e-Ethics JUNE 2002
Can't See the Forest: Hospitals as Foreign Culture
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Discussion of cultural sensitivity
in medicine frequently focuses
on confusion and conflict that
arise when patients from non-Western
backgrounds hold beliefs
or maintain practices that impede
recommended treatment plans.
Consideration of these cases is
important. Greater understanding
of how diverse cultures perceive
and care for disease equips
healthcare professionals to communicate
better with patients and
find ways to accommodate important
healing rituals and interpretations
of illness. However, behind
the "trees" of difference represented
by various customs or religions
lies the "forest" of medicine itself.
Taking for granted our own familiarity
with the culture of medicine
may result in behaviors that
offend or frighten patients and
their families, irrespective of their
particular values or traditions.
Through education and practice,
providers become acculturated
to the environment, language,
and customs of medicine, which,
over time, become second nature.
Professional competence depends
in part on one's ability to interpret
and respond to environmental
cues (such as "code blues"), speak
the language (for example, "The
patient presents with a chief complaint
of pain in the lower right
quadrant"), and participate skillfully
in routine rituals (making unit
rounds or caring for patients
whose bodies are exposed). Some
medical schools include
practicums in which students
become patients for a day, thus
gaining a sense of what hospitals
are like from the other side of the
bed. However, such encounters
cannot recreate the personal vulnerability
engendered by actual
disease or injury, as a number of
gifted writers have recounted after
their own experiences as patients.
Describing the lupus that affected
most of her adult life, Flannery
O'Connor wrote, "In a sense sickness
is a place, more instructive
than a long trip to Europe, and it's
always a place where there's no
company, where nobody can follow."
1
The isolation imposed by illness
itself can be exacerbated by
the experience of hospitalization,
during which patients retain few
tangible reminders of who they are
and how they usually present
themselves to the world.
Imagine entering another
country and being required to
remove all of your clothing right
down to your shoes in exchange
for a single garment identical to
that worn by fellow tourists.
Accommodations are guaranteed,
but you have no say in choosing
your fellow lodgers, and little or no
control over personal habits such
as eating, sleeping, or bathing.
Because these aspects of inpatient
care are routine, we forget the very
real but unspoken way an absence
of one's own things and the disruption
of familiar routines contribute to a sense of depersonalization
and isolation.
Patients have also described
how alienated they feel when staff
fail to address them by name, or
do so casually, as by calling adult
patients by their first names. Busy
staff sometimes fail to introduce
themselves or colleagues to
patients, and develop a manner of
bedside consultation that includes
little or no direct communication
with patients. As Anatole Broyard
described it, "I had a very curious
relationship with the doctors.
They came in groups of six. . . .
They looked at me. They shook
their heads, and they left me lying
in a pool of sweat. . . . To the typical
physician, my illness is a routine
incident in his rounds, while
for me it's the crisis of my life."
2
The challenge of Broyard's observation
lies not in acknowledging
its accuracy, but in allowing its
truth to shape our practices
regarding when, where, and how
we communicate with colleagues—
and especially with
patients and their families, who
should be the principal beneficiaries
of our professional education
and training.
Reynolds Price's account of the
initial diagnosis of his spinal
tumor illustrates how inurement
to the seeming necessities of medical
culture may cause staff to forget
distinctions between public
and private space in the hospital:
. . . I was lying on a stretcher in
a crowded hallway, wearing only one
of those backless hip-length gowns
designed by the standard medical-warehouse
sadist. Like all such wearers
I was passed and stared at by the
usual throng of stunned pedestrians
who swarm hospitals round the
world. . . . The initial internist would
show his concern through years to
come; but all I recall the two [original
doctors] saying that instant, then and
there in the hallway mob scene, was
"The upper ten or twelve inches of
your spinal cord have swelled and are
crowding the available space. The
cause could be a tumor, a large cyst
or something else. We recommend
immediate surgery." . . . Then they
moved on, leaving me and my brother
empty as wind socks, stared at by
strangers. . . . What would those two
splendidly trained men have lost if
they'd waited to play their trump till I
was back in [my] private room? . . .
At least on private ground, with the
door shut, the inevitable shock of
awful news could have been
absorbed, apart from the eyes of alien
gawkers, by the only two human
beings involved. It might have taken
the doctors five minutes longer; and
minutes are scarce, I understand, in
their crowded days. I also know that
for doctors who work, from dawn to
night, in the same drab halls, it all no
doubt feels like one room. But any
patient can tell them it's not, and I've
often wondered how many other such
devastating messages they bore that
day to actual humans as thoroughly
unready as I for the news.
3
Price's discomfiture did not result
from "culture-clash" as frequently
understood. If anything, he probably
had more in common with his physicians
than many other patients, since
he was a well-educated, well-known
professional who was also a native of
the region where he was hospitalized.
Whether patients are from across
the globe or across the street, understanding
our role as guides through
and interpreters of the "forest"—medical
care and practice—can ease
patients' vulnerability and fearfulness,
and thus make the inpatient experience
one of genuine care as well as
healing.
1. Flannery O'Connor, The Habit of Being:
Letters of Flannery O'Connor, ed. Sally
Fitzgerald (NY: Farrar, Straus and Giroux, 1988),
p. 163.
2. Anatole Broyard, Intoxicated by My Illness
and Other Writings on Life and Death (NY:
Fawcett Columbine, 1992), pp. 33, 43.
3. Reynolds Price, A Whole New Life: An Illness
and a Healing (NY: Atheneum, 1994), pp. 13-14.
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