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Cross-cultural issues in pediatric emergency medicine
Guest Editor Louis C. Hampers, MD, MBA, FAAP Medical Director, Emergency Department The Children’s Hospital, Denver Assistant Professor of Pediatrics The University Of Colorado School of Medicine
Cross-Cultural Issues in Pediatric Emergency Medicine
T
HE TITLE OF THIS ISSUE OF Clinical Pediatric Emergency
Medicine may raise some eyebrows. Historically, this journal has focused each issue on a distinct clinical pediatric disease, problem, or patient population. Yet the topic of “cross-cultural”
care resists any efforts to be so narrowly constrained. It transcends not just all pediatric emergency medicine, but all health care. Broadly defined, a cross-cultural medical encounter exists any time a practitioner evaluates or treats a patient whose background, socioeconomic status, ethnicity, language, nationality, or belief system differs from their own. One can scarcely envision an emergency department (ED) visit when at least some of these conditions don’t apply. How, then, can we consider this topic in a manner that provides the clinician with useful, practical guidance? As several of our contributors note, the United States is in the midst of profound demographic changes. In the foreseeable future, there will no longer be a single majority ethnic or cultural group (if such a monolithic entity ever existed in the American “melting pot”). These conditions have tangible clinical consequences, and practitioners ignore them at their (and their patients’) peril. Much research in pediatric emergency medicine has centered on developing guidelines and algorithms to manage specific presentations or disease states. Rarely does such work consider the instances when the practitioner misses the correct diagnosis or families misunderstand their instructions, don’t return for follow-up care, can’t fill their prescriptions, or choose other paths of “noncompliance.” No decent asthma care
74
PREFACE
guideline would rely on a pulse oximeter prone to
the filter of folk beliefs and practices. They include
giving random or inconsistent results. Similarly,
actual case examples in which failure of practitio-
high quality emergency care can’t be provided
ners to understand or recognize folk practices re-
when the methods used to gather information and
sulted in demonstrable harm to patients.
implement treatment plans are flawed. “Cultural
We then consider some specific populations at
competence” isn’t simply a feel-good phrase, it is a
risk for adverse outcomes secondary to cultural
clinical imperative.
barriers between practitioners and families. Lest
Elsie Tavares and Glenn Flores begin by alerting
the reader think that all cultural barriers involve
us to the many ways that cultural and language
immigrant populations, Eron Friedlaender and Eva-
barriers negatively impact acute care. They first
line Alessandrini help us understand the world of
present a model for conceptualizing the entire
the medically indigent family. Many are foreign-
acute care encounter. They then explain how such
born, but most are not. Practitioners occupying a
barriers can compromise nearly every aspect of this
higher socioeconomic status may easily fail to real-
model. It becomes difficult to conclude that high
ize the ways that hardships such as poverty, violent
quality care can be provided to such populations
crime, single parenthood, and reliance on public
unless these obstacles are addressed.
assistance may impact the outcomes of our treat-
Even if the reader remains unconvinced, the pa-
ment plans.
per by Elizabeth Jacobs, Alice Chen, Leah Karliner,
Andrea Weathers and Herbert Garrison describe
Julia Fortier, and Sunita Mutha very plainly de-
the acute care of children of migrant worker fami-
scribes how culturally appropriate care is viewed as
lies. This often overlooked and murky demographic
a civil right and informs the ED practitioners of
presents unique challenges for ED providers. Dis-
their obligations under the law. In addition to sug-
advantages such as lack of a permanent address or
gesting ways to improve the quality of ED care
substandard housing, child labor-related exposures,
delivered, this is a concrete and practical review
and fear of deportation all conspire against the
which deserves to be read by ED managers and
health status of these children. The ED often rep-
other administrators responsible for ensuring that
resents their only substantive interaction with the
their facility is in compliance with various regula-
US health care system, and an uninformed provider
tory agencies.
may let a crucial opportunity slip away.
To help us meet some of these obligations, Ethan
Julia Kim and Mary Allen Staat detail the consid-
Wiener and Ivonne Rivera provide a practical list of
erations for children of recent international adop-
“dos and dont’s” when working with a medical in-
tions. Although the new parents of these children
terpreter. Ms. Rivera draws upon her considerable
tend to be culturally familiar to their ED providers,
experience in training interpreters and advising
the illnesses of these foreign-born patients may not.
hospitals regarding their proper use. This should
Many ED physicians have encountered a young
prove a handy reference for providers who work
child “just brought over” whose new parents are
with interpreters in a variety of settings.
concerned about persistent coughing or fever. Fail-
The contribution of Denice Cora-Bramble,
ure to consider the child’s original environment can
Frances Tielman, and Joseph Wright then chal-
result in an overly narrow or misplaced differential
lenges us to look beyond the “biomedical model” of
diagnosis.
disease so integral to our training, and see illness
The observations and suggestions contained in
the way many of our patients’ families do: through
this issue apply to a rapidly changing population. As
PREFACE
75
such, they retain relevance for both trainees as well
emergency practitioners in the 21st century United
as senior staff. I am extremely grateful to all the
States.
