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FORUM Crossing Cultural Barriers a Patient at a Time Tarayn Grizzard Photo by Jeff Cleary He was wizened, tiny, leather-brown from years in the sun, and so wrinkled that his face seemed kindly even as he lay in front of us, working hard, heaving his chest up and down 25 or 30 times a minute, hungering for air. My patient that night, Mr. M, an elderly Indochinese refugee with respiratory distress of unknown etiology, was having a tough time despite all the breathing treatments my intern and I had ordered--not that we could ask him. Unable to communicate with him in his own language, our sleep-deprived brains worked all night to pick up any clues that might reveal an improvement in his overall status, without avail. His exam and O2 saturation levels only confirmed that the medicines we were giving him were not working well. The only thing we can do as providers is to care enough to ask about aspects of lifestyle and personal history that might affect the current disease. That is, we have to learn about the person in front of us. --Tarayn Grizzard Even more confusing was that his electronic medical record--a true blessing given our nighttime lack of an interpreter--gave us little indication that he had serious lung disease or any reason to be this sick. Other than a distant smoking history, he had no risk factors for severe lung disease like emphysema; he hadn't even been hospitalized very often. He was up-to-date with all of his preventive care, saw his doctor regularly, and seemed to be in relatively good physical condition per his primary care doctor's notes. His physical exam was benign except for his heaving, wheezing chest, and his blackened and often absent teeth, which gave us no insight into the mystery of what was wrong with him. Right Under Your Nose Of course, it turned out that Mr. M had actually given us all the hints we needed the minute he opened his mouth. Through an interpreter the next day, we learned that Mr. M's teeth were blackened by years of chewing betel quid after meals, accelerating tooth decay that was aggravated by poor nutrition and lack of dental care. Chewing betel quid--areca nuts wrapped in betel leaves--is common in Southeast and South Asia, especially among older men and women. Unbeknown to those of us caring for Mr. M in and out of the hospital, areca nuts can cause bronchospasm and lead to respiratory distress. Even in chronic users, the arecoline in the nuts can lead to severe distress, respiratory failure, and the need for intubation in some patients, especially those with any underlying lung disease. To make matters worse, the arecoline released by chewing the areca nut rendered some of the medications we had given Mr. M ineffective at best. At worst, these medications could have caused an adverse reaction, a worsening of his respiratory symptoms precipitated by the interaction of the medication with the arecoline in his system. After 40 years of chewing, his advanced age and mildly damaged lungs were being roughly tested, with the lungs currently losing out. Despite the confusion surrounding Mr. M.'s current illness, all of his symptoms eventually abated, and he soon went home with instructions not to chew betel, or at least to take a puff or two from an albuterol inhaler first. In the final assessment, the issues surrounding his care were complex and culturally dense. The Person as Point of Entry In hindsight, the case reinforces the importance of cultural competency and reveals the certainty that serious gaps in our cultural knowledge remain. Why didn't the hospital or Mr. M's physician--who seemed to have an excellent long-term relationship with Mr. M--know about his habitual use of herbal medicines? What other providers could have known about this potentially harmful habit? No one could have expected a busy on-call hospital team to figure out something that had remained undetected by the doctor who knew him best. What alarms me still isn't what we and others nearly missed in terms of Mr. M's health habits--but why. We could easily have assumed that Mr. M had bad teeth because he grew up in a developing country with poor nutrition. Or we could have assumed that chewing tobacco or smoking had caused the profound decay. Neither assumption would have helped Mr. M prevent further attacks or enabled us to provide him with optimal care. In a busy hospital or clinic, it is easy to forget the profound cultural differences that might exist between patient and physician. There is no guarantee that one will have sufficient time, energy, or insight to appropriately explore the differences even if one is aware that they might exist. The only thing we can do as providers is to care enough to ask about aspects of lifestyle and personal history that might affect the current disease. That is, we have to learn about the person in front of us. Caring for the patient, especially one who is substantially different from his or her physician, isn't about learning a hodgepodge of socio-anthropological facts and bits of foreign language--not to say that these things aren't helpful as well. But even with them, it isn't always possible to bridge cultural gaps and give patients the care they need. What matters is the consistent effort, the trying each and every time to care for the patient as a person, even if some attempts ultimately are unsuccessful or time-consuming or frustrating. The patients who trust us to care for them despite all of these differences deserve this most of all. --Tarayn Grizzard, a third-year medical student at HMS