TRANSCULTURAL MEDICINE. Dealing with patients from different cultures

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1 TRANSCULTURAL MEDICINE Dealing with patients from different cultures

2 To all patients, colleagues, and authors - from many ethnic groups - who taught me a lot so as to enable me to teach others

3 TRANSCULTURAL MEDICINE Dealing with patients from different cultures including 35 articles published in the British medical press BASHIR QURESHI FRCGP, DCH, AFOM(RCP), FRSH, MICGP, FRIPHH General Practitioner and Community Health Officer, Hounslow, Middlesex, UK Writer, lecturer and broadcaster in Transcultural Medicine Formerly, Member of the Communications Executive of the RCGP, editor of Faculty News, editor of London Medicine, Member of Council of The Royal Society of Health and its Special Purposes and Finance Committee Member of the Editorial Board of Health Trends KLUWER ACADEMIC PUBLISHERS DORDRECHT / BOSTON / LONDON

4 Distributors for the United States and Canada: Kiuwer Academic Publishers, PO Box 358, Accord Station, Hingham, MA {)358, USA for ai/ other countries: Kiuwer Academic Publishers Group, Distribution Center, PO Box 322, 3300 AH Dordrecht, The Netherlands British Library Cataloguing in Publication Data Qureshi, Bashlr Transcultural medicine. 1. Medicine. Cultural aspects I. Title 610 ISBN-13: e-isbn-13: / Library of Congress Cataloging In Publication Data Qureshi, Bashlr. Transcultural medicine. Includes index. 1. Transcultural medical care. 2. Transcultural medical care-great Britain. I. Title. RA418.5.T73Q ' ISBN Copyright 1989 by Bashir Qureshi Softcover reprint of the hardcover 1 st edition 1989 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers, Kiuwer Academic Publishers BV, PO Box 17, 3300 AA Dordrecht, The Netherlands. Published in the United Kingdom by Kiuwer Academic Publishers, PO Box 55, Lancaster, UK. Kiuwer Academic Publishers BV incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W Junk and MTP Press. iv

5 CONTENTS Preface: Why we must practise transcultural medicine Acknowledgements vii ix Part I: GENERAL ASPECTS 1. Avoiding communication problems 3 2. Ethnic terminology and occupations 7 3. History-taking and the examination 9 4. Factors affecting diagnosis and how to avoid diagnostic traps Psychiatric disorders among different ethnic groups Diet-related diseases Avoiding diagnostic traps related to customs Diseases related to visits to country of origin Therapy and multi-ethnic groups: factors affecting treatment Alternative therapies and ethnic groups 44 Part II: SPECIAL CONSIDERATIONS 11. Cultural conflicts in a mixed marriage Disease patterns in mutli-ethnic groups in the UK Hidden corners of ethnic medical history Gaps and needs in ethnic care Transcultural factors in the consultation: the three generations concept Management of ethnic Asian patients in general practice Obstetric problems in multi-ethnic women Family planning and culture Paediatric problems in various ethnic groups Pharmacists' understanding of cultural customs and dangers of multi-therapy Midwife, health visitor and nurse: dealing with patients from different c~u~ 1~ 22. Cultural aspects of the MRCGP examination Muslim patients and the British GP Nutritional problems in ethnic groups Skin problems encountered in multi-ethnic patients 193 Part III: SELECTED POINTS 26. Multi-cultural medicine: a series in the British Medical Journal Transcultural medicine: education and examination 218 Appendix: Resources available 223 Index 224 CONTENTS v

6 PREFACE WHY WE MUST PRACTISE TRANSCULTURAL MEDICINE Health professionals and GPs should concern themselves with ethnicity, religion and culture as much as with the age, sex and social class of their patients. Transcultural medicine is the knowledge of medical and communication encounters between a doctor or health worker of one ethnic group and a patient of another. It embraces the physical, psychological and social aspects of care as well as the scientific aspects of culture, religion and ethnicity without getting involved in the politics of segregation or integration. English general practitioners and health professionals tend to regard everyone as English, and to assume that all patients have similar needs. Would that it were as simple as that! For economic reasons - based on supply and demand - the mass migration of working populations from the new Commonwealth countries, along with their dependent relatives (including their parents) to Britain took place during one decade - the 1960s. Broadly speaking, the workers were in their thirties and forties, and their dependent parents were in their fifties and sixties. All these will, of course, be 30 years older in the 1990s. In fact, general practitioners and hospital consultants will see increasing numbers of people from ethnic minority groups, along with the indigenous populations. The needs of these ethnic minority citizens will differ considerably from those of the ethnic majority groups because of their different cultures, religions and ethnicity. Many doctors are scarcely aware of this trend at present; but lack of vocal demand does not mean absence of need. TRANSCULTURAL MEDICINE Science variables should be understood to include age, sex, social class, race, religion and culture; how can anyone call himself a scientific worker if he accepts the first three and disregards the latter variables? A multicultural approach in medicine helps in the identification, quantification and management of the problems of multi-ethnic patients, especially the elderly and women who are most likely to adhere to their own culture. Even those easterners who become westernised hardly ever change their religion and surely retain their ethnic characteristics. PREFACE vii

