THE PATIENTS’ STORIES Mr and Mrs G, an African American Couple Mr G is a 66-year-old African American man diagnosed with stage IV squamous cell cancer of the lung in October of 1999. He has chronic obstructive pulmonary disease and has a 40 pack-year smoking history. A retired factory worker, he lives at home with his wife in a large city in Alabama. After diagnosis, he received radiation therapy and a trial of chemotherapy with vinorelbine and cisplatin. In the fall of 2000, with evident progression of the disease, his pain and dyspnea increased, adding to the symptom burden of asthenia, anorexia, and delirium. On December 6, 2000, he was admitted to an inpatient palliative care unit with symptomatic hypercalcemia. He was treated with fluids and pamidronate, and approximately 1 week later was discharged home with hospice services. He and his wife were interviewed on December 7, 2000 by Dr C, Mr G’s European American physician.

http://lib.ajaums.ac.ir/booklist/JAMA_December%20%203%20%20(No.23)_74.pdf

Negotiating Cross-Cultural Issues at the End of Life

Culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying. With increasing diversity in the United States, encounters between patients and physicians of different backgrounds are becoming more common. Thus the risk for cross-cultural misunderstandings surrounding care at the end of life is also increasing. Studies have shown cultural differences in attitudes toward truth telling, life-prolonging technology, and decision-making styles at the end of life. Using 2 case studies of patients, one of an African American couple in the southern United States and the other of a Chinese-American family in Hawaii, we outline some of the major issues involved in cross-cultural care and indicate how the patient, family, and clinician can navigate among differing cultural beliefs, values, and practices. Skilled use of cross-cultural understanding and communication techniques increases the likelihood that both the process and outcomes of care are satisfactory for all involved.

Negotiating Cross-Cultural Issues at the End of Life: You Got to Go Where He Lives

Bad Blood: The Tuskegee Syphilis Experiment

Individuals living with HIV often have complicated histories, including negative experiences such as traumatic events, mental illness, and stigma. As the medical community in the United States adapts to managing HIV as a chronic disease, understanding factors such as these negative experiences that may be associated with poorer adherence to treatment regimens, greater HIV risk behavior, and lower patient quality of life becomes critical to HIV care and prevention. In less wealthy nations, these issues are also critical for addressing quality of life as well as medication adherence in the areas where antiretroviral therapies are being made available. This article presents a review of the literature regarding the following psychosocial factors as they relate to HIV/AIDS in the US and globally: traumatic events; mental illness, including depression, anxiety, and posttraumatic stress disorder; lack of trust in the healthcare system and government; and experiences of stigma among individuals with HIV disease. These factors have been found to be prevalent among individuals with HIV/AIDS, regardless of gender or race/ethnicity. Traumatic events, mental illness, distrust, and stigma have also been linked with poorer adherence to medication regimens and HIV risk behavior.

http://www.hnrcinternational.ucsd.edu/romaniadocs/B9-HIV%20stigma.pdf

Trauma, mental health, distrust, and stigma among HIV-positive persons: implications for effective care.

The increasing diversity in the US population is reflected in the patients who healthcare professionals treat. Unfortunately, this diversity is not always represented by the demographic characteristics of healthcare professionals themselves. Patients from underrepresented groups in the United States can experience the effects of unintentional cognitive (unconscious) biases that derive from cultural stereotypes in ways that perpetuate health inequities. Unconscious bias can also affect healthcare professionals in many ways, including patient-clinician interactions, hiring and promotion, and their own interprofessional interactions. The strategies described in this article can help us recognize and mitigate unconscious bias and can help create an equitable environment in healthcare, including the field of infectious diseases.

The Impact of Unconscious Bias in Healthcare: How to Recognize and Mitigate It

The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists and bioethicists may benefit from reflection upon the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as a reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been completely removed from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities and health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the wellbeing of the patient and the primacy of the patient-physician relationship against with the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to assure quality health care for the individual patient while affecting societal changes to achieve "health for all."

The medical ethos and social responsibility in clinical medicine.

The effect of symptom-limited maximal treadmill exercise was evaluated in 34 patients with sickle cell trait (SCT) and 43 controls. Systolic time intervals were measured before and after exercise in 15 of the sickle cell trait subjects, and in 11 controls. Rate pressure product, degree of ST segment depression and incidence of ventricular arrhythmias in subjects with SCT were not significantly different from similar measurements in the control group. No significant difference in electromechanical systole QS2, left ventricular ejection time (LVET), pre-ejection period (PEP)/LVET or ejection fraction (EF) were found between the groups. These data indicate that healthy subjects with SCT do not have an increased incidence of exercise-induced ventricular arrhythmias, myocardial ischemia, or diminished ventricular function compared to normals. Further studies are indicated to elucidate factors that may be operative in sudden death syndrome.

The risk of sudden death in sickle cell trait: Noninvasive assessment of cardiac response to exercise

The medical profession will face many challenges in the new millenium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists, and bioethicists may benefit from reflection on the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based, market-driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been removed completely from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities in health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of “racist medicine” or of a “new eugenics”. There is a need to balance medicine’s devotion to the well-being of the patient and the primacy of the patient-physician relationship against the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to ensure quality health care for the individual patient while effecting societal changes to achieve “health for all”.

/pdf/medical-ethos-and-social-responsibility-in-clinical-medicine-1m5pb339vl.pdf

Charles K. Francis

Papers

The medical ethos and social responsibility in clinical medicine.

The risk of sudden death in sickle cell trait: Noninvasive assessment of cardiac response to exercise

Medical ethos and social responsibility in clinical medicine

Hypertension detection, treatment and control: a call to action for cardiovascular specialists.