Teaching and Learning Moments
When I was an undergraduate student at Cornell University, I studied the barriers to HPV vaccination in the Native American Hopi tribe. Despite having one of the highest rates of cervical cancer, Hopi women did not use the HPV vaccine. When asked why during a focus group meeting, a member of the tribe retorted: “I don’t trust the vaccine. It might have smallpox like the blankets that killed my ancestors.” Understanding these reasons for mistrust, over the next two years, I designed educational materials that carefully explained how the vaccine worked (by introducing viral proteins) and how it could prevent a hysterectomy from possible metastatic complications (tailored towards the Hopi belief that organ removal was unnatural). Over a number of years, vaccination rates in the community slowly started increasing.
Fast forward a few years. I was working at a government-sponsored clinic in the middle of Baltimore that primarily cared for the underserved. One of the patients, Geoffrey, was a 48-year-old African American male with a long history of uncontrolled diabetes. He had been to the clinic a few times before but was consistently inconsistent with taking his insulin injections, despite receiving them for free.
As I began my medical interview with Geoffrey, I made sure to ask the typical diabetes screening questions: Do you feel any numbness or tingling? Is your vision okay? Are you compliant with your medications? Geoffrey merely shrugged his shoulders in response and avoided my gaze. He insisted he did not take his medications but wouldn’t say why. Rather than reprimanding him, I told him I cared about his health. I told him I did not want him to end up in the hospital. I told him it was my personal goal to keep him safe. Then I asked if he could help me do that. Perhaps sensing that my concern was genuine, Geoffrey looked directly into my eyes and revealed that he was homeless. He could not take his insulin because it needed to be refrigerated and he did not have access to a fridge. With this information, I consulted with my attending, and we figured out that his medication could be put in a thermos and used for several weeks, which would allow him to control his blood sugar and keep his diabetes in check.
Underserved minority patients often harbor a sense of mistrust towards the medical establishment, mistrust that is usually deeply rooted in the mistreatment they have endured. However, my experiences with the Hopi and Geoffrey taught me that these groups are not ignorant, but, rather, they need to feel like their concerns are appropriately addressed before they will trust a physician and heed his medical recommendations. Physicians must develop a cultural understanding with their patients to achieve positive treatment results. Openly discussing patients’ unique feelings and expectations is a key first step to building trust. Encouraging them to disclose any fears or beliefs they may have in a nonjudgmental environment facilitates an open dialogue that enables them to feel more comfortable. Furthermore, convincing patients that you are willing to work with them allows them to feel appreciated and heard, making them more willing to participate in the treatment plan. Developing a cultural understanding with patients may be a slow process, but it is arguably one of the most important parts of being a physician.
Acknowledgments: Ajay Kailas would like to thank Susan C. Taylor for mentoring him throughout his medical school career and teaching him the critical value and importance of cultural understanding and treating underserved patients to the best of his ability.
Ajay Kailas and Susan C. Taylor, MD
A. Kailas is a third-year medical student, University of Central Florida College of Medicine, Orlando, Florida; e-mail: firstname.lastname@example.org.
is associate professor, Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.