7 "Measure what is measurable and make measurable what is not" (Galileo). My observations, made over 25 years in this less-researched area, are now open to peer audit. I do not plead for anyone ethnic population or belong to any pressure group, but solely stress the need for understanding during a crosscultural consultation in a medical setting. WHAT'S NEW? In this book some problems of patients from different ethnic backgrounds will be identified and quantified so as to help British health professionals and GPs - during history-taking, clinical examination, investigations and diagnosis, drug therapy and general consultation - with a clear indication of what doctors should do differently as a result of seeing how things can go wrong or be misunderstood in a particular case. Categorisation or generalisation is the only way to measure facts and populations. Nevertheless, there remains the need to be flexible when categorising because there will be exceptions to every rule. While giving plenty of factual details, I shall be very careful when general ising about ethnic minorities as they may well differ as much between groups as they do from indigenous British people. There is more to good quality of care than trying to save everybody's time and money. The essence of good practice must be to tailor appropriate and sensitive care to an individual situation. The art of general practice and health care goes beyond the textbooks. There is much literature on the medical model (physical, psychological and social) and, currently, increasing information is available on one-ethnic studies. This book should be considered as an addition to the existing knowledge. Properly practised, Transcultural Medicine highlights the interface between various cultures, asks no-one to change personal views and stays clear of discrimination, either positive or negative. It simply suggests ways of improving the quality of care by distinguishing varying needs in a cross-cultural contact, whether during a ten-minute consultation or an hour-long medical examination. We can solve problems only if we can talk about them calmly. I should welcome communication from any readers who may have different observations. Here is an opportunity for mutual learning! London, 1989 BASHIR QURESHI viii PREFACE

8 ACKNOWLEDGEMENTS am grateful to the following organizations for giving permission to reprint various articles, as follows: The Royal Society of Health: Qureshi, B.A. (1981). Nutrition and multi-ethnic groups, J. Roy. Soc. Health, 101, No.5, Oct., pp Qureshi, BA (1985). Family planning and culture. J. Roy. Soc. Health, 105, No.1, Feb., pp Qureshi, BA (1985). Disease patterns in multi-ethnic groups in the UK. J. Roy. Soc. Health, 104, No.4, Oct., pp Qureshi, BA (1986). Contraceptive advice: how the English differ from the Americans. J. Roy. Soc. Health, 106(3), June, pp Qureshi, BA (1986). Hidden corners of ethnic medical history. J. Roy. Soc. Health, 106, No.5, October, pp Modern Medicine: Qureshi, B.A. (1982). Skin problems in ethnic Asians: avoiding diagnostic traps. Modern Medicine, 27, No.3, March, pp Qureshi, B.A. (1984). Transcultural medicine. Modern Medicine Promptcard, Sept. Rural Pharmacist: Qureshi, BA (1982). Dangers of multi-therapy. Rural Pharmacist, No.7, Nov., pp Current Practice: Qureshi, BA (1983). You offer but they need - gaps in the NHS care of multi-ethnic groups. Current Practice, No.4, Feb., p.26 Newbourne Publications: Qureshi, B.A. (1983). Understanding cultural customs and dangers of multi-therapy. Primary Health Care, 1, No.4, March, pp.9-10 Qureshi, B.A. (1986). Dealing with patients from different cultures. Midwife, Health Visitor and Community Nurse, 22(12), December, pp and 447 Royal College of General Practitioners: Qureshi, BA (1983). The gap in the care of multi-ethnic groups, Report, RCGP 1983 Spring Meeting, Oxford, pp (published by Thames Valley Faculty) Qureshi, BA ( ). MRCGP Study Day for Overseas Graduates. J. Roy. Coli. Gen. Practit., 33, No. 251, June 83, p.381-2; 34, No. 262, May 84, p. 290; 35, No. 275, June 85, p.306 Qureshi, B.A, ( ). Annual Study Day for Overseas Graduates, 1983 RCGP Members' Reference Book, p.100; 1984 RCGP Members' Reference Book, p.119 Qureshi, B.A. (1983). Skin problems in multi-ethnic groups RCGP Members' Reference Book, pp Qureshi, BA (1986). Nutritional problems in ethnic groups RCGP Members' Reference Book, pp ACKNOWLEDGEMENTS ix

