Anthropological Perspectives In Medicine - Rhode Island ...

Volume 91 No. 12 December 2008

�Anthropological PerspectivesIn Medicine

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357VOLUME 91 NO. 12 DECEMBER 2008

Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode IslandMedical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postagepaid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St.,Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919,phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected].

UNDER THE JOINTEDITORIAL SPONSORSHIP OF:

The Warren Alpert Medical School ofBrown UniversityEdward J. Wing, MD, Dean of Medicine& Biological Science

Rhode Island Department of HealthDavid R. Gifford, MD, MPH, Director

Quality Partners of Rhode IslandRichard W. Besdine, MD, ChiefMedical Officer

Rhode Island Medical SocietyDiane R. Siedlecki, MD, President

EDITORIAL STAFFJoseph H. Friedman, MD

Editor-in-ChiefJoan M. Retsinas, PhD

Managing EditorStanley M. Aronson, MD, MPH

Editor Emeritus

EDITORIAL BOARDStanley M. Aronson, MD, MPHJohn J. Cronan, MDJames P. Crowley, MDEdward R. Feller, MDJohn P. Fulton, PhDPeter A. Hollmann, MDAnthony E. Mega, MDMarguerite A. Neill, MDFrank J. Schaberg, Jr., MDLawrence W. Vernaglia, JD, MPHNewell E. Warde, PhD

OFFICERSDiane R. Siedlecki, MD

PresidentVera A. DePalo, MD

President-ElectMargaret A. Sun, MD

SecretaryJerald C. Fingerhut, MD

TreasurerNick Tsiongas, MD, MPH

Immediate Past President

DISTRICT & COUNTY PRESIDENTSGeoffrey R. Hamilton, MD

Bristol County Medical SocietyHerbert J. Brennan, DO

Kent County Medical SocietyRafael E. Padilla, MD

Pawtucket Medical AssociationPatrick J. Sweeney, MD, MPH, PhD

Providence Medical AssociationNitin S. Damle, MD

Washington County Medical SocietyJacques L. Bonnet-Eymard, MD

Woonsocket District Medical Society

RHODE ISLANDPUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETY

Medicine � Health VOLUME 91 NO. 12 December 2008

COMMENTARIES

358 Medical NotesJoseph H. Friedman, MD

359 One Man’s Poison...[is another’s unfurrowed brow]Stanley M. Aronson, MD

CONTRIBUTIONSSPECIAL ISSUE: Anthropological Perspectives on MedicineGuest Editor: Renée Shield, PhD, and Jeffrey Borkan, MD, PhD

360 Anthropological Perspectives On Medicine: IntroductionRenée Shield, PhD, and Jeffrey Borkan, MD, PhD

361 Towards Cultural Humility in Healthcare for Culturally Diverse Rhode IslandJeffrey Borkan, MD, PhD, Kathleen A. Culhane-Pera, MD, MA, andRoberta E. Goldman, PhD

365 Negotiating Clinically Workable Solutions Across Cultures: Lessons LearnedBonnie B. O’Connor, PhD

369 Cultural Bias and ‘No-Scalpel Vasectomies’: Lessons Learned by a BrownAnthropologist in Mexico

Matthew Gutmann, PhD, MPH

374 Overweight and Diabetes In American Samoa: The Cultural Translation ofResearch Into Health Care Practice

Rochelle K. Rosen, PhD, Judith DePue, EdD, MPH, Stephen T. McGarvey, PhD, MPH

378 Evaluating Geriatrics In the Medical School Curriculum: Using Student JournalsTimothy W. Farrell, MD, Susan Campbell, MA, Aman Nanda, MD,Renée Shield, PhD, and Terrie Wetle, PhD

COLUMNS

382 GERIATRICS FOR THE PRACTICING PHYSICIAN – The Practicing Physicians’ GuideTo Pressure Ulcers in 2008Rachel Roach, MSN, ANP, GNP, WCC

384 HEALTH BY NUMBERS – Evaluation of Case Management Services for LeadPoisoned Children in Rhode IslandDaniela N. Quilliam, MPH, and Peter R. Simon, MD, MPH

387 PUBLIC HEALTH BRIEFING – The Quadrivalent Human Papillomavirus VaccineAnna Wheat

389 Letters To the Editor

391 PHYSICIAN’S LEXICON – A Purgatory of Ambiguous WordsStanley M. Aronson, MD

391 Vital Statistics

392 December HeritageCover: Aztec God, oil, painting by anoctogenarian physician based upon arelic uncovered in Sotchimilco,Mexico.

358MEDICINE & HEALTH/RHODE ISLAND

We all trained in the days of the “gi-ants.” Although when I was in trainingthere were few living giants, all my men-tors had trained in the days of the giants.There used to be giants, but they all diedout just before you started training,whenever that was. I sometimes do longfor those days, although they were notgood days for patients. I wish I could writea note in the chart that was three wordslong, “spinal arachnoid cyst,” but Icouldn’t, and certainly I shouldn’t.

Medical notes should be accurate. Ishudder when I think of the patients I re-ferred to a famous neurologist who hadpeculiar theories relating handedness, au-toimmune dysfunction and neurologicalproblems. His histories were fictional. Hemade them up to fit his theories. Historiesmust be accurate. They must also be con-cise, so that the reader can read them in abrief time-frame. The examination shoulddocument what was evaluated and theimpression should briefly give an hypoth-esis, or a diagnosis, explaining the thoughtprocess which led to the opinion.

It is an unfortunate aspect of ourcurrent medical predicament that we fre-quently lack the time to sit and think andthen to write in a thoughtful manner. Iworry that that time will never comeback. It did exist though, back in the daysof the giants.

– JOSEPH H. FRIEDMAN, MD

Disclosure of Financial InterestsJoseph Friedman, MD, Consultant: Acadia

Pharmacy, Ovation, Transoral; Grant ResearchSupport: Cephalon, Teva, Novartis, Boehringer-Ingelheim, Sepracor, Glaxo; Speakers’ Bureau:Astra Zeneca, Teva, Novartis, Boehringer-Ingelheim, GlaxoAcadia, Sepracor, Glaxo SmithKline, Neurogen, and EMD Serono.

Medical Notes�

Commentaries

My daughter is an intern. She waslamenting the poor quality of her notes inpatient charts. “I write sloppy notes. Theydon’t have all the information they should.They’re not complete. I’m embarrassed.”I reassured her that her notes were prob-ably fine, maybe even excellent since she’svery exacting and her own harshest critic.Nothing she does is ever below average,which is, of course, the vicious cycle thatmost of us in medicine suffer from, highexpectations and compulsive natures. Inbaseball, a batting average tells us who isaverage, who is below and who is above.In professional life, other than looking atincome, which is usually not how we rateourselves, grant dollars or numbers of pub-lications for medical researchers, there areno hard data to use to rate ourselves. Likethe children in Lake Wobegon, we all con-sider ourselves above average. However,back to medical notes…

I told her about my note on JohnnyD when I was a subintern in pediatrics.Johnny was about 7 and suffered fromhemophilia. He was a frequent flier whowas admitted to the hospital every fewweeks. One early time he had hit his headand bled into his brain. His hyperactivityeither stemmed from that or simply wors-ened with that. Now that he was seven, herequired admission with almost every babytooth coming out. There was no factorVIII replacement in those days. In retro-spect, Johnny wasn’t very complicated, butas a subintern I thought he was. After all,he had been admitted scores of times.

Medical student presentations atrounds at my medical school were expectedto be “complete.” This required a review ofeach hospitalization (and from memory).Obviously this was well nigh impossible forJohnny’s case, but I did what I could. Toprepare for this I decided to summarizeeach hospital admission for the admissionnote. I went through many charts, summa-rizing each clinical course. In retrospect Ithink this could have been collapsed into:27 hospitalizations for bleeding related to

hemophilia, hyperactivity, all treated withepsilon amino caproic acid,a non-specificclot enhancing drug, no end in sight.

I thought I had done a good job. Infact, I had done a good job. More impor-tantly, I learned an important lesson. Thehematology fellow came by, reviewed thecurrent record and asked to see the stu-dent who wrote the 5 page note on Johnny.I introduced myself. He said, “That’s agreat note but you should know that noone is going to read it. It’s too long. Whohas time to read a note so long?” I wascrushed but he was correct. I wouldn’tread a note that long by a medical student,maybe by anyone other than a world re-nowned medical scholar.

When I was a neurology resident, Icame across a note from the opposite endof the spectrum. At morning report wepresented to the chair, in a microencapsu-lated form, all the admissions from the pre-ceding day: “Mr. Jones, 76 year old manwith a left middle cerebral artery stroke;Mrs. Smith, 46 year old woman with my-asthenia exacerbation; Mr. Doe, 27 year oldman with several seizures; Mr. X, 68 yearold man with a spinal arachnoid cyst;Mrs…” “Stop”, said the chief.

“How did you diagnose a spinalarachnoid cyst?”

This was in the days before MRI orspinal CT.

“I didn’t,” said the resident. Dr V.did and the patient was admitted for amyelogram, and then for his operation.”

“How did Dr. V. diagnose a spinalarachnoid cyst?”

“I don’t know,” said the resident.“That’s all he wrote in his note, ‘Patientadmitted for myelogram of spinal arach-noid cyst.’”

The next day the chief asked whatthe myelogram showed.

“Spinal arachnoid cyst.”“How the heck did he know that,”

asked the chief?“I don’t know” replied the resident,

“that’s all he wrote in the note.”


One Man’s Poison … [is another’s unfurrowed brow]�

By 1944, the toxin elaborated by these bacteria was finally iso-lated and purified. Gram for gram, it became the world’s mostlethal poison. Scientists have since demonstrated that the toxinattacks the nerve endings, preventing nerve impulses fromreaching, and thus activating, muscle fibers. In summary, thesole known effect of the botulinus toxin is to inactivate nerveendings and cause muscle flaccidity and paralysis. The effectsare temporary, wearing off in weeks or months, but botulismwill be fatal if the muscles needed to aid in breathing are widelyimpaired. Having isolated the neurotoxin, the development ofan effective antitoxin vaccine was quickly achieved.

Cases of botulism caused by sausage contamination havebecome increasingly rare. Most cases of botulism now are sec-ondary to improperly sterilized home canning of foods.

There had been a time, once, when the name Bo-Toxmight have suggested a rising star from the movies or the worldof jazz [such as Bo Diddley, Bo Bice or Bo Derek]. But thediscoveries of Jean and Alastair Carruthers, a husband and wifeteam of physicians, during the 1990s, brought specific mean-ing to the term as a shortening of the words, botulinus toxin.They noted that the injection of an extremely dilute solutionof this toxin often flattened the folds of the human forehead,sometimes called the glabellar wrinkles, by paralyzing the sub-cutaneous muscles. The therapeutic erasure of these wrinkles,often associated with advanced aging, caused a rejuvenation ofthe cosmetically treated face lasting up to six months. By 1999over 4.7 million botox treatments had been undertaken.

And thus, from a banal form of food poisoning in Ger-man sausage, to a recognition that certain Clostridium bacteriaelaborate a highly poisonous neurotoxin, and finally the ex-tracting of this botulinus toxin, taming it by extreme dilutionand thus converting it into a widely used, safe cosmetic aid inerasing wrinkles and other unseemly skin folds. Other benefi-cial uses of bo-tox include counteracting the severe musclespasms that often accompany limb fracture, the treatment ofneck muscle spasms, strabismus [cross-eyedness], a newertherapy for tension or migraine headache and yet other medi-cal conditions. Truly, beginning with the world’s most power-ful poison, a wondrous transformation, a Cinderella story.

– STANLEY M. ARONSON, MD

Disclosure of Financial InterestsStanley M. Aronson, MD, has no financial interests to

disclose.

CORRESPONDENCEe-mail: [email protected]

The ancient Sumerians, ancestors to the Babylonians, Hebrewsand Assyrians, had shown resourcefulness in taking discardedscraps of meat, seasoning them with salt and herbs, choppingthem up and then molding them into cylindrical shapes bystuffing the mash into cleansed animal intestine. Homer, in hisOdyssey, talks of blood sausages; and there are sufficient refer-ences to this form of preserved meat to verify that the prepara-tion of sausages was also widely practiced in ethnic cultures farremoved from the Middle East and Mediterranean. The En-glish word, sausage, is derived directly from the French word,saucisse, which in turn has descended from the Latin, salsus,meaning to salt and thus to preserve. Yet another Latin wordfor sausage is botulus.

The ancient Roman cuisine, particularly in the southernItalian region of Lucania, was richly enhanced by varieties ofsausage. These meat-containing delicacies became closely asso-ciated with the promiscuous Roman fertility festival ofLupercalia; so much so that the early Church determined thateating sausage was a sin. By the Tenth Century, the ByzantineEmpire outlawed its production and consumption.

In the Middle Ages sausages continued to enliven the peas-ant diet despite ecclesiastic disapproval. Each European na-tion developed its own formula of meats, animal blood andherbs such that geographic enclaves were closely identified withtheir own distinctive wines, cheeses and sausages. Germany tookgreat pride in its immense variety of sausage, collectively calledwurst, often naming them after one or another German city[eg, Frankfurter.]

The German penchant for sausage led inevitably to pub-lished instances of food poisoning associated with poorly pre-pared sausage. It is not that cases of sausage poisoning wereconfined to the German states. Rather, the German medicalprofession was then sufficiently advanced to underwrite nu-merous medical periodicals reporting new or unusual illnesses.In 1822 the German physician Justinus Kerner described casesof food poisoning, ascribing them to the consumption of indif-ferently prepared sausages. By 1870 these isolated cases of sau-sage poisoning were called botulism, named after the Latin wordfor sausage, to distinguish such cases from other varieties offood poisoning. The underlying biochemical cause of botu-lism, however, remained a mystery.

The incubation interval in individuals suffering from acutebotulism—the time between ingestion of poisoned food andthe arrival of symptoms—tends to be brief, generally less thana few hours. The roster of acute symptoms includes abdominalpain, nausea and vomiting, followed by a dry mouth andblurred vision. If the intoxication is more severe, these inaugu-ral symptoms are followed by difficulty in speaking and swal-lowing and weakness of limb muscles. In even more severe cases,there is respiratory compromise due to the involvement of themuscles needed to breathe.

In 1895 the Belgian bacteriologist Emile van Ermengemisolated specific bacteria from sausages which had caused botu-lism, microorganisms now classified as Clostridium botulinum.


Physicians and patients in RI are increasinglydiverse. This simple fact underscores therelevance of anthropology to the prac-tice of medicine in the US and RI. Weoffer this issue as a tantalizing glimpse intothis field to demonstrate howanthropology’s principles and methodsilluminate understanding of health andhealthcare.

A simple definition of medical an-thropology is that it is the applicationof anthropological principles to thepractice of medicine and healththroughout the world. Anthropologybroadly concerns itself with how indi-viduals of varied cultures live their livesand interpret their experiences. Gener-ally speaking, people are born, traversechildhood, suffer illnesses, age, and die.How these universal experiences are in-terpreted through the varied lenses ofculture constitutes our field. Anthropo-logical inquiry classically uses qualitativemethods to suspend expectations, ob-serve, participate, interview, conductfocus groups and oral histories, amongother approaches, to question assump-tions and seek these meanings; quanti-tative methods may also be used to en-able generalization.

In RI numerous anthropologiststeach, do research and often collabo-

rate with physicians. The editors of thisissue are a cultural anthropologistwhose career has focused on the expe-rience of aging, health care, healthpolicy, medical education and researchin this country and a physician-anthro-pologist whose work has centered onprimary care, health policy, medicaleducation and research in RI and Is-rael.

This collection displays some of thecurrent medical anthropological trendsand perspectives in Rhode Island rang-ing from clinical research to medicaleducation. The introductory paper byDr. Borkan et al outlines practical prin-ciples of working effectively with pa-tients from various cultures living in RI.Dr. O’Connor describes a particularmedical case of culture clash in RI tounderscore ways to bridge understand-ing. Dr. Gutmann’s description of howMexican men choose to have vasecto-mies shows the relevance of folk beliefsfor medical decision making. Dr. Rosenet al show the use of focus groups andinterviews in American Samoa to engagepatients and providers in effective strat-egies for preventing and managing dia-betes. Finally, Dr. Farrell’s team demon-strates how the anthropologically-in-spired method and analysis of medical

Anthropological Perspectives On Medicine: IntroductionRenée Shield, PhD, and Jeffrey Borkan, MD, PhD

�students’ reflective journals about theirgeriatrics curriculum is an importantwindow into how students perceive thecurriculum and begin development intomature physicians. Each paper containsimplications for medical practice that wehope RI physicians will find useful andrelevant.

