What listening to patients can teach us

Abstract

Through ethnography, an anthropologist once said, we can find the strange familiar and the familiar strange. Some of the ideas expressed by the Vietnamese patients in Mull and colleagues' study may sound strange to us—or even “wrong.” For example, some patients explained how their diabetes was caused by depression from their refugee flight and from adjustment to living in the United States. Others used bitter gourd and banana tree sap to treat their illness. American medicines, said some, are “hot,” and so they do not help a “hot disease” like diabetes. Some patients believed that insulin could cause death. But are these ideas really so strange to physicians? Epidemiologic data have linked depression and diabetes; traditional herbal plants are the basis for many modern pharmaceutical preparations, and many Latino patients also espouse a disease theory of hot-cold imbalance and express fear of insulin. So the strange is actually familiar, and the gulf between cultural groups is narrower than we might think. Native Americans, Mexican Americans, and African Americans all have ideas about loss of their culture in the etiology of diabetes, about the value of herbal preparations for treating diabetes, and about insulin's role in impairing physical function and even causing death.1,2,3 Ethnography can also result in the familiar seeming strange. For example, in examining disease etiology, why does biomedicine focus on the physical aspects and minimize the psychological and spiritual aspects? In recommending treatment, why do providers view insulin as benign, given the risks involved in using it? In providing care, why does our system not ensure adequate diabetes care for low-income people? Ethnographic findings can help us gain insights into our own medical cultural system. Finally, we can apply the information from this study to Vietnamese American patients, and we can use the ethnographic approach in our interaction with patients of all cultural backgrounds. We can ask patients about their beliefs, values, and practices, and then we can respond to their cultural needs. We do not have to focus just on issues such as overeating and underexercising; we can also look to psychological distress, intergenerational conflicts, and the challenges that our patients face in adjusting to life in the United States. We do not have to focus on oral hypoglycemic agents and insulin; we can look to our patients' desire to use alternative therapies. And we do not have to accept lack of English proficiency or lack of insurance as reasons that patients receive poor diabetes care; we can fight for health care for all Americans. Applied ethnography can help us provide culturally and linguistically appropriate services,4 demonstrate core residency competencies,5 and work toward the national goal of reducing health disparities.6 Ultimately, listening to our patients through ethnography can improve the delivery of health care.