9 Pulse (Morgan Grampian Professional Press Ltd): Qureshi, B.A. (1983). Patient care, cricket and transcultural confusion. Pulse, 48(31), July 30, p.36 Qureshi, B.A. (1983). Transcultural medicine. Pulse Reference Series, 43, Oct.29, pp.26-35; Nov.S pp.3s-44; Nov.12 pp Qureshi, B.A. (1984). Beware when diagnosing 'battered Muslim children'. Pulse, 44, Oct. 27, No. 42, p.43 Qureshi, B.A. (1985). Cultural conflicts In marriage and contraception. Pulse Reference Series, 45, Jan. 26, pp John Wright (Institute of Physics): Qureshi, B.A. (1984). Muslim patients and the British GP. The Medical Annual, 1984, pp.2s9-271 (Bristol: John Wright) Qureshi, B.A. (1986). Management of ethnic Asian patients In general practice. The Medical AI , ed. D.J. Pereira Gray, pp (Bristol: John Wright) Medical Publications Ltd: Qureshi, B.A. (1984). Have a mind for Muslim matters. GP, June 29, p.21 Qureshi, B.A. (1984). Ethnic customs can affect the skin. GP, Sept. 28, p.33 Qureshi, B.A. (1985). Cultural needs in birth control. GP, AprilS, p.33 British Medical Journal: Qureshi, B.A. (1985). Multicultural Medicine series. Br. Med.J., 290, pp.1632, 1956; 291, pp.790, 872,1020; 294, p.160; 295, pp.818, 890 Qureshi, B.A. (1987). As she Is spoke: Medicine and Books - Book review of 'English in Medicine'. Br. Med. J., 294, p.1607 Maternal and Child Health/Barker Publications Ltd: Qureshi, B.A. (1985). Obstetric problems in multi-ethnic women. Maternal and Child Health, 10(10), Oct., pp Qureshi, B.A. (1987). Paediatric problems in multi-ethnic groups. Maternal and Child Health, 12(1), Jan., pp.1s-20 Cambridge University Press: Qureshi, B.A., Farrah Sheikh, Donaldson, D., Morgan J.B. and Dickerson, J.W.T (1986). Birth weight and feeding practices of Infants in Southall, Mlddx. Proceedings of Nutritional Society, 45(2), p.60a Family Planning Information Service: Qureshi, B.A. (1986). Transcultural family planning consultations. Family Planning Today, (FPA & HEC), First quarter 1986, p.s The Medical Tribune Group: Qureshi, B.A. (1986). Skin problems encountered In multi-ethnic groups. Dermatology in Practice, 4(4), August, pp Prism International: Qureshi, B.A. (1986). Skin diseases can pose problems for minorities. Skin Concern, p.6 Update-Siebert Publications Ltd: Qureshi, B.A. (1988). Multicultural aspects of contraception. Update: the Journal of Postgraduate General Practice, 37(S), Sept. 1, pp x ACKNOWLEDGEMENTS

10 I take this opportunity to thank the many colleagues who encouraged me in various stages of my research, especially Professor John Dickinson (Nutritionist), Drs David Donaldson (Consultant Pathologist), John Fry (GP and author), Howard Griffith (Editor of Pulse, Stephen Lock (Editor of BMJ), Dermot Lynch (GP and politician), Lotte Newman (Vice-Chairman of RCGP Council), Joyce Parker (Pharmacist), Denis Pereira-Gray (Chairman of RCGP Council), Jill Pereira-Gray (Assistant Editor RCGP Publications), Patrick Kerrigan (Medical Editor of Pulse), Richard Smith (AsSistant Editor of BMJ), Keith Thompson (Examiner, MRCGP and DCH) and Freddie West (Editor of Journal of the Royal Society of Health). I also thank Dr Peter Clarke (Publishing Director of Kluwer Academic Publishers, Medical Division) for his dedicated time, support and advice at all stages of preparation of this book. Phil Johnstone and Unda Thomas (Kluwer Academic Publishers) were most helpful in the final stages of production. Finally, I extend my thanks to Jacqueline Priestley for her unfailing help and encouragement, and for typing the manuscripts and proofreading. Without her help this book would not have been written. London, 1989 BASHIR QURESHI ACKNOWLEDGEMENTS xi

Patient Safety. John Sandars Senior Lecturer in Community Based Education Medical Academic Education Unit, University of Leeds, Leeds, UK

Patient Safety. John Sandars Senior Lecturer in Community Based Education Medical Academic Education Unit, University of Leeds, Leeds, UK Patient Safety Patient Safety EDITED BY John Sandars Senior Lecturer in Community Based Education Medical Academic Education Unit, University of Leeds, Leeds, UK Gary Cook Consultant Epidemiologist, Stepping