Category Archives: different culture

The changing face of rural America

–Therese Zink

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

How do we meet the needs of patients that extend beyond the clinic.  These are often called the social determinants of health. These play an important role in keeping people healthy and helping them achieve health.  Health care professionals need a team to address these issues and that team includes public health, social workers, as wells a policy makers and community advocates.  Pay attention in you community.  Is your preceptor aware of the other factors affecting a patient’s situation?  An alcohol problem? Housing problems? No money for food? Family problems?

Sometimes new Americans or immigrants have a more difficult situation because supports do not yet exist to help them and language barriers make it hard to communicate. If you community has immigrants, how are they welcomed into the health care setting?  Interpreters? Signage? Specific patient education? Multi-lingual providers? Art on the clinic walls?

If you were in charge what would you do differently?

Advertisements

Avoid medical-speak

From Good Will

–Donald Kollisch

“Like a sponge,” Elwin was thinking, sitting in his father’s old chair. “The doctor said my lungs are filled up like a sponge that they need to wring out.”

He pictured a large sponge—the kind his father used to use to wipe down the horses after a full day’s work, knobby and heavy and dripping in his hands. Elwin held the image in his mind as he tried to clear his laboring lungs. Some sections were softer and more supple; others were stiff and scarred. Water was stuck in the stiffer cavities so he wasn’t able to squeeze it out. That was what made his breathing fast and shallow—the way it had been ever since he’d come in from moving the John Deere into the barn.

(Excerpted from Good Will and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Elwin was a retired farmer. His doctor gave him a concrete image to understand his congestive heart failure. Avoiding medical-speak is important. Sometimes when we are new to medicine we like to use the big words to impress or friends and colleagues. When presenting to attendings and preceptors we are supposed to use the proper medial terms. But when explaining illness to patients medical-speak doesn’t work.  Translate medical lingo into concepts and images your patients will understand. That may vary depending on a patient’s culture and experience. In the above story, Dr. Kollisch was talking to an old farmer –he understood sponges and water and washing his draft horses. One of the magical moments in talking with patients is when your patient helps you identify the image that makes sense to him or her.  Share one of those moments with us if you can. . .

Who lives rural today

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer of German ancestry who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

 (Excerpted and used with the permission of the authors, published in The Country Doctor Revisited, KSU, 2010)

 The global age with its increasingly diverse communities is now true in many small communities across the US. In Minnesota many communities settled by Scandinavians or Germans now integrate communities who speak such languages as Spanish, Hmong or Somali. Integrating immigrants into a new community takes some planning. Local leaders need to reach out to leaders in the new communities.  Health care settings need to adapt with interpreters, patient education that is appropriate for the cultural values and eventually staff who are from the immigrant community. Health care professionals need education about the beliefs and values of the immigrant community.

 If the community where you are rotating serves diverse ethnic groups, how well has the hospital /clinic reached out and prepared for the different communities? Do not mention the name of your community in your response. Consider the availability of interpreters, patient education materials, diverse staff and the relationships between the hospital/clinic and the community.

DINE: Navajo, People

–Maureen Connolly

Tsaile is cool at five thousand feet,
little snow, lots of space.

Weekdays I rise in the dark, watch the sun
bleed across the Lukachukai Mountains
out my kitchen window.
I see patients in the Indian Health Center:
pregnant women, diabetics, old women
in long skirts and velvet blouses, infants
brought in on cradleboards, injured men.

I learn how to speak some Navajo
how to listen to what is not said.
At the end of the day I walk outdoors
to where I sleep in the compound
near the dwellings of the other doctor
and the nurses. On the other side
of my little house, the sun bleeds
purple and orange over a pearled sky.

Once a week, I drive a winding road
into the dust and mud of Chinle
to a tiny emergency room bulging
with people. This winter babies
on the reservation are having trouble
breathing. There aren’t enough beds.

Friday nights at the trading post,
I look at axes in a barrel, consider
popcorn versus pretzels, pick up
a free copy of the Navajo Times.
Weekends I hike the canyons.

In Window Rock I go to a rodeo
for the first time, sit on rough
planks in the stands, a white
woman alone among the Navajo.
Mothers put fry bread in toddler
mouths. Prepubescent girls eye
cowboys walking to the chutes
spurs glinting on their boots.
Boys enter on bucking calves
then grown men clinging to huge steers.

Clowns open gates, tempt belligerent
animals away from fallen riders,
know that elusive thing, when
to step out of the line of danger.
I leave early, fearful of livestock
or a drunken driver wandering
into my headlights on the dark
journey through the mountains.

I attend mass in a hogan-shaped
church, its curved inside walls shared
by St. Francis and the corn goddess.
Statues of a medicine woman and man
stand alongside the Nativity crèche.
I discover the Irish and Navajo have
nearly the same word for “people.”

The night before I am to go home
it snows for hours into the quiet.
By morning the mountain passes
near Tsaile are closed. I head my
rented sedan the opposite direction
from the airport in Albuquerque
in hopes of circling back.

In Navajo country a milk-blue sky
blurs into rich cream land,
rust-red canyons claimed
by the snow. A brindled horse,
breath foggy in the air, stands still,
ears erect, against the horizon.
The landscape, impossibly, expands.

Two jeeps appear, one before
me, one behind, angel me
a hundred miles, no other
vehicles in sight, past scattered
Navajo villages, above the timberline,
over a mountain. I slide
onto the interstate, the jeeps are gone.

Near Gallup I stop at a convenience
store, dizzied by its repleteness.
Albuquerque can only be entered
from the west, they say, the snow.
I am coming from the west. I aim
for Albuquerque, home, my lover.

Then the airport and a plane that will fly.
More people, things, speed, sound.
A prayer forms itself.
I continue to move in and out of danger.

Dr. Connolly describes her time working on the Navajo reservation. She is aware of her foreignness, her otherness, in that setting, a different culture, with strange traditions; she describes her awareness of being different. At times she senses danger due to her unfamiliarity with the setting, but she has some resolution.

Today in many rural settings the provider may be from an ethnic group or race different from his/her patients. In some settings, international medical graduates, who were raised and educated outside the US, provide care to patients quite different from themselves. In other communities immigrants from outside the US have settled, drawn by connections with a church or seeking employment opportunities. Some communities and medical settings do a good job of integrating cultures different from the people who settled there over a century ago. Local businesses welcome the immigrants; schools have special programming for immigrant students; clinics and hospitals hire translators and immigrants as support staff, place signage in other languages. In other communities there may be tensions between the different races and cultures.

If you are in a setting where a variety of cultures are learning to live and work together, notice how they have or have not negotiated their differences. Has the majority culture welcomed the minority? What more could be done?