Editorial

Abstract

In this issue, we introduce a new feature, Cultural Currents. Through this offering, we will provide insight and practical guidance in recognizing and responding effectively to cultural issues that otherwise might disrupt the therapeutic alliance of primary care physicians and patients, or even lead to missed or misdiagnosis and errors in treatment. In practice, we often feel that there is another person or host of people in the room—these ghosts appear to control the encounter in ways we don't understand or even perceive, entering the room with the patient and representing a force far beyond us. In such cases, the working of cultural misperceptions may be at work. As a medical student, I did a psychiatry elective at the Morningside Hospital in Edinburgh, Scotland. One elderly woman kept complaining that every morning she was “putting on the grail” and that this was getting more severe. Neither I nor my English supervisor had any idea what she meant. While in residency in the South Bronx of New York, I cared for many Puerto Rican men suffering from “ataques” and found that a placebo injection of normal saline often allowed them to gracefully leave the Emergency Department with the support of their families, although I was bewildered as to why. More recently, at our practice here in Boston, I have come across Somali refugees suffering from depression and PTSD whose world view does not include the concepts or words for depression (see Murug, Waali, and Gini: Expressions of Distress in Refugees From Somalia1). In each of these encounters, I felt at a loss to understand what the patient was feeling and thinking or how I could be of most help. My experiences mirror those common to all of us on the frontlines of primary care. While the complexities of such cultural chasms between us and our patients may be apparent to us, for our patients, they simply may be perceived as barriers to care or serve to reinforce prior negative experiences of health care and worsen feelings of helplessness, stigma, distrust, and frustration, with resultant hostility and nonadherence. In health care, concepts such as cultural sensitivity, cultural competence, and other similar terms embrace awareness and skill at creating relationships that acknowledge the personhood, family, social lineage, and national backgrounds of patients while not stereotyping them. This can be facilitated by detailed knowledge of various cultural groups, augmenting the interpersonal competencies and interviewing skills that set apart exceptional primary care providers. Through Cultural Currents, we will present such knowledge and practical clinical guidance in a format that is a variation on the Grand Rounds or patient case presentation. Often, valuable insights are embedded in the experience of skilled practitioners, including those of cultural backgrounds distinct from the mainstream, rather than being evidence based. In this issue, “The Cuban American With Depression in Primary Care” delves into the experiences, values, and perceptions frequent among immigrants from Cuba and the marked differences within subgroups. As we evaluate manuscripts for Cultural Currents, we will engage peer reviewers with similar backgrounds and clinical experiences. We look forward to sharing these with the Companion readership and challenge you to share your experiences through the Cultural Currents format, letters to the editor, or other journal venue. Oh, and “putting on the grail” is an old Scottish slang expression for crying and despondency. I missed it until she was hospitalized for severe depression.