Renée Shield, PhD, is Clinical Asso-ciate Professor of Community Health, andDirector, Resource Center for GeriatricsEducation, The Warren Alpert MedicalSchool of Brown University.

Jeffrey Borkan, MD, PhD, is Profes-sor and Chair of Family Medicine, Me-morial Hospital of RI, The Warren AlpertMedical School of Brown University.

Disclosure of Financial InterestsJeffrey Borkan, MD, PhD, has no

financial interests to disclose.Renée Shield, PhD. Grant support:

Donald W. Reynolds Foundation

CORRESPONDENCE:Jeffrey Borkan, MD, PhDMemorial Hospital of RI111 Brewster StreetPawtucket, RI 02860phone: (401) 729-2256E-Mail: [email protected]

Renée Shield, PhDBrown UniversityBox G-121(6)Providence, RI 02912Phone: (501) 863-9958E-Mail: [email protected]


Towards Cultural Humility in Healthcare forCulturally Diverse Rhode Island

Jeffrey M. Borkan, MD, PhD, Kathleen A. Culhane-Pera, MD, MA, Roberta E. Goldman, PhD

�Patients, physicians, and society clamorfor accessible, affordable, high qualityhealth care. Though variously defined,quality care may mean, “doing the rightthing, at the right time, in the right way,for the right people—and having the bestpossible results.”1 Quality health care is ef-fective, safe, timely, patient-centered, equi-table, and efficient.2 Patient-centered care“is respectful and responsive to individualpatient preferences, needs, and values andensuring that patient values guide all clini-cal decisions.” 2 To provide such care, phy-sicians and ancillary staff must be cultur-ally competent. Acquiring such compe-tency may be daunting, given the range ofethnicities and groups in your practice area,not to mention local, familial, or individualvariations. Where is the clinician to start?This article provides a general frameworkfor achieving the competency, or as we pre-fer, the tools and the humility that are es-sential for delivering quality care.

Rhode Island has been described as amicrocosm of the US population. In 2006,23% of RI’s children lived in immigrantfamilies, a percentage similar to that of theUS (22%). About a quarter of these fami-lies are linguistically isolated; half of thechildren living in immigrant families arepoor or low income; about half have par-ents with low education; almost a third haveone or both parents with a college educa-tion or graduate degree.3 About 80% ofRhode Islanders are non-Hispanic White;6.3% are Black; 2.7% are Asian; .6% areAmerican Indian; and 11% identify as His-panic or Latino of any race.4 Historically,many Rhode Islanders hail from English,Italian, Irish, Portuguese, and CapeVerdean ancestries. Portuguese and CapeVerdeans continue to migrate to the state,joined recently by imigrants from the formerSoviet Union, Africa, Asia, Southeast Asiaand India, and Latin America (particularlyColombia, the Dominican Republic, PuertoRico, Mexico, and Guatemala). Between1990 and 2000, the predominant regionsof birth of immigrants were: Latin America(36.8%); Europe (32.9%); Asia (16.4%);and Africa (10.1%).4

CULTURALLY COMPETENT CAREAND CULTURAL HUMILITY

When physicians provide culturallycompetent medical care, they inquireabout, respond to, and respect the patients’beliefs and desires, regardless of the patient’sage, gender, religion, ethnicity, or language.(Other terms include cultural sensitivity,cultural responsiveness, or cultural appro-priateness). Cultural humility is a life-longattitude and approach to cultural compe-tence. We believe that healthcare profes-sionals must be humble about their knowl-edge of patients’ beliefs and values, engagein self-reflection so that they are aware oftheir own assumptions and prejudices, andact to redress the imbalance of power in-herent in physician-patient relationships.

Biomedicine tends to focus on thepathological processes of disease. Patients,in contrast, often focus on the psychologi-cal experience of illness, while the patient’sfamily and community focus on the patient’ssickness—the social determinants and rami-fications of disease and illness. Culturallycompetent medical care requires that phy-sicians understand cultural as well as socialand psychological factors that influencehow patients maintain health, treat disease,experience illness, and respond to suffer-ing. Culture influences beliefs about nearlyeverything in the healthcare equation, fromthe understanding of bodily functions anddisease etiology, to treatment choices.

CLASSIFICATION OF DISEASESSince ethnic groups have differing

classification systems for diseases, it is dif-ficult to translate disease concepts acrosscultures. Entities that are recognized bycertain ethnic groups and not others areoften classified as folk illnesses or culture-bound syndromes. Such ailments have adefined etiology, course, and treatment,and include expressions of mental or so-cial distress. For example:

One of our patients, Mrs. YolandaJackson*, a 72-year-old African-American woman, has what she con-ceptualizes as high blood. At times,

Mrs. Jackson can feel her blood ris-ing up to her head. When she drinkspickle juice and vinegar, she can feelher blood return back to normal. Her28-year-old European-Americanmale physician believes she has hyper-tension and recommends a low saltdiet, exercise, and medication.

“High blood” is a culture-bound syn-drome while “hypertension” is a main-stream biomedical disease. Concepts of folkillnesses and biomedicine may be consistent,complementary, or contradictory. In thiscase, the two cultural systems may conflictdue to their differences explanations of thedisease (symptomatic or chronic) and thetreatment (foodstuffs or medication). Mrs.Jackson and her physician could take stepsto understand each other, compromise, andimplement an approach that relieves bothher illness and her disease.

THEORIES OF DISEASE CAUSATIONEtiologies typically fall into four cat-

egories, influenced by the culturalgroup’s concepts of the natural, social,and supernatural realms. Biomedicineemphasizes individual and natural causes,but patients may consider these othercauses to be equally or more important.

1. Individual etiologies include be-havioral risk factors for disease (e.g.,lifestyle, diet, habits, and sexual behav-iors) and presume the individual is re-sponsible for the illness.

2. Natural etiologies include germs,environmental factors, humoral factors (hot/cold elements), and the heavenly bodies(moon, planets, constellations). Because theseetiologies are seen as factors beyond humancontrol, the individual has little personal re-sponsibility for causing the illness.

3. Social etiologies arise from social in-teractions or conflicts (e.g., conflict betweenfriends or family members; jealousy, envy, orhatred; giving someone the “evil eye”).

4. Supernatural etiologies reflectthe culture’s religious beliefs. For example,an angry God may punish sinful thoughtsor actions; kharma forces from previous


lives will influence events in this life; lackof respect for ancestral spirits can causesickness. Prevention or cure is providedby religious prescriptions.

Mr. Eugene Schmidt, a 65-year-oldthird generation German Americanman, has lung cancer and wonderswhy it happened to him. His physi-cian says it developed because hesmoked tobacco for 50 years. His wifethinks God is punishing him, as he hadturned away from the CatholicChurch early in their marriage. Hisdaughter admonishes him for not eat-ing the vitamin supplements she hadbought for him. His son encourages himto sue the ship building industry wherehe worked during World War II.

TYPES OF TREATMENTSThe patient, family, or community

members may apply a variety of popular andlay treatments to relieve symptoms, cure ill-nesses, or prevent further harm; e.g., herbs,amulets and other protective clothing, ritu-als (including prayers and offerings), mas-sage, nutrition, sleep, or exercise, or hygiene.Coining and cupping are common South-east Asian lay practices to treat illnesses causedby the build-up of bad wind, or pressure.The healer first rubs the skin with a men-tholated cream, then rubs a silver coin vig-orously over the affected area to release thepressure or create suction with a cup, whichrelieves the illness. (The bruises from suchtreatments have occasionally been inter-preted as marks of child abuse.)

Ana Soares is a 76 year old womanfrom Portugal who prevents gettingcolds and other respiratory diseases byensuring that her head is covered whenshe goes from her hot kitchen to anycolder environment, even if it is forjust a minute. If she does get a respira-tory infection, she treats it with a hotmixture of water, honey, and sage.

Sacred or secular healers who haveacquired authority through inheritance,apprenticeship, religious position, or divinechoice apply folk treatments. Healers in-clude herbalists, bonesetters, traditionalmidwives, spiritualists, shaman, andinjectionists. For example in Rhode Island’sLatino communities, Puerto Ricans andDominicans may consult an “espiritista” in

a local “botanica”, herbal/spiritist shop andpurchase herbs, or colored and scented lo-tions, liquids and candles. The colors andscents are associated with particular healthor life circumstance properties, and areused to improve health, love, wealth, rela-tionships, and luck, among other attributes.

INTERPRETATION OF BODILY SIGNSAND SYMPTOMS

Individuals declare themselves “sick”when they explain their signs or symptomsas abnormal. Socially, family members orhealers or healthcare providers must con-cur before the patient can assume the sickrole and legitimately withdraw from workand family responsibilities and receive as-sistance from others. Different interpreta-tions of bodily signs and symptoms as nor-mal or abnormal will influence this process.

Mr. Garcia Lopez, recently settledin the US from Mexico, was confused.His son was sent home from school witha draining ear, a common occurrencein Mexico, and not a cause for alarm.But then later the same month, his sonwas not permitted by school authori-ties to stay home after he was fright-ened (asustado) from a near-miss caraccident, which could have made himvulnerable to many types of illnesses.

The significance patients attach to signsor symptoms of an illness is influenced bythe individual’s cognitive ideas or explana-tory models (EM) about the sickness event.6

People’s EMs can change as symptomschange, as response to treatment occurs, or

as the patient accepts other ways of thinkingor others’ experiences. The patient, familymembers, social network, and health careproviders all have their own EMs for the sick-ness event, which may be congruent,complementary, or contradictory. Whenphysicians understand these diverse EMs,they can respond to patients’ needs, expec-tations, and fears, aim educational messagesat patients’ uncertainties, and negotiate di-agnostic and therapeutic approaches.

A necessary skill in providing cultur-ally competent care is eliciting and listen-ing to patients’ and family members’ storiesof their illness experiences, which includesthe events, their models and beliefs aboutcausation, their feelings about their disease,their quest for therapy, and their reactionsto biomedical recommendations. (Table 1)

MEDICAL DECISION MAKINGCultural beliefs, knowledge and expe-

rience, explanatory models, access, cost, andperceived efficacy influence medical deci-sion-making. Ethnic identity—the extentto which individuals align themselves witha socio-cultural group—may influencepeople to seek healers or professionals fromtheir ethnic background. When peoplerelocate, their ethnic identity may be modi-fied through acculturation. Acculturationcan change a person’s alignment from tra-ditional healing practices to mainstreamhealing systems and can lead to intra- andinter-familial conflicts regarding treatments.The degree of social dissonance—the dis-tance between the patient and the healerin terms of differences in ethnicity, socio-economic class and all that encompasses,

Table 1: Eliciting the Patient’s and Family’s Story and Models1. Would you please tell me more about yourself?2. How does this illness fit into or change your story?Illness/Problem3. What health problems or illnesses do you have, what do you think caused them,

and what kind of care have you sought? (conventional medical care, comple-mentary-alternative, traditional)? How have they been helpful? Not helpful?

Impact of the Illness on the Individual4. How is this illness affecting your daily functioning and the things that are

most important to you?5. What do you miss most from before you were ill?6. What do you think will happen in the future?Impact of Illness on the Family7. What changes have occurred in the family since the illness began? (daily

routines, care, finances, etc.)8. How well do you feel the family is coping? Is there anything the family

wishes they could do differently?


language, or religion—may become impor-tant. The greater the dissonance, the lesslikely the patient will choose the healer oradhere to treatment recommendations.

Patients can sequentially or simulta-neously seek assistance from the three typesof treatments (lay, folk, and professional sec-tors): a hierarchy of resort. People often be-gin with lay treatments in the form of self-help or family remedies. If lay treatmentsare insufficient, patients seek out folk heal-ers or professionals.. Patients may make de-cisions themselves, or may look to familymembers or social networks members foradvice. Patients seek assistance from differ-ent traditions depending on the situation,the fit between the sickness and the heal-ing approach, the perceived effectivenessof the therapies, as well as their ethnic iden-tity and degree of acculturation. Physiciansshould inquire what treatments and heal-ers patients have already received, as well aswhom they will consult to make decisions.

HEALER/SICK PERSONRELATIONSHIPS

Every cultural system has expectationsabout the healer/sick person/family rela-tionship. The social and cultural rules gov-erning this relationship influence the styleof communication, the appropriateness ofcertain discussions, the protocol about shar-ing or withholding information, and theamount of power or authority the healerexerts over the patient and family.

To care for patients from other cul-tures, physicians must be sensitive to cul-tural differences between them and theirpatients. Physicians must be familiar withgeneral information about a cultural group,but they cannot assume their patients’ be-liefs and values based on the general cul-tural information. Rather than stereotyp-ing, physicians can use general informationabout a group to generate hypotheses aboutan individual person or family, and thenask people about their lives, their expecta-tions, and their desires.

CLINICAL APPLICATIONSOver-use of stereotypes and gener-

alizations can lead to too little care.

Mai Nguyen, a 29-year-old fe-male refugee from Vietnam, cameto a community health center for acomplete physical exam before start-ing a new job, and had numerous

somatic complaints. She was hesi-tant to talk about emotional, fa-milial, or intimate matters andrefused a gynecological exam. Heryoung physician consulted col-leagues who advised accepting hercomplaints as being consistent withVietnamese “culture”. However,after several encounters with thepatient, the physician learned thatthe patient had escaped Vietnamin a small over-crowded boat andhad undergone significant traumaand sexual abuse while at sea, andrealized that her behaviors werenot just “cultural”. Indeed, her mul-tiple somatic complaints were re-lated to post-traumatic stress disor-der and required social and psychi-atric interventions.

Over-use of stereotypes and gener-alizations can lead too much care.

Moshe Kadosh, a 54-year-oldJewish immigrant to the UnitedState from a village in Morroco,saw his primary care physician soonafter arriving for complaints of si-nus pressure, headache, and dizzi-ness. The physician becamealarmed when the patient de-scribed discussions with spirits, in-cluding hearing the voices of someof his ancestors and long-dead lo-cal holy men, and so referred himto a psychiatrist. After the initialvisit, the psychiatrist postulated hewas schizophrenic and admittedhim to the inpatient psychiatristward. Only after working with apsychiatry resident form the samecountry who interviewed him in hisnative language, did it become ap-

parent that he was not psychotic,but was only exhibiting some of hisnormal spiritual beliefs, as well asexpressing his distress in culturallyappropriate ways.

CULTURE OF BIO-MEDICINE:Like all healing systems, modern bio-

medicine is influenced by historical, so-cial, economic, political, religious, andscientific events. It has its own language,vocabulary, and concepts. It also has itsown values, and each discipline (familyphysicians, surgeons, psychiatrists, etc.)are sub-cultural groups with variations onthe general biomedical beliefs, values, andbehaviors towards health and disease. Asa sub-culture of Western society, biomedi-cine has values of the larger society, whichspecifically fit bio-medicine.

Dr. Jim Zedler, a new internbegins working up his first patientin the outpatient clinic of his aca-demic health center. The patientis a 32-year-old married womanrecently arrived from Africa whocomplains of diarrhea and lowerabdominal pain, which althoughpresent for the last several months,have worsened in the past week. Hecompletes his history and physicalexamination, and orders a broadseries of laboratory and imagingtests. He becomes disappointed andfrustrated when he is unable to pro-vide a definitive etiology and apatho-anatomical diagnosis. Evenworse, the woman’s complaints ofpain worsen. After several visits,he decides that the woman’s pain is“in her head”, a conclusion whichangers her. After an assessment byhis preceptor, it becomes clear that

Table 2: Working with Interpreters1. Discuss expectations with interpreter before beginning, including first-

person singular, verbatim translation.2. Make sure everyone has been introduced.3. Sit facing the patient, and speak to the patient, not the interpreter.4. Use lay English terms and non-complex language structure.5. Pause intermittently to allow interpretation.6. Don’t assume universal meanings to nonverbal gestures.7. Periodically check the patient’s understanding.8. Do not expect interpreters to resolve conflicts or disagreements or to

actively negotiate outcomes.


the woman has lactose intolerance,which has been exacerbated by herrecent dietary changes after mov-ing to the US, and she is a victimof domestic abuse. The intern hadnot picked up on the cues and hadconsidered both her domestic situ-ation and her diet out of the realmof his investigation.

CULTURALLY APPROPRIATECOMMUNICATION

Culturally appropriate communicationthat respects the individual’s beliefs, practices,and background, yet allows the health carepractitioner to make precise diagnoses, is akey skill needed in medical practice. Com-munication between the physician and pa-tient is significantly influenced by culture, asreflected in non-verbal expressions, mannerof address, and appropriate styles and topicsof communication. Nonverbal expressionscan have different, even opposite, meaningsin different cultures. Appropriateness of styleand topic of conversation can vary widelyand physicians’ sensitivity to such differencescan improve the physician-patient relation-ship. Cultural generalities about non-verbalcommunication, like all cultural generalities,will not hold for all patients. Physicians haveto monitor their patients’ responses, ask fortheir input, and seek assistance from bicul-tural colleagues.

