TRENDS * TENDANCES
Health care system must adapt to meet needs of multicultural society, MDs say Olga Lechky O ne of the biggest challenges facing the health care system is the delivery of high quality care in an increasingly pluralistic society. Experts in multicultural medicine say the reason we face the challenge is simple: the systems currently in place are designed for people who speak either English or French, and hold traditional Western values. However, the reality in today's Canada is that at least one in six people is an immigrant with
beliefs far removed from Canada's traditional European Judeo-Christian roots, and who speaks neither of the country's official languages. And this trend is expected to continue, says Dr. Morton Beiser, as Canada accepts more and more immigrants from "nontraditional" areas.
"Somewhere around a million-and-a-quarter new people coming into Canada over the next 5 years will be from Africa, Asia, the Middle East and South America," says Beiser, head of the Culture, Community and Health Studies Program at the Clarke Institute of Psychiatry in Toronto. "These are places where people speak a diversity of languages that are not English or French, where ideas about family and community are different, as are ideas about Olga Lechky is a freelance writer living in North York, Ont. 2210
CAN MED ASSOC J 1992; 146 (12)
appropriate health care and per-
ceptions about health and illness." While the Canada Health Act, the Multiculturalism Act and the Canadian Charter of Rights and Freedoms all guarantee equal access to high-quality health care for all people in Canada regardless of racial and ethnic background, Beiser says this ideal has yet to be attained. In reality, patients who aren't part of Canada's cultural mainstream tend to receive less health care, and the care they do receive is often substandard. "We have a rhetoric about cultural sensitivity and cultural appropriateness, but we haven't really gone beyond espousing the rhetoric," says Beiser. In fact, cultural sensitivity often translates to cultural stereotyping and unintentionally results in inappropriate care. Dr. Ralph Masi, multicultural
health coordinator in the Ontario Ministry of Health, says cultural sensitivity in health care has largely become a politically correct platitude that is often used as an excuse to avoid the real and difficult issues involved in serving the health needs of a pluralistic society. "We've been sensitized to death over the last 5 or 6 years. The time has come to move beyond raising awareness about cultural sensitivity to the development of specific systems that truly reflect the needs of the Canadian population as it is today - its ethnic and racial diversity. The
real issues involve access, equity and racism. "We still tend to design programs and services for a culturally homogenous population and either ignore cultural diversity or tack on little programs for multicultural patients," says Masi. "We have yet to face up to the systematic discrimination that exists within our profession and the fact that our processes [in designing educational and health care delivery systems] exclude input from culturally diverse groups. "We have a responsibility to seek them out and hear their voice right at the early planning stages. It's not enough just to invite them to participate. We also have to have a firm system in place that ensures that they are actually given an opportunity to speak and to be heard." One of the first priorities, says Masi, should be On overhaul of the curriculum in medical schools. Although the teaching of multicultural issues in medicine has improved in recent years, it still has a long way to go in adequately preparing tomorrow's physicians to cope with the linguistic and cultural kaleidoscope they will inevitably see in practice. The current courses at some of Canada's medical schools are tokenism, say both Beiser and Masi. They argue that multicultural issues must be addressed throughout the entire period of LE 1 5 JUIN 1992
training, not just in one short course or lecture. "We can't teach about every individual culture, but you can teach cross-cultural medicine," says Masi. He also points out that courses in multiculturalism, when offered at all, tend to be elective and thus attract the students who least need them. "All our students will go out to practise in a pluralistic society and they all have to be prepared. Now we just throw them out into the community and let them sink or swim." Beiser and Masi see the upcoming redesign of the medical curriculum at the University of Toronto as an excellent opportunity to include multicultural content at all levels of training. A planned move away from didactic lectures to more case-management training will allow students to learn that culture is an integral part of each patient's well-being and affects all aspects of their health, says Beiser. "We would like to get to the point where physicians think of a person's cultural background as automatically as they think about the functioning of their liver or heart. By refocusing on the person, not just the disease, we will be able to better serve everybody, no matter what their culture." Dr. John Parboosingh, associate dean of continuing medical education at the University of Calgary, believes that the medical community should not be seeking new solutions to a new problem. Rather, the issue of caring for patients from various cultures should be viewed as a continuing attempt to improve a long-standing problem - physicians' general lack of good clinical-communication skills. "The approach should be to improve our communication skills so that we can interact with any patient," he says. "The major problem we have with all patients, regardless of cultural background, is that we don't listen. We apply JUNE 15, 1992
