Pulse
When Worlds Collide
Doctors and parents don’t always think alike. How a few pediatricians deal with the differences.
The infant’s diagnosis was gram-negative meningitis. Pediatric hospitalist Cynthia Howard, M.D., M.P.H.T.M., was confident about her treatment recommendation—hospitalization and a 21-day course of antibiotics. But after a few days, when the baby was stabilized, the parents, who are Hmong, said they wanted to take the child home to see a shaman.
Howard, who directs the global pediatrics program at the University of Minnesota, believes parents often do know what’s best for their children. As a young physician in Nigeria, for example, she saw parents refuse treatment for a newborn with multiple disabilities because they knew neither they nor their community had the resources to care for the child. But she also knew that in the case of the Hmong baby, antibiotics were needed.
Howard tried to reach a compromise with the parents, suggesting that the shaman come to the hospital. She also had a Hmong physician talk to them. But in the end, the parents decided they wanted to take the child home.
Howard found herself having to get a court order to keep the baby in the hospital. Although she doesn’t question that decision, she admits the situation was one of the most difficult she’d ever been in. “It wasn’t as though anyone was wrong,” she says. “It’s just that what they thought was best and what I thought was best were in two different worlds.”
As if the doctor-patient relationship isn’t challenging enough, physicians who treat children have the added dimension of dealing with parents. And as Minnesota’s population has become more diverse, physicians have found parents don’t necessarily share their worldview and values. Here, a few Minnesota physicians share the types of conflicts they’ve struggled with and what they do when parents’ values differ from their own.
Frank Talk
Minneapolis pediatrician Carolyn McKay, M.D., is one who thinks there are more values conflicts between doctors and patients today than there used to be because so many people are coming from other parts of the world. McKay, who sees many East African families at Fairview Children’s Clinic, says she often has a different view than these parents on issues such as how much activity their children, particularly their daughters, need; whether tonsils should be removed and antibiotics given; and what children should know about sexual development and when.
But for McKay, the most common conflict centers around food. “Most of our Somali mothers tell us point blank they want their children fat,” she says. “We’re seeing children who are frankly obese and have increased risk of type 2 diabetes, and parents who don’t want us to say anything about it,” she says.
McKay acknowledges that the problem of obesity in children extends far beyond immigrant communities. But with Somalis, she believes culture plays a role. Fat is considered healthy. She says some of the mothers criticize one another if their children are thin and hand-feed children until they are school-aged.
So McKay tries to teach the women about eating habits and food. When she asks them what they think is good food, they typically list meat, butter, and other calorie-dense foods, she says. And then she frankly states her own view that whole grains and vegetables are better choices.
McKay, who has been in practice since 1972, thinks parents are more likely to heed her advice now than when she was a new doctor. “When you’re almost the same age as the parents, it’s very different talking to them,” she says. “I’m the grandma doctor. I can get by with saying things that I never could have said when I was younger.”
Focus on the Family
Nimi Singh, M.D., M.P.H., who also sees patients at Fairview Children’s Clinic, believes that some physicians may over-emphasize the role of culture in their dealings with parents. She points to a recent article by Arthur Kleinman (who coined the term “cultural competence” in the 1970s) and Peter Benson that suggests that in their attempt to be culturally competent, physicians often assume that culture plays a bigger role than it actually does in any given case.
Singh, who is director of adolescent medicine in the University of Minnesota’s department of pediatrics, describes a recent interaction she had with a 16-year-old Somali patient and her father that illustrates the point. The girl had chronic headaches. Singh ruled out physical causes and realized the headaches were stress-induced. The patient was a straight-A student who, after school and on weekends, took care of her younger siblings and did housework while her parents worked several jobs.
Singh thought the father ought to know what she believed about the girl’s headaches. Yet she was hesitant to say anything, knowing that in many traditional cultures, the role of older children is to help run the household. “I had to make a decision about whether it was appropriate to bring this up,” she says, thinking the father might not understand or listen. As it turned out, the man was more than receptive and willing to help his daughter make changes. The headaches lessened dramatically after one week, Singh notes.
Singh says the experience taught her a lesson. “When I reflect on that case, I see how I might have made the decision not to bring it up with the parents for fear of causing guilt or bringing up something that was impossible to change,” she says. “But on some level, that would have been paternalistic on my part—to think that I understood the culture and economics of this family and … that the family wouldn’t be able to handle the information.”
Singh agrees with Kleinman’s and Benson’s argument that physicians need to recognize that people live their ethnicity differently. She says the best way for physicians to do that is by asking themselves a few basic questions: “Who is the person sitting in front of me? What’s their story? From their perspective, what’s contributing to the ailment that they’re seeking care for? Then, she says, they need to say to the parent, “This is my best understanding of what I think is going on here. What do you think?” Singh says parents are almost always receptive to her opinions when she approaches them this way.
Personal Decision or Public Health?
Pediatrician Dawn Martin, M.D., M.P.H., a staff physician at Hennepin County Medical Center (HCMC) and chair of the Minnesota Immunization Practices Advisory Committee, says one area of conflict for many physicians and parents these days is whether babies should be vaccinated. It’s a cornerstone of pediatrics, she says, so doctors feel strongly. But parents, fueled by information they’ve read online, religious teachings, or other forces, can be equally adamant.
She notes that physicians are practicing at a time when many parents haven’t seen the diseases vaccines prevent. Those who have, in Martin’s case her Spanish-speaking and Somali patients, view immunization positively. A 2006 survey of these and African-American patients at HCMC found that 99 percent of them were positive about immunization. “For many of these families,” she says, “that’s rooted in real-life experience with vaccine-preventable disease.”
She notes that the parents most likely to refuse vaccines are typically U.S.-born and Caucasian. In some cases, they’re motivated by religious beliefs; in others, by fear of autism and belief in non-Western medical approaches to health. Martin says it’s important for her to try to show respect for patients whose views may differ from hers in order to maintain their trust. “We need to be strong advocates for vaccination yet at the same time listen to each family’s unique concerns and fears,” she says.
A colleague at HCMC, Teresa Reid, M.D., who has an interest in complementary and alternative medicine, notes that physicians and parents can easily become alienated over an issue like immunization, which they both feel fervently about.
“When you go head to head with a family member who doesn’t want to immunize, you just turn them off right away. What winds up happening is you don’t get them to take any immunizations,” she says.
Reid’s approach is to tell the parents that she knows her values might differ from theirs but that they have the right to make the decision for their child. “Then they tend to soften and back up a little bit. They’ll listen,” she says. Then she tells them what she thinks they “absolutely need to have right now,” figuring that if she can convince them to get a couple of vaccinations, that’s better than none.
Reid says she feels her approach is a win-win for both her and the parents of her patients. “I come away feeling good about how I interact with families, and they feel good about how they interact with me.”—Carmen Peota