Victoria BearClaw, 82-year-oldNative American, feels insulted everytime she attends the medical clinic inthe city rather than on the reservation.The doctors and nurses talk quickly;they don’t wait even a full second be-fore she can reply, and then they’re ask-ing her another question as though she’sdumb or can’t hear. And then they don’treally listen to her concerns as she tellsthe full story. Also, they look directly at

her as though staring, and they calledher by her first name rather than call-ing her Grandmother in a respectfultone of voice. She always feels as thoughthey don’t really care about her andher sufferings.

TRANSLATORSProfessionally trained interpreters pro-

vide grammatically correct first-person ver-batim translations for physicians and patients,including interpreting medical language intolay terms. Using family members as interpret-ers is particularly problematic. Differencesin age and gender, may result in discussionsabout inappropriate topics (children hear-ing about intimate details of their parent’slives). Differences in language skills maymean the relative has inadequate knowledgeof English medical terminology or medicalterms in their own language. Seeking trainedinterpretation services over the phone is pref-erable in such cases. In addition, recent leg-islation in Rhode Island makes it illegal touse an individual under the age of 16 to in-terpret, although many immigrants expecttheir children to interpret for them. In gen-eral, physicians should huddle with the in-terpreter prior to the clinical encounter,clarify guide rules and expectations, ask for“word for word” translations, and listen tothe interpreter’s insights about cultural prac-tices, meanings, or idioms. (Table 2).

SUMMARYThis article presents a framework for

quality care that attends to culture andethnicity. Tools and approaches forachieving cultural competency and hu-mility are provided that may help improvethe care of the patients, irrespective oftheir backgrounds or beliefs.

*All names used in this manuscript havebeen changed to ensure confidentiality.

ACKNOWLEDGMENTPortions of this article were extracted with

permission from The Behavioral Sciences andHealth Care by O. J. Sahler & J. E. Carr, 2ndedition, ISBN 978-0-88937-307-5 , 2nd edi-tion, pp. 130–9. {Culhane-Pera, KA, Borkan,JM} ©2007 by Hogrefe & Huber Publishers.Cambridge, MA · Toronto · Göttingen· Bernwww.hogrefe.com

REFERENCES1. Agency for Healthcare Research and Quality. Your

Guide to Choosing Quality Health Care. Rockville,MD: Agency for Healthcare Research and Qual-ity; 2001. http://www.ahrq.gov/consumer/qnt/

2. Institute of Medicine Committee on Quality ofHealth Care in America. Crossing the QualityChasm: A New Health System for the 21st Century.Washington, DC: National Academies Press, 2001.

3. 2008 Rhode Island Kids Count Factbook. Provi-dence, RI: Rhode Island KIDS COUNT. 2008

4. US Census Bureau. Quick Facts. http://quickfacts.census.gov/qfd/states/44000.html

5. US Census Bureau. American FactFinder. http://factfinder.census.gov/servlet/QTTable?_bm=y&-g e o _ i d = 0 4 0 0 0 U S 4 4 & -qr_name=DEC_2000_SF3_U_DP2&-ds_name=DEC_2000_SF3_U&-redoLog=false

6. Kleinman A, Eisenberg L, Good B. Culture, ill-ness and care: clinical lessons from anthropologicand cross-cultural research. Annals Intern Med1978;88:251-8.

7. Berlin EA, Fowkes WC. A teaching frameworkfor cross-cultural health care application in familypractice. West J Med 1983; 139:130-4.

Jeffrey Borkan, MD, PhD, is Profes-sor and Chair of Family Medicine, Me-morial Hospital of RI, The Warren AlpertMedical School of Brown University.

Kathleen Culhane-Pera, MD, MA, isAdjunct Professor of Family Medicine andCommunity Health, University of Minne-sota, and Associate Medical Director, WestSide Community Health Services.

Roberta Goldman, PhD, is ClinicalAssociate Professor of Family Medicine, Me-morial Hospital of RI, The Warren AlpertMedical School of Brown University.

Disclosure of Financial InterestsThe authors have no financial inter-

ests to disclose.

CORRESPONDENCE:Jeffrey Borkan, MD, PhDMemorial Hospital of RI111 Brewster StreetPawtucket, RI 02860phone: (401) 729-2256E-Mail: [email protected]

Cultural Humility (HUMBLE) Model

H: Be Humble about the assumptions you make about knowing the worldfrom your patients’ shoes

U: Understand how your own background and culture can impact your careof patients

M: Motivate yourself to learn more about the patient’s background, culture,health beliefs and practices, as well as the unique points of view of theirfamilies and communities

B: Begin to incorporate this knowledge into your careL: Life-long learningE: Emphasize respect and negotiate treatment plans


For roughly 20 years, clinicians haverecognized cultural competence as im-portant to medicine. A case from earlyon illuminates what may have changed –and what has not – in the ensuing twodecades. More importantly, it shows thatcultural competence is a crucial clinicalskill set, not simply an abbreviated formof anthropological knowledge.

CASE ANALYSISTBL, a 26 year-old Hmong man, was

admitted via the Emergency Departmentto an urban, East Coast teaching hospi-tal for upper GI bleed from previouslyundiagnosed esophageal varices. He hadno history of hematemesis, and had com-plained of no discomfort prior to this sud-den-onset event. On workup he wasnoted to have abdominal ascites and con-siderable edema of the extremeties. Hewas diagnosed with chronic hepatitis andportal hypertension. Recommendedtreatments included sclerotherapy of thevarices, and liver transplant.

Seen through biomedical eyes, atransplant offered Mr. L the hope of manyyears of good quality of life. No transplantportended rapid deterioration and highrisk of re-bleeding (at 20-30% risk of fa-tality per episode). Other therapies in-cluded sclerotherapy of the varices, medi-cal management of his portal hyperten-sion, and a diet of clear liquids with supple-mental intravenous nutrition. Meticulousinformed consent procedures would befollowed. The treatment plan would bedemanding, but a team of skilled physi-cians and nurses would see the patient andfamily through it; the transplant center wastop-notch. The patient was young andotherwise healthy, an excellent candidatefor transplant. The informed consent pro-cess included careful explanations, withillustrations and simple sketches; the cli-nicians encouraged questions, and repeat-edly and willingly answered them. Thehepatologist was optimistic, willing tospend “extra” time with the family.

From the Hmong perspective, thingslooked very different. There were con-

siderable misgivings about the healthcare team and treatment plan—startingwith the diagnosis. How could anyonebe sick for years without knowing it,without even feeling bad? Who were allthese people involved in Mr. L’s care?Why were they all there? Where was theone you trusted? Some of these peoplewere young and unskilled and clearly“practicing” on Mr. L. Alarmingly, manycaregivers displayed poor knowledge andattention by asking questions that hadbeen answered several times already. Agreat many declined to answer thefamily’s questions, suggesting they “talkto the doctor about that” – but whichone? and when? What were these peopleconcealing, ducking their questions?Even the most senior doctor would notdirectly answer basic and straight-for-ward questions (“when will he get bet-ter?”). Obviously, family members wouldneed to be ever-present and vigilant, ac-tively protecting Mr. L.

In addition, there were three influ-ential “disconnects” between the culturesand expectations of hospital medicineand the Hmong patient, family, and com-munity: the special needs and appropri-ate treatment of sick people; the issue ofconsent and where, precisely, it was lo-cated; and the functions, meanings, andnature of the Liver.1

TREATMENT OF THE SICKThe presence of family members at

every juncture in illness and recovery, andthe importance of proper nutrition intimes of debility, were crucial for Mr. L,his family and community supporters.Hospital personnel would have preferredto limit visitors to two or three, duringprescribed visiting hours, which familymembers declined to follow. TheHmong custom called for a family ad-vocate to accompany Mr. L at all times,since the ultimate safety of patients—notto mention the gauge of practitioners’competence—is a family responsibility.The hospital’s rejection of accompani-ment during the first sclerotherapy in-

tensified distress, raising a “very big sus-pect that some of the doctor[s] might tryto do something to my people” (TBL,author interview). Accommodating therequest during the second treatment en-gendered even more distress: not havingbeen given an explanation, Mr. L’s accom-panying ‘brother’ (in clan lineage terms,different from US definitions of sibling-brothers) feared he was being choked.His reports dovetailed with an existingoral tradition of potential bizarre Ameri-can medical abuses: that after patientsdie, American doctors open up theirheads to take out their brains; that Ameri-can doctors take large amounts of bloodout of patients; and that American doc-tors might try to eat the kidneys, liver,and brain of deceased patients.2

Mr. L’s clear-liquid diet created deepdistress for him, and concern within hissupport system. Several days into his hos-pitalization, when Mr. L was asked howhe was doing he replied with quiet sor-row, “I want to eat rice.” For traditionalHmong, rice is the dietary centerpiece,their “staff of life.” It is the fundamentalingredient of every meal and, lacking otheringredients, can convey both the physicaland emotional satisfaction of nourishment.How could a sick man be denied thisquintessentially life-sustaining food?(Those too ill to eat are nourished with arice-water broth.) Repeated entreaties forrice were met with sympathetic explana-tions of why this was impossible – but theconversations went no further. This wasto remain one of Mr. L’s most traumaticmemories of the hospital experience (TBL,author interview).

LOCUS OF CONSENTHmong families traditionally seek

and select the treatments for their sickmembers.3 The individualism so centralto American culture—and underpinningthe concepts of patient Autonomy andInformed Consent—is indifferent in tra-ditional Hmong culture. Individuals arenot expected to make important decisionsfor themselves; the more consequential

Negotiating Clinically Workable Solutions Across Cultures:Lessons Learned

Bonnie B. O’Connor, PhD�


the decision, the more critical family andcommunity consultation become. As awar orphan, Mr. L had no birth familyto advise him. He was therefore excep-tionally grateful to clan and lineage mem-bers: at one point 17 people in his roomdebated in minute detail the implicationsof suggested treatments.

Though his own opinions and pref-erences were sought in these discussions,Mr. L demurred. He worried that his fam-ily members’ better judgment might beswayed by emotion if he expressed prefer-ences. He also felt that since the problemwas his own, he could not trust the clarityof his own thoughts: he was confused byits proximity and immediacy (TBL, authorinterview). Hospital staff were anxiousabout coercion or ‘undue influence’ of thepatient by these numerous and ‘unrelated’(by US kinship norms) advisors, and theycontinued to proffer the consent form,and address their questions, only to thepatient. They would likely have foundtroubling the notion that the actual con-sent resided in a collective process: the pa-tient could provide only the signature—and he wanted it that way.

CONSIDERATIONS SPECIFIC TO THELIVER

To traditional Hmong, the liver car-ries the special symbolic significance withwhich American macro-culture investsthe heart.4 It is the locus of feeling andpersonality, character and motivations.What kind of person might one becomethrough liver transplant? Who wouldwant to emerge from surgery a strangerto himself and others?

There were also ominous religiousand spiritual implications. Alongside theChristianity they had practiced for manyyears, Mr. L and other community mem-bers retained several profoundly affectingtraditional Hmong religious beliefs, in-cluding the existence of multiple souls perperson, and anatomical location of one ofthe major souls in the liver. What if Mr. Lshould die during surgery, after removalof his liver? The ghastly prospect was amutilated, soulless body, incapable of re-animation, and a rootless soul unable topursue its proper spiritual destiny. Risksto reincarnation, and to Mr. L’s survivingfamily members from an unquiet, earth-bound spirit, were numerous and fright-ful. Incredulity at the notion that

someone’s “dead liver” could be installedand made functional in a new body paledby comparison. All things considered, themetaphysical risks of liver transplant con-siderably outweighed the physical risks,and their consequences were more severe,longer-lasting, and affected more people.

CONSTRUCTING COLLABORATIVESOLUTIONS

The immense disjunction of expec-tations, treatment goals, and worldviewsin this case seems to defy resolution. Yetsolutions might have been found, had theresources and concerns of both belief sys-tems been brought together. The hospi-tal kitchen might have offered rice-wa-ter as part of Mr. L’s clear liquid diet; orfamily members might have brought himclear rice broth from home. Worriesabout rumored American abuses mighthave been explored with empathy andreassurance, not dismissed with scorn.Questions might have been invited andanswered as to why Mr. L seemed tochoke during sclerotherapy, and why noone stopped the endoscopies when hedid. Even the radically different ‘moralanatomies’ and concerns about the livermight have found a jointly crafted solu-tion. Indeed, several friends and familymembers did generate a possible scenariofor transplant. It went like this:

Could a Hmong shaman, skilled inthe soul-calling that is often required ininstances of soul loss, accompany Mr. L tothe operating room? Could s/he call forththe soul from Mr. L’s liver, maybe even tendit during surgery, and/or call it back to itsnew home after the transplant procedurewas completed? Well, yes, that might bepossible. If the liver donor could be as-sured to have received the proper last ritesof his/her religion, so that the soul inhab-iting that liver would have gone on itsspiritual way and the organ could be re-ceived as an empty vessel, would that makea difference? Possibly; worth considering.Would the transplant surgeon permit theshaman into the OR? Mr. L’s hepatologistwas willing to propose it.

In the end, transplant was refused:it was just a step too far. Of thehepatologist’s concern for his life expect-ancy without transplant, Mr. L observedphilosophically, “If I am going to die,then I want to die with my liver.”

RELEVANCE TODAYWhat makes this 20-year old case rel-

evant to the practice of medicine in RhodeIsland today? Now that at least two genera-tions of Hmong have been born and aregrowing up in the US, gaining acculturativedistance from the old ways of the initial refu-gee generation? Now that the Hmong com-munity of Rhode Island, relatively small tobegin with, has largely migrated to largerUS Hmong population centers? Now thatthe likelihood that many of you will treatHmong patients is fairly slight, especiallyaway from the greater Providence area?

One answer is that many of the chal-lenging features of Mr. L’s case might holdfor any person, of any ethnicity, nationality,language fluency, or educational back-ground—involving as they do the meetingof lay people and medical professionals,neither of whom has much understandingof the lives, goals, experiences, knowledge,values, and mandates of the others. Sadly,these features are as likely to be found inclinical settings now as they were then.

The central lessons of cultural compe-tence, of culturally-responsive care, are not“content” lessons about specific identitygroups. Rather they are about the natureof diplomatic relations between any twogroups: lessons about the importance ofunderstanding and accommodation, andthe consequences of their absence; aboutthe difficulty of explaining ourselves to oth-ers when so much of what propels us liter-ally ‘goes without saying’; and lessons aboutthe potential for crafting workable solutionsby drawing on the cherished beliefs, val-ues, and goals of all parties, no matter howincongruent they may seem.

CULTURAL COMPETENCE RULES OFTHUMB

The study of cross-cultural cases al-lows us to derive broadly applicable con-ceptual guidelines for culturally compe-tent care.

Among them are the following:

“Culture is the entire non-biologicalinheritance of human beings. Everythingthat is socially constructed and learnedis a part of culture.”5

Anything that humans have acquiredfrom other humans that has not comethrough biology, has been acquiredthrough culture. This applies as much tomedical knowledge and practice as to


shamanic knowledge and practice, to sci-ence as to religion, to systems of author-ity relations and recognition, to dietaryrules, to kinship systems, and modes ofcommunication. We all operate on thebasis of cultural assumptions, expecta-tions, and norms. This self-awareness isclinically relevant knowledge that wardsoff the false presumption that culture isa curiosity, or that it comes through thedoor only with patients.

“Difference” requires a reference point.Different from what? from whom?

Answering this question helps keep us hon-est and accurate. The answer (e.g., “dif-ferent from me” or “from most of my otherpatients, with whom I seem to have a goodworking relationship”) provides a founda-tion for building solutions. Continue theinquiry: different in what respects? Whichis important to the situation (“the differ-ence that makes a difference)”?6 How dothe differences affect providing care thatis acceptable to both patient and physi-cian? (Table 1) We must remind ourselvesthat “Difference does not equal Deficit.”

Cultural Barriers are always betweenthe groups in question.

It is tempting to assign the barrier tothe group that is “not-me.” We often (usu-ally unconsciously) assign the barrier to the“other” group because our own culturaltemplates are largely invisible to us. Thuswe commonly say that “the patient doesn’tspeak English” to identify a “language bar-rier.” The real barrier is the fact that weand the patient do not share a language.It is easy—and incorrect—to leave our-selves out of the equation.

