VOL 3, No 1, January 2001
Diverse sea island population challenges physicians
“Culture — ‘. . . the sum total of ways of living developed by a group of human beings to meet biological and psychosocial needs. It refers to . . . values, norms, beliefs, attitudes, . . . and traditions that are linked together . . . to preserve the society.’—Elaine Pinderhughes: Understanding Race, Ethnicity and Power
Future generations of physicians may be prepared for
constant changes in the administration of health care services,
but if population projections are correct, there is another change to consider:
how to deal with patients of diverse cultures and beliefs.
Through the College of Medicine's Promoting, Reinforcing and Improving Medical Education (PRIME) Project, physicians from MUSC may be better prepared to adapt to a more diverse patient population. Recently, students were introduced to the values, attitudes and behaviors of Gullah and Hispanic peoples who make up a large segment of the population of the sea islands off the South Carolina and Georgia coast.
Dr.
Stephen McLeod-Bryant listens to Annette Maranville relate her experiences
caring for the culturally diverse residents of Johns Island.
Stephen McLeod-Bryant, M.D., served as speaker and moderator for a noontime lecture on the people of the sea islands from a health care perspective. He admitted he was “very leery” of these types of presentations due to people's tendency to stereotype individuals.
“It's too easy to fit people into a box,” he said. The sea islands, he said, are home of many Gullah-speaking people, people who consider themselves sea island residents and Hispanics. “Those three terms are not interchangeable,” McLeod-Bryant said, and he cautioned the students against forming quick assumptions about such patients.
“Someone may identify himself as a Gullah person, but you really don't know anything about him,” he told the audience. “The individual who identifies himself as such is still a whole unique individual within that culture.”
In the past, McLeod-Bryant has asked incoming psychiatry residents to describe their cultural identity. In descending order of popularity, they described themselves with the following words: race, geographic origin, economic class, religion and nationality.
Following his remarks, McLeod-Bryant brought on Annette Maranville,
a nurse with the Bon Secours St. Francis Hospital Wellness House on Johns
Island, which promotes wellness, offers health education and provides preventive
care to the people of James, Johns and Wadmalaw islands as well as migrant
workers and their families. McLeod-Bryant and Maranville, sitting at center
stage, held a conversation regarding the complexities of caring for culturally
diverse patients.
At the core, Maranville said, it is important to take nothing for granted
when treating patients. What they have—or don't have—at home can impact
on how compliant they can be in following a caregiver's advice. Often,
patients served by the Wellness House have no plumbing or electricity.
“I did a home visit with one of the staff members when I first came there, It was a very small house, and I asked the staff member ‘So, where's the bathroom?’ And she said, as she pointed out to the field, ‘Right there,’” Maranville recalled. “We forget this is in our own backyard.”
With a population of approximately 10,000, Johns Island is second in area behind Long Island, N.Y. Wadmalaw Island has less than 3,000 population. Although James Island is within the Wellness House's service area, many of its residents seek their health care needs elsewhere, due to their proximity to Charleston and better access to public transportation. Although separated by only the Stono River, Johns Island is much more rural and more isolated than its neighbor. There is no public transportation. The exclusive enclaves of Kiawah and Seabrook, although located on Johns Island, are separate communities, set apart from the main island. Johns Island has one health clinic, but no physicians, save for those at Seabrook, according to Maranville.
The bridges linking the islands are relatively recent fixtures, she said, coming along in the 1940s. Therefore, many of the island’s residents have traditionally been deprived of access to health care that other nearby communities have enjoyed. As a consequence, many island residents developed a sense of isolation, independence and distrust of outsiders, she said.
To effectively serve the residents, Maranville said, you have to look at everybody as an individual, expecting respect and giving it in return. “The trust factor, I think, has to be ‘A-number-one.’ You're certainly not going to tell me about your medical history if you don't know me.”
Students
listen to McLeod-Bryant and Maranville over pizza and soft drinks.
Rather, expect to receive a patient's history in segments, which accumulate as trust builds, she added. Also understand that health care in one culture may not receive the priority it does in another, she said. “If you don't have a lot of food and you don’t have running water, health care is not going to be a priority until you're sick.”
Another element of the Gullah culture, McLeod-Bryant and Maranville agreed, is the extensive use of herbs as remedies, a result of the residents’ isolation and independence. Residents boil and drink certain herbs for everything from chest colds to infections, “and I'm sure there's a lot more herbal medicine going on that we as health care providers don't know about,” Maranville said.
McLeod-Bryant said there probably would be times when the physician's values would clash with those of the patient. In those situations, attempt to reach a compromise that both parties can live with.
“You've got to negotiate, you've got to work this out (with the patient),”
McLeod-Bryant said. “There may be times when you have to say, try your
(herbal medicine) and come back in a couple of weeks, and if you're still
having problems, let’s give something else a try” in order to build a therapeutic
alliance.
‘Student-driven’ PRIME program getting good reviews for content
Now midway through the first year of a four-year grant, MUSC’s Promoting, Reinforcing and Improving Medical Education (PRIME) project is getting good reviews in providing cultural diversity training to students.Three of the six noontime presentations have been held, each drawing close to 100 or more students. Cultural issues have been introduced into the doctoring curriculum and small group sessions have been held solely for the purpose of discussing and understanding cultural diversity of all types in a doctor-patient relationship.
