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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Potential pitfalls in the care of Filipino-American patients
Observations from practice with Filipino patients
Wanted: Application of Medical Anthropology
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George W. Saba, Clinical Professor University of California, San Francisco; San Francisco General Hospital, Family and Community Med
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Compared to other ethnic groups in the United States, the health care needs of Filipino Americans have been understudied. Misunderstandings frequently exist between health care providers and Filipino American patients. Jokes abound about practitioners’ frustration with Filipino American patients who agree to adhere to a treatment plan and then fail to follow through. Such attitudes risk discrimination in our delivery of health care to Filipino-Americans. Gay Becker’s excellent study takes a big step towards addressing our impoverished understanding of important values that influence the health and behavior of Filipino American patients. Becker’s work highlights some potential pitfalls for the practitioner. 1) Striking a Balance between Diversity and Commonality. Becker repeatedly clarifies that Filipino-Americans are not a homogenous group. While this may seem obvious, we have not often acknowledged the intra- group differences within a particular race or ethnic group. Our tendencies to want cohesive, simple answers encourage us to take the data from a small sample of one cultural group and generalize it to all members. How do we strike a balance between common concepts, such as bodily experience, among many responders and the diversity within all Filipino-Americans? The discovery of pervasive concepts suggests that they represent dominant cultural values. However, not all people, nor all members of a particular family, may be equally wedded to that value. Clinically, we should be careful not to assume that all people hold the same value, but inquire about how they respond to a value that is common in their culture. This inquiry can allow for differences within generations, gender and timing of immigration. The expert on what is culturally important in clinical care is the patient in front of us. Research like Becker’s guides us to identify important questions to ask our patients, such as how dominant cultural values have influenced their life and health, rather than blindly apply the findings as fact. In this sense, Becker’s balance between studying a group that is diverse but which also exhibits some commonalities is valuable for not only for the care of Filipino-Americans but also the field of cultural competence. 2) Practitioner Beliefs and Values. Becker highlights the “long-term colonial relationship of the United States to the Philippines,” suggesting that this has increased Filipino-Americans'familiarity with Western culture prior to immigration. We must also ask, in a complementary way, how has this relationship affected our assumptions about the health care needs of Filipino- Americans? Many of my colleagues ascribe their frustration in caring for Filipino-Americans to their attitude that Filipino-Americans are just like us— i.e., they endorse biomedicine (as attested by Becker); they speak English (so literacy should be less of a problem); and they agree to follow through with recommendations (otherwise they would openly disagree if they felt like it). The cultural differences between ourselves and Filipino-Americans may not seem as obvious as they may be in patients from other cultural groups who speak a foreign language and present “exotic” understandings of health care. We must critically reflect on our own assumptions and biases in order to explore how they affect our clinical decisions and the functioning of our relationships with Filipino- Americans, and of course with all patients. 3) Expanding the Focus of Intervention. Unconsciously, we often expect that individual practitioners once becoming culturally competent should be able to rectify cultural discrepancies between themselves and patients within the context of the clinical relationship. Understanding, awareness and communication should correct most barriers. But Becker’s research demonstrates what an unreasonable task that may be by highlighting the deeper societal roots of cultural values. Practitioners and patients often feel mutually frustrated that their precious clinical visits become repetitive conversations on what should have happened regarding diet, exercise and the taking of medication. The social constraints of food in daily interpersonal relationships of Filipino-Americans (revealed in this study) appear stronger than an interaction with a health care provider every three months. The challenge for us is how to discover how best to address the conflict between two strong societal values--responsibility for a healthy life and the interpersonal meaning of food. Office level interventions may need to be bolstered by creative, community level interventions that influence the day-to-day experience of Filipino- Americans. Such pitfalls such as stereotyping, practitioner’s biases, and a limited focus of interventions can be revealed through thorough and in depth qualitative research. Becker provides not only important information about a neglected group of the patients we serve, but also provides a model for exploring cultural issues in primary care. Competing interests: None declared |
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William B. Shore, Family Physician UCSF