Culture is not identical to race, ethnicity,nationality, religious affiliation, orminority group status.7

Diversity within identity groups is asgreat as diversity among them. Phrases like“our culturally diverse patients” refer ac-curately to an entire patient population,but not to particular subsets. “Culturallydiverse” is not a proper euphemism forethnic minority membership – althoughits usage in the health professions gives thatimpression. A scan of journal articlesquickly reveals this implicit equation, by

the juxtaposition of “cultural diversity” intitles and “ethnic minorities” in the open-ing sentences or paragraphs. The highvalue placed in medical culture on linguis-tic and conceptual precision should moti-vate us to reject these careless usages.

Cultural competence is not “snapshotanthropology.”

It is useless to memorize facts about“what x people believe” to facilitate cross-cultural interactions. The enormousrange of variability within culturalgroups, coupled with the tremendousdynamism of cultures, makes this a futileexercise. A little knowledge in this respectis dangerous, because it facilitates stereo-typing and its resulting damage. Al-though physicians should have some ba-sic understanding of the cultural reper-toires of groups in their patient rosters,that understanding should be used likeepidemiologic data: to outline a broadphenomenon that might be taken intoaccount, but that gives no informationabout a particular patient.

If one of your patient groups wereHmong, the case of Mr. L would be in-formative about traditional beliefs andpractices operating in the early resettle-ment years. Some of these will still berepresented in the US Hmong popula-tion today; one might want to inquireabout them. It would also be essential toknow that today’s Hmong communitiesare extremely conversant with electronictechnologies (used in part to preservecultural traditions), use the Internet, in-clude at least one state legislator and scoresin local government positions, and areincreasingly represented across the pro-fessions. The growing ranks of Ameri-can Hmong holding doctoral degreesinclude 59 physicians – among themXoua Thao, Brown Med 1989.8 Hmongculture has undergone rapid, extensivechange in a short period of time. A staticpicture of “what Hmong people believe”would hinder good medical care.

CONCLUSIONIn the end, culturally responsive care

is individually responsive care, informedby understanding of the patient beforeyou, in the context of family, community,and culture. Patients themselves are of-ten the best sources for this information.

Table 1. Questions for Health Care Encounters9

Seek answers to the following questions with respect to all the participants(physicians, nurses, chaplains, patients, families, etc.)

• What do you/they feel is the most pressing problem?• What does the particular diagnosis or treatment/prevention recommendation

mean to you/them (cognitively, emotionally)?• What special requirements or avoidances do you/they understand to

accompany this condition?• What are your/their goals for treatment/prevention? What do you/they want

to gain from them? To avoid?• What range of healing/health maintenance resources are you/they familiar

with, and which do you/they feel are applicable to the patient’s situation?• What level of priority do you/they assign to the medically indicated course of

action, when weighed against other life goals and constraints?• What is important to your/their sense of self or identity?• What are your/their expectations of sick people and their care-givers?• Who do you/they feel should be in charge of decisions and actions that

affect the patient?• Who is considered family, and how is their kinship defined (by you/them)?• What do you/they feel is the proper or essential role of family members and

significant others with respect to the patient? The role of health professionals?• What do you/they define as an appropriate decision making process? Who

needs to be involved? Why?• What sources of authority do you/they recognize? Where does the authority

of health professionals fit into your/their hierarchy?• What concessions can you/they bear to make?• What are the consequences of having your/their important values and goals

disregarded or thwarted?• What common ground can you discover?


Cultural competence is a key clinical com-petency, and like other clinical compe-tencies it entails an interplay of knowl-edge, skills, and attitudes. It requires con-tinual practice and updating throughdeliberate rehearsal and new learning.Perhaps more than others, it requires re-flective and mindful practice. Culturalcompetence begins with self-assessmentand self-awareness.

ACKNOWLEDGEMENTSI’m grateful to TBL et al. for invit-

ing me into these negotiations. TBL diedin 2000, aged 39, with his own liver.

REFERENCES1. O’Connor B. Healing Traditions: Alternative

Medicine and the Health Professions. University ofPA Press, 1995.

2. Hurlich M, Holtan NR Munger RG. Attitudesof Hmong toward a medical research project. InHendricks, Downing, Deinards, eds. The Hmongin Transition. Center for Migration Studies ofNew York and Southeast Asian refugee StudiesProject of the University of Minnesota,1987:427-45.

3. Culhane-Pera KA, Vawter D, et al., eds. Healingby Heart: Clinical and Ethical Case Stories ofHmong Families and Western Providers. Nashville,Vanderbilt University Press, 2003.

4. Bliatout BT. Understanding the differences be-tween Asian and Western concepts of mentalhealth and illness. Presentation to the Depart-ment of Health and Human Services, Region VII,at Portland, OR, conference, Southeast Asian Refu-gee Federation Orientation Center, May 1982.

5. Hufford DJ. Cultural and social perspectives onalternative medicine. Alternative Therapies HealthMed 1995;1:53-61.

6. Bateson G. Mind and Nature: A Necessary Unity.E.P.Dutton,1979: 99.

7. Hufford DJ. Culturally sensitive delivery of healthcare and human services. Proceedings of the Governor’sConference on Ethnicity. Harrisburg, PA, The Penn-sylvania Heritage Affairs Commission, 1990.

8. w w w.ch r i s t i anhmong f e l l owsh ip .o rg /doctors3.html Accessed 6/26/08.

9. O’Connor B. Promoting cultural competence inHIV-AIDS care. J Assoc Nurses AIDS Care 1996;7(Suppl.1):41-54.

Bonnie B. O’Connor, PhD, is Assis-tant Director, Pediatric Residency Pro-gram, Hasbro Children's Hospital.

Disclosure of Financial InterestsThe author has no financial inter-

ests to disclose.

CORRESPONDENCE:Bonnie B. O’Connor, PhDHasbro Children’s Hospital593 Eddy Street/Potter 200.9Providence, RI 02903phone: (401) 444-3718e-mail: [email protected]


Cultural Bias and ‘No-Scalpel Vasectomies’:Lessons Learned by a Brown Anthropologist in Mexico

Matthew Gutmann, PhD, MPH

“Well, you know, they did it to me a fewyears ago…” That is how I began myinterviews with men who wanted vasec-tomies in Oaxaca, Mexico, at the begin-ning of each operation. It broke the iceand got the men talking. They told mewhy they decided to get sterilized, aboutdiscussions they had with their wives be-fore the procedure, and, invariably, aboutanxieties as to their post-operative sexualdesire and performance. Sometimes aman would get jumpy and I would ex-cuse myself. The last thing he neededwas to be interviewed, I assumed. Butthe doctors and the men themselveswould insist, “No, stick around!” I be-came the anthropologist-as-emotional-anesthesiologist.

Vasectomies were not common inthe mountain provincial capital ofOaxaca in southern Mexico, where I con-ducted ethnographic fieldwork from2001-2002. But I was not looking forcommon men—whatever that termmight mean. I was eager to understandthe motivations of a small subset of menin Oaxaca who had been sterilized, whythey decided to do so, and what lessonscould be drawn for the population withregard to reproductive health and sexu-ality. The answer turned out to be de-ceptively straight-forward. For many ifnot all the men I spoke with throughoutmy year in Oaxaca, the most commonexplanation was that their wives had al-ready suffered enough—taking birthcontrol for years, getting pregnant, giv-ing birth. Now it was their turn. WhenI asked these same men why they hadlong relied on their wives to use contra-ceptives in the past, and why they hadnot used a male form of birth control,the men responded with a simple in-credulous question? “Like what? Thecondom?”

In Oaxaca as elsewhere in the world,most artificial, modern forms of contra-ception—and all the most reliable ones—are for women. The men asked me if Ithought they had much of a choice aboutwhat form of birth control to use. I re-sponded honestly that the choices avail-

able to the men of Oaxaca were part of alarger picture that involved, among oth-ers, the international pharmaceutical in-dustry that develops and manufacturesbirth control devices and medications.Unless these companies make and mar-ket a modern contraceptive, it will notbe available in Oaxaca or anywhere else.

This article discusses why some menin Oaxaca, Mexico, get vasectomies.Through this research I explore broaderissues relating to men’s sexuality, includ-ing common assumptions about men’s“natural” sexual desires and practices.Numerous issues influence a man’s deci-sion to get this permanent form of con-traception, including cultural, historical,physiological, commercial and individualfactors. A key issue that emerged in thecourse of a larger study on men’s repro-ductive health and sexuality in Oaxaca ishow cultural folk beliefs about supposedmale sex drives influence men’s decisionsabout birth control. Indeed, I have spentthe better part of my professional careeras an anthropologist of Mexico trying tountangle common-place stereotypesabout what men—and Mexican men,working class Mexican men, Latino men,and so on—do and don’t do or think.1,2

This research is a small piece of alarger study of heterosexual couples thatI conducted in Oaxaca de Juárez, a met-ropolitan area of around 500,000people located in a mountain region 300miles south of the Mexican capital.2 Ap-proximately half the population of thestate, totaling over 3 million people, self-identifies as belonging to one or anotherindigenous group (the largest beingZapotec and Mixtec). According tonearly all indices, living standards inOaxaca are among the lowest in Mexico,especially in the countryside. My ethno-graphic fieldwork in Oaxaca City in2001-2002 was carried out in two va-sectomy clinics, the state-run AIDSclinic, and in the Ethnobotanical Gar-den of Oaxaca. where I worked as a la-borer clipping cactus and digging ditchesfor planting and irrigation. I intervieweddozens of Oaxacans from all walks of life,

focusing on men who were consideringvasectomies, as well as their wives and girl-friends. Most of our conversations tookplace in clinics and the homes of thesemen and women.

I observed 22 vasectomies in threedifferent clinics and I interviewed doz-ens of other men and women in cliniccorridors. Interestingly, both ethno-graphic fieldwork with dozens of menand archival research on files for hun-dreds of other men in this project showthat men who get vasectomies are notclearly distinguished by any particulardemographic features related to age, in-come, education, or being of particularethnic groups. I interviewed dozens ofmen before, after, and during their va-sectomies. Initial contact took place inclinics. With several men I followed upwith visits to their homes, where I wouldtalk with both the man and his wife forseveral hours. With some men contactcontinued after the two interviews; withmost, this was it. Demographically, menwho sought sterilization reported alreadyhaving as many children as they wanted.While they had income and educationlevels slightly higher than the state aver-age, far more impressive was the range ofthese levels. I also watched three tuballigations to witness what I had been toldwas a dramatically more serious surgery.As performed in Oaxaca’s public clinics,there can be no doubt about this.

When talking with medical person-nel in Oaxaca I was often offered aculturalist explanation to explain whatmen in Oaxaca who were thinking aboutthe operation had to overcome. In fact,this cultural rationale was sometimes usedto explain why fewer men opted for ster-ilization in Mexico compared to men incertain other countries and to women inMexico itself: supposedly there were dif-ferences between “macho” and “non-macho” cultures, as if those men who doget sterilized in Oaxaca might be actingin a manner unrepresentative of theirmacho culture. In addition to the factthat “macho” means different things tomen and women of different ages,1 such

�


a line of reasoning skirts the larger con-text of decision-making about birth con-trol in Oaxaca. Building on the notionof a female contraceptive culture, it is ofgreat significance that there were fewmodern forms of artificial birth controldesigned for men. This circumstance isnot unique to Oaxaca. Therefore, theproblem of how to understand men’sparticipation in birth control, such as bychoosing to get a vasectomy in Oaxaca, isgoverned by the cultures of global phar-maceutical companies and basic researchon male hormones 3 as much as by spe-cifically local gender identities and rela-tions of inequality (e.g., “machismo”).

Factors influencing thevasectomy decision.

Despite their best intentions, and totheir great chagrin, contrary to what theymight like to have others believe, doctorsin Oaxaca (as in Rhode Island) are greatlyinfluenced by folk beliefs about malesexual practices and urges. As often asnot, these beliefs are based in “what ev-eryone knows” far more than scientificknowledge.

The most common series of eventsleading to a vasectomy in Oaxaca in-volved women receiving counselingabout contraception at a clinic eitherfrom a nurse or a doctor, who raised theidea of vasectomy. Often women wereshown a board depicting birth controlpills, I.U.D.s, condoms, and drawings ofhypodermic needles and male and femalesterilization. If women liked the idea oftheir husbands getting sterilized, theycould tell them about the operation. Ifthe man was amenable, he and his wifereturned for a visit with a doctor whospecialized in the procedure.

Most of the men I interviewed as towhy they opted for vasectomies expressedsympathy for women’s suffering in the pastand their desire to have the women avoidsuch suffering in the future, either throughanother unwanted and potentially harm-ful pregnancy or through a tubal ligation.“You’ve already suffered in one way or an-other with the kids, in childbirth, so there’snothing wrong with them operating onme,” Marcos, a taxi driver originally fromMexico City told me, adding, “We don’tappreciate that women really suffer in child-birth with our children.” Another man, alsoin his mid-forties and a bus driver, said suc-

cinctly, “women suffer with I.U.D.s,”Marcelo, 29 years old, the father of threechildren, and a policeman on the outskirtsof the city, confessed that his wife had in-structed him, “Te toca un poco sufrir” (It’syour turn to suffer a little). Esteban, in hislate 20s, also reflected the critical role thatnegotiations with his wife had played inleading to his decision to get sterilized: “Be-cause I didn’t want her to go through withit. I, well, the truth is that I love her a lot,no? So I don’t want her to suffer. So I sayto her, ‘So you don’t have to be…’ Because[male sterilization] is simpler, more thananything, and then the time you need torecuperate is less. First I talked with thesocial worker and I said to her, “‘What do Ineed to do it?’”

Virtually all men I talked to abouttheir desire for sterilization cited their re-lations with their wives and other women,a significant factor when consideringhealth care education and promotion.

No-Scalpel Vasectomies andOther Half-Truths

In Mexico since the mid-1990s the“no-scalpel” method of vasectomy hasbeen central to efforts to promote malesterilization. (A scissors-like instrumenttears rather than cuts the skin.) Medicalpractitioners in Oaxaca insisted to me thatthe no-scalpel vasectomy represented thedifference between few patients and nopatients. The development of this proce-dure had more to do with seeking ways toattract more men to the operation by re-moving the dread of the incision than itdid with technical advantages. This maystem from a basic symbolic distinction thatmen make, so that the more metaphori-cally feminine scissors—more delicate thanscalpels, some say— threaten men less thanthe hypermasculine surgical knife. Thatis, the reasons men today accept vasecto-mies more readily may have more to dowith symbolism than the technical aspectsof the procedure that now tears ratherthan cuts a tiny hole in their scrotum.

Misunderstandings aboutvasectomies: Animal models.

Another example of seemingly in-nocuous symbolic interventions on thepart of health personnel was evident whena particular doctor began many vasecto-mies by asking the patient in a joshingtone, “Have you talked to your wife about

this?” When the man responded that hehad, the doctor followed up: “And haveyou talked to your girlfriend, too?” I neverheard a woman getting a tubal ligationasked a corresponding question about herhusband and boyfriend.

Among those who reported knowl-edge of vasectomy on epidemiologicalsurveys, few men outside vasectomy clin-ics had a clue what the operation entails.Anthropologist friends in both Mexicoand the United States asked me whatparts of the penis and/or testicles werecut in the procedure. Men commonlytold me that before their vasectomiesthey thought the procedure was “likewith animals,” that it involved castrationand/or cutting off part of the penis. Somemen who grew up in the countryside saidthey knew what was involved.

With bulls, two men wrap a ropearound the girth, then pull on it hard toknock the air out, forcing him to fall andtemporarily debilitating him. They tiethe ends of the rope to two trees and be-gin to massage the area, approximately10 centimeters, between the body andthe testicles of the bull. This will makethe scrotum relax. Then they tie a stringaround the bull’s scrotum. When thestring is tightened, the vas deferens areeffectively severed.

With pigs and goats, the testicles arelaid on a hard surface (like a rock) andthe vas are smashed with a hammer. Or,alternatively, as a friend from the Ethno-botanical Garden advised, you can twistthe testicles of a goat and smash themwith a rock. You should definitely notcut off the testicles of sheep and goats,he believed, because these animals infecteasily. Pigs, on the other hand, could becastrated without running the risk of in-fection, though this involved cuttingthrough three layers of skin in order toextract the bolitas.

It may be understandable that fewmen consider sterilization.

Fears about sexual relations.The main fear men expressed about

vasectomy was that they would neveragain have sexual relations with a woman.Their apprehension was twofold: manymen feared that they would be physicallyunable to sexually perform after the va-sectomy. As Enrique put it, “I think thatmore than anything it scares you, no? To


think that…to think that afterwards it’snot going to work.” Some men also wor-ried that they would not want to havesexual relations with women again. Dur-ing numerous vasectomies the half-jok-ing banter revolved to a related sexualanxiety, i.e., worry that they might “beturned” as a result of the procedure.That is, that they would want to have sexwith only men.

