Narrating Medicine: How Cultural Differences Challenge Doctors

The pediatric resident was frustrated.

On the exam table was a 6-month-old baby — quite overweight. In fact, the child was heavier than an average 1-year-old. But his mother just laughed when the resident asked how she was feeding the baby.

When the resident and I looked at the medical record, we saw that for months residents had been discussing feeding with the mother. Telling her that she should stop formula feeding because her breast milk was more than sufficient. Telling her not to give solid foods because her breast milk was enough. And telling her that if she was going to give the baby formula or solid food, she should try to pay attention to when the baby's cry means hunger and when it means a wet diaper or a need for attention.

Over one-third of adults and about 17 percent of children in the United States are obese. And since people who are obese have more high blood pressure, diabetes and heart disease than their peers, it’s not surprising that there are 11 million office visits per year for adults with obesity.

Yet according to a new CDC report, only 40 percent of these 11 million visits for obesity include a discussion of diet and exercise.

Dr. Marjorie Rosenthal (Courtesy)
Dr. Marjorie Rosenthal (Courtesy)

Many health care providers don’t want to talk to their patients about diet and exercise because they think the patients may feel judged. And sometimes doctors don’t talk about fitness and nutrition because they actually think talking won't change anything. Which makes it safe to assume that office visits for obesity rarely include a discussion about the life experiences of the patients and the parents of patients. This suggests that a critical issue — and a key part of any treatment plan — is never addressed.

Parents’ medical history has always been an important aspect of a child’s medical care. But the central importance of all this has only recently emerged: New research has shown how life experiences affect brain development and hormone responses and how that affects parenting behavior and the health of the child in the next generation.

It’s hard enough to do this with families who speak English and come to the doctor’s appointment ready to talk about themselves. With this overweight 6-month-old, it was even harder: The resident was using a Swahili phone interpreter and the mother was a refugee.

Interpreters are a vital but tricky part of office visits for families who don’t speak English. Professional interpreters (as opposed to family members interpreting) improve understanding and outcomes for the more than 20 million Americans who don’t speak English well but they aren’t always available. With this mother, speaking a language that is uncommon in New Haven, we used a professional phone interpreter -- certainly better than no interpreter but over the phone cultural nuance and body language can be lost.

Knowing the mother was a refugee fleeing a Swahili-speaking country should have completely reframed our view of the patient’s weight. For U.S. children, our filter includes the statistics about childhood obesity and sugar consumption; but in this case, we should have employed a more global filter.

At the Yale/New Haven Primary Care Center we screen for familial social factors. For example, we screen all new mothers for depression, housing stability and safety. But it’s unclear how well the screening works when translated into the language and culture of this mother.

In our center, we have a designated refugee clinic where we ask about the whole family’s experience as refugees. But this child is not enrolled in that clinic because as pediatricians, we enroll children in the refugee clinic only when the child is a refugee. This 6-month-old baby was born here, in our hospital.

As an American child, he will benefit from the safe water supply, vaccinations and other preventive and public health aspects of the United States. While the health risks to childhood refugees include tuberculosis, under-nutrition, obesity and other chronic conditions, the risks to American-born children of refugees is less understood. Yet re-framing this patient’s story as an American child of a refugee woman, who may have experienced trauma and food insecurity, it makes sense that this child is being fed more than he needs.

While we don’t know exactly why this mother is feeding her baby this way, it doesn’t take too much of a leap to imagine that the mother’s prior experience with a limited food supply has led her to overfeed her child. Or that she is controlling what she can in her life -- she can decide how much to feed the baby and she can probably stop his normal baby cries by feeding him. We don’t actually know what this mother was thinking -- she was speaking Swahili to the phone interpreter and not a lot of it. She didn’t say any of this through the interpreter but to be honest, we didn’t ask.

Caring for the health of children means two-generation care. It means understanding the mental health, physical health and life experiences of the whole family.

Professional guidelines recommend that pediatric providers ask about parental experiences. Parents are usually OK with being asked about their own health, and the Affordable Care Act allows us to get reimbursed for asking and counseling about maternal mental health.

Yet, we don't always ask. There often remains a sense that the family won’t want to talk about it or that we won’t change our treatment plan anyway, or that the patient won't have access to the outside providers we refer them to.  Honestly, we don’t do as good a job as we could in considering how the whole family’s life affects that of the child. For the sake of babies like this one, we need to do better.

Marjorie S. Rosenthal, M.D., MPH, is assistant director of the Yale Robert Wood Johnson Clinical Scholars Program, associate research scientist in the Department of Pediatrics at the Yale University School of Medicine and public voices fellow with The OpEd Project.


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