That’s the research specialty of a New England professor who spoke at pediatric Grand Rounds last week. He lives in an area with a large Puerto Rican population, and he was using them as an example of the importance of being sensitive to cultural issues, and how they affect patients’ perceptions of their illness, and their compliance with Western-style treatment. And I couldn’t help thinking, He’s claiming to be so free from stereotypes; but why is he talking just about the differences between Puerto Ricans, and Mexicans, and Central Americans, and Brazilians, as subsets of the “Hispanic” group? What about the Appalachians, and the New Englanders, and the Scandinavian north-MidWesterners, and the Deep South; not to mention immigrant Africans, and African-Americans by region? Just plain white Americans have just as many cultural subgroups, and believe me they all have health beliefs at least as interesting/important/unaccepted by doctors as Hispanics do.

Then he related all this research about Puerto Ricans think causes asthma, and what they usually do to treat a child with it. Remedies, in addition to prescribed medicines, included prayer, massage, calming the child, using Vicks, and drinking various syrups. That all sounds splendid to me, seriously. I mean, we’re so reliant on our “scientifically proven,” biochemically explicable medicines. But even our best studies only show a 70% response rate, maybe; or a 20% improvement over placebo. And yet we confidently assure patients that if they do what we say, they will be cured. And he was commenting patronizingly on how many Puerto Ricans, and in fact white Americans too, place such strong reliance on prayer. Curious, isn’t it? <choking>

And then that afternoon in clinic, I saw two patients who seemed to me to be examples of the blindness of the stereotypical modern medical mindset. One young woman brought her six-month old baby and her two-year old toddler to see the doctor, accompanied by her 4yr-old and 7yr-old daughters. The nurses rolled their eyes on seeing her name on the schedule. The doctor picked up the charts and murmured, “I won’t make you see these guys alone.” So I was expecting some real chaos, some really neglected kids.

As soon as we walked in and I was introduced, all three ambulatory children ran over and hugged me. Ok, so that’s not a sign of real discretion. Then, while mom held the baby on the table and discussed him with the doctor, the three other children danced and wrestled with each other on the floor. But mom didn’t yell at them, didn’t drag them ineffectually off each other, wasn’t distracted from the doctor’s conversation. And they didn’t injure each other. To me, that indicates a fairly harmonious family. In many other families I’ve seen, mom spends the whole visit yelling at the one or two healthy kids to sit down and hold still, to the complete disruption of the consultation. I don’t know; to accept that little kids can roll around and wrestle, without needing to be kept in rigid order all the time, seems fairly intelligent and calm on the mother’s part. Also, apart from that hug, the children weren’t really in my face, demanding attention. Both of the littlest children let me pick them up cheerfully, so the mother could deal with the other one on the table.

After we got outside, the doctor told me that he suspects the 6-month-old has fetal alcohol syndrome. He thinks the baby’s face looks unusual. Even though mom always brings the kids to every checkup and every appointment; even though, in the four years he’s known her he’s never had cause to suspect her of being intoxicated, or of using any other substances. He hasn’t said anything to mom about it; he’s waiting to see if there are developmental delays as the baby gets older.

I don’t know; to me the family looked fun. (Although she is a single mother, and the younger three children were clearly by a different father than the oldest one.) It felt like the simple fact that she had four children under the age of 7 was a huge block that the doctor and nurses couldn’t get past. Why do we have to make assumptions because she has a lot of children?

Then, another mother brought her 7yr-old daughter for a regular checkup. I felt brilliant because by review-of-systems questioning I turned up a history very suspicious for asthma, which mom was not concerned enough to mention without questioning. Her major concern was her daughter’s behavior. Again, with the girl sitting on the table, she complained to the doctor, “She doesn’t do what she’s told. At school, she rolls around on the floor, and won’t obey the teachers. At home, whatever I tell her to do, I get a big fight. She always wants to have things her own way, and she’ll throw things around if I try to stop her. She won’t go to her room when I send her, or stand in the corner.” And other comments, which to me sounded like downright disobedience, or perhaps oppositional-defiant disorder, if you want a psychiatric term. Of course, she was prescribed ADD medicine; without ever talking to the girl at all; what a funny way to treat an intelligent, verbalĀ patient, to prescribe for a problem without talking to her about it.

I mean, come on! What that girl needs is (excuse me, Kristina) a good spanking, to teach her to obey her mother, and the promise of a spanking every time the teacher says she’s been disobedient at school. From everything mom said, it’s not a lack of attention that is troubling this girl, but a definite desire to do the opposite of what she’s told. The mild discipline her mother is using obviously isn’t working. But what blindness, what total commitment to “biomedicine” as the solution to everything, to prescribe medicine for this problem!

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