Men’s sexualized relationship withwomen in Oaxaca was often the thorniestto analyze. “Will it work” was not for mostmen simply a question of “Will I still beable to have an erection and ejaculate?”The relationship of vasectomy to manhoodand manliness (hombría), and men’s con-cerns about the outcome of the operationwith respect to their subsequent sex lives,was described by some men as a consum-ing anxiety about being able to still satisfya woman sexually. The relationship be-tween vasectomy and manliness is inti-mately connected to that between vasec-tomy and sexual pleasure. And to the ex-tent that men’s sexual pleasure is associ-ated with women’s sexual desires and ful-fillment, one may well ask, again, aboutmale sexual predilections and urges.

When commonsense notions andapproaches to men’s sexuality gain theimprimatur of scientific explanation, ra-tionale, and rationalization as deliveredby duly licensed health personnel, theybecome medicalized. The belief that men“can’t help themselves” (such as, regard-ing adolescent masturbation and extra-marital affairs) was pervasive in Oaxacaacross class and ethnic lines and reflectedin popular sayings and attitudes. Whatconstituted natural and normal malesexuality in Oaxaca was informed by bothinternational family planning programsand local conventions and convictionsthat helped shape the policies that doc-tors and other health workers consideredappropriate for the region. The languageof family planning manuals was repletewith references to masculinity and malesexual drives.

Among health care specialists and thepopulation at large in Oaxaca several be-liefs concerning male sexual practices andurges that have little basis in biologicallyestablished fact are enshrined as scientifictruth. In this process of medicalization,men’s sexualities are made to seem inher-ently problematic, and many medicalpractitioners assume that men’s sexualitiesare more or less similar, that men are “con-trolled” by their sexualities, and that theirsexualities are innately problematic.4 Fur-ther, in considering health problems asso-ciated with male sexualities like impotenceand infertility, a medicalized model con-siders as secondary the broader social andpolitical relationships—for example, be-tween women and men and between menthemselves. Instead, such a model accen-tuates individual bodily malfunctions andabnormalities, for example, a lack of sexualdesire on the part of men. The broaderstudy on which this article is based con-siders in more depth the ways suchethnomedical beliefs about male sexuali-ties among biomedical personnel aregrounded in folk wisdom yet presented asscientific truth, and the relationship ofmedicalized thinking about male sexuali-ties to broader questions of sexual repro-duction and women’s sexuality.

Why men choose vasectomies inOaxaca, Mexico, may appear of no morethan esoteric interest to medical person-nel in Rhode Island. However, this casestudy illustrates how cultural bias inter-feres with medical practice. Few doctorsare eager to acknowledge cultural bias intheir treatment of patients, yet such rec-ognition is important if health care is tobe understood as more than biomedicalprocesses. Although this example is spe-cific to one region in Mexico, it may pro-vide an approach to understanding men’sreluctance regarding vasectomies any-where, and it illustrates how cultural be-liefs are critical factors in the acceptanceof certain medical procedures.

REFERENCES1. Gutmann M. The Meanings of Macho: Being a

Man in Mexico City. 10th anniv. ed. Berkeley: Uni-versity of California Press, 2006.

2. Gutmann M. Fixing Men: Sex, Birth Control, andAIDS in Mexico. Berkeley: University of Califor-nia Press, 2007.

3. Oudshoorn N. The Male Pill: A Biography of aTechnology in the Making. Durham, NC: DukeUniversity Press, 2003.

4. Sapolsky R. The Trouble with Testosterone: AndOther Essays on the Biology of the Human Predica-ment. New York: Simon and Schuster, 1997.

Matthew Gutmann, PhD, MPH, isProfessor of Anthropology, Brown Univer-sity.

Disclosure of Financial InterestsThe author has no financial inter-

ests to disclose.

CORRESPONDENCE:Matthew Gutmann, PhD, MPHDepartment of AnthropologyBrown UniversityProvidence RI 02912Phone: (401) 863-7732e-mail: [email protected]


Overweight and Diabetes In American Samoa:The Cultural Translation of Research Into Health Care Practice

Rochelle K. Rosen, PhD, Judith DePue, EdD, MPH, Stephen T. McGarvey, PhD, MPH�This paper describes the qualitative methodsand research process for translating evi-dence-based methods for managing type2 diabetes in the US to the American Sa-moan context.

The US territory of American Samoais 2600 miles southwest of Hawaii, abouthalfway between Hawaii and NewZealand. The independent country ofSamoa lies just to the west. Together theyform an island chain populated by thesame ethnic group of native Pacific is-landers. Before World War II residentsused subsistence farming and fishing; dia-betes was rare. More recently, non-com-municable chronic disease rates are ris-ing in both adults and children.1

Increases and changes in dietary in-take and reductions in physical activity,the “nutrition transition,” began in ear-nest in both Samoas after World War II.2

These changes, which were rapid from1970 –2000, led to levels of overweightand type 2 diabetes, especially in Ameri-can Samoa, the more economically de-veloped of the two polities. Adults inAmerican Samoa and Samoa now sufferfrom a high prevalence and 4-year inci-dence of overweight, obesity, type 2 dia-betes, hypertension and lipidemia andtemporal increases in each location.2,3,4

These levels are higher in American Sa-moa, with >80% of men and >90% ofwomen overweight, based on PolynesianBMI standards, BMI> 26 kg/m2.

Type 2 diabetes has reached epi-demic proportions in American Samoa.The prevalence rate among men aged 25to 54 years in 1990 was 12.9%, 17.2%in 2002.2 Among women of the same agerange, the prevalence rate doubled from8.1% in 1990 to 16.7% in 2002. Type 2diabetes prevalence rates among adultsaged 18 to 74 years in 2002 were 21.6%and 18.0% in men and women, respec-tively.

Socio-economic status (SES) playsa role. Samoans of higher SES in Ameri-can Samoa have more favorable profilesof obesity and chronic disease risk.5 Wespeculate this is due to higher SES indi-

viduals and families learning about over-nutrition and health and having moreaccess to high quality health care. Wehave much to learn about how non-Sa-moan foods are related to social prestige,from the earliest imported canned meatsin the 19th century to fast-food today.

These rapid changes in obesity andassociated health conditions occurred soquickly that health care systems, commu-nities, families and individuals have notreadily responded.2,6 Concepts such asthe health risks of obesity, patterns ofbody image favoring substantial bodysize, and the low awareness of the needfor lifetime management of chronic con-ditions, facilitate obesity and obesity-re-lated disease such as diabetes.

METHODSTo tailor an intervention to local

needs, the research team sought to learnabout diabetes care as well as the experi-ence of living with diabetes in AmericanSamoa via several qualitative researchsteps. (Table 1)

Preliminary meetings withcommunity partners

Our team met with communitypartners for extensive meetings beforeand after the grant funding was achieved.Subsequently, we chose a communityhealth worker model where lay healthworkers served as a bridge between pa-tients and health professionals to supportdiabetes self care.

Qualitative interviews with diabetescare providers and focus groups withdiabetes patients

These steps sought to identify attitudesabout food, exercise, self care, and the chal-lenges of being diagnosed with diabetes, orcaring for people with diabetes.

We conducted 15 in-depth inter-views with providers and staff at the com-munity health center where we worked.We also conducted 6 focus groups with39 patients, both recently diagnosed andthose living with diabetes for decades.

Translation and adaptation of measuresto the local context and language

The randomized trial will employ abaseline assessment using diabetes beliefand self care assessments, an assessmentof depression symptoms, and the PatientActivation Measure. These instrumentshave been developed and psychometri-cally evaluated in English,7,8 but neverused in American Samoa. Linguistictranslation involved a forward and backprocess: one member of our staff trans-lated the assessment questions. Anotherstaff member back-translated the Sa-moan-language items into English. Theoriginal English question was comparedagainst the English version translatedfrom the Samoan. Where necessary, al-terations were made for accuracy.

Cognitive interviewsWe used cognitive interviews to find

out whether participants understood theSamoan translation of the original En-glish-language question. A researcheradministered a sub-set of the survey ques-tions to a participant, who answered us-ing the required response format. Then,guided by questions and probes, the par-ticipant was asked to think aloud, explain-ing how and why s/he answered the ques-tion as s/he did. Through this processwe clarified the meaning of words orphrases, probed the recall and retrievalfrom memory of information needed toanswer the question, and consideredwhether the available response formatsenabled the participant to provide anappropriate, accurate answer.9

Assessments of the plannedintervention by local research staff

We reviewed material from both fo-cus groups and provider interviews withthe local Samoan research staff whowould be making home visits. Thesematerials included flipcharts for teach-ing about diabetes, communication strat-egies, referral resources and documenta-tion forms. This process identified whereedits and revisions were needed.


Post-intervention provider interviewsand intervention patient focus groups

At the conclusion of the one-yearintervention we will again use qualitativemethods to assess the success andsustainability of the intervention throughinterviews with providers and focusgroups with participants.

RESULTSPreliminary analysis of providerinterviews and focus groups

We present early results of our quali-tative interviews and focus groups, high-lighting how these data have informedour intervention design. Since many ofthe major themes within the two data setsoverlap we present these results accord-ing to those themes, rather than by pro-vider interview or patient focus groupmodality.

Barriers to self care Most diabetes patients understood

that a high fat diet, lack of exercise, andstress caused or contributed to diabetes,and that the best control strategy was tolimit high fat, sugar-laden food, and toexercise regularly. But many patientsstruggled to incorporate those strategiesinto their lives.

Many participants noted thathealthy food is costly, and that much ofthe imported foods are processed, frozenand/or expensive. The inexpensive foods,such as turkey tails and mutton flaps, arevery high in fat. Both patients and pro-viders articulated how difficult it can befor patients to maintain a healthy diet.Patients worried they would not feel fullor be satisfied eating healthy foods. Some

patients had no control over the foodsprepared by family members, and couldnot resist the foods at ritual family gath-erings, called fa’alavelaves. Others askedwhether traditional foods, like taro andbanana, could be eaten in moderation orshould be avoided completely.

Providers identified other barriers tocare; e.g., patients did not have enoughmoney to pay for medication co-pays,clinic visits and blood draws. Some pa-tients could afford to fill only one pre-scription at a time. Only those who werefinancially secure could buy glucometersand strips.

Patients often sought care only aftera crisis, like hospitalization, blurred vision,or numbness. Some patients’ symptomshad reached an advanced stage, even tothe point of blindness, or the need foramputation of a leg or foot. Many wereaware of their symptoms for a long time,but did not seek help either because theyfeared learning they had the disease andwould have to change their lifestyle orbecause they just did not want to believethey had diabetes.

Many patients did not understandthe fluctuations in their blood sugar andwhy this happened, even while takingtheir medications. A participant re-marked: “As of now, when I check my sugarlevel, I really don’t know what is high andwhat is low…” . At times, some partici-pants found that the medications did notappear to relieve their symptoms. As aresult, many stopped taking medications:they felt the medications were ineffectiveor even worsened their symptoms. Inaddition, many participants lacked trans-portation to get to the hospital or clinic

for appointments.

The Role of family and familyevents

Many islanders live in extended fam-ily residences, a social organization thatinfluences diabetes management. A fewolder participants noted that their chil-dren, who were responsible for prepar-ing foods, were not receptive to the wishesof the family member with diabetes:“There are times for me because I am get-ting old now, all I want to eat is soup…butmy kids fix something else and all that comesto my mind is that I am going to just throwit away because it’s not what Iwanted…kids like to eat fried foods …andthey don’t prepare it in favor of the personwho wants it.”

Fa’alavelaves are Samoan ceremoniesand cultural gatherings, usually con-nected to a lifecycle event like a weddingor a funeral, which require significantdonations of money or time. They arewidely cited as central to fa’a Samoa, theSamoan way of life. Yet our interviewsand focus groups pointed to thefa’alavelaves as a source of stress as well asof social solidarity. Many participants in-dicated that the events were an obstacleto their diabetes care. One participantremarked, “the truth is that one of the causesof this disease called diabetes in our coun-try is fa’alavelave that happens within ourown families.”

In addition to the stress accompaniedby organizing and contributing money tothese events, many participants said thatit was very difficult to eat healthy duringthem. “Even though there are guidelines setfor diabetics about what kinds of things toeat, there are times in our culture whenfa’alavelaves happen…when they serve thefood, you are not thinking about what foodsare restricted for eating and what foods arehealthy. When the food is served at thosetimes, you just eat it.” One participant de-scribed the cultural and social expectationsrelated to food consumption: “If you don’teat the food, there are also cultural feelingsabout this. You know, like you are not a manif you do not eat all the food.”

Stress, depression and DiabetesAmerican Samoans have said, anecdot-

ally, that their blood sugar rises with stress.6

The most commonly cited source of stress isfamily financial obligations, including those

Table 1. Qualitative research design for Diabetes Carein American Samoa

1. Preliminary meetings with community partners2. Qualitative in-depth interviews with diabetes care providers3. Focus groups with diabetes patients4. Linguistic translation and adaptation of measures to the local context in the

Samoan language5. Cognitive interviews using translated and back translated questionnaire

items6. Assessments of the planned intervention by the projects’ American

Samoan research staff

INTERVENTION IN RANDOMIZED CONTROLLED TRIAL

7. Post-intervention in-depth interviews with providers8. Post-intervention focus group with intervention patient-participants

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related to fa’alavelave. Here a participantaddresses the pull of these commitments:

if they are supposed to give some-thing for the church versus the moneyto spend on the medication or thegoing into the hospital, [patients] willtake the fa’alavelave and church firstand this is second. So when it comesto health, health is low priority as faras the Samoan. You’ve got to give tothe church first, you’ve got to give tothe fa’alavelave… They will go bor-row money to give to the fa’alavelave,give to the church, but as far as some-thing for themselves, [like] health…,it come at less of a priority.

Other sources of stress include lackof income; job difficulties; disagreementwith a spouse; children; and illness.

Providers suggested that patientswould not independently raise concernsabout depression or stress, so researchstaff would need to ask about them di-rectly. Patients might not even know ofthe link between stress and health.While our clinician participants articu-lated several sources of stress in their pa-tients’ lives, some felt the patients didnot recognize the linkage:

“I very seldom hear people talkabout [stress] like it is a big issue or abig problem … most of the people[I] have encountered, they said ‘stress?what does stress have to do with it?’It is like new to them when I saystress. So I think that is one thingthat most of our healthcare provid-ers need to try to talk about insteadof just food and exercise …[they]need to mention that too, stress.”

As for older patients,

“…they don’t know what stress is.They think that when they get a lot ofstress it’s from the fa’alavelave, a lot offa’alavelave that [they] are involved in,something bad or someone in the fam-ily passed away. And all those thingsthat they think of, it’s that but not fromthe disease that they have.

For Samoans, stress and depressionare deeply private concerns, rarely dis-cussed. Consequently, it may take several

times to introduce the topic before peopleare willing to discuss it candidly, or at all.

How to be an effectiveCommunity Health Worker (CHW)

In interviews with clinicians and careproviders, participants were positive, evenenthusiastic, about our use CHWs. (Theyhad been used on island for other healthconcerns.) Our participants had a vari-ety of suggestions about how and whento visit patients. Particularly importantwas that CHWs needed to show culturalsigns of respect, both to patients and tofamily members, including greeting el-der family members first:

First and foremost in the Samoanculture you gotta learn to excuse your-self before the family. You knowmaybe they were doing somethingand we are there interrupting. Soin a respectful manner you wouldexcuse yourself and then introduceyourself and what you are doing.

Since the patient with diabetes maynot be the person who cooks the familyfood, it is important to involve thatcook—often a difficult task.

I think that one of the challengesis getting the family involved. Mostof the time…I tell them to come in[and] please bring in your familymembers so we can teach them at thesame time. Because the patientsthemselves aren’t cooking themeal…the family members are. Soif we can get the family members tocome in, and teach them as well, andeducate them about diabetes, I thinkthat is the biggest challenge I face now.

CONCLUSIONThe transition from a traditional to a

modern lifestyle has been rapid in Ameri-can Samoa since WWII and especiallysince the 1970s. A similar transition hasoccurred among immigrant communitiesin the mainland US. Rhode Island has avariety of immigrant groups. Just as pre-paring for our research intervention inAmerican Samoa required careful atten-tion to cultural translation, clinical prac-tice with patients also requires keen atten-tion to the patients’ backgrounds, experi-ences, languages and beliefs.

The qualitative methods used in pre-paring for this diabetes intervention inAmerican Samoa can guide clinical careand behavioral research in Rhode Island.Interviews with local community membershelped us learn how patients sought outcare. Interviews with care providers andfocus groups with patients helped us learnabout barriers and facilitators of care. Be-cause we sought to design materials forCHWs, we needed to learn about boththe patients’ perspective of living with achronic illness and the providers’ experi-ence of providing care. In our prelimi-nary analysis, both patients and providersidentified similar challenges, especially:healthy eating, exercise and understand-ing stress. Both sides stressed fa’alavelaveand the challenges these feasts offer tohealthy eating, as well as the role of thosefeasts as a cultural stressor.

