Dr. Jokela is head of internal medicine, University of Illinois College of Medicine at Urbana-Champaign, Urbana, Illinois.
Given the fact that many residents in the United States do not perform their training where they attend medical school, they are prone to encounter potentially awkward situations regarding local cultural dimensions new to them. During morning sign-out rounds, one such situation unfolded amongst a group of internal medicine residents. This experience reemphasizes the value of simply observing the cues given to us by our residents.
The internal medicine resident night float excitedly presented his admission to me and the team. The patient, a woman in her early 50s, was brought in by her husband because she had become confused. Aside from her mental status and a large right breast mass, her exam, including her vitals, was remarkably normal. Her labs, however, revealed a dangerously high serum calcium level of 23 mg/dL. She had been diagnosed with a breast mass four years ago but declined a biopsy.
The six residents, four students, and the chief resident all were animatedly and urgently discussing the management of what appeared to be advanced metastatic breast cancer. Then one of the night float residents quietly said, “It is unusual to see a presentation like this in this country.”
The resident continued, “We see this not uncommonly in India, but here, this is very unusual.” The other residents chimed in, saying that during medical school in India and Pakistan, they commonly saw disenfranchised patients presenting with advanced disease, but that comparatively, they saw this less often here in the United States. They subtly implied that for them, this woman was not a “typical” disenfranchised patient, possibly culturally, or otherwise. We briefly discussed the relevance of insurance status and access to care and how these factors affect clinical outcomes. The point was that, yes, even here in the United States, and apparently not unlike some locales in south central Asia, patients may present in the advanced stages of their disease. The residents politely murmured their understanding, but they did not seem convinced.
Something was missing. When I asked, “What is this patient's background?” the residents shifted uncomfortably. It suddenly became clear: the residents did not know. Then one of the medical students spoke up and said, “I think she may be Amish.”
The pieces of the puzzle fell into place. The residents were not familiar with the customs of the Amish, so we promptly embarked on a cultural mini-course. I also recognized a curricular need within our program. The residents were intently absorbing all that they could, hearing that the Amish generally do not use electricity in their homes, drive horse-drawn buggies, wear a distinctive dress, and teach their children in their own schools. They are intensely private people living simply and separately, practicing their Christian religion. “Are they Catholic?” one of the residents asked.
The enthused residents seemed relieved, as they freely asked questions without fear of embarrassment. They were grateful, buoyed by our conversation and their newfound knowledge. They better understood their patient, her family, and, on some deeper level, the principle that indeed she has a choice.
This situation illustrates the simple importance of remaining sensitive to the subtle cues given to us by our residents. As educators, it is imperative that we remain astute observers of our residents. All of our residents, regardless of their backgrounds, may remain reluctant to bring cultural issues to our attention. Embarrassment about knowledge deficits or simple discomfort addressing such issues, which magnify the cultural gaps between our residents and their patients, remain barriers. As educators, we owe it to our residents, and their patients, to help shed light on these cultural knowledge deficits as they come to our attention. This will help all of us become more culturally sensitive and aware and, ultimately, better physicians.
Janet A. Jokela, MD, MPH