Tag Archives: cultural differences

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?

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Lost On Call

–Ann Neuser Lederer

was on call, and tense. Newly employed as a visiting nurse on the edges of
Appalachia, I had recently moved to this place
from a large rust belt city hundreds of miles to the north.
Our territory extended down to the river cliffs,
and outward through patchworks of farms.
I didn’t know it very well, especially in the dark.
It was a weeknight. I was tired from the day’s work.
The beeper jolted me awake.
I fumbled into my clothes, neatly folded nearby, awaiting.
I was called out to a place I had never been, on the edge of the county,
to a death of a patient I had never known.
It was the middle of the night. There were no lights anywhere.
I peered at the directions written on the paper.
Ever so slowly I made my way down the winding tree-lined lane.
It was one of those roads with steep drops on both sides and no shoulders.
Only the halo ahead, created by the headlights,
hinted which way the next curve might lead.
As I turned a bend, I spotted from the corner of my eye an odd red glow,
low to the ground, seemingly coming out of nowhere.
Slowly, I realized it was a pile of something smoldering.
I did not know anything about field fires then.
Wondering, tempted to imagine, I forced myself to attend to the task at hand.
I could not find the turn-in for the house. I must have passed it, so I backtracked, tried again, a little scared. A full moon rose over the bare tree limbs, soothing me with its steady presence. I followed a twisty road up a hill.

Far to the back of a farm, a trailer was parked. This was the place.
They sat, awaiting my knock.
They had no running water. The corpse had soiled himself,
maybe a good while before dying. They wanted him clean for the mortician.
They brought a bucket and I tried my best.
Fresh diaper, and shirt, buttoned to the neck. Hair brushed. Mouth closed.
Ready.
Now, the red glow in the dark field, the white moon above,
lighting the road up the hill are permanent reminders of potential surprises,
against the nights of dread.

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

Nurse Lederer was called to help in a setting quite different from one familiar to her. She was called outside her comfort zone to care for a patient who was poor and dying. As she describes the setting, I felt her fear and discomfort. Sometimes medicine calls us outside of our selves, to walk in the shoes of another, to see what it feels like to live in a world different from the one we know. You don’t need to go to another country to experience a different culture. We have reflected on this in other blog entries [December 19, 2011 and January 9, 2012].  It may be the same culture, but it might be a different sense of personhood—what it feels like to be old or disabled or have a mental illness. So far in your career, have any patient encounters given you the chance to experience life from another perspective? If so, tell us about it, preserve privacy please, no identifying information. What did you learn? How did it alter your view of the world?

Read other work by Ann Neuser Lederer.

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.

Learning from an Amish Birth

–Emily Kroening

Finally the day was done; I’d been up 36 hours and could not bear the thought of doing one more thing . . . my cell phone chimed. Rita, the midwife said, “One of the Amish families is in labor at home. They usually go quickly. Meet me in the hospital parking lot; I’ll be loading my blue van.”

Twilight yielded to darkness, as Rita and I followed the four-lane asphalt road through town, merged to two-lane blacktop, then twisted through a network of gravel roads. The night was inky black; no moon, no stars, only the occasional spotlight at an “English” farm. The agreement between the Amish community and the clinic was that if an Amish woman would come into the clinic for an initial prenatal visit, then she would receive home visits from the midwives for the duration of her pregnancy and could deliver at home as long as there were no complications. Women who had several children often had an Amish lay midwife handle the delivery. “But we are the couple’s quick transportation to the hospital if something goes wrong,” Rita said. “Since Amish don’t have phones, someone has to run to a neighbor’s to call for help. Otherwise it’s horse and buggy.”

Rita turned her van into a farm and the headlights outlined a small frame house. A lantern’s golden glow lit the front window. “Watch your step,” Rita warned. I stepped cautiously over frozen piles of horse manure and jagged ruts in the driveway as we unloaded the van, stacking our tubs on the front porch.

Herman, the husband, welcomed us at the door. He was tall and muscular, his woolly beard stretched past his collar. We wiped our feet on a small dmat and entered the kitchen. The house smelled like supper, something with tomatoes and onions. A wood stove, with a pile of logs nearby, radiated a toasty warmth.