Whenever a research or clinical in-strument is translated, back translationprovides an opportunity to confirm andclarify the effectiveness of the translation.In this project we used cognitive interviews,commonly used in survey item develop-ment and design, to clarify not only theeffective linguistic translation of the lan-guage used in the questions, but also tofurther understand the cultural elementsthat shaped participants’ understandingof, and answers to, the survey questions.

Reviewing our intervention materi-als with the staff who are going to imple-ment them and inviting their insights wasparticularly useful. For example, the staffrecommended using both English andSamoan on each page of materials, andwe are now adapting our materials. Staffsuggested hands-on teaching techniquesand helpful logistical strategies for coor-dination of care. Additionally, our staffvalued the opportunity to be treated asexperts in their culture and appreciatedtheir role in the design of the materialsthey would be using with patients.

In clinical practice with patients ofdifferent cultural backgrounds, it is im-portant to assess patients’ and providers’beliefs and understanding about themedical condition. We find that it is alsoimportant to inquire about patients’ ownsolutions, and to seek the expertise ofhealth workers, because the integrationof patients’ cultural elements with mod-ern intervention practices ensure that theintervention will be most effective.


REFERENCES1. Friedman JF, Kurtis JD, McGarvey ST. The dual

burden of infectious and non-communicable Dis-eases in the Asia-Pacific region. Med & Health/RI2007; 90:346-50.

2. Keighley ED, McGarvey ST, et al. Nutrition andhealth in modernizing Samoans. ED Keighley,In R Ohtsuka, SJ Ulijaszek (eds). Health Changein the Asia-Pacific Region: Biocultural and Epide-miological Approaches. Cambridge UniversityPress, 2007:147-91.

3. McGarvey ST. Cardiovascular disease (CVD) riskfactors in Samoa and American Samoa, 1990-95.Pacific Health Dialog: J Community Health ClinMed for the Pacific 2001; 8(1): 157-62.

4. Keighley ED, McGarvey ST, et al. Farming andadiposity in Samoan adults. Am J Human Biol2006; 18:112–21.

5. Ezeamama A, Viali S, et al. The influence of so-cioeconomic factors on cardiovascular disease riskfactors in modernizing Samoans. Soc Sci Med2006; 63: 2533-45.

6. Elstad E, Tusiofo C, et al. Living with Ma’i Suka.Prev Chronic Dis 2008:A79. Epub 2008 Jun15.

7. Hibbard JH, Stockard J, et al. Development ofthe Patient Activation Measure (PAM). HealthServices Research. 2004; 39:1005-26.

8. Spitzer RL, Kroenke K, Williams JB. Validationand utility of a self-report version of PRIME-MD.Patient Health Questionnaire. JAMA1999;282:1737-44.

9. Willis GB. Cognitive Interviewing: A Tool For Im-proving Questionnaire Design. Thousand OaksCalifornia: Sage Publications, 2005.

Rochelle K. Rosen, PhD, is AssistantProfessor (research) Centers for Behavioraland Preventive Medicine, The MiriamHospital and Department of CommunityHealth, Warren Alpert Medical School ofBrown University.

Judith DePue, EdD, MPH, is Clini-cal Associate Professor, Centers for Behav-ioral and Preventive Medicine, TheMiriam Hospital and Warren Alper tMedical School of Brown University.

Stephen T. McGarvey, PhD, MPH, isProfessor of Community Health and An-thropology, Director of the InternationalHealth Institute, Brown University.

Disclosure of Financial InterestsThe authors have no financial inter-

ests to disclose.

CORRESPONDENCE:Rochelle K. Rosen, PhDCenters for Behavioral and PreventiveMedicine1 Hoppin St., Suite 500 Providence, RI 02903 Phone: (401) 793-8182e-mail: [email protected]


Evaluating Geriatrics In the Medical School Curriculum:Using Student Journals

Timothy W. Farrell, MD, Susan Campbell, MA, Aman Nanda, MD, Renée Shield, PhD, and Terrie Wetle, PhD�“I really enjoy the conversations

I have with the elderly as part ofthe Doctoring course, but my com-fort in interacting with them as ahealth care provider is stilllow…the more exposure I get to theelderly, however, the less averse theidea of working with older patientsbecomes…the most significantchange in my thinking about theelderly was the acknowledgement ofa couple of misconceptions…”

This article discusses the experiencesof first-year medical students with olderpatients in the “Doctoring” course in thefall of 2007, as well as their responses toaging content integrated into the curricu-lum. We developed an evaluation projectto assess the impact of the new curriculumand its aging content. Rather than relysolely on a quantitative survey of pre-postattitude change related to the curricularchanges, we elicited students’ reflections onthe relevance of the geriatrics curriculumto their medical education, their emergingidentities as physicians-in-training, and theirexperiences via entries in weekly journals.

The goals of this journaling projectwere threefold. First, we hoped to ana-lyze successes and opportunities for im-provement within the new geriatrics cur-riculum. Second, we attempted to gaugestudents’ changing views regarding theprospect of caring for elders. Finally, weaimed to shed light on the “meta-theme”of students’ development towards be-coming medical professionals. The inte-gration of geriatrics content within theredesigned medical school curriculumhas been developed with Donald W.Reynolds Foundation support, now com-pleting the second year of a four-yeargrant. We recruited eight first-year vol-unteers in the spring of 2007 to writeweekly journal entries on their reactionsto and evaluations of aging-related coursecontent and exposure to older patients.We wanted to know: “How have medi-cal students responded to the recent in-clusion of geriatrics within the new cur-riculum at Brown Medical School?”

Our interdisciplinary team adopteda qualitative approach inspired by an-thropological field methods and increas-ingly used in health services research to“code” the journals. These journals alsoenabled faculty to capture students’ re-sponses to curriculum in real time, allow-ing for mid-course corrections.

Although previous analyses of medi-cal student responses to geriatrics curriculaused quantitative surveys, 1 qualitativestrategies have gained greater recognitionin recent years. The AGS (American Ge-riatrics Society) competencies guided thedevelopment of a coding structure toevaluate medical student responses to ageriatrics curriculum at the University ofCincinnati. 3, 4 Medical students at theUniversity of Missouri-Kansas City pairedwith elderly “mentors” kept reflective jour-nals limited to this component of the geri-atrics curriculum. 2 Web-based geriatricsportfolios developed at the University ofMichigan tracked students’ mastery ofgeriatrics curriculum, but did not allowfor students’ reflections.5 To the best ofour knowledge, our project is the first at-tempt to qualitatively analyze medical stu-dents’ responses to a geriatrics curriculumwithout using a survey instrument or an apriori guide to coding responses. We choseto better understand students’ range of ex-periences by asking them to reflect andwrite about them.

METHODSAfter obtaining Brown University

IRB approval, we asked the MD class of2010 for volunteers via e-mail. Interestedstudents came to an informational meet-ing. Prospective participants returned for

individual meetings to review and signthe consent document. Students whosuccessfully completed the semester’sjournal assignments were provided amodest honorarium. Two members ofour team conducted all correspondencewith journalers throughout the semester.Weekly emails to the participants weresent with journal assignments consistingof two standard questions. (Table 1)During most weeks the team added athird question, tailored to that week’s con-tent. For example, in the middle of theDoctoring course, the third questionasked students to assess their interview-ing skills. (Table 2) Student names werereplaced by code numbers. Each weekour team correspondents acknowledgedreceipt of the journals and frequentlyprovided feedback.

Eight student journalers began theproject; four students completed the se-mester. When the semester was over, alljournalers, including those who haddropped out, were invited to a “thankyou lunch” to gain feedback. Studentswho had not completed the project wereasked their reasons for stopping; mostcited competing responsibilities andcourse work demands. Recruitment ofjournalers has continued. We have justcompleted two more semesters ofjournaling in which both first and sec-ond-year medical students participated,and we expanded the journaling projectto the clerkship years in 2008-2009.

Coding committee and processAll journals were first reviewed by

the two team members who ensuredthat names and identifying information

Table 1. Standard Journal Questions

1. What are your experiences, reactions, and insights related to thegeriatrics content you have received in your medical school courses?

2. What are your experiences, reactions, and insights regarding the olderpatients (> or = 65) you have encountered in your communitymentoring through the Doctoring course? (This includes standardizedpatients.) You may also report on encounters you may have with theelderly in other settings. You may wish to compare your experienceswith older patients to experiences with younger patients.


of students and others named in the re-ports were eliminated. Journals weretransformed into a standard format anddistributed to our interdisciplinaryanalysis team (a health services re-searcher, gerontologist, medical anthro-pologist, and two geriatrics-trained phy-sicians). The team members read thejournals numerous times to develop ananalytic “coding structure,” i.e., a list ofrelevant and common thematic ele-ments.6 The initial coding structureemerged from preliminary readings ofjournal transcripts between fall 2007and spring 2008, and was based largelyon a division between didactic (i.e., stu-dents’ coursework) and experiential (i.e.,clinical contacts with older patients) con-tent. Codes also identified topics, such

as students’ social and cultural back-grounds, their perspectives on ageism,and their views regarding the care of ge-riatric patients. Weekly team meetingsinvolved a line-by-line review of thecoded transcripts to discuss each teammember’s rationale for assigning a givencode to specific material. As the teamprogressed through the journals, thecoding structure was revised and re-fined. During this process, the teamgained familiarity with the narrativematerial and developed consensus aboutcode definitions. Throughout this pro-cess, a detailed “audit trail” documentedteam decisions, alterations in codes, andemerging themes.

The development of a coding struc-ture to identify themes arose in a man-

ner similar to that described by Westonet al. for the analysis of qualitative data.Weston stressed three main principles forthe analysis of qualitative data:

1. “Coding is not what happens be-fore the analysis, but comes to con-stitute an important part of theanalysis. There is a reciprocal re-lationship between the develop-ment of a coding system and theunderstanding of a phenomenon.

2. A team builds codes and codingbuilds a team through the creationof shared interpretation and un-derstanding of the phenomenonbeing studied.

3. Collaboration in qualitative re-search requires a kind of rigor thata lone or independent researchermight not be aware of or need.” 6

In keeping with Weston’s principles,themes and subthemes generated fromthe conceptual framework of our initialcoding structure were revised duringeach meeting. Both the initial codingstructure and the identification of newthemes required consensus among thegroup. Finally, the interdisciplinary na-ture of our team fostered vigorous dis-cussion and led to rigorous developmentof codes and themes.

STUDENTS’ RESPONSES TO THEGERIATRICS CURRICULUM

The overall goals of this medical stu-dent journaling project were threefold.First, we hoped to analyze successes andopportunities for improvement withinthe new geriatrics curriculum by gaug-ing students’ responses. This analysis ledto mid-course corrections, e.g., discussionwith the relevant course directors tostreamline and better integrate the de-livery of geriatrics content during didac-tic sessions. Student suggestions for ad-ditional content were also noted:

“I would have liked to hearabout how anxiety manifests inolder patients. Perhaps there aredifferent concerns that older pa-tients have. Also, I would haveliked to hear about how receptiveolder patients are to psychotherapyand cognitive behavior therapy.”

Table 2. Additional (Third) Journal Questions

Wk 1: 3rd question not askedWk 2: Do you see a clinical application of course content this week,

especially as it might pertain to older people?Wk 3: What has been most surprising or unexpected about what you’ve

learned regarding dementia or memory loss?Wk 4: How might stereotypes you hold influence your care of older

patients?Wk 5: How might aspects of culture (your own and that of the older

patients you see) affect how you interact with them?Wk 6: Do you see particular challenges and/or opportunities in counseling

older persons on psychiatric issues?Wk 7: Write about how alcohol and/or drug abuse might pose different

issues for an older person and/or for the clinician treating him or her.Wk 8: In assessing your interviewing skills at this point, are you noticing

any particular challenges or satisfactions in interviewing older ascompared to younger patients?

Wk 9: What are your thoughts about the hospital experience for olderpatients?

Wk 10: Please discuss special concerns older patients might have withdiabetes.

Wk 11: How did the epidemiology/quantitative reasoning course contenthelp you to understand aging populations?

Wk 12: Please reflect on how your interviewing skills improved over thisyear and how your approach to older patients may be different thanthat with younger patients.

Wk 13: Looking back over your experience in the community last year, whatobservations or insights have you developed regarding the care ofolder persons?

andPlease describe whether and/or how the course content inMedMicroID may have particular relevance to older personscompared to younger persons.

Wk 14: Please write about how your exposure to older patients over thisacademic year may have changed your level of interest in workingwith older patients in the future.

Wk 15: Thinking back to the beginning of the year, please write about anynew insights you’ve had about older patients that you might not havepredicted then. For instance, do you look at older people differentlynow? If so, how?


Based on positive comments, theanatomy lab “treasure hunt,” in whichexperienced geriatrician faculty membersused cadavers to demonstrate findingsunique to geriatrics patients, was ex-panded in the project’s second year. Par-ticular successes within the first-year di-dactic curriculum, such as the inclusionof geriatric patient guest lecturers andpatient videos, were noted with enthusi-asm. One student put it this way:

“But with a simple procedurethat was done, we saw this womanwalk briskly in weeks, without awalker and without assistance. Wecannot doubt the power of the eld-erly to recover.”

The second goal was to gauge stu-dents’ responses to the prospect of car-ing for elders. Students wrote elo-quently about stereotypes (e.g., ageism),challenges in caring for the elderly (e.g.,multiple comorbidities, polypharmacy,and complex psychosocial situations),gratifying aspects of geriatrics (e.g.,learning about older patients’ fascinat-ing life stories), and the relevance of theirown individual and cultural back-grounds to caring for the elderly. Onestudent wrote:

“Care for the elderly is a crucialpart of my culture, as we view theelderly not only as sources of wisdomand experience, but also our livinglegacy; we exist in many ways be-cause of them, and because of this itis our obligation to care for them.”

Students often expressed surprise attheir lack of awareness:

“What really didn’t occur to me be-fore this year was striving for healthyaging. I had encountered older pa-tients, but it was always in the hospi-tal setting. I didn’t know that therewas assisted living. Perhaps becausemy family believes that older peopleneed to be taken care of by their chil-dren, I had never thought that inde-pendence could be a positive attributefor an older person.”

Another student noted:

“Outside of the geriatric content,we seem to study perfect systems. Thisintegration provides a good oppor-tunity to appreciate the inevitablecomplexities of all our patients—young and old.”

Third, we examined the “meta-theme” of students’ development towardsbecoming medical professionals. Part ofthis development involves an appreciationof the challenges and uncertainties inher-ent in patient care, especially in geriat-rics. Where students sometimes com-mented on the complexity of care forolder patients, they also recognized thatcomplexity was a part of the practice ofmedicine. One student wrote:

I feel that…the most important‘take-home message’ for me is that it’sa person that I am treating, not amedical chart or series of symptoms.”

Students’ responses tojournaling

In addition to the journals, feedbackfrom students at the “thank you lunch”provided additional perspectives. Stu-dents liked the regular chance to reflecton the week’s studies and clinical encoun-ters; they enjoyed writing as a contrast-ing relief to memorization and science.Students took seriously their contributionsto the improvement of the curriculum.They witnessed the curriculum changingand understood that they had a hand inits evolution. One of the journalers sub-sequently expressed a view that we heardfrom others:

“…though on busy weeks[journaling] is an extra thing to do,it was also nice to have a reason todo some reflective thinking andwriting.”

The few negative perceptions fromstudents included running out of newthings to say, feeling too pressured bycoursework to spend time writing, andfeeling constrained by the questions asked.

Overall, the excitement and apprehen-sion of these students about entering themedical profession comes through in thejournals, even among those students whowere not interested in geriatric medicine asa career. It is hoped that this type of self-

reflection, as exemplified by the followingjournal excerpt, contributes to the devel-opment of the medical student journalersas emerging medical professionals:

“I hate that my grandmother’slast hospital visit was characterizedby doctors who didn’t listen…thisintrospective process has helped meto see the real importance of com-munication and understanding. Ihope the geriatric integration helpsBrown produce the type of physi-cians that I would want caring formy grandmother.”

IMPLICATIONSImplications for MedicalStudents

What are some of the preliminarylessons learned from this medical studentjournaling project? First, qualitative re-search methods offer insights which aredifficult or impossible to obtain usingquantitative strategies.8 For example, stu-dents reflected thoughtfully about thecontribution of the geriatrics curriculumto their medical education. For many stu-dents, even those entering pediatrics, ex-posure to geriatrics was felt to have honedtheir interviewing skills and increasedtheir comfort in caring for complicated,frail patients. For students contemplat-ing careers involving geriatric patients(e.g., primary care and surgical special-ties), this early exposure to geriatrics gen-erated recognition of its crucial impor-tance to high-quality patient care. Forstudents considering geriatrics as a career,integration of geriatrics appeared to in-crease their interest.