authors who contributed to this issue. Each was approached because of their reputation, work and expertise on their topic. Together they have produced an integrated, practical guide for pediatric
Louis C. Hampers, MD, MBA, FAAP Guest Editor © 2004 Elsevier Inc. All rights reserved. doi: 10.1016/j.cpem.2004.01.002
Cross-Cultural Issues in Pediatric Emergency Medicine
T
HE TITLE OF THIS ISSUE OF Clinical Pediatric Emergency
Medicine may raise some eyebrows. Historically, this journal has focused each issue on a distinct clinical pediatric disease, problem, or patient population. Yet the topic of “cross-cultural”
care resists any efforts to be so narrowly constrained. It transcends not just all pediatric emergency medicine, but all health care. Broadly defined, a cross-cultural medical encounter exists any time a practitioner evaluates or treats a patient whose background, socioeconomic status, ethnicity, language, nationality, or belief system differs from their own. One can scarcely envision an emergency department (ED) visit when at least some of these conditions don’t apply. How, then, can we consider this topic in a manner that provides the clinician with useful, practical guidance? As several of our contributors note, the United States is in the midst of profound demographic changes. In the foreseeable future, there will no longer be a single majority ethnic or cultural group (if such a monolithic entity ever existed in the American “melting pot”). These conditions have tangible clinical consequences, and practitioners ignore them at their (and their patients’) peril. Much research in pediatric emergency medicine has centered on developing guidelines and algorithms to manage specific presentations or disease states. Rarely does such work consider the instances when the practitioner misses the correct diagnosis or families misunderstand their instructions, don’t return for follow-up care, can’t fill their prescriptions, or choose other paths of “noncompliance.” No decent asthma care
74
PREFACE
guideline would rely on a pulse oximeter prone to
the filter of folk beliefs and practices. They include
giving random or inconsistent results. Similarly,
actual case examples in which failure of practitio-
high quality emergency care can’t be provided
ners to understand or recognize folk practices re-
when the methods used to gather information and
sulted in demonstrable harm to patients.
implement treatment plans are flawed. “Cultural
We then consider some specific populations at
competence” isn’t simply a feel-good phrase, it is a
risk for adverse outcomes secondary to cultural
clinical imperative.
barriers between practitioners and families. Lest
Elsie Tavares and Glenn Flores begin by alerting
the reader think that all cultural barriers involve
us to the many ways that cultural and language
immigrant populations, Eron Friedlaender and Eva-
barriers negatively impact acute care. They first
line Alessandrini help us understand the world of
present a model for conceptualizing the entire
the medically indigent family. Many are foreign-
acute care encounter. They then explain how such
born, but most are not. Practitioners occupying a
barriers can compromise nearly every aspect of this
higher socioeconomic status may easily fail to real-
model. It becomes difficult to conclude that high
ize the ways that hardships such as poverty, violent
quality care can be provided to such populations
crime, single parenthood, and reliance on public
unless these obstacles are addressed.
assistance may impact the outcomes of our treat-
Even if the reader remains unconvinced, the pa-
ment plans.
per by Elizabeth Jacobs, Alice Chen, Leah Karliner,
Andrea Weathers and Herbert Garrison describe
Julia Fortier, and Sunita Mutha very plainly de-
the acute care of children of migrant worker fami-
scribes how culturally appropriate care is viewed as
lies. This often overlooked and murky demographic
a civil right and informs the ED practitioners of
presents unique challenges for ED providers. Dis-
their obligations under the law. In addition to sug-
advantages such as lack of a permanent address or
gesting ways to improve the quality of ED care
substandard housing, child labor-related exposures,
delivered, this is a concrete and practical review
and fear of deportation all conspire against the
which deserves to be read by ED managers and
health status of these children. The ED often rep-
other administrators responsible for ensuring that
resents their only substantive interaction with the
their facility is in compliance with various regula-
US health care system, and an uninformed provider
tory agencies.
may let a crucial opportunity slip away.
To help us meet some of these obligations, Ethan
Julia Kim and Mary Allen Staat detail the consid-
Wiener and Ivonne Rivera provide a practical list of
erations for children of recent international adop-
“dos and dont’s” when working with a medical in-
tions. Although the new parents of these children
terpreter. Ms. Rivera draws upon her considerable
tend to be culturally familiar to their ED providers,
experience in training interpreters and advising
the illnesses of these foreign-born patients may not.
hospitals regarding their proper use. This should
Many ED physicians have encountered a young
prove a handy reference for providers who work
child “just brought over” whose new parents are
with interpreters in a variety of settings.
concerned about persistent coughing or fever. Fail-
The contribution of Denice Cora-Bramble,
ure to consider the child’s original environment can
Frances Tielman, and Joseph Wright then chal-
result in an overly narrow or misplaced differential
lenges us to look beyond the “biomedical model” of
diagnosis.
disease so integral to our training, and see illness
The observations and suggestions contained in
the way many of our patients’ families do: through
this issue apply to a rapidly changing population. As
PREFACE
75
such, they retain relevance for both trainees as well
emergency practitioners in the 21st century United
as senior staff. I am extremely grateful to all the
States.
authors who contributed to this issue. Each was approached because of their reputation, work and expertise on their topic. Together they have produced an integrated, practical guide for pediatric
Louis C. Hampers, MD, MBA, FAAP Guest Editor © 2004 Elsevier Inc. All rights reserved. doi: 10.1016/j.cpem.2004.01.002