Special Theme: Cultural Competence: OTHER: Teaching and Learning Moments
KAMEI, ROBERT K. MD
Dr. Kamei is director of residency training and associate professor of clinical pediatrics, Department of Pediatrics, University of California, San Francisco, School of Medicine.
The author acknowledges the Fulbright Senior Scholar Award program and thanks Dr. Sunita Mutha and Dr. John Takayama for their helpful comments on this article.
I had the opportunity to be a guest faculty member at Sanglah General Hospital, the public teaching hospital of the Udayana University School of Medicine, in Denpasar, Bali. Bali is home to 3.5 million people and is one of approximately 13,000 islands that make up Indonesia, the largest archipelago and fourth most populated country in the world. Although Indonesia is the largest Muslim country in the world, approximately 80% Bali's population is Hindu.
A particular case comes to mind, which illustrates the difference in medical cultures between Indonesia and the United States. The grandchild of a Balinese physician was born several weeks prematurely. The prenatal course was uncomplicated, but the baby quickly became anemic and in respiratory distress. The infant was given a blood transfusion and supplemental oxygen, but did not respond and died soon afterwards. The senior attending physician clinically diagnosed all of these events as due to “extreme prematurity,” with little radiologic or laboratory confirmation. Although everyone was saddened by this baby's death, the family was satisfied with this medical explanation. There was no further discussion of the baby's differential diagnosis or hospital care by physicians in any educational or clinical setting. After only a few days, this tragic event seemed to become a distant memory to hospital staff.
After I gave my condolences to my colleague about his grandchild's death, he replied to me with a smile on his face, “everything that could have been done was done.” Indeed, “everything” had been done because, according to Balinese culture, the fate of the infant was largely predetermined by God. As he tried to make light of the situation, there was still a hint of sadness in his eyes. Grief is often suppressed by the Balinese because it is considered to be a disagreement with God and harmful to one's own health, creating an imbalance between the body and the universe, and diminishing one's resistance against illness. Grieving is also considered contagious, and a threat to the balance and health of the community at large, and may interfere with the recently deceased soul's ascent to heaven.
Of course, there are other reasons why the family or physicians did not wish to pursue the exact etiology of this baby's death more vigorously. The physicians frequently stated that financial concerns influenced their general tolerance for such medical uncertainty. Clinical laboratory tests are not easily available for patients and their cost is generally prohibitive for families. In the minds of most Balinese, there seems to be little reason for anyone to pay additional physician or laboratory costs to evaluate a patient who will most likely die anyway or to perform an autopsy for a patient who has already died. In addition, the Hindu religion prohibits autopsies, so they are rarely done, even for patients who are not Hindu.
I speculated about the different reactions this case would have received from physicians in the United States. Some of the reasons for these differences became clearer as I learned about the powerful influences religious and cultural beliefs have on everyday aspects of modern Balinese society, including the medical system. This was evident not only in the family of this child who died shortly after birth, but also in the attitude of the physicians involved, whose culture is less frequently considered. This culture includes the personal culture of the physician, and the “acculturation” developed during medical training and subsequent practice.
Working with physicians in a different cultural setting exposed many of my own clinical blind spots and invited me to self-reflect on the influences culture, values, and personal biases have on my work as an academician, pediatrician, and teacher in the United States. While I have always tried to be respectful of the impact of my patient's cultural values on how I practice medicine, I now understand more completely how my medical and educational cultures have shaped my thoughts and how I, in turn, influence the medical acculturation of medical students and residents that I teach.