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The report by Gay Becker, PhD., “Cultural Expressions of Bodily Awareness Among Chronically Ill Filipino Americans”, gives insights into behaviors I have observed in over 25 years of practice with urban Filipino American patients. As discussed, Filipinos are very responsible in their approach to their health care. The value of wanting to “please” their doctors can result in increased adherence to treatment plans; however, it can also result in misperceptions because, in their desire to please, they will not voice any conflicts between cultural values and proposed treatment plans. Bodily awareness can be appreciated clinically in many forms. Filipinos often use the term “dizziness” in reference to multiple non- specific complaints, e.g., generally feeling out of sorts, feeling tired or fatigued, or musculo-skeletal vague complaints. The term rarely refers to true dizziness or vertigo. Filipino women do not take medications while they menstruating. This can be important clinically when prescribing medications for chronic illness as well as for acute problem, e.g., a course of antibiotics. Filipinos often see blood draws for analysis as withdrawing important bodily fluids; offering them tomato juice after a blood draw can minimize anxiety about this. As the authors discuss, food and diet are important in Filipino culture. If patients bring a gift of food, they can feel insulted if the gift is not enthusiastically accepted and eaten. More important clinically, counseling patients about diet for diabetes, hypertension, or hyperlipidemia can be challenging. They have difficulty declining “restricted” foods at family dinners and celebrations. A next-step study could be an investigation of effective strategies to increase dietary adherence for chronic illnesses. Competing interests: None declared |
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Kathleen A. Culhane-Pera, family doctor Ramsey Family and Community Medicine Residency
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Thanks to medical anthropologist Dr. Gay Becker who has shown us why anthropology is a core social science for primary care medicine. As I read it, I had one major question/ problem/ issue/ wondering, running in my head over and over. And given this new online feature, I decided to ask if others feel the same way!? Why is it that I always want more from anthropological research? It’s as though it just tantalizes me, provides me with stimulating insights, but doesn’t go far enough. I want to know what to do. How do I apply this information to the clinical setting? What format works best, and what doesn’t work? And does culturally responsive care make a difference in health outcomes? Thinking about the first question (How do I apply this information? ) for a minute: If I had Filipino patients, I would first read her references -- to increase my understanding of these densely packed four pages-- and reflect upon how the cultural information may be influencing my patients. I would then don an anthropology hat, in addition to my biomedical hat, listen to patients in my clinic, and then struggle with them, as they adjust to chronic diseases…. all the while reflecting about my own beliefs and biases, which are thrown in bas-relief by the contrasts in beliefs and practices. But still, I have questions. What ideas are most important? How do ideas of health, treatment, and prevention help us help people? If we have Filipino patients with newly diagnosed chronic disease, can citing these concepts of balance help us frame our first words about the diseases and our recommendations? If we have Filipino patients who struggle with changing their lifestyle, can evoking the images of traditional health help them adopt dietary restrictions and exercise regimens? If we have Filipino patients whose chronic diseases are “out of control”, do these ideas help them? Are there other concepts that “successful” people with chronic diseases have, which are even more important? And how do we do it, in the current structure of medical care? Can we, alone, in 15 minute appointments, in acute care settings? Can we, in partnership with medical teams of Filipino providers, diabetes educators, nutritionists, and exercise physiologists, in modified and newly constructed chronic care settings? Do group visits help? Are bilingual bicultural providers essential? Can we do our best job by partnering with community members, who have struggled with chronic diseases? Indeed, what works best for whom? As we figure out how to apply the information well, do health care outcomes improve? Do patients have better blood pressure control, glycemic control, weight loss, fewer hospitalizations for asthma exacerbation, if they have received culturally specific information in culturally appropriate manners? Addressing these questions is up to us as primary care researchers. We need to take it from here, to conduct the research that addresses these applications, that applies anthropologists’ knowledge. I think Dr. Becker would agree, as she says “… the goal of qualitative research is to uncover and delineate new perspectives for research and practice…” But my questions don’t stop there. I also wonder, what research approach works best, to address these questions. Should we stick to the traditional roles of scientists doing top-down research, with patients' permission (but not necessarilly community members’ permission)? Or should we move to being co-participators, co-creators, co-discoverers, and co- owners of research with community members? And should we move to combining research with action, where the interventions are imbedded with research questions, not separate from them? We can thank Dr. Becker for doing a huge piece of the work, which sets the stage for clinical and community applications. And we can ask anthropologists to be co-researchers on the team with primary care providers and community members, engaged in community-based participatory action research. Competing interests: Academic interests in medical anthropology! |
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