Implications for facultyThe preliminary lessons learned for

faculty and community mentors are com-pelling. Courses with an uneven or inef-fective approach to integrating geriatricsinto the curriculum were identified sothat adjustments could be made. Stu-dents generated ethical questions aboutthe intensity of medical care (especiallyat the end of life) and resource alloca-tion, even when not specifically asked tocomment on these weighty issues. Thisfocus suggests that increased attention tosuch ethical themes may be warranted.Students also seemed to arrive at the in-dependent conclusion that, while not ev-


ery medical student will graduate as ageriatrician, a basic knowledge of geriat-rics is essential in almost any medical dis-cipline. Finally, students appreciated theopportunity to participate in thejournaling process: they were stakehold-ers in the geriatrics curriculum.

Overall, the message from studentswas: “Give us geriatrics content, as longas it is well-integrated and allows time forthoughtful discussion.” At the very least,even among those students without aninterest in geriatrics, the habit of thought-ful interviewing accompanied by attentivelistening during the patient encounter andactive reflection after the patient encoun-ter will serve them well. This evaluationjournaling project is an example of a valu-able research tool to inform the educationof and clinical impact on medical students.This ongoing effort to qualitatively assessinsights from medical student journalers,even as they enter their clerkship years, willcontinue to inform the integration of ge-riatrics content within the Warren AlpertMedical School curriculum.

REFERENCES1. Alford CL, et al. An introduction to geriatrics for

first-year medical students. J Am Geriatric Soc2001; 49: 782-77.

2. Arnold L, Shue CK, Jones D. Implementation ofgeriatric education into the first and second yearsof a baccalaureate-MD degree program. Acad Med2002: 77: 933-4.

3. Goldenhar LM, Kues JR. Effect of extracurricu-lar geriatric medicine training. J Am Geriatric Soc2008; 56: 548-52.

4. Goldenhar LM, Kues JR. Effectiveness of a geri-atric medicine student scholars program. J AmGeriatric Soc 2006; 54:527-34.

5. Supiano MA, Fantone JC, Grum C. A web-basedgeriatrics portfolio to document medical students’learning outcomes. Acad Med 2002: 77: 937-8.

6. Weston C, et al. Analyzing interview data. Quali-tative Sociolog 2001: 24: 381-400.

7. Retooling for an aging America: Building thehealth care workforce. Institute of Medicine Re-port: 14 April 2008. http:/www.iom.edu/CMS/3809/4011/53452.aspx

8. Curry L, Shield R, Wetle T. (eds.) Improving Ag-ing and Public Health Research: Qualitative andMixed Methods. American Public Health Associa-tion, Washington DC, 2006.

Timothy W. Farrell, MD, is a Geriat-ric Medicine Fellow, the Division of Geri-atrics, The Warren Alpert Medical Schoolof Brown University.

Susan Campbell, MA, is Project Coor-dinator in Gerontology, The Warren AlpertMedical School of Brown University.

Aman Nanda, MD, is Assistant Pro-fessor of Medicine, The Warren AlpertMedical School of Brown University.

Renée Shield, PhD, is Clinical Asso-ciate Professor of Community Health, andDirector, Resource Center for GeriatricsEducation, The Warren Alpert MedicalSchool of Brown University.

Terrie Fox Wetle, PhD, is AssociateDean of Medicine for Public Health andPublic Policy, and Professor of CommunityHealth, The Warren Alpert Medical Schoolof Brown University.

Disclosure of Financial Interests

All authors. Grant Support: DonaldW. Reynolds Foundation.

Aman Nanda, MD. Grant Support:Amgen. Consultant: Forrest Pharmaceu-ticals.

CORRESPONDENCE:Timothy W. Farrell, MDRhode Island HospitalDivision of Geriatrics593 Eddy StreetProvidence, RI 02903Phone: (401) 787-6355e-mail:[email protected]


A 78 year-old woman is sent to the emergency departmentemergency departmentemergency departmentemergency departmentemergency department(ED) from a nursing home for evaluation following a fall. Shehas a medical history of hypertension and osteoporosis, andtakes metoprolol XL, HCTZ, and calcium carbonate with vi-tamin D. After spending 7 hours in the ED, she is admitted tothe orthopedic floor with a right hip fracture. The admittingnurse finds a stage 2 pressure ulcer (PU) on her coccyx andblisters on her heels. The nursing home record does not docu-ment PUs. This article discusses evaluation of patients for riskof PUs and reviews measures for PU prevention. Evaluationand treatment will be addressed in a future column.

BACKGROUNDHospitalized patients have an incidence of PUs as high as

30%; more than half of those ulcers occur in older adults. Be-ginning in October 2008, CMS stopped reimbursement tohospitals for treatment of hospital-acquired PUs .1 As a result,it is hoped that hospitals will focus on early evaluation of pa-tients at risk to assess for preexisting ulcers and take preventivemeasures. Similar measures should follow in nursing homes.

PU prevention and management have been mandated foryears in nursing homes that receive Medicare funding. Theregulations became more stringent in 1994.2 Prevalence ofPUs in long term care facilities (LTCF)s is as high as 23.9%.3

Medicare dictates that nursing homes which receive federaldollars institute protocols for prevention and management ofPUs. Facilities failing to institute wound care procedures riskcitation, loss of reimbursement and fines. These proceduresinclude assessment of the patient’s skin on admission, a com-prehensive risk assessment, creation of a plan of care based onthat individual’s risks, and on-going monitoring. Early assess-ment is critical to establish where the ulcer developed—thenursing home or the hospital—for reimbursement purposes.The initial assessment should include a skin examination in theED for hospitalized patients as part of the admission diagnosislist to up-code for PU treatments, which average $18,688 perulcer.6 If a PU is not recognized and documented on admis-sion, even though present, the PU will be considered hospital-acquired, and the hospital will not be reimbursed.

RISK ASSESSMENTStandardized assessment tools will stratify an individual’s

risk of developing a PU. The Norton4 and Braden5 Scales ratepatients based on mental status, mobility, nutrition, activity,moisture/continence, and sensory perception. Raising aware-ness of the individual’s risk can allow preventive measures to beimplemented in a timely fashion. Assessment needs to occurearly and often during hospitalization. As a patient’s condition

changes, interventions need to be adapted.Assuming that the patient’s skin is intact at the initial ex-

amination, a risk assessment on admission should be obtainedusing those scales. The score will dictate interventions for pre-vention of hospital-acquired PUs.

ADDRESSING RISK FACTORS OF MOBILITY AND PRESSUREA common PU risk for patients in the hospital or nursing

home is decreased mobility, resulting from either illness ortreatment modalities. It is important to encourage and facili-tate mobility in patients able to ambulate. Avoiding sedationand restraints, and eliminating IVs and Foley catheters enablepatients to be active. Initiating physical therapy early in theadmission can be invaluable for mobilizing patients. For pa-tients unable to ambulate or position themselves in bed, it isnecessary to assist them to change position at frequent inter-vals. Tissue ischemia occurs in areas compressed between bonyprominences and support surfaces in a short time, and perma-nent injury can occur in as little as two hours.7

Most hospitals and many nursing homes use pressure re-duction mattresses on all their beds. For prevention of PUs,such mattresses may be sufficient for patients at average risk.For patients at high risk, alternative surfaces should be ordered.Inexpensive options, such as egg crate mattresses, sheepskinsand water or gel-filled overlays, do not provide pressure relief.They may even increase moisture, compounding the problem.More advanced surfaces include low air loss mattresses, whichallow slow leakage of air through a system of small holes, caus-ing the patient to “float.”8 Air-fluidized mattresses and alter-nating pressure mattresses are more costly, and generally arereserved for patients with an existing PU or with unusuallyhigh risk.

ShearShear adds injury to pressure. Shearing occurs when grav-

ity acts to cause internal opposing motion of tissue against bone.The classic example is the patient who is positioned in bed withthe head of the bed up too high: they will gradually slide downtoward the foot of the bed, causing movement of tissue planes.This force will contribute to pressure ulcers just as the pressureeffect itself will. Shearing can stretch tissues and produce tearsin capillaries.9 Prevention of shearing injury is achieved bymaintaining the angle of the head of the bed elevation or lat-eral rotation of the body at 30 degrees or less.

MoistureMoisture increases the risk of PUs. Perspiration, urine,

feces and wound exudates alter the pH of the skin, strip away

The Practicing Physicians’ Guide To Pressure Ulcers in 2008Rachel Roach, MSN, ANP, GNP, WCC

GERIATRICS FOR THEPRACTICING PHYSICIANDivision of Geriatrics Quality Partners of RI

Department of Medicine EDITED BY ANA TUYA FULTON, MD

THE WARREN ALPERT MEDICAL SCHOOLOF BROWN UNIVERSITY


the acid mantle and make the skin more prone to breakdown.10

Superimposed candidiasis or cellulitis is also more likely in theface of excessive moisture, and encourages skin breakdown.Minimizing moisture and protection of intact skin is impor-tant to PU prevention. Incontinence is best managed by sched-uled toileting. Urinary catheters should be avoided. Multiplebarrier products are available for skin protection.

NUTRITIONA patient’s nutritional status has substantial impact on pre-

vention and healing of PUs. A serum albumin of less than 3.5increases pressure ulcer risk. Other factors associated with therisk of under-nutrition and weight loss include the need forassistance with eating; consumption of less than half of mealsor snacks; oral pain; poorly fitting dentures; dysphagia; vegeta-tive signs of depression; mental status deficits; and certain dis-eases—diabetes, COPD and cancer. Consultation with a dieti-cian and speech therapist will help prevent and address nutri-tional deficits.11

CONCLUSIONThe recent CMS quality improvement initiatives provide

strong encouragement to hospitals and hospital practitionersto improve assessment and prevention of patients’ risk for PUsor face lower reimbursement rates for treatment of the ensu-ing PUs. In the future, nursing home practitioners are likely tosee similar incentives for PU prevention. Documentation ofpreexisting ulcers, PU risk assessment and measures in placefor prevention of PUs will facilitate reimbursement for the costlyand important care provided to patients.

Rachel Roach, MSN, ANP, GNP, WCC, is a Teaching Asso-ciate, Division of Geriatrics, Department of Medicine, RhodeIsland Hospital, The Warren Alpert School of Medicine at BrownUniversity.

RESOURCESBraden Scale: http://www.hartfordign.org/publications/trythis/issue05.pdfmedpac.govNorton Scale: http://www.woundcarehelpline.com/NortonScale.pdf

REFERENCES1. Miller ME. Pay for Performance in Medicare. Testimony before the US Senate

Medicare Payment Advisory Commission. July 27, 2005. MedPac Website.http://www.medpac.gov.

2. Allman RM, Laprade CA, et al. Pressure sores among hospitalized patients.Ann Intern Med 1986:105:337-42.

3. Williamson J. Pressure’s on. http://www.mcknights.com/Pressures-on/article/107737.

4. Cuddigan J, Avello EA, eds. Pressure Ulcers in America: Prevalence, Incidence,and Implications for the Future. Reston, VA: National Pressure Ulcer AdvisoryPanel; 2001.

5. Norton D, McLaren, Exton-Smith AN. An investigation of geriatric nursingproblems in the hospital. London. National Corporation for the Care of OldPeople (now the Centre for Policy on Ageing); 1962.

6. Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale forPredicting Pressure Sore Risk. Nurs Clin N Am 1987; 22: 417-28.

7. Frantz RA, Gardner S, et al. Integration of pressure ulcer treatment protocolinto practice. Outcomes Manag Nurs Pract 2001;5:112-20.

8. Kirman CN, Molnar JA. Pressure Ulcers, Nonsurgical treatment and princi-pals. Jul 2008 eMedicine.

9. Agostini JV, Baker DB, Bogardius ST. Making Healthcare Safer: A CriticalAnalysis of Patient Safety Practices. Chap 27. www.hhs.gov.

10. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient.Advances Skin Wound Care 2002:15:170-6.

11. Gilmore S, Rolumson G. Clinical implications associated with unintentionalweight loss and pressure ulcers in elderly residents of nursing facilities. J AmerDietetic Assoc 1995;95:984-92.

Disclosure of Financial InterestsThe author has no financial interests to disclose.

9SOW-RI-GERIATRICS-12008

THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were per-formed under Contract Number 500-02-RI02, funded by the Cen-ters for Medicare & Medicaid Services, an agency of the U.S. De-partment of Health and Human Services. The content of this pub-lication does not necessarily reflect the views or policies of the De-partment of Health and Human Services, nor does mention of tradenames, commercial products, or organizations imply endorsementby the U.S. Government. The author assumes full responsibility forthe accuracy and completeness of the ideas presented.


Evaluation of Case Management Services for Lead PoisonedChildren In Rhode Island

Daniela N. Quilliam, MPH, and Peter R. Simon, MD, MPH

RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH EDITED BY SAMARA VINER-BROWN, MS

Rhode Island mandates that all children under the age of sixbe screened for lead annually, and that all lead test results bereported to the RI Department of Health. Following the rec-ommendations of the Centers for Disease Control and Pre-vention (CDC) , the Rhode Island Childhood Lead Poison-ing Prevention Program (RI CLPPP) considers children un-der the age of six with a venous blood lead level (BLL) > 10micrograms per deciliter (µg/dL) to be lead-poisoned.1 Healtheffects below this level are well documented;2 ,3 however, dueto lack of efficacious interventions below 10 µg/dL, RI CLPPPhas retained this threshold as its “action level” for childhoodlead poisoning.

The services offered to lead poisoned children in RI varydepending on the severity of the poisoning. (Table 1) Casemanagement services are offered through one of four certi-fied lead centers, non-profit Medicaid-funded agencies.

In 2007, RI CLPPP conducted an evaluation of case man-agement services. The three main ob-jectives of the evaluation were to de-termine if: 1) there were demographicdifferences between families acceptingand refusing services; 2) parentalknowledge of lead increased after re-ceiving services; and 3) case manage-ment services had an impact onchildren’s BLLs.

METHODSData from three databases main-

tained by the RI Department ofHealth were linked in order to con-duct the analyses.

A total of 827 children were re-ferred to case management betweenJanuary 1, 2004, and December 18,2006. The complete dataset was usedto calculate acceptance rates of casemanagement services. The remaininganalyses were conduced on a subset ofdata that excluded 340 cases with in-complete data, either because the caseswere on-going or lost to follow-up.This subset of data included 487 caseswhere families had successfully com-pleted case management services, orhad refused services.

Parent knowledge was measuredusing an assessment tool comprised of

eleven multiple-choice questions. The family completed theassessment during the first visit (pre-test) and again severalvisits later (post-test). Scores on the pre- and post-test werecompared to determine if there was a change in knowledgeafter case management services were administered.

RESULTSOf the 827 referrals made to case management during

the study period, 611 (73.9%) accepted services. The accep-tance rate for case management services increased from 68.1%in 2004 to 84.5% in 2006, while the refusal rate declinedduring this time. (Figure 1)

The subset of 487 cases for which there was completedata was used to compare the demographic characteristicsof families accepting services with those refusing services.(Table 2) The two groups are similar in terms of mother’s edu-cation, primary language spoken, and race/ethnicity.

Table 1. Lead Action Levels in Rhode Island

Figure 1. Lead Poisoning Case Management Capture Rates,Rhode Island, 2004-2006


Parental lead knowledge was assessed using a pre- and post-test format. The average score on the pre-test was 62.0%; theaverage score on the post-test was 85.5%. Post-test scores werenot associated with the number of home visits received or parent’sprimary language. However, post-test scores did increase slightlythe longer families were enrolled in case management.

An analysis was also conducted to determine the rate ofchange in the BLLs of children before and after case man-agement services. Six months after referral to case manage-ment services, children accepting services had a mean BLLdecline of 8 µg/dL; those refusing services had a 6 µg/dLdecline. At twelve months after referral, the BLLs of thoseaccepting services had declined an additional 2 µg/dL, whilethe BLLs of those children refusing services had increased by4 µg/dL. The blood lead levels of children accepting servicesdeclined another 1 µg/dL by 18 months after referral, whilethe BLLs of those who refused did not change. (Figure 2)Overall, the children receiving services had a greater decline

in average BLLs from 20.9 µg/dL to 9.8 µg/dL, compared to 15.9 µg/dL to 14.1 µg/dLamong the children that refused. This de-cline was significant among those childrenaccepting services.

