London and its Asian patients
As a final year medical student in the East End of London I have had had three years of clinical experience in a very multi-cultural environment. I live in the vicinity of the hospital so that exposure continues beyond my working day. Tower Hamlets has long been an area of immigration: Huguenots, Jews, Bangladeshis and most recently Somalis.
The 1991 census found 35.6% of the Tower Hamlets community to be from an ethnic minority background - the third highest percent in the country. Currently the largest minority group is the Bangladeshi community from the Sylhet region of Bangladesh. They are Muslims who continue to hold to many of the beliefs and cultural practises of their homeland. Many women and older people do not speak English and of those employed, many work in menial poorly paid jobs. It has not always been easy to communicate with the patients that I meet, nor to understand health beliefs that cause them to behave in a way different from that which I expect. My aim is to overcome these barriers and provide better healthcare for those from an Asian background. I chose to spend my elective in India. Although the community I visited was in many ways very different from the local Bangladeshi community, I believe that I learnt many lessons that I can bring back and apply in London.
Lok and comparisons with London
Lok Hospital, Thane, India, is a small hospital owned by a Christian charity. It has 36 inpatient beds, a six-bed intensive care unit, a large outpatient department, theatres and facilities for many specialities. There is a mixture of private and charity patients. The majority are from a Hindu background, with a significant number of Christians and Muslims. Those from higher social classes speak fluent English. Others may only speak Indian dialects. I spent eight weeks in Lok hospital and drew comparisons between the patients there and those of Indian sub-continent background in the Royal London Hospital.
Language
Communication requires both a technical understanding of the language, and a familiarity with expressions, mannerisms and all the nuances that allow us to express emotions and feelings or imply that which we chose not to verbalise. At Lok I found that many words of my rather limited Sylheti vocabulary were very similar to Hindi and other local dialects. Familiarity with the local body language helped me communicate and helped the patient feel far more relaxed.
Diseases
Three of the most common diseases I saw in India were tuberculosis, malaria and type II diabetes mellitus, the first two being largely the result of environment, the latter having a strong genetic predisposition. The same three are also seen amongst the Indian sub-continent patients in the UK, diabetes being four to five times more common in Asians than non-Asians. TB and Malaria are also present in higher levels in this group, mainly in those who have recently been abroad. I hope in London that I shall be quicker to diagnose diseases that may not be common among the general population, tailoring my differential diagnosis to ethnic group.
Social Customs
Examining a patient from another ethnic background can be very difficult, especially if the patient is female. I saw a lot more examining through light clothes in India than we have been taught is acceptable in the UK. This is necessary considering the numbers of patients seen, and the need to preserve the modesty of the patient. Although this should not replace proper patient exposure for thorough examinations, these ways of treating Indian patients definitely also have their role in the West. Even understanding how Indian dress is worn can help preserve the modesty of the patient. A Bangladeshi woman can keep on her sari petticoat when changing into a hospital gown. This ensures legs remain covered and helps maintain the women's dignity.
Shaking hands is normal for many but for others it is embarrassing, particularly if a male doctor shakes the hand of an Asian woman. In Lok Hospital I chose to use a nod of my head to indicate greetings to patients. This seemed to be considered polite and acceptable. When working with the Muslim population in London I shall continue to avoid handshakes unless a hand is offered to me.
Doctor-Patient Relationship
The relationship between patients and their doctors in India appeared far more paternalistic than is now acceptable in the West. Lok was less this way than the state hospitals, but certainly more than the average British hospital. This may stem partly from India's very strong social hierarchy. Families have a clear authority structure and junior members were expected to submit to their seniors. Instructions were far more common than discussions, diagnosis and treatment were often discussed with relatives prior to the information being given to the patient, and treatment options were not fully explained. The relatives seemed to expect this and the patients appeared satisfied. Such behaviour can often be regarded as an expression of the relatives care for the patient, relieving them of the responsibility of thinking about the issues around their illness and leaving them to concentrate on regaining health.
A female patient may be much happier with a husband answering for her rather than speaking for herself: a younger patient may be content for a parent or an older sibling to discuss their situation with the doctor. This may prove more satisfactory than a tongue-tied patient struggling to answer and suffering acute embarrassment.
Health Behaviours
When Asian women in London present with "all over body pain" they may be expressing feelings of not being well, which they cannot describe. In other cases this pain appears to be a result of the somatisation of psychological problems such as fear or anxiety. Similar presentations are also common among women in India.
The Bangladeshi community in London value medicines bought from the chemist more than those in the supermarket. Similar interest in 'visible' healthcare was also apparent in India. Nurses commented how much the patients liked the multi-vitamin drip they received, more than colourless fluids, because it was coloured yellow. Women of lower social classes-attended their GPs for normal saline drips at regular intervals. After this 'medicine' they felt invigorated. Placebo effect seems to be very important. Remembering this may help tailor medical care to increase compliance.
Conclusion
Following my elective I aim to:
Jesus always met people where they were. His is the true example of an other-centred life. I need to follow his example. Only when such barriers are broken down will my patients see the light of Christ in me, and only then will they be able to respond to him themselves.
