Perhaps even more important, the Hmong adhere to a strict social hierarchy: males are held in higher esteem than females, the elderly higher than the young.6,11,14 Therefore, Mr. V’s desire to ask his brothers for advice before consenting to surgery makes sense within his cultural norms and was not a stalling tactic as the surgeons believed.
Try to understand the patient’s concept of illness. We found Mr. V to have capacity within the confines of his medical understanding. He knew the operation was major surgery, and he wanted to consult with his elder brothers—all eight of them (most of whom live in Minneapolis)—prior to consenting. Conversely, the surgeons could think only within the confines of their cultural and clinical understanding. They wanted to perform the procedure expediently to avoid additional diabetic sequelae.
We discussed these concerns with the patient and surgeons and struck a compromise: the surgeons agreed to defer surgery for 10 days, as long as Mr. V indemnified them against complications secondary to the delay. After that, the surgery would be performed regardless of whether Mr. V had consulted his brothers. Mr. V also agreed to continue IV antibiotic therapy. This compliance is not paradoxical: the Hmong often accept antibiotics because of their relatively rapid efficacy.6
For clinicians wishing to understand the Hmong and their view of illness, Anne Fadiman’s The Spirit Catches You and You Fall Down is an excellent resource.6 Kleinman’s seminal work on treating patients from other cultures also emphasizes the importance of eliciting the patient’s understanding in order to diagnose and negotiate treatment.15 Several good textbooks address transcultural patient care; curiously, most are nursing rather than physician texts (see “Related resources,”).
Treatment: Recovery’s rocky road
Closure was delayed for 8 days, during which no complications arose. Mr. V tolerated the antibiotics well. He contracted a low-grade fever at times, but septicemia did not re-emerge.
We continued to follow the patient, who on several occasions became delirious. He was neither violent nor agitated, so he was not treated with neuroleptics, which can cause delirium in Hmong patients.3,4
The patient contacted his brothers and consented to closure surgery, after which he recuperated well for 3 days. On day four, however, he developed respiratory failure. He was resuscitated, intubated, and transferred to the intensive care unit. He was extubated and returned to the floor 24 hours later, at which time he appeared despondent. He exhibited depressed mood, blunted affect, anorexia, anhedonia, and minimal interaction with family or physicians.
Could a different approach to treatment have produced a more favorable response? Also, would you address Mr. V’s depression and, if so, how?
Dr. Krassner’s observations
One might argue that being culturally sensitive and exposing Mr. V to the risks of infection and respiratory distress was a poor medical judgment. This argument takes into account only the biological aspect of Mr. V’s illness, however. Viewed from a biopsychosocial perspective, Mr. V’s course, even with its vicissitudes, was not a “failure” in any sense. He consented to the procedure on his own terms. We identified roadblocks to treatment and unearthed cultural resources (in our case, the patient’s brothers) that could enhance or even replace traditional psychiatric treatments.
To treat Mr. V’s depression, we first assessed the symptoms. We then tried to understand how he experienced his illness within the context of his culture.8 Mr. V’s symptoms certainly implied depression, but in many Asian cultures, patients with depression often present with somatic complaints.1
Also, how were we to know that these symptoms were not due to what Asian cultures refer to as loss of vital energy—or qi—because his sadness and frustration compressed on his heart?1 In order to treat Mr. V’s depression, we must instead call it qi. Only then can we diagnose and treat the patient in a way that makes sense to him or her.15
Even arriving at a differential diagnosis is complicated. For example, if Mr. V were Chinese, we would have to include (in addition to our own narrowly defined depression and dysthymia): mên, depressed or troubled; fan-tsao, anxious or troubled; kan-huo, angry; and hsin-ching pu-hao, generalized, nonspecific emotional upset or bad spirits.15
Further treatment: From grave to grateful
Mr. V was started on sertraline, 50 mg/d, for symptoms of depression. He tolerated the agent well (no GI upset or other side effects). After only 1 week, he had a brighter affect and was more conversant. He expressed thanks for all we had done for him.
The remainder of his recovery was incident-free, and he was discharged 6 days later on sertraline, with psychiatric follow-up arranged with the county mental health services’ Southeast Asian Team.