: 387-397.