“Diversity is not limited to black and white issues,”said Kathy Whitaker,
student program manager for the Office of Diversity and co-principal investigator
for the American Medical Student Association's (AMSA) PRIME project. “Diversity
encompasses a wide range of issues. To be a health care provider today
requires awareness, understanding and respect for diverse issues, if the
ultimate goal is to proficiently treat the patient.”
Ricky Choi, co-president of MUSC's chapter of AMSA, has been deeply
involved in revamping the diversity portion of the college’s curriculum.
“We as medical students are instructed to memorize epidemiological statistics to prioritize diagnostic differentials, but any clinican will tell you that the patients rarely read the textbooks,” said Choi, a second-year student in the parallel curriculum with an interest in pediatrics and public health. “It is imperative that a physician use his or her interpersonal skills and humble understanding of other cultural beliefs to guide the clinical decision-making process. Development of these skills is a lifelong process, and ideally we should plant the seed early in a student-doctor's career. Hopefully the reorganized diversity training during orientation and the lecture series will be that seed.”
Although the PRIME project is relatively new, cultural and diversity training in the College of Medicine is not. In 1997, Thaddeus Bell, M.D., director of university diversity and associate dean for minority students in the College of Medicine, and Layton McCurdy, M.D., dean of the College of Medicine and vice president for medical affairs, introduced diversity awareness as part of the first year students' orientation. The orientation was later followed up with small group sessions in the fall of each year.
As a result of the small group sessions, a group of second-, third-and
fourth-year medical students got together, wrote script and produced a
video dealing with cases of insensitivity either witnessed or experienced
by the students. The tape was used as part of the training sessions
to promote dialogue on diversity issues. Feedback from students indicated
that diversity was too important to be dealt with on a one-time basis.
Instead, it needed to be a continuous process. This led to the submission
of the of the AMSA PRIME Project grant proposal by Amy Blue, Ph.D., assistant
dean for curriculum and evaluation, in conjunction with Whitaker and the
Office of Diversity.
The PRIME initiative is a one-year grant awarded by AMSA. While the
funding amount is not large—less than $6,000 — the purpose of funding such
projects is to jumpstart education of medical students about their responsibility
to respond to the associated medical needs of diverse populations that
are different from their own in terms of race, ethnicity, sexual orientation,
disability status and cultural background.
The timing of the PRIME project is important. Minority groups in the United States are expected to grow dramatically in number during the next several decades. By 2050, it’s expected that nearly half of the U.S. population will be composed of members of linguistic and cultural minority groups.
A student advisory board comprised of 25 members, representing all four classes, will help steer implementation of the new elements into the first-year curriculum. Surveys will go out to students asking them to critique the material and seek suggestions for future offerings.
The amount of student input, Whitaker said, helps to make the project successful.
“We want this to be student-driven,” she said.
Continuing Medical Education
March3
Focus on the Complicated Patient with Hypertension
Greenville Hyatt Hotel, Greenville
8 - 9
Outcomes Management: From Theory to Action
Westin Francis Marion Hotel
19 - 21
OB/GYN Spring Symposium
Charleston Place Hotel
22 - 24
Office Practice of Primary Care
Mills House Hotel
26 - 27
11th Charleston Pulmonary Update
Charleston Place Hotel
...from the Dean
With the start of the New Year, we also find ourselves approaching the start of our third year of the Medical Educator, this monthly newsletter to keep you, the college's faculty, staff, residents and students informed about the curricular activities occurring in our undergraduate, graduate and continuing medical education programs.
Dr.
Layton McCurdy
During the past year, we continued our substantial progress with renewal in the undergraduate curriculum, particularly with successful completion of many curriculum Year One goals and the implementation of changes in the second year curriculum. We have acquired national attention with our curriculum change efforts. Additional exciting changes are anticipated during this calendar year and will continue our tradition of excellence in preparing physicians.
Our graduate and continuing medical education programs are also attracting national recognition for their innovations with the graduate medical education core curriculum and physician learning initiatives.
We continue to stand out as an institution dedicated to life-long learning
across the medical education continuum.
All of these efforts are due to the hard work, dedication and vision
of our faculty. I value their commitment to providing excellence in education
for all learners.
Keep reading the Medical Educator to stay informed. As I have stated each year, share it with others and use it as point of discussion and feedback so all of us can participate in designing the curriculum.
Layton McCurdy
Don't miss this
January29
12 - 1 p.m.
Appletree Society Brown Bag: “The Virtual Classroom: a discussion on the use of the Internet for teaching and learning”
Richard Hernandez, Thierry Bacro and Alexander Chessman
Room 405, Administration/Library Bldg.
For information, call Dr. Amy Blue at 792-3409.
February
2 - 3
7:30 a.m.
Achieving Excellence in Graduate Medical Education:
Moving Beyond the ACGME (Accreditation Council for Graduate Medical Education)
Institutional Review
Mills House Hotel
7
4 - 7 p.m.
Using Clinical Cases for Learning
Skeet Bradley, M.Ed.
Gazes Auditorium
13
4 - 7 p.m.
Using Clinical Cases for Learning
Skeet Bradley, M.Ed.
Gazes Auditorium
Topics covered will include:
- Why use cases for learning;
- Methods for using cases, such as PBL, case based, large and small-group formats;
- Designing case problems; and
- Evaluating learner's performance.
For information or to register for the date of your choice, call 792-2081. CME and CEU credit will be given for those in attendance.
The Medical Educator is produced by the Office
of Public Relations