Medicine is a social science in its very bone and marrow.
Lower socioeconomic status is arguably one of the most powerful single contributors to premature morbidity and mortality in the United States and worldwide.2 Immigrants and racial/ethnic minorities represent a disproportionately high percentage of the socioeconomically disadvantaged in the United States, and thus shoulder a higher burden of this morbidity and mortality.3 However, numerous studies have demonstrated striking disparities in health based on race and ethnicity even when corrected for socioeconomic status and other factors.4
Efforts to eliminate disparities in health care have focused on the issue of “cultural competence” throughout the health care system, particularly in academia, where the minds and attitudes of new generations of physicians are developed. At the level of the individual provider, cultural competence has been defined as “a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups.”5 This definition, and most efforts in the area of cultural competence, under-emphasize the important impact of social factors on the provision of health care to diverse populations. As we shall see, the distinction between social factors and cultural factors is not always clearcut, but both are directly relevant to patients' health and medical care.
Medical education at all levels has begun to adapt to the challenges of diversity in health care. This is evidenced by several cross-cultural curricula published recently,6,7,8 the new cultural diversity standards from the Liaison Committee for Medical Education (LCME), and several national conferences that have either focused entirely or placed strong emphasis on these issues. These conferences include the Society of General Internal Medicine's 24th annual meeting, which had the theme “Addressing Disparities in Health”; the National Conference on Quality Health Care for Culturally Diverse Populations, sponsored by a consortium of foundations and private and federal agencies; and “Cross-Cultural Medical Education and Practice: Imperatives for Medical Educators in the 21st Century,” organized by the Northeast Consortium for Cross-Cultural Medical Education and Practice.
LACK OF EMPHASIS ON SOCIAL FACTORS
However, cross-cultural medical education typically fails to address social factors, which include not only the usual predictors of socioeconomic status (income and education), but factors such as illiteracy, immigration experiences, religion, social stressors, and social support networks. While understanding cultural differences is crucial to optimal care, for many patient encounters (particularly with patients of lower socioeconomic status) the greater barriers to health will be social in nature. Failing to address these important areas risks inadvertently teaching future doctors to view culture as the explanation for what are fundamentally social issues. Since medical students and residents frequently train in “safety net” institutions, this issue is magnified, and they are at particular risk of developing negative stereotypes for various cultural groups as poor and undereducated. The following case vignette illustrates these points:
Mrs. G is a 66-year-old woman from the Dominican Republic who speaks English reasonably well. She has a history of type 2 diabetes and has been on several oral medications, but her glucose has been poorly controlled. She has had several visits with the nutritionist and was recently started on insulin. Aside from feeling thirsty, she is without symptoms. She frequently misses appointments, is usually late, and has a somewhat passive attitude towards her medical conditions. Her fingerstick glucose is recorded only sporadically. On one visit, after arriving over an hour late, she became very frustrated and tearful. When questioned about this she responded that the diabetes was making her very sick. This led to yet another discussion about checking her fingersticks more frequently and taking her insulin more consistently.
If we interpret Mrs. G's situation and behavior as culturally based, certain stereotypes could be invoked. She is Dominican, or more generally, Hispanic. She seems emotional, is somewhat fatalistic toward her health, and pays little attention to punctuality. What the doctor failed to learn is that she cares for the three children of her daughter, who works two jobs. Most of her family is in the Dominican Republic, and she has little social support here since her husband died several years ago. She has had to take a bus and a train to get to the doctor's office since she was relocated to a different public housing area. This has also separated her from the church where she had been actively involved. Additionally, she is having great difficulty paying for the medications, which Medicare does not cover.
Without a doubt the social context of this particular patient has direct relevance to the management of her diabetes. In fact, further manipulation of the medical regimen, or “scare tactics” regarding imminent diabetic complications, may be futile without some attempt to acknowledge and address these social issues.9 Whatever cultural beliefs or values she may have as a Dominican immigrant are likely to be overshadowed by the much more tangible social issues she faces. In fact, this vignette clearly could portray a European American or African American woman facing very similar social issues. The distinction between cultural and social is not always clear-cut—in fact, there is often overlap. For Mrs. G, the fact that she lives in public housing and has a difficult commute to her visits is not due to her cultural background as a Dominican. These problems are socioeconomic ones. That she is a religious Catholic may influence her culturally, but becoming separated from her church due to her relocation is a social issue. Her fatalistic attitude could have some religious and/or cultural basis, but is more likely shaped by years of socioeconomic hardship and limited control over the course of her life.10
Courses that teach about certain cultural characteristics (e.g., those of “the Hispanic patient”) would be unlikely to be helpful in this case. What is important is that doctors in training be sensitive to the patient's social context, know how to explore the relevant issues, and use what they learn to provide better care and to avoid developing negative stereotypes. The influences of social and cultural factors on illness vary with the individual and the particular circumstances.
