CLINICAL SCENARIO

90 year old Mandarin speaking Chinese male patient with PMHx of cholelithiasis presents to the clinic with his daughter for an annual physical. The patient’s daughter says that he has only sought traditional Chinese medicine practitioners and never seen a Western doctor. Patient has never had an annual exam. He moved to the United States three months ago and the daughter explains how she would like him to receive an annual physical due to his old age. Patient has never taken and currently does not take medications. His daughter explains that he has smoked 5 – 6 cigarettes a day for over seventy years. Patient obtained an education up to middle school level and worked in a candy factory. Denies history of cancer, cardiovascular diseases, unintentional weight loss, fever, chest pain, shortness of breath, constipation, nausea, vomiting, or diarrhea. 

Why it requires cultural awareness/humility:

This scenario requires cultural awareness as the provider must communicate with a non-English speaking elderly patient with a limited educational background. The provider should be considerate that what may be considered general knowledge was not made aware to the patient. The provider should be mindful of these barriers in order to patiently and adequately communicate with the patient to address his health needs. 

The cultural factors that need to be considered:

• The patient does not speak English. A translator is needed in order to effectively communicate with him.

• The patient previously only sought the help from traditional Chinese medicine practitioners. The practice of physical annuals, extensive lab and imaging studies, and specialities are entirely new for the patient. These aspects must be explained with patience and in detail. 

• The patient is new to a foreign country. This places greater emphasis on establishing trust and a relationship with the patient in order to best collaborate and communicate in regards to healthcare goals. 

Any beliefs that might be different from western medicine beliefs or unique considerations that care of this patient might require:

• The patient has never taken medications in his life. As this is also his first annual physical, the diagnosis of existing conditions that require medication may come to light. The patient may be reluctant to take regimented medications that are foreign to him. 
• The patient is unfamiliar with the practice of annual physicals, lab work, and imaging studies. He may consider these tests to be extensive, a long duration, financially costly, and unnecessary. 
• The patient does not speak English. A translator or native-language speaking provider is recommended in order to best communicate with the patient. 

Areas where conflict might develop:

• A language barrier may complicate communication between the provider and patient. A translator or provider who speaks the patient’s language is best recommended so that health education and treatment plans can be effectively communicated. 
• The patient did not receive a high level of education. The provider needs to adjust his explanations in such a way that the patient can understand. Greater patience is also required on the part of the provider so that the patient clearly understands the information communicated. 
• The patient is elderly and likely set in his ways. As he has been a lifelong smoker, it is unlikely that a provider will be able to convince him to stop smoking. 

What would be expected of the student in demonstrating Cultural Competence/Humility – what things would the student be expected to say/do/avoid/suggest/consider in this scenario:  

• The student should utilize a translator to communicate with the patient.
• The student should exhibit positive and open body language such as nodding and uncrossing arms. The student should avoid rolling his eyes and crossing arms if he disagrees with the patient or does not understand the patient’s reasoning.
• The student should give the patient time to explain his health needs and concerns to assess his education and health awareness. 
• The student should avoid using medical terms or complicated vocabulary. 
• The student should educate the patient on healthcare testing, speciality referrals, and medication treatment plans. However, the student should also accept what the patient is comfortable with complying with.
• “Can you explain to me why you never had an annual physical in the past?”
• “What can I help you with today?”
• “I understand this is taking a long time as it is the first time we’re meeting. However, I’d  like to start some lab tests to better assess your current health situation. Would you be alright with that?”
•  “I strongly recommend that you complete further lab work and imaging studies. I understand this will take a long time but it will give us the best details as to your current health status so we can best help you.”

Any patient counseling or education that would be required in the situation:

• Educate the patient on the risks of smoking and encourage either quitting or reducing the number of cigarettes smoked per day.
• Educate the patient on the importance of receiving annual physicals in order to assess health status. 
• Refer the patient to providers who speak Mandarin.