the same formula to all patients rather than listening to what each patient is saying. We should relate to patients' values rather than imposing our values." The University of Calgary has recently introduced multicultural content into its undergraduate curriculum by including a cultural dimension in a 5-week clinically based course students must complete before their clerkship. "During that period the students do a lot of work trying to integrate a great deal of information about individual patients," explains Jocelyn Lockyer, director of continuing medical education and adjunct professor of medical education. "They don't simply treat a cardiac patient or a respiratory patient. They have to take everything they know about the patient's life into consideration." For example, one of the cases the students tackle involves a woman with abnormal vaginal bleeding. During the examination they find out the patient fears a required hysterectomy because she holds cultural values about the uterus being integral to her sexual identity. She also believes she would become sexually undesirable to her husband. "At first the students were quite disappointed and couldn't really see the importance of this," says Parboosingh. "They had expected a lesson in endocrinology." By the end of the course, however, they came away with an appreciation of the need to adopt a holistic approach to each patient because that approach is fundamental to good clinical care. Research currently being carried out through the Clarke's Culture, Community and Health Studies Program is expected to yield viable models of health care for a pluralistic society. "We haven't yet developed the knowledge base we really need in order to develop really sensitive health care," says Beiser. "We will have achieved really good and sensitive
care when we get to the point where so-called mainstream services are all multicultural." The program at the Clarke Institute, which has an interdisciplinary faculty of psychiatrists,
epidemiologists, psychologists,
nurses and social workers, focuses on four major areas: the psychoso-
cial adaptation of immigrants and refugees, the health of native Canadians, cultural influences on the expression of illness, and development of health delivery models for a culturally diverse population. In addition to conducting research, the program also has a training component, which provides input into curriculum development at the University of Toronto, as well as residency placements and postdoctoral fellow-
ships. Staff also consult with hospitals, clinics, social service agencies, all levels of government and ethnocultural groups to assist in
planning and implementing training and services. "Mental health is an important part of our work, but I try to de-emphasize that aspect," says Beiser. "The distinction between mental and physical health is an artifact of Euro-North American culture. It doesn't work terribly well, so there's no reason to perpetuate that separation. Our emphasis is much broader, trying to adopt a more holistic approach." Research projects now under way include a study of the settlement of Southeast Asian refugees in Canada, the emotional and cognitive development of First Nations children, cross-cultural communication and empathy, and psychosocial factors in life-threatening illness. Although culture is often viewed as a barrier, it is actually an asset in curing disease and promoting wellness. Masi provided an example: the overwhelming failure of drug- and alcohol-treatment programs designed for aboriginal people but based on white middle-class values. When the CAN MED ASSOC J 1992; 146 (12)
2211
programs were redesigned to include traditional healing ceremonies and input and participation by the entire community, abstinence rates soared. Beiser also stresses the importance of not dwelling on cultural diversity as a problem, but to view it as an opportunity for enrichment by learning about the effective methods many cultures
use to deal with disease. The road to cultural enrichment in medical care will not be easy, but it certainly won't be dull, he says. "I wouldn't want to underestimate the amount of work we have to do. I think we have a good background and knowledge base to begin to develop new models of care, new programs, to develop training for our next gen-
eration of health care providers. It will have to evolve over time and it will be a long struggle. But it's a struggle we can't avoid or escape given the reality of our demographics. "But I really believe it's a struggle that's worth while, not only because we have to do it, but because we'll be the better for it."E
Cultural awareness part of the health care agenda at Toronto hospital Olga Lechky