As a final year medical student in the East End of London I have had had three years of clinical experience in a very multi-cultural environment. I live in the vicinity of the hospital so that exposure continues beyond my working day. Tower Hamlets has long been an area of immigration: Huguenots, Jews, Bangladeshis and most recently Somalis.
The 1991 census found 35.6% of the Tower Hamlets community to be from an ethnic minority background - the third highest percent in the country. Currently the largest minority group is the Bangladeshi community from the Sylhet region of Bangladesh. They are Muslims who continue to hold to many of the beliefs and cultural practises of their homeland. Many women and older people do not speak English and of those employed, many work in menial poorly paid jobs. It has not always been easy to communicate with the patients that I meet, nor to understand health beliefs that cause them to behave in a way different from that which I expect. My aim is to overcome these barriers and provide better healthcare for those from an Asian background. I chose to spend my elective in India. Although the community I visited was in many ways very different from the local Bangladeshi community, I believe that I learnt many lessons that I can bring back and apply in London.
Lok and comparisons with London
Lok Hospital, Thane, India, is a small hospital owned by a Christian charity. It has 36 inpatient beds, a six-bed intensive care unit, a large outpatient department, theatres and facilities for many specialities. There is a mixture of private and charity patients. The majority are from a Hindu background, with a significant number of Christians and Muslims. Those from higher social classes speak fluent English. Others may only speak Indian dialects. I spent eight weeks in Lok hospital and drew comparisons between the patients there and those of Indian sub-continent background in the Royal London Hospital.
Language
Communication requires both a technical understanding of the language, and a familiarity with expressions, mannerisms and all the nuances that allow us to express emotions and feelings or imply that which we chose not to verbalise. At Lok I found that many words of my rather limited Sylheti vocabulary were very similar to Hindi and other local dialects. Familiarity with the local body language helped me communicate and helped the patient feel far more relaxed.
Diseases
Three of the most common diseases I saw in India were tuberculosis, malaria and type II diabetes mellitus, the first two being largely the result of environment, the latter having a strong genetic predisposition. The same three are also seen amongst the Indian sub-continent patients in the UK, diabetes being four to five times more common in Asians than non-Asians. TB and Malaria are also present in higher levels in this group, mainly in those who have recently been abroad. I hope in London that I shall be quicker to diagnose diseases that may not be common among the general population, tailoring my differential diagnosis to ethnic group.
Social Customs
Examining a patient from another ethnic background can be very difficult, especially if the patient is female. I saw a lot more examining through light clothes in India than we have been taught is acceptable in the UK. This is necessary considering the numbers of patients seen, and the need to preserve the modesty of the patient. Although this should not replace proper patient exposure for thorough examinations, these ways of treating Indian patients definitely also have their role in the West. Even understanding how Indian dress is worn can help preserve the modesty of the patient. A Bangladeshi woman can keep on her sari petticoat when changing into a hospital gown. This ensures legs remain covered and helps maintain the women's dignity.
Shaking hands is normal for many but for others it is embarrassing, particularly if a male doctor shakes the hand of an Asian woman. In Lok Hospital I chose to use a nod of my head to indicate greetings to patients. This seemed to be considered polite and acceptable. When working with the Muslim population in London I shall continue to avoid handshakes unless a hand is offered to me.
Doctor-Patient Relationship
The relationship between patients and their doctors in India appeared far more paternalistic than is now acceptable in the West. Lok was less this way than the state hospitals, but certainly more than the average British hospital. This may stem partly from India's very strong social hierarchy. Families have a clear authority structure and junior members were expected to submit to their seniors. Instructions were far more common than discussions, diagnosis and treatment were often discussed with relatives prior to the information being given to the patient, and treatment options were not fully explained. The relatives seemed to expect this and the patients appeared satisfied. Such behaviour can often be regarded as an expression of the relatives care for the patient, relieving them of the responsibility of thinking about the issues around their illness and leaving them to concentrate on regaining health.
A female patient may be much happier with a husband answering for her rather than speaking for herself: a younger patient may be content for a parent or an older sibling to discuss their situation with the doctor. This may prove more satisfactory than a tongue-tied patient struggling to answer and suffering acute embarrassment.
Health Behaviours
When Asian women in London present with "all over body pain" they may be expressing feelings of not being well, which they cannot describe. In other cases this pain appears to be a result of the somatisation of psychological problems such as fear or anxiety. Similar presentations are also common among women in India.
The Bangladeshi community in London value medicines bought from the chemist more than those in the supermarket. Similar interest in 'visible' healthcare was also apparent in India. Nurses commented how much the patients liked the multi-vitamin drip they received, more than colourless fluids, because it was coloured yellow. Women of lower social classes-attended their GPs for normal saline drips at regular intervals. After this 'medicine' they felt invigorated. Placebo effect seems to be very important. Remembering this may help tailor medical care to increase compliance.
Conclusion
Following my elective I aim to:
- improve my skills in Sylheti and other languages
- provide care for my patients in a culturally sensitive way, working with rather than against health beliefs
- use ethnically appropriate differential diagnoses
Jesus always met people where they were. His is the true example of an other-centred life. I need to follow his example. Only when such barriers are broken down will my patients see the light of Christ in me, and only then will they be able to respond to him themselves.
