■ Professionalism and ethics:

Integrating professional duties, societal expectations and personal wellbeing

Exploring cultural barriers to adherence - 2

Type of activity: Video

Activity summary

The two video segments for this activity "Exploring cultural barriers to adherence" demonstrate how exploring cultural factors may enhance patient comprehension, collaboration and satisfaction. The facilitation questions and suggestions to faculty will help learners to understand the importance of cultural factors in patient care, and thereby the value of adapting their history-taking approach to explore these factors.

Transcript

Setting: Medical office setting, patient is sitting in doctor's office during follow-up appointment.

Doctor: Your blood pressure is still quite high. I'm a little puzzled by that, I would have expected it would have gone down by now since you were here a couple of months ago. You've been taking the medications I prescribed?

Patient: (sheepishly) Um, actually, no... After I got home, I decided not to fill the prescription. I was hoping that my blood pressure will come down on its own.

Doctor: (surprised) Oh, okay. Well, have you at least reduced your salt intake as we discussed?

Patient (hesitantly): Well, you know what, that's kind of complicated...

Doctor: (waits for patient to pause) All right, maybe we better take a step back. Listen, why don't we both have a seat? (gestures to patient to move from exam bed to chair) So, do you have any concerns about your health that we haven't talked about?

Patient: Well, I mean, I could lose a couple of pounds or I could exercise more maybe. I mean, who wouldn't these days, right? (becomes more serious) Um, you know, doctor, to tell you the truth, I was bit surprised when you told me that I have a problem with high blood pressure because I feel fine.

Doctor: Well, what's your understanding of high blood pressure?

Patient: Well, I mean, in my case it's just one of the numbers that's slightly off, I don't think it's that important. I don't think it's affecting my health at all.

Doctor: Well, in fact, with high blood pressure you often don't know it's a problem until it's too late. But before we get to that, why don't you tell me a little bit more about why you didn't take the medication I prescribed?

Patient: Well, you know, last year my uncle went to see his doctor, he didn't feel well and he gave him medications for his heart and some blood pressure medications. And after that he got really, really sick, and ended up in hospital for 2 weeks. Now he's on disability. My aunt had to quit her job to take care of him. And I just... you know, I'm very careful when it comes to meds. I don't want something like this to happen to me. You know, we all think that he may have been just under a lot of stress and that was it.

Doctor: So, what are your ideas for dealing with your high blood pressure?

Patient: Well, since you asked... (pulls empty bottle out of pocket) I mean, I have this herbal supplement that my aunt told me about that apparently is supposed to be really, really good for your blood pressure. You know, where I come from we're really big on natural remedies before we take medications. My grandfather for example, he was ninety-two, he never took a single prescription in his life.

Doctor: (genuinely) Huh! Well, that's interesting. You also mentioned you're having trouble with reducing the salt in your diet. Let's talk about that a little bit.

Patient: Yeah, I mean, my wife is also reminding me constantly that I'm supposed to reduce salt, and my parents are the same. Their doctor is after them to reduce salt as well.

Doctor: Who does the cooking at home?

Patient: Well, since my parents live with us, my mother does. I mean, she's a great cook, she cooks all traditional meals. And she feels it's her responsibility, so even if we have a day off, she will not let anybody near the kitchen, so she does.

Doctor: So, mealtimes are important in your family?

Patient: Well, yeah, we try at least 3 times a week, for all of us to get together, my kids, my parents, and then we have a meal, which is a nice traditional meal just like we did back at home. And, in fact, it's one of the things that reminds us of home. We like to get our kids involved to see a part of their culture, which is how that food is prepared and things like that. And another thing that doesn't help is the fact that we go to a lot of parties within our community, and people host dinners, we take turns. And you know, it's all food prepared traditionally just like back home—it's very spicy, it's very salty—so it is hard.

Doctor: It's really difficult to keep the salt out of your diet then, yeah? Okay, well, what else would you like to get out of this appointment today?

Patient: I was going to talk to you. I was hoping to get some more information from you regarding me taking these supplements before I take the medications.

Doctor: Anything else?

Patient: No, I would just like to get your opinion on that.

Doctor: Okay, well, before we get to that, I'd like to pass on some information that I think may help us make some of those decisions...

Patient: Okay...

Concluding facilitation question: What could you do now to approach the patient's non-adherence?

Facilitation questions

After watching the video segment:

  1. What additional information did the physician obtain?
  2. What could the physician do now to approach the patient's non-adherence?

Suggestions to faculty

This activity consists of an interaction where a patient recently diagnosed with hypertension is being reassessed by his family physician. The first video segment depicts an interaction that is largely unsuccessful, due to how the physician responds to the patient's admission that he has not adhered to the physician's advice. In the second video segment, the physician utilizes a more patient-centered approach to explore the patient's underlying motivations (using the CIAO mnemonic: Concerns, Ideas, Activities, and Objectives). During the debriefing, discuss with the learners how incorporating key areas where culture and medicine intersect in the patient interview (using the CIAO mnemonic or any other strategies) may improve the patient's level of engagement and facilitate a change in behaviour.

Additional suggestions:

  1. Have learners explore their personal culture (thinking broadly about culture), either in pairs or within the large group.
  2. Assign learners to work in small groups to research the beliefs, values and practices of a specific cultural group and prepare a brief presentation for the large group.

Additional resources

CanMEDS: Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.