andemonium greeted Ruth Lee as she rushed into the dying man's room. The patient's large family was obviously upset, screaming in Chinese at nurses who were in turn bewildered and defensive. After hearing both sides in the dispute, Lee, an expert in transcultural nursing at the Toronto Western Division of the Toronto Hospital, was able to get to the root of the problem. It was simple enough. The nursing staff had told the family that the patient was being moved into another ward in an hour and asked the family to pack up his belongings. The family, with a slim command of English, had understood that their father was going into another world in an hour. The family was angry at the nurses' insensitivity and rudeness they wanted to comfort him in his last hour, and packing his belongings was the last thing on their minds. "It was just one word that caused such distress to the family," Lee observes. "Ward to us is a common word used in the hospital, but for people who don't speak much English it's a word P
Olga Lechky is a freelance writer living in North York, Ont. 2212
CAN MED ASSOC J 1992; 146 (12)
that they're unlikely to have been exposed to. When I explained to everyone what the misunderstanding was they all laughed, but at that moment it was very stressful. It almost destroyed 6 weeks of a good relationship that had been established between the nurses and the family." Helping patients and staff negotiate their way through a maze of linguistic barriers is just one of the roles Lee and colleagues in the Toronto Western's Multicultural Health Service (MHS) perform. Through the use of trained interpreters, the hospital's largely ChiToronto Hospital
Lee: overcoming cultural barriers
nese, Southeast Asian and Portuguese clientele are able to negotiate the labyrinth of tests, specialist consultations and treatments. That labyrinth may seem a routine feature of a large teaching hospital, but it is often foreign and frightening to a newly arrived immigrant who does not speak English. While language is an obvious barrier to communication that's readily recognized, cultural barriers present a much more subtle problem. "A person may speak good English but still hold cultural beliefs that could cause misunderstandings with staff," Lee warns. For example, it is common in many cultures to crowd family and friends into the patient's room at all times of the day, even though this is against hospital regulations. The staff may find this annoying and disruptive, but for the patient and family it's a sign of respect and support that is essential to the healing process. The family brings the patient's favourite foods and carries out rituals believed to speed recovery. The patient is expected to remain immobile and let visitors do everything for him. Initiative and self-reliance on the part of the patient would be considered rude and disrespectful. LE 15 JUIN 1992
Health care system must adapt to meet needs of multicultural society, MDs say Olga Lechky O ne of the biggest challenges facing the health care system is the delivery of high quality care in an increasingly pluralistic society. Experts in multicultural medicine say the reason we face the challenge is simple: the systems currently in place are designed for people who speak either English or French, and hold traditional Western values. However, the reality in today's Canada is that at least one in six people is an immigrant with
beliefs far removed from Canada's traditional European Judeo-Christian roots, and who speaks neither of the country's official languages. And this trend is expected to continue, says Dr. Morton Beiser, as Canada accepts more and more immigrants from "nontraditional" areas.
"Somewhere around a million-and-a-quarter new people coming into Canada over the next 5 years will be from Africa, Asia, the Middle East and South America," says Beiser, head of the Culture, Community and Health Studies Program at the Clarke Institute of Psychiatry in Toronto. "These are places where people speak a diversity of languages that are not English or French, where ideas about family and community are different, as are ideas about Olga Lechky is a freelance writer living in North York, Ont. 2210
CAN MED ASSOC J 1992; 146 (12)
appropriate health care and per-
ceptions about health and illness." While the Canada Health Act, the Multiculturalism Act and the Canadian Charter of Rights and Freedoms all guarantee equal access to high-quality health care for all people in Canada regardless of racial and ethnic background, Beiser says this ideal has yet to be attained. In reality, patients who aren't part of Canada's cultural mainstream tend to receive less health care, and the care they do receive is often substandard. "We have a rhetoric about cultural sensitivity and cultural appropriateness, but we haven't really gone beyond espousing the rhetoric," says Beiser. In fact, cultural sensitivity often translates to cultural stereotyping and unintentionally results in inappropriate care. Dr. Ralph Masi, multicultural
health coordinator in the Ontario Ministry of Health, says cultural sensitivity in health care has largely become a politically correct platitude that is often used as an excuse to avoid the real and difficult issues involved in serving the health needs of a pluralistic society. "We've been sensitized to death over the last 5 or 6 years. The time has come to move beyond raising awareness about cultural sensitivity to the development of specific systems that truly reflect the needs of the Canadian population as it is today - its ethnic and racial diversity. The
