Between September 2013 and June 2015, all sixth-year medical students doing their internship at a medical center in eastern Taiwan were trained to write mini-ethnographies for one of the patients in their care [1]. The mini-ethnographies were analyzed by authors with focus on the various aspects of cultural sensitivity and a holistic care approach.
The purpose of this experiment was to use mini-ethnographies narrating patient illness to improve the cultural competence of the medical students. To improve the quality of medical services, it is critically important that health care professionals must take into account the culture, language, health beliefs, and environmental differences found in patients. A cultural competence that is a crucial skill that helps health care providers to reduce inequality in health care.
At present, questionnaires are the primary means of assessing cultural competence, which are self-report surveys of knowledge, attitude, or skills. However, despite the efforts by researchers to increase the validity of the questionnaires, this approach is still subject to bias. Instead ethnography, used in conjunction with medical anthropology, is an effective and qualitative research instrument that provides a complete understanding of the individuals residing in certain social environments, including their life, culture, actions, and unique views. They help doctors understand the illnesses and life experiences of the patient and also help doctors empathize with the patient. The application of ethnography to health care not only improves cultural competence but also enhances the application of evidence-based practice through an understanding of the actual living conditions of certain communities and the conceptualization of the meaning of their health behavior.
During the first class of each semester, the students were trained to write mini-ethnographies and given reference principles and writing samples. The students were required to write a mini-ethnography, the assignment of the semester, for one of the patients in their care and hand it in at midterm. Then, in groups of three, the students discussed the contents of their assignments with their advising teacher, who gave them feedback and guided them in reflection in an effort to strengthen the effects of the mini-ethnographies on cross-cultural care training.
The eight questions proposed by Arthur Kleinman regarding the cultural aspect of cross-cultural medical assessments served as the focus of the patient records: 1) What do you think has caused your problem? 2) Why do you think it started when it did? 3) What do you think your problem does inside your body? 4) How severe is your problem? Will it have a short or long course? 5) What kind of treatment do you think you should receive? 6) What are the most important results you hope to receive from this treatment? 7) What are the chief problems your illness has caused you? 8) What do you fear most about your illness/treatment?
During the 2 years of this study, 91 students handed in mini-ethnographies, of whom 56 were male (61.5%) and 35 were female (38.5%). From the mini-ethnographies, three core aspects were derived: 1) the explanatory models and perceptions of illness, 2) culture and health care, and 3) society, resources, and health care. Based on the qualities of each aspect, nine secondary nodes were classified: expectations and attitude about illness/treatment, perceptions about their own prognosis in particular, knowledge and feelings regarding illness, cause of illness, choice of treatment method (including traditional medical treatments), prejudice and discrimination, influences of traditional culture and language, social support and resources, and inequality in health care.
Student B29 remarked on how his patient attributed his disease to past life karma, which eased the misery caused by his cancer:
Even though the cancer has had a profound impact on his life, he accepts it and sees it as spiritual practice. He believes that the sins he committed in his previous life can only be forgiven after he completes this spiritual practice, in this life, and that the heavens must have arranged this because he has not repaid his debt. The fact that he has not died yet is because he has yet to serve this purpose.
This fatalism does exist not only in Buddhism but also in Christianity:
She does not believe that her heart failure was exacerbated by her drinking or indiscriminate use of painkillers. Rather, she thinks that this is a punishment given by God, so she must pray with greater earnest. She tries to participate in all church events and possesses very little insight with regard to her own prognosis.
Traditional culture, language, prejudice, and discrimination are important aspects of cultural sensitivity in healthcare work. This could potentially reveal that culture is still not a primary concern for the medical students.
Student C16 noticed his patient’s desire for a traditional Chinese medicine (TCM) treatment. However, he questioned its effectiveness and even suggested his patient, Grandma Chen, not to administer TCM on her own.
Up to the time of her discharge, Grandma Chen was still thinking of the tonics and herb medicine that would benefit her liver and prevent her from needing surgery. I reminded her not to administer traditional herb medicine on her own.
Student B26 was one of the few to notice that differences between ethnic groups in language and traditional medical treatments led to inequality in health care:
Ms. Lin is Amis (an aboriginal tribe). Originally, their medicine focused on traditional folk remedies, or they relied on witch doctors. In her old age, she was forced to accept western medicine, which she had never encountered before. The terms surgery and chemotherapy may be as familiar to us as the alphabet we use every day, but for Ms. Lin, who had lived the majority of her life in traditional Amis culture, the shock was definitely no trivial matter.
Society, resources, and health care also did not appear to be a point of focus for medical students.
Student C37 raised a very practical issue, stating that without continued care and concern, the distribution of resources is merely a temporary solution to economic problems:
In government social welfare institutions, the donations from good Samaritans may provide these children with the funds or resources that they need for living or medical treatments. However, what they lack even more is care and patience from others. After all, few people are willing to put much effort into taking care of someone who has no close relationship with them.
Student A17 described the unequal distribution of medical resources due to geological barriers, which made the residents of remote areas ‘orphans’ in medical care:
Due to the meager medical resources in Fuli Township (a remote township in Taiwan), the patient’s husband is reluctant to have her discharged from the hospital. They are worried that they will not be able to get medical treatment in time if an emergency occurs after they return home.
In the conclusion they found that in teaching medical students’ cultural competence, we should teach them not only about ethnic and cultural differences but also how to examine and understand the explanatory models of their patients with regard to their illnesses. This requires clinical workers to have moderate familiarity with this framework, and mini-ethnography is an effective teaching method that can help students to develop cultural competence.
[1] HSIEH, Jyh-Gang; HSU, Mutsu; WANG, Ying-Wei. An anthropological approach to teach and evaluate cultural competence in medical students – the application of mini-ethnography in medical history taking. Medical Education Online, [S.l.], v. 21, sep. 2016. ISSN 1087-2981
