“How do you say cultural competence in Korean?”
“I am always treated with respect in America. So why don’t they care about me here?”
My first patient at my community clinic rotation struggled to speak English. But she came prepared, her words memorized, printed from Google Translate.
“All I want is help.”
She had immigrated from Korea not too long ago and found this community health center for her first dental care in over ten years.
“When I came to the clinic last week,” she said, tears filling her eyes, “they said I need a cleaning.”
I listened carefully, watching her expressions to better understand her Google-translated English.
“But they left spaces between my teeth.” They did. The natural spaces that we all have — embrasures — were no longer filled with a layer of calculus. “My tongue digs into those spaces. And it hurts.”
Her tongue showed a small ulcer at its tip. Every word that she said was true, though she and I understood this truth differently.
“And the doctor showed me what came out of my gums. She called it calculus.” The patient mimed a small rod with her hands. “But it didn’t smell. Calculus smells.”
“Sometimes,” I nodded. “Not always.”
“And it didn’t crumble. It had to be metal.”
I sat at her level, repeating my understanding of her concerns back to make sure she not only felt heard but was heard.
“I think a dentist put the metal there in Korea to close the spaces between my teeth. But the dentist last time didn’t listen.” Her speech grew panicked. “She took it out, leaving a hole in my gums.”
The patient pointed to this hole, and again, factually, she was right. There was a depression — possibly from a periodontal instrument, most likely from long-standing calculus pushing on the gums.
I put my hand on the patient’s knee, letting her know I understood.
“I have never been so miserable.” Her head sunk to her chest. “This cleaning changed my life, and it is horrible.”
There was nothing I could do.
“All I want is help. The other dentist said she would help, and she isn’t even here.” As rotating externs, this, too, was true. We worked with the community clinics for only a short time, preventing patients from ever really establishing a long-term relationship with their dentist.
“She hurt me,” the patient finished, “and I only wish someone would help.”
I only wished there were a simple way to help.
By objective measure, my patient received treatment at the Western standard of care. Orajel could soothe her tongue if I could find the Korean to explain that, but I could not reverse her cleaning. Other than offering a listening ear, I was helpless as a helping professional.
And I asked myself, how could we as a profession have done better? Everyone did their absolute best, and still, I know my colleagues, and I all would want, for this patient and every patient, a way to do better.
Community health centers are the first step towards doing better. These centers, as described by the CDC, are located in an area of high need and governed by representatives of the community served. They serve as medical homes for our patients; their records shared among specialties so that we can provide comprehensive, integrated health care. Both walk-in appointments and reduced fees are available. Essentially, the community health center addresses many of the barriers that keep our patients from receiving care. According to the American Dental Association, these barriers include cost, fear, a busy schedule and lack of a dentist in the area.
However, health centers — for reasons beyond the reach of the health centers themselves — are imperfect.
Not every health care center, for instance, has full interpreter services. The primary reason — funding — though the reason doesn’t matter when the patient’s care is compromised. When my patient’s primary language was Korean, the best we could do was offer patience and the choice of an English or Spanish intake form. And my patient was not alone in this dilemma. The 2011 American Community Survey shows that 20 percent of the U.S. population does not speak English. So without interpreters, our patients and providers simply try to get by. We understand pieces of what is said and communicate fragments of a story. We accept a communication barrier and the adverse health outcomes it creates.
Community health centers, too, simply cannot bridge every cultural barrier that divides many patients from their providers. If before this patient’s cleaning, someone had been aware of her cultural differences and discussed her values, perhaps her terror in the aftermath could have been prevented. Most likely, her providers did all of this, and this patient simply needed more time to accept the care, time the system didn’t allow.
Cultural competence, as explained by the Canadian Medical Protective Association, is neither persuading the patient to accept the Western standard of care nor is it shifting one’s standard to meet a different cultural view. However, it is a method of opening discussion and empowering the patient with a culturally accessible understanding of the treatment options.
According to American Family Physician, 47 percent of the U.S. population will be comprised of minority groups by 2050. In that statistic is a possible rise in upsetting experiences like the one I witnessed with my patient. Alternatively, though, in that statistic is a rise in the diversity and cultural awareness of each of our providers.
My first patient in the health center shared with me a humbling lesson: We as providers are limited in what we can do. We are limited by language, culture and resources. We are limited by our patient’s pasts and by our own cultures. We are not limited, however, in our ability to see these issues. We are not limited in our ability to voice our concerns and take a stand for change.
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