Rita introduced me to Ann, who labored in the rocking chair next to the stove. She wore a white linen gown, the typical undergarment, and a white bonnet, a kapp. Her mother was busy drawing water for tea from the pump that protruded from the corner of the cement kitchen floor. Edward, Herman and Ann’s one year-old son, hid among the folds of his grandmother’s traditional blue dress.

Rita and I accompanied Ann into the adjoining bedroom. A double bed with a rough wooden headboard, an oak dresser with an oil lamp, and the baby crib were tucked into the small space. Herman had built the crib for Edward. After checking her vitals, I helped Ann stretch out on the bed. Her uterus tightened with a contraction. Rita reassured Ann that her contractions were good. We listened for the familiar dlup, dlup, dlup . . . of the baby’s heartbeat. A rate of 140, perfect. I gloved my hand and checked Ann’s cervix. It was open to three centimeters and the length had thinned halfway. This would be a long night, but the novelty held my weariness at bay.

The bedroom was pleasantly warm. An alarm clock perched on the dresser cast a monumental shadow on the wall. Rita handed it to me and told me to set the alarm every fifteen minutes, the interval for checking the baby’s heartbeat. The clock was the old-fashioned kind with a large clock face and metal ringer on the top. The key in the back grated as I wound it, setting the time: 8:30. Its soft ticking faded into background as we set up our theater: baby pack, instrument pack, sterile gloves, oxygen—just in case. We lay a plastic sheet over the mattress, letting it drape to the floor and covered it with towels.

We settled into routine. Grandmother entertained Edward and busied herself around the kitchen where Herman rested in a rocker near the stove with Rita nearby in a straight-back chair. In between contractions Ann and I talked about our lives. We were the same age—24. Ann took off her kapp and pulled pins from her coiled hair, releasing long blonde curls much like my own. Although they spoke German at home, Ann’s English had only the hint of an accent. Born down the road, she attended school through eighth grade. Then she worked for a neighboring family as a helper, caring for children and assisting with household chores. “Are you married?” she asked me.

I shook my head. “Right now my focus is to get through medical school. Then maybe I’ll have time to think about having a family.”

The metallic bell of the alarm clock interrupted our conversation. Rita peered in while I listened for the baby’s heartbeat. It continued to be strong. With an intense contraction, Ann moved onto her hands and knees. Laboring quietly and moaning occasionally, she did not ask for pain meds. After each contraction, I wiped her forehead with a washcloth, then massaged her boney shoulders, ropey biceps, and firm back. She was smaller than I, probably stronger as well, from physical labor. She talked of doing laundry in tubs by hand and tending the garden. My world was suspended as I shared these intimate moments with her. Her world—set apart from my 21st century life of e-mail, iPods, and cell phones. Only the metronomelike click of the clock and the periodic chime of the bell marked time…

Read the version published in Family Medicine, February 2008

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

During her rural elective in medical school, Dr. Kroening rotated at a clinic/hospital that served the Amish community. The clinic/hospital was able to negotiate an agreement with the Amish community that worked for both. The Amish were able to continue home births with back-up for emergent problems and the medical folks were reimbursed and able to work within their malpractice/liability constraints. This is an example of serving your community—working out an agreement that respects the needs of all involved. During this birth Dr. Kroening experienced the world of someone her age, from a very different culture, who lived a very different life: doing laundry in tubs, tending a garden, caring for children, living without electricity or computers versus e-mail, iPods, and cell phones. Such experiences can be life altering for us—the opportunity to step back and examine and appreciate people who have very different lives and perspectives from our own. This is one of the gifts of medicine—the privilege of sitting on the sidelines of the lives of others. We may ask ourselves: How do we partner with them? How do we encourage them? How do we help them heal themselves? How are we touched by the interactions?  Reflect on patient encounters that provided you with a bird’s eye view into a world different from the one you know. Feel free to share it, but preserve the privacy of the individuals involved.