real issues involve access, equity and racism. "We still tend to design programs and services for a culturally homogenous population and either ignore cultural diversity or tack on little programs for multicultural patients," says Masi. "We have yet to face up to the systematic discrimination that exists within our profession and the fact that our processes [in designing educational and health care delivery systems] exclude input from culturally diverse groups. "We have a responsibility to seek them out and hear their voice right at the early planning stages. It's not enough just to invite them to participate. We also have to have a firm system in place that ensures that they are actually given an opportunity to speak and to be heard." One of the first priorities, says Masi, should be On overhaul of the curriculum in medical schools. Although the teaching of multicultural issues in medicine has improved in recent years, it still has a long way to go in adequately preparing tomorrow's physicians to cope with the linguistic and cultural kaleidoscope they will inevitably see in practice. The current courses at some of Canada's medical schools are tokenism, say both Beiser and Masi. They argue that multicultural issues must be addressed throughout the entire period of LE 1 5 JUIN 1992
training, not just in one short course or lecture. "We can't teach about every individual culture, but you can teach cross-cultural medicine," says Masi. He also points out that courses in multiculturalism, when offered at all, tend to be elective and thus attract the students who least need them. "All our students will go out to practise in a pluralistic society and they all have to be prepared. Now we just throw them out into the community and let them sink or swim." Beiser and Masi see the upcoming redesign of the medical curriculum at the University of Toronto as an excellent opportunity to include multicultural content at all levels of training. A planned move away from didactic lectures to more case-management training will allow students to learn that culture is an integral part of each patient's well-being and affects all aspects of their health, says Beiser. "We would like to get to the point where physicians think of a person's cultural background as automatically as they think about the functioning of their liver or heart. By refocusing on the person, not just the disease, we will be able to better serve everybody, no matter what their culture." Dr. John Parboosingh, associate dean of continuing medical education at the University of Calgary, believes that the medical community should not be seeking new solutions to a new problem. Rather, the issue of caring for patients from various cultures should be viewed as a continuing attempt to improve a long-standing problem - physicians' general lack of good clinical-communication skills. "The approach should be to improve our communication skills so that we can interact with any patient," he says. "The major problem we have with all patients, regardless of cultural background, is that we don't listen. We apply JUNE 15, 1992
the same formula to all patients rather than listening to what each patient is saying. We should relate to patients' values rather than imposing our values." The University of Calgary has recently introduced multicultural content into its undergraduate curriculum by including a cultural dimension in a 5-week clinically based course students must complete before their clerkship. "During that period the students do a lot of work trying to integrate a great deal of information about individual patients," explains Jocelyn Lockyer, director of continuing medical education and adjunct professor of medical education. "They don't simply treat a cardiac patient or a respiratory patient. They have to take everything they know about the patient's life into consideration." For example, one of the cases the students tackle involves a woman with abnormal vaginal bleeding. During the examination they find out the patient fears a required hysterectomy because she holds cultural values about the uterus being integral to her sexual identity. She also believes she would become sexually undesirable to her husband. "At first the students were quite disappointed and couldn't really see the importance of this," says Parboosingh. "They had expected a lesson in endocrinology." By the end of the course, however, they came away with an appreciation of the need to adopt a holistic approach to each patient because that approach is fundamental to good clinical care. Research currently being carried out through the Clarke's Culture, Community and Health Studies Program is expected to yield viable models of health care for a pluralistic society. "We haven't yet developed the knowledge base we really need in order to develop really sensitive health care," says Beiser. "We will have achieved really good and sensitive
care when we get to the point where so-called mainstream services are all multicultural." The program at the Clarke Institute, which has an interdisciplinary faculty of psychiatrists,
epidemiologists, psychologists,
nurses and social workers, focuses on four major areas: the psychoso-