DISCUSSIONThe percent of families accepting case

management services has increased in recentyears, indicating that RI CLPPP is reachingmore families of lead-poisoned children. Thiscan be explained, perhaps, by the fact thatcase managers have smaller caseloads, whichallows them to dedicate more time to eachfamily, and be more persistent when offeringservices. The demographics of the familiesaccepting and refusing services are similar, in-dicating that our outreach efforts are notmissing a particular subgroup. The increasein scores on the lead knowledge assessmentfrom the pre-test to the post-test suggests thatthe educational component of the case man-agement services are effective in increasingparents’ awareness and knowledge about lead.The results of the analysis suggest that theBLLs of children receiving services decreasemore steadily than those refusing services. Thisindicates that case management is one ofmany factors that can have a positive impacton a child’s blood lead level.

REFERENCES1. Centers for Disease Control and Prevention: Why notchange the blood lead level of concern at this time? http://www.cdc.gov/nceh/lead/faq/changeBLL.htm.2. Canfield RL, Henderson CR, et al. Intellectual impair-ment in children with blood lead concentrations below10mg per deciliter. NEJM 2003; 348:1517-26.3. Selevan SG, Rice DC, et al. Blood lead concentrationand delayed puberty in girls. NEJM 2003; 348:1527-36.

Daniela N. Quilliam, MPH, is a Public Health Epidemi-ologist in the Division of Community, Family Health, and Eq-uity, Rhode Island Department of Health and Teaching Associatein the Department of Community Health, The Warren AlpertMedical School of Brown University.

Peter R. Simon, MD, MPH, is the Medical Director for theRhode Island Childhood Lead Poisoning Prevention Program,Assistant Medical Director for the Division of Community, Fam-ily Health and Equity, Rhode Island Department of Health, andClinical Associate Professor in the Departments of CommunityHealth and Pediatrics, The Warren Alpert Medical School ofBrown University.

Disclosure of Financial InterestsThe authors have no financial interests to disclose.

Table 2. Demographic Characteristics of Families Accepting CaseManagement Services Compared to Families Refusing CaseManagement Services

Figure 2. Changes in Blood Lead Levels Over Time: ChildrenAccepting Case Management Services Compared to ChildrenRefusing Case


The human papillomavirus (HPV) is a group of over 100viruses, 40 of which can be transmitted through mucosal cellsduring vaginal or anal intercourse, thereby infecting genitalareas. Different HPVs infect the body in distinctive ways. Inmany cases there are no obvious symptoms (until late sequelaesuch as cervical cancer manifest themselves), but some of theviruses cause genital warts, genital lesions (abnormal cells), andsome of the viruses cause cancers of the cervix, vulva, vagina,anus, or penis. Most people’s immune systems will clear HPVwithin two years,1 but sometimes the virus persists, and if un-treated, may eventually cause cancer.

HPV is the most common sexually transmitted disease.According to the Centers for Disease Control and Prevention(CDC), 20 million Americans are currently infected with HPV,and 6.2 million are newly infected every year. At least 50% ofsexually active men and women will become infected with HPVat some point in their lives.1 At any given time, about 1% ofthe population is infected with genital warts caused by HPV.2

THE QUADRIVALENT HPV VACCINEGardasil®, manufactured by Merck and Co, is a quadriva-

lent HPV vaccine approved for administration to females be-tween the ages of 9 and 26. It confers immunity against fourof the most common types of HPV – types 6, 11, 16 and 18.HPV types 6 and 11 are responsible for 90 percent of genitalwarts; types 16 and 18 are responsible for 70 percent of cervi-cal cancers. The vaccine is a bioengineered, component vac-cine made up of virus-like particles produced from the surfaceproteins of HPV types 6, 11, 16 and 18. The vaccine containsno viral DNA and is not infectious.3 Approved by the FDA inJune 2006, it does not contain antibiotics or mercury com-pounds such as thimerosal4 (the vaccine preservative alleged –without supportive data – to cause autism).

HPV vaccine should be used to prevent HPV infection inwomen who are not infected. Vaccination before sexual debutis recommended, as early as age 9 at the discretion of the phy-sician. Routine vaccination is recommended for girls ages 11-12. “Catch-up” vaccinations are recommended for girls andyoung women ages 13 - 26. The FDA has not approved thevaccine for males.

ADMINISTRATIONGardasil® is administered in three independent 0.5 ml

doses at 0, 2, and 6 months. The vaccine is available as a sterilesuspension for injection in a single-dose vial or a pre-filled sy-ringe.4 The vaccine should be stored at 2°C—8°C (36°F—46°F) and should not be frozen or exposed to light; its shelf lifeis 36 months. Side effects include soreness at the injection site,headache, fatigue, or vague feeling of discomfort after injec-tion. Persons should not receive the vaccine if (1) they have

The Quadrivalent Human Papillomavirus VaccineAnna Wheat

DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTH

RHODE ISLAND DEPARTMENT OF HEALTH EDITED BY JOHN P. FULTON, PHD

ever had a life threatening allergic reaction to yeast, any othercomponent of the vaccine, or a previous dose of the vaccine,(2) they are pregnant, or (3) they are suffering from a moder-ate or severe illness. The vaccine retails for $120 per dose for atotal of $360, not including the price of the office visit.

EFFECTIVENESSFour clinical trials have been completed to test HPV vac-

cine; one evaluated a monovalent (HPV 16) vaccine — a phaseII study; three evaluated the quadrivalent vaccine — one phaseII and two phase III studies.4 As reported in 2007 by the Advi-sory Committee on Immunization Practices,4 the quadrivalentvaccine was shown to be quite effective:

“Various endpoints were assessed in the different stud-ies, including vaccine type-related persistent HPV infec-tion, cervical intraepithelial neoplasia (CIN), vulvarintraepithelial neoplasia (VIN) and vaginalintraepithelial neoplasia (VaIN), and genital warts. Theprimary endpoint and the basis for licensure was the com-bined incidence of HPV 16- and 18-related CIN 2/3 orAIS. These endpoints served as surrogate markers forcervical cancer. Studies using an invasive cervical cancerendpoint were not feasible because the standard of careis to screen for and treat CIN 2/3 and AIS lesions toprevent invasive cervical cancer. Furthermore, the timefrom acquisition of infection to the development of can-cer can exceed 20 years. ... Quadrivalent HPV vaccinehas a high efficacy for prevention of vaccine HPV typeHPV 6-, 11-, 16-, and 18-persistent infection, vaccinetype-related CIN, CIN 2/3, and external genital lesions(genital warts, VIN and VaIN) when analyses were re-stricted to participants who received all 3 doses of vac-cine, had no protocol violations, and no evidence of in-fection with the relevant vaccine HPV type (seronega-tive and HPV PCR-negative through 1 month after dose3). ... Participants infected with one or more vaccine HPVtypes before vaccination were protected against diseasecaused by the other vaccine HPV types. No evidenceexists that the vaccine protects against disease caused bynon-vaccine HPV types.”4

RECOMMENDATIONSThe CDC4, The American Academy of Pediatrics (AAP)3,

The Society for Adolescent Medicine (SAM)5 , The Ameri-can College Health Association (ACHA)6 , The AmericanCancer Society (ACS)7 , and The American College of Obste-tricians and Gynecologists (ACOG)8 have developed recom-mendations for the use of quadrivalent HPV vaccine. The fol-lowing consensus has emerged in the scientific literature:


1. Routine vaccination is recommended for girls 11-12years old, ideally before sexual debut. Vaccination canbe administered as young as age 9 at the discretion ofthe physician.

2. Catch-up vaccination is recommended for girls 13-26years old who have not been vaccinated or who havenot completed the three-dose vaccination series.

3. Quadrivalent HPV vaccine is administered in a 3-doseschedule. The second and third doses should be ad-ministered 2 and 6 months after the first dose.

4. The minimum interval between the first and second dosesof vaccine is 4 weeks. The minimum recommended in-terval between the second and third doses of vaccine is12 weeks. Inadequate doses of quadrivalent HPV vac-cine or vaccine doses received after a shorter-than-rec-ommended dosing interval should be re-administered.

5. Quadrivalent HPV vaccine can be administered at thesame visit as other age appropriate vaccines, howevereach vaccine should be administered using a separatesyringe at a different anatomic site.

6. Lactating as well as immunosuppressed females can re-ceive the vaccine.

7. Pregnant women, females with moderate to severe acuteillness, or anyone allergic to any part of the vaccine (suchas yeast) should not get the vaccine.

8. Regular cervical cancer screenings should ensue despitevaccination status.

Several additional recommendations are well worth noting:

CDC: If the quadrivalent HPV vaccine schedule is in-terrupted, the vaccine series does not need to be restarted.If the series is interrupted after the first dose, the seconddose should be administered as soon as possible, and thesecond and third doses should be separated by an inter-val of at least 12 weeks. If only the third dose is delayed,it should be administered as soon as possible.4

ACOG: Testing for HPV is currently not recommendedbefore vaccination.8

ACOG: Sexually active women can receive the quadriva-lent HPV vaccine. Women with previous abnormal cervi-cal cytology or genital warts also can receive the quadriva-lent HPV vaccine. The quadrivalent vaccine can be givento patients with previous CIN, but practitioners need toemphasize that the benefits may be limited, and cervicalcytology screening and corresponding management basedon ACOG recommendations must continue.4

CURRENT HPV VACCINE CONTROVERSIESExpected Impacts vs. Unanswered Questions

Dr. Anne Schuchat, Director of CDC’s National Center forImmunization and Respiratory Diseases, notes that the quadriva-lent HPV vaccine “has been tested in thousands of women aroundthe world and has been found to be safe and effective in providingprotection against the two types of HPV that cause most cervicalcancers.”9 Projected clinical gains include decreased incidence of

genital warts, cervical lesions, cervical dysplasia, and cervical can-cer. Furthermore, the quadrivalent vaccine has the potential to becost-effective if administered to females of the appropriate ages.For example, a study done by the Department of Health Policyand Management at the Harvard school of Public Health dem-onstrated the potential monetary savings of large-scale immuniza-tion. Assuming that the vaccination gives lifelong immunity, sav-ings will be seen to the highest degree when girls are vaccinated inpreadolescence (before age 14), theoretically allowing the delay ofinitial cervical cancer screening, and allowing longer intervals be-tween subsequent screenings. Both outcomes would produce sub-stantial savings10 for those vaccinated as well as third-party payers.

Despite the potential advantages of quadrivalent HPV vac-cine, the medical world has been cautious in its adoption, prima-rily because the vaccine is new, and the usual questions attendantat the time of vaccine roll-out have arisen. Will the vaccine actu-ally decrease the burden of cervical cancer and death? For howlong will effective immunity be conferred by the three-dose se-ries?11 Will boosters be needed? (When? How frequently? Atwhat cost?) Will use of the vaccine create selective pressure onparticular HPV types, causing other types to become dominant incervical lesions, genital warts, and other conditions? Given thecurrent price of the quadrivalent HPV vaccine, will it be acces-sible in the developing world?12 Will the price decline, and howsoon? Will developing nations have access to vaccine at reducedcost? And most importantly, will use of the vaccine strengthen orweaken the existing (highly effective) infrastructure for cervicalcancer screening in the U.S. and internationally? Resolving thesequestions will require decades of use and careful observation.13

Parental Consent vs. Child’s SexualityAdolescents under 18 years of age represent a group that

can be targeted before the initiation of sexual activity, but do nothave the authority to vaccinate themselves against the virus.14

Currently, if a parent opposes the HPV vaccine because they seeit as a “go ahead” for their child to engage in sexual activity, ateenager under the age of 18 can be denied permission to re-ceive the vaccine, even though they do not need such permissionto access birth control and testing for sexually transmitted infec-tions. Assuming that the use of HPV vaccine becomes the com-munity standard of practice throughout the United States, theissue of parental permission will undoubtedly be addressed.

DISCUSSIONThe most important question remains: “Do the benefits of HPV

vaccine outweigh the unknowns?” On the one hand, there is con-siderable evidence that the vaccine is safe and effective in preventingHPV types 6,11,16 and 18, and nothing has been published todiscredit either the safety or the efficacy of the vaccine. On theother hand, the duration of immunity conferred by the vaccine isunknown, and concerns have arisen that receipt of the vaccine maycause some women to eschew regular pelvic examinations and Papsmears. As well, suppression of current dominant oncogenic sero-types may cause other types to become dominant, with unknownresults. At five-year follow-up the vaccine is 100% 15 effective; thereis no indication of diminished efficacy. Time will tell whether abooster is indicated, when, and for whom. Nonetheless, five years ofprotection (and counting) during the early, high-risk years of sexual


activity (ages 15-24) is good protection. Public health must advo-cate for the continued use of pelvic examinations and Pap smears;HPV vaccine promises to reduce disease burden, but is not a cure-allfor cervical cancer. As for the “type spreading” phenomenon, thequadrivalent HPV vaccine is no different than any other vaccine.Suppressing specific microorganisms creates selective pressure forthe emergence of formerly insignificant genetic variants, and “new”genetic variants, as well. Only careful monitoring and cost-benefitanalysis can determine if the intervention is worthwhile, despite itsunintended but predictable consequences.

REFERENCES1 . Centers for Disease Control and Prevention. Sexually Transmitted Diseases.

http://www.cdc.gov/std/HPV/STDFact-HPV-vaccine-hcp.html2 . Koutsky LA, Galloway DA, Holmes KK. Epidemiology of genital human

papillomavirus infection. Epidemiol Rev 1988; 10: 122-63.3 . Committee on Infectious Disease at the American Academy of Pediatrics. Pre-

vention of human papillomavirus infection. Pediatrics 2007; 120:666-8.4 . Markowitz LE, Dunne EF, et al. Quadravalent Human Papillomavirus Vac-

cine: Recommendations of the Advisory Committee on Immunization Prac-tices (ACIP). MMWR 2007; 56: 1-24.

5 . Friedman LS, Kahn J, et al. Human papillomavirus (HPV) vaccine. A positionstatement of the Society for Adolescent Medicine. http://www.adolescenthealth.org/PositionPaper_Immunization.pdf

6 . ACHA Vaccine Preventable Disease Committee. ACHA guidelines. July 2008.The American College Health Association, Baltimore MD/.

7 . Saslow, et al. American Cancer Society guideline for human papillomavirus(HPV) vaccine to prevent cervical cancer and its precursors. CA: A Cancer JClinicians 2007; 57: 7-28.:http://caonline.amcancersoc.org/cgi/content/full/57/1/7

8 . Committee on Adolescent Health Care and the ACOG working group onImmunizations. Committee opinion. Obstet Gynecol 2006; 108: 699-705.

9. CDC Media Relations. CDC’s advisory committee recommends humanpapillomavirus vaccination. Press Release June 29, 2006. http://www.cdc.gov/od/oc/media/pressrel/r060629.htm

10. Kim JJ, Goldie SJ. Health and economic implications of HPV vaccination inthe US. NEJM 2008; 358:821-32.

11. Haug C. Human papillomavirus vaccination. NEJM 2008;359:861-2.12 Baden LR, Curfman GD, et al. Human papillomavirus vaccine. NEJM 2007;

356:1990-1.13. Daling JRm Sherman KJ. Cancers of Vulva and Vagina. Oxford University

Press, New York 1996.14 . Charo RA. Politics, parents, and prophylaxis. NEJM 2007; 356: 1905-8.15 . Villa LL, Costa RL, et al. High sustained efficacy of a prophylactic quadriva-

lent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccinethrough 5 years of follow-up. Br J Cancer 2006;95:1459–66.

Anna Wheat, a student in the MPH Program of Brown Uni-versity, is an intern for the Rhode Island Comprehensive CancerControl Program, based at the Rhode Island Department of Health.


Dear Dr. Friedman, Thank you for writing about electronic medical records

in Medicine & Health/Rhode Island [September 2008]. I amwriting this letter to inform you of the best-kept secret in elec-tronic medical records (EMR): the VA Medical Center.

I always enjoy your articles, and this one was no exception.In my own internist’s office I often feel like my doctor does noteven know the color of my eyes. I always feel nervous when myone-word answers lead to a half-minute interlude of typing.Just recently the Rhode Island Free Clinic, where I volunteer,switched over to EMR, and the frustrations from those scroll-down boxes may have led to our losing some of our invaluablevolunteer providers.

The advantages of EMR, as you listed, are numerous. Atthe VA, where I am currently on my medicine clerkship, theyhave had EMR since 1995. When a patient is admitted to thehospital, I can immediately see everything from a cardiologyconsult note 10 years ago to his last five EKGs. I can see hismost recent CT scan of the head as well as his outpatientneurologist’s recommendations based on those findings. Witha simple double-click I can see a patient’s weight over the last15 years displayed as a line graph. Labs and pