Being sensitive to a patient’s cultural identity can be a crucial element of their healthcare, writes Dr Aajuli Shukla
As part of general practice training and practice accreditation one needs to do cultural sensitivity and awareness training in the form of an Indigenous health training workshop and/or online training module.
I must admit, I did not quite understand the difference between the two terms. Sensitivity versus awareness. Cultural awareness relates to being aware of similarities and differences between diverse cultural groups in terms of beliefs, ideas and values.
Being culturally sensitive relates to a deeper understanding of one’s own cultural beliefs and values and the way they may impact the way we communicate with someone who might be from a diverse cultural group.
It also means understanding the way someone from a distinct cultural group might perceive us based on their own value system.
Most of us are already culturally aware. We know that Australia is multicultural and diverse country, but being culturally sensitive as a health practitioner involves a deeper reflection which is fundamental to understanding the power differentials inherent in health-service delivery. It acknowledges that we are all bearers of culture and that our actions can easily damage culture, just as a callous remark can cause emotional harm.
The fact Indigenous health outcomes are much worse than general Australian health outcomes is well known to most people, and especially those of us who study medicine here. Most of us during medical school have also done rotations in Indigenous health, either in urban Aboriginal medical centres, the Northern Territory or Western Australia, and observed the overt disparities Indigenous people face every day.
But how do you teach someone who may have studied in another country, or not done those rotations, about Indigenous health in a one to two-day workshop?
The workshop and the associated learning module is, in fact, very informative. I found the history portion of it especially useful, not having studied this in high school in Australia and not having learnt it in detail through medical school.
But perhaps the most useful aspect of the training were the case studies. As most doctors know, the education that stays with us is always the human story. Almost all the workers there had a story to share concerning health inequity, stolen identities and resilience in the face of it all.
I decided to talk to one of my patients about this. Along with looking after her health, we often talk about her family, as most GPs do. I knew she identified as Aboriginal, but I realised I never asked her the all-important question: “Where do your people come from?”
The workshop discussed the diversity of the Aboriginal population and how important that question can be to further the bond between patient and doctor. For privacy reasons, I shall not expound on her answer, but it revealed a whole new avenue of her identity that I had previously been completely unaware of, despite knowing her for two years now.
What’s interesting about this workshop is that it made me reflect on cultural sensitivity as a whole.
Australia does multiculturalism quite well. The immigrant story is often woven into Australian identity with some angst, but without too much tragedy. Several of my colleagues and friends have family members, relatives and ancestors who came to Australia in a myriad of ways and have established themselves as part of Australian society.
There is still vast room for improvement, both in Indigenous health and in the way we manage health in culturally diverse groups, but we do try very hard.
As an Indian-Australian, I have not experienced any overt racism – although my accent always begets the question: “Where are you from?” This is often due to a genuine interest. but how do I tell them I feel like saying “Australia”, because I have never actually lived in India.
I have a powerful sense of an Indian identity, but I consider Australia home.
During the workshop, we introduced ourselves including where we came from and all of the Indigenous coordinators always said: “My name is so and so and I come from …” And they named their tribe, and the geographical area they came from.
When it came time to introducing myself I suddenly got stuck. And this has never happened before, what do I say? Culturally, am I meant to be a native of my country of birth, the country I have lived the most number of years in, the country I hold a passport for, the country my parents come from, or the country I consider home? So, the Netherlands, United Arab Emirates, New Zealand, India or Australia?
I know this is not a common problem. Most of us haven’t had to move between too many countries. My parents just seemed to have varying, very good reasons to move and I have lived a very privileged and happy life. But it does make things complicated over where I stand in terms of my own cultural awareness and sensitivity. It forced me to reflect on not just the way I manage Indigenous health, but the way I manage the health of other culturally diverse groups.
There are several examples where a person’s cultural identity becomes an important aspect of their health concerns: a Sri Lankan woman finding it hard to leave an abusive relationship due to her concerns about society’s perception of her own daughter; an Indigenous patient finding it hard to take his medications as his wife does not know about his diabetes yet; a young Caucasian male with a conservative family discussing his anxiety at coming out as homosexual to his family and friends.
These are all real examples, and similar to what a lot of what my colleagues see in their day-to-day practice. Without being sensitive to our own opinions on this and the cultural context of these cases, we are only hearing half the story.
As practitioners, we all have our own opinions. These may be cemented by our religious background, our life experiences and the culture we were raised in. It has become increasingly important for us as health workers to try to understand how we practise cultural safety. Taking a cultural-safety approach implies a health advocacy role: working to improve healthcare access; exposing the social, political, and historical context of healthcare; and interrupting unequal power relations.
There are times when patients in my room express a belief or an idea that I do not fully agree with. It is at times like these I have found myself trying to figure out the difference between a variation of opinion versus the difference between right or wrong.
Physical abuse, verbal abuse and drug and alcohol dependence may have a cultural context for a patient, but can never be used to justify the “rightness” of them. But in order to help a patient through any of them, we have to acknowledge and understand how their life experiences and culture have shaped them. It often leads to much better outcomes and a much more satisfying patient-doctor relationship.
A young woman I have been managing came to me initially as she had moved suburbs and was taking an antidepressant for her low moods, as well as going to therapy. As part of my initial history, I asked her about whom she lived with and whether she was born in Australia. Her parents were immigrants from Iran with stable jobs.
After further reviews with her, I realised that part of her low moods came from her very low self-esteem because she was unable to live up to the expectations her family had for her – something she had never explored with any health worker before. This is a common first or second-generation dilemma: “How do we live up to the struggles our family have had to face to come here” or generational guilt.
Over time we did some mindfulness training, and, to an extent, knowing that I also came from a family of immigrants emboldened her to ask me to speak to her parents. It led to a very satisfying session where I played the mediator as they talked to each other. Slowly, she has come off her medications.
As GPs, we hold a privileged insight into people’s lives, and often into their most private thoughts.
A GP’s room is a safe place, a confidential place where patients often talk about things for the first time and air thoughts they have probably never discussed with anyone else.
We hold a vital role as the listener – often listening is one of the best therapies we can offer – and it is why we are trusted.
General practitioners themselves are an incredibly diverse group in terms of opinions, ethnicities and life experiences. GPs often have their own way of doing things when the situation is more grey than black or white.
Everyone has an opinion on the way the world works and it is important to listen, but sometimes as a GP, it is important also to recognise where I stand.
Hearing the patient’s narrative is often a very good way of breaking down cultural barriers in practice.
Dr Aajuli Shukla is GP Editor of The Medical Republic and practises in Blacktown in Sydney’s western suburbs
