My job as a standardized patient (SP) at several different medical schools means that I spend a lot of time being interviewed and examined by students at every stage of their education. Occasionally, the interview is of such a nature that the SPs are told to dress in a certain “costume” because it signifies to the student that there is something about our cultural representation that affects our medical care. During these encounters, the students are to ask me if there are any cultural or religious beliefs I adhere to that that they should take into account when it comes to my medical care. If they ask this, I openly provide them with information that is essential to how they should direct the interview. If they don’t ask this, I still answer their questions but never volunteer the vital cultural component to the case.
One of these cases involves a pregnant woman who has terrible acid reflux. She has medication for the GERD, which helps when she can take it, but she can’t always take it since she is a Hasidic Jew and on the Sabbath, she is unable to take her medication. She is visiting the doctor to see what non-medication alternatives there are that can help her on the Sabbath. For this case, the SPs are instructed to cover our hair, and to cover ourselves completely from head to toe. There are also specific answers we are to give that should indicate to the students that they should ask additional questions that elicit a response about our religion and culture. Any question the student asks about religion or culture allows me to mention that I can’t take my medication on the Sabbath, which should open the door for students to follow up.
Another case involves a woman who is skeptical of traditional medicine and doctors, and whose regular medical provider is a naturopath. An upcoming overseas work assignment is requiring her to get immunizations from a traditional doctor. She doesn’t believe in immunizations, so she is hoping that the student can provide her with natural alternatives to these. As with the pregnancy heartburn case, the SP instructors ask that the SPs wear outfits that will signal to the students that we are a part of a different cultural outlook, which means, essentially, dressing like a 1960s hippie. For this case, there are also scripted answers that include prompts to the students that, should they ask, allow me to share how my holistic culture affects my medical care. I then explain how I refuse to put anything into my body that I see as a toxin and will only use natural remedies, substance, and ingredients.
The purpose of both these cases is not for the students to provide the SP with the alternatives they are seeking, but rather, to see how they address and incorporate the SPs culture into the interview. Will they dismiss the SPs personal beliefs and opinions and provide traditional counseling anyway? Will they chastise the SP for not being willing to follow prescribed advice? Will they make assumptions about this patient and her care? Will they ask questions to try to understand the patient and her needs? Will they be sympathetic? Or will they fail to even address the cultural aspect of the case?
Over the past twelve years, I’ve done these cases numerous times. For the first several years, most of the students were able to identify the cultural component of these cases, and they even asked good questions and tried to understand the patient’s culture so they could provide the best possible outcome. What I have noticed in more recent years, however, is that the students are increasingly failing to even address the cultural aspect of the case, and I’m not sure why. All aspects of the cases have remained the same. So why are so many of the students failing to identify the necessary cultural element in these cases?
Perhaps as American culture has become increasingly more sensitive to inclusiveness over the past decade (to be clear, this is a very positive thing and something I am definitely in favor of), I’m wondering if that mindset may have unintended consequences in the medical education community. It’s wonderful to live in an era where there is such a melding of cultures and religions and different belief structures, but has this melding made these students blind to the fact that there are differences in people that have an impact on their medical care and need to be addressed? Or has it made the students afraid of acknowledging obvious differences for fear of offending the patient by even asking questions? In many instances, cultural or religious differences may not be obvious, so it makes sense that a medical student or provider wouldn’t immediately think to ask. But in these SP cases, the instructors have gone out of their way to provide students multiple opportunities to recognize that their patient is part of a specific culture, and that trying to understand that culture might have large implications on the patient’s medical care.
I am not able to, but if I could provide feedback to the students in these particular SP cases, I would tell them that it is always a good idea to ask a patient if there are any cultural, religious or personal aspects of their lives that they would like incorporated into their medical care. It’s a simple and neutral question to ask patients in any and all settings. I wish my own medical providers would ask me this at my medical appointments.
Students need to understand that asking this question is in no way being insensitive but is actually vital to providing excellent, comprehensive and patient-centered care. Although in many cases, the answer will be “no,” it still shows the patient that this medical provider is truly interested in them, wants to understand them and their concerns, and is eager to ensure they get the best possible medical care. Such a doctor will always have my trust and my business.
Esther Covington is a professional standardized patient.
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