Practising evidence-based medicine in the face of counter evidence from another culture can be confronting, writes Dr Leon Piterman
We live in a multicultural society with over a quarter of our population, including me, born overseas. Our recent census data also indicates that the population mix is changing with more migrants coming from China, India and the Middle East, to our shores.
Many of us who have lived here most of our adult life have experienced the benefits of migration. These include culture, cuisine and fashion, to mention just a few.
As a child, the only items I witnessed on the menu at the local restaurant were fish and chips or steak and eggs. I am now presented with a kaleidoscope of restaurants and cuisine choices from a dozen countries within a short walk from where I live.
Migrants to Australia also bring with them a plethora of health beliefs. Occasionally these belief systems around the causation of disease or its management will collide with traditional western teaching.
It is, of course, impossible for GPs practising in a multicultural community to understand every culture’s health beliefs and practices, such as diseases caused by the evil eye, a curse, a cold wind, and treatments including alcohol compresses to the neck for respiratory infection, cupping and a range of herbal remedies.
Naturally, being patient-centred requires us to inquire about the patient’s health beliefs, to listen respectfully, and, at the same time, express an opinion based on our knowledge and the evidence we have for appropriate treatment.
This is not always simple as the case below, which has troubled me for decades, illustrates.
THE STORY OF CHRISTOS
Soon after commencing general practice, I was called to the home of a local Greek family worried about fever and vomiting affecting a nine-month old child. I was met at the door by the tearful and worried mother, who ushered me into the bedroom where baby Christos was concealed under a mountain of blankets designed to keep him warm.
The bedroom was crowded with his parents, and two sets of grandparents, looking very suspiciously at this young GP.
Here was an opportunity to apply my craft. The baby needed to be cooled. I quickly removed the blankets and asked for a cold sponge to cool the baby down while I took a history and conducted a physical examination on the now naked child.
I noted the look of horror on the face of the grandparents as I applied a tepid sponge. No sooner had I done this, than Christos had a convulsion. I was suddenly confronted not only with a very sick infant, but also with a room full of crying and screaming family members. There was no doubt in their mind that my treatment had caused the convulsion.
The convulsion lasted several minutes but, of course, it seemed like an eternity. The baby has been given milk before my arrival which he had duly vomited, but I was concerned about further vomiting and aspiration.
I nursed him on the side while his father called the ambulance.
Once the fitting finished, I tried bravely to explain the likelihood that this was simply a febrile convulsion knowing full well that meningitis needed to be excluded. As things settled and the ambulance took over I phoned the admitting officer at the Children’s Hospital and explained the nature of the problem and sought sympathy from her about my predicament.
Sadly, none was forthcoming. I felt traumatised and needed to debrief. By the time I returned to the clinic, all my colleagues had gone home. Fortunately, our senior receptionist was still there and offered a coffee. A measure of Johnny Walker might have been more useful.
After a sleepless night, I phoned the hospital. Lumbar puncture was normal. In the meantime, the baby had developed a rash. Typical measles. Why, oh why, is early diagnosis so difficult? Christos spent three days in hospital and was discharged with instructions to remain isolated at home and to be reviewed by me, or another GP, with a follow up at the hospital two weeks later.
It was with some trepidation that I knocked on the door of the family home. On this occasion, the grandparents were not there. I doubt they would have let me in.
GPs, as well as specialists, are haunted by fear of misdiagnosis and mismanagement which, coupled with fear of litigation, are major stressors.
This case, which in fact had a good outcome, had a considerable impact on me and influenced my management of sick children, particularly those from cultural backgrounds different to mine.
We like to think that we practise evidence-based medicine. Doing so in the face of counter evidence from another culture can be confronting.
Remaining tolerant and non-judgmental can be easier said than done.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 yearsÂ
Do you have similar professional experiences you’d like to share? Please email: grant@medicalrepublic.com.au