cial adaptation of immigrants and refugees, the health of native Canadians, cultural influences on the expression of illness, and development of health delivery models for a culturally diverse population. In addition to conducting research, the program also has a training component, which provides input into curriculum development at the University of Toronto, as well as residency placements and postdoctoral fellow-
ships. Staff also consult with hospitals, clinics, social service agencies, all levels of government and ethnocultural groups to assist in
planning and implementing training and services. "Mental health is an important part of our work, but I try to de-emphasize that aspect," says Beiser. "The distinction between mental and physical health is an artifact of Euro-North American culture. It doesn't work terribly well, so there's no reason to perpetuate that separation. Our emphasis is much broader, trying to adopt a more holistic approach." Research projects now under way include a study of the settlement of Southeast Asian refugees in Canada, the emotional and cognitive development of First Nations children, cross-cultural communication and empathy, and psychosocial factors in life-threatening illness. Although culture is often viewed as a barrier, it is actually an asset in curing disease and promoting wellness. Masi provided an example: the overwhelming failure of drug- and alcohol-treatment programs designed for aboriginal people but based on white middle-class values. When the CAN MED ASSOC J 1992; 146 (12)
2211
programs were redesigned to include traditional healing ceremonies and input and participation by the entire community, abstinence rates soared. Beiser also stresses the importance of not dwelling on cultural diversity as a problem, but to view it as an opportunity for enrichment by learning about the effective methods many cultures
use to deal with disease. The road to cultural enrichment in medical care will not be easy, but it certainly won't be dull, he says. "I wouldn't want to underestimate the amount of work we have to do. I think we have a good background and knowledge base to begin to develop new models of care, new programs, to develop training for our next gen-
eration of health care providers. It will have to evolve over time and it will be a long struggle. But it's a struggle we can't avoid or escape given the reality of our demographics. "But I really believe it's a struggle that's worth while, not only because we have to do it, but because we'll be the better for it."E
Cultural awareness part of the health care agenda at Toronto hospital Olga Lechky
andemonium greeted Ruth Lee as she rushed into the dying man's room. The patient's large family was obviously upset, screaming in Chinese at nurses who were in turn bewildered and defensive. After hearing both sides in the dispute, Lee, an expert in transcultural nursing at the Toronto Western Division of the Toronto Hospital, was able to get to the root of the problem. It was simple enough. The nursing staff had told the family that the patient was being moved into another ward in an hour and asked the family to pack up his belongings. The family, with a slim command of English, had understood that their father was going into another world in an hour. The family was angry at the nurses' insensitivity and rudeness they wanted to comfort him in his last hour, and packing his belongings was the last thing on their minds. "It was just one word that caused such distress to the family," Lee observes. "Ward to us is a common word used in the hospital, but for people who don't speak much English it's a word P
Olga Lechky is a freelance writer living in North York, Ont. 2212
CAN MED ASSOC J 1992; 146 (12)
that they're unlikely to have been exposed to. When I explained to everyone what the misunderstanding was they all laughed, but at that moment it was very stressful. It almost destroyed 6 weeks of a good relationship that had been established between the nurses and the family." Helping patients and staff negotiate their way through a maze of linguistic barriers is just one of the roles Lee and colleagues in the Toronto Western's Multicultural Health Service (MHS) perform. Through the use of trained interpreters, the hospital's largely ChiToronto Hospital
Lee: overcoming cultural barriers
nese, Southeast Asian and Portuguese clientele are able to negotiate the labyrinth of tests, specialist consultations and treatments. That labyrinth may seem a routine feature of a large teaching hospital, but it is often foreign and frightening to a newly arrived immigrant who does not speak English. While language is an obvious barrier to communication that's readily recognized, cultural barriers present a much more subtle problem. "A person may speak good English but still hold cultural beliefs that could cause misunderstandings with staff," Lee warns. For example, it is common in many cultures to crowd family and friends into the patient's room at all times of the day, even though this is against hospital regulations. The staff may find this annoying and disruptive, but for the patient and family it's a sign of respect and support that is essential to the healing process. The family brings the patient's favourite foods and carries out rituals believed to speed recovery. The patient is expected to remain immobile and let visitors do everything for him. Initiative and self-reliance on the part of the patient would be considered rude and disrespectful. LE 15 JUIN 1992
