How does Dr M respond to Patient C? She very appropriately and wisely asks why, and the patient responds with a pivotal further disclosure: “Because I’m scared.” Dr M then charges on: “You know, that’s interesting that you are scared to take the medicine. Some people are scared not to take their medicine; they worry that if they don’t take it they might get sicker.”
This depicts the instrumental mode that infects most of us at least some of the time, and some of us almost all the time. Dr M has very little curiosity about what scares Patient C. Instead she is simply looking for the best angle to preach to the patient about why compliance with the prescribed regimen is so important. This robs Dr M of any opportunity to explore the fears in detail and perhaps do something positive to reassure Patient C.
Somewhat surprisingly, given the way that Dr M has snubbed her, Patient C actually makes another effort to tell her story and describes how the medicine man told another patient with diabetes not to take her medicine. But this hint that the patient is seeking a way to treat diabetes that is perhaps more in concert with traditional tribal practices is unheeded by Dr M, who simply rejects the idea that a medicine man would tell a patient with diabetes not to take medicine.
A sustained partnership with a diabetic patient requires finding out the patient’s goals and preferences, warning the patient of possible mismatches between their personal agendas and what is known medically about the optimal management of diabetes, and finally trying to negotiate a treatment plan that will best preserve the patient’s other life commitments and sense of autonomy, while at the same time preventing complications in both the short and long term. But to do this requires, first of all, that the physician be sufficiently curious about the patient’s life goals and beliefs. Dr M seems notably lacking in this curiosity. She just knows that if a patient has diabetes, the most important things in that patient’s life become proper diet, exercise, and compliance with medications. If the patient does not happen to think this way, then Dr M does not really want to know why. She will simply spend each visit continuing to repeat why she is right and the patient is wrong. The reasons not to practice this way, sadly, are the same as why (as the popular saying has it) a person should not try to teach a pig to sing—it does not work, and it annoys the pig. An additional reason, as Dr M’s own case proves, is that it also annoys the physician.
A physician does not have to engage in a so-called cross-cultural medical practice to run into these issues. I have plenty of these sorts of problems trying to provide good care for my white, middle-class patients with diabetes. Actually, to be more accurate about it, every encounter with a patient is a cross-cultural exercise. But the need to embrace both the BPS model and a sustained partnership model are driven home by dramatic examples from practice among patients whose belief systems are even more clearly at odds with the medical mindset. A recent book7 describing a case of epilepsy in a Hmong child, leading eventually to a near-persistent vegetative state, is illustrative. The author began by asking who was to blame: Did stubborn, ignorant parents engage in noncompliance amounting to medical neglect, as it seemed to the competent and caring physicians? Or did the child in fact get sicker each time the Western medicines were employed and seem to improve only when traditional Hmong remedies were given, as the parents insisted? In the end, the author concluded that the question of blame is unanswerable, but much could be done to prevent such an impasse from occurring.
Success stories
The following are 2 minor success stories from practice among Southeast Asian patients.
A middle-aged Hmong male (from a community that avoids all contact with Western medical institutions whenever possible) had severe, recurrent right-upper-quadrant pain. A Western physician diagnosed gall bladder disease and recommended cholecystectomy. The patient underwent a healing ceremony in which a shaman bestowed magical powers on water that was then used to cleanse the abdomen. When the pain persisted after the ceremony, the patient accepted the conclusion that the pain was not of spiritual origin and consented to surgery. He had an unremarkable postoperative course and reported that he was cured of the pain.7