Clearly, the brief and perfunctory social history that has become acceptable in medicine leaves physicians ill prepared to deal with the complex ways in which social factors can affect the medical encounter. In the case of Mrs. G the brief history would show her to be a 66-year-old retired woman living with her daughter's family who has never smoked and rarely drinks alcohol. Once this information is gathered on the initial visit, further social exploration on subsequent visits is often given little formal attention. While it would be impractical to perform an in-depth social analysis for every clinical encounter, some patients may need a more detailed social history. The specifics of each case should determine the timing (initial or subsequent visit), the extent, and the particular issues on which to focus.
FOUR DOMAINS OF THE SOCIAL CONTEXT
The social context can be structured along four major domains that receive little attention in traditional medical teaching: social stressors and support networks, changes in environment, life control, and literacy. Exploration of these domains can be helpful for all patients, but is particularly important in cross-cultural encounters, given that non-majority patients are more likely to have low incomes, be undereducated, be from single-parent homes, and have been born outside the United States.11 The questions and interview tools for each of these domains should be thought of as a social context “review of systems.” Like the traditional review of systems, they should be used in a selective manner, focusing on the pertinent issues. For example, questions regarding Mrs. G's social stressors, support, and financial difficulties could have been most helpful and pertinent. Practical ways of exploring and dealing with these social issues are described subsequently and refer to this case. While there may be no easy solutions to many of these difficult social issues, recognizing them and working with patients to minimize their adverse effects on health and medical care may help foster trust, enhance communication, and improve outcomes.6,9
Social Stressors and Support Networks
Each individual's life presents a unique balance of social stressors and support networks for dealing with them, both in constant flux. While these are not always relevant to the medical encounter, in some circumstances they are the entire reason for it.12,13 Somewhere in between these extremes is the case of Mrs. G, who has diabetes, the biomedical rationale for her visit. Her diabetes has been poorly controlled, a source of frustration for herself and her physician. The most obvious reason for this is the multitude of immediate social stressors that diminish the relative importance of the more abstract problem of diabetes. In addition, her lack of family and social support, due both to her immigration and recent relocation, leaves her ill equipped to handle her difficult social situation. While these may not be the reason for her visit, they are a central cause of her poor diabetes control. Another major stressor in her life is her daughter's dependence on her for the care of her children. Some basic questions for eliciting a patient's life stressors and social support network are presented in List 1.
Important sources of stress in patients' lives include the other factors described in the list (i.e., financial problems, housing problems, new environments, etc.) as well as relationship problems, domestic violence, substance abuse, family conflict, and crime, among a multitude of others. Some of these issues require special attention beyond the scope of this discussion. Social support often comes from family, close friends, and social or religious groups. A less obvious source of support is a patient's faith or belief in a greater purpose such as God, a movement of some type, or a vision for the future such as the success of one's children.
While physicians can provide an important source of counseling and support, it is usually beyond the scope of the physician's role to solve the difficult issues of social stress or lack of a support system. Nonetheless, it is important to recognize the key problems, assess their effects on the patient's health and the medical encounter, and help the patient to develop his or her own social supports and other potential methods of dealing with both medical and social issues. Adopting a more “biopsychosocial” approach will prevent medicalization of fundamentally social problems, avoiding potentially costly (and not necessarily benign) work-ups and treatments.12,13 For Mrs. G, starting to attend the local church in her new neighborhood might lead to an important source of support. Often, a social worker or counselor can be an extremely useful resource for developing community ties.
Change in Environment
Change in environment refers to any migration, whether from a different country, city, town, or even neighborhood, that requires adaptation to new physical and social surroundings. While some individuals may be able to make a fluid transition to the new way of life, others have greater difficulty. On a very practical level, there may be difficulty negotiating the unfamiliar new customs and physical environment, particularly those of the U.S. medical system. More complex issues arise when patients are accustomed to a very different health system. For example, a recent Russian immigrant presented with a headache and was very insistent that he receive a CT scan. He was used to a health system where expensive tests are tightly rationed, and offered to those with very convincing arguments only. Similarly, a woman from rural Ecuador described a long list of complaints. In her previous health care experience, visits to the doctor were few and far between, and she had been raised to believe that it was her responsibility to inform the doctor of any symptom she had experienced in the interim. Understanding these differences may improve negotiation and management of patients who may be perceived as “difficult.”
On another level, the adaptation to an entirely new way of life imposes enormous stress on the individual (as mentioned in the previous section). The reasons for the migration, ranging from fleeing political persecution and torture to attending a U.S. university, may be crucial in understanding past and present stresses. A resulting change in social status (e.g., from physician to lab technician) may also be relevant. Mental illness and psychosomatization are potential consequences of such stress and should be recognized and managed with sensitivity and awareness of the social context. Some of the questions in List 1 are examples of how to begin exploring a patient's change in environment.
Understanding the patient's unique migration experience can help the physician to build rapport and trust, allay certain concerns (such as fear of deportation), acknowledge a source of distress that may be causing psychological or psychosomatic problems, and focus on interventions that facilitate the patient's transition. Community-based organizations can be a helpful resource in this setting. While Mrs. G's immigration from the Dominican Republic was not difficult or traumatic, exploring it may help reveal her lack of social support here in the United States. Also, discussing her change in environment to the new public housing area may uncover important issues regarding the separation from her regular church and her difficulties with transportation.
Life control can be defined as the ability to influence the direction and course of events in one's life through tangible or intangible means. Several more tangible social factors that are predictors of socioeconomic status (SES), such as financial resources, job security and benefits, health insurance, and education, lead to certain levels of objective life control.14 There is an additional subjective component to life control, determined by personal and psychological factors, that may impart a heightened sense of control despite low SES. A patient's social support network, including family and friends, social or religious organizations, and spirituality, as discussed earlier, contributes to this subjective life control.14 Besides the obvious difficulty of affording adequate health care, lack of life control can manifest as a sense of helplessness and fatalism and an orientation to the present with a compromised ability to plan. In the case of Mrs. G, she not only has difficulty affording her medication, but due to her low level of life control (related to poverty and lack of education, among other things) she feels a sense of helplessness regarding her diabetes management. She has difficulty focusing on future consequences of diabetes, as she is faced with more immediately pressing issues of daily life.
Some practical and sensitive questions designed to explore both objective and subjective aspects of life control are shown in List 1. These should serve as guidelines, to be modified or expanded upon depending on the particular situation. Often it is clear when a patient has a low level of control. In these cases the questions help to clarify the issues by allowing the patient to express his or her concerns to a nonjudgmental listener. Some clues as to when these questions may be helpful include concerns about costs of tests or treatments, frequent missed appointments, and a passive attitude towards medical care. While these issues may be very sensitive for some patients, addressing them in an empathic manner can promote better communication and trust.
When explaining a medical condition and recommending tests or treatments in this context, it may be helpful to focus on more concrete and tangible effects and benefits. For example, improving Mrs. G's diabetes control may help with her fatigue, excessive urination, and frequent yeast infections. On a practical level, helping patients keep track of appointments on a calendar, the use of a pill box instead of multiple medication bottles, and involving patients directly in some aspect of their medical care can help patients improve their sense of life control. Helping patients to access public and private programs such as Medicaid, Child Health Plus, Women Infants and Children (WIC), and pharmaceutical programs to sponsor costly medications can be invaluable in building the patient's trust and cooperation. On a broader scope, physicians and health care institutions can form partnerships with community-based organizations to help empower communities and individuals to take control of their health care.
Illiteracy is much more common than might be assumed, with about one fourth of the U.S. adult population unable to understand fairly basic written materials.15 Minorities and persons of lower socioeconomic status have disproportionately high levels of illiteracy.15 Besides being strongly correlated with poor health, unrecognized illiteracy can be very detrimental to the medical encounter. Medication bottles, patient education handouts, test instructions, and appointment reminders all rely on patients' ability to carry out written instructions. Even patients who have basic reading skills may have problems with more advanced written materials such as forms for informed consent and health care proxy.
Inability to read is often a source of shame for patients, and is not readily revealed to the health provider. Providers should heighten their awareness of possible illiteracy, and when it is suspected, the issue should be approached in a sensitive and respectful manner, as described in List 1. Once illiteracy is recognized, alternative methods for presenting information to patients can be provided. More in-depth verbal instructions, videotaped information, and medication bottles using symbols instead of words are a few options. Another simple intervention is to tape individual pills to a card with symbols representing the time of day they are to be taken. Patients may also be referred to adult education centers if they are interested in improving their reading skills.
The practical, patient-based approach to social analysis described above—the “social review of systems”—is a fundamental component of our cross-cultural curriculum for medical students and residents.6 This approach emphasizes key social barriers to effective health care, which may be important to any patient, but particularly for minority and immigrant populations, whose social and financial realities are often very different from their physicians'. While social and racial and ethnic disparities must clearly be addressed through large-scale health and public policy efforts, physicians and medical educators have the opportunity to intervene at a more personal level. By incorporating an emphasis on the social context in cross-cultural medical education and broadening the role of the social history, we can better train physicians to care for the socioculturally diverse patients who make up the intricate, challenging, and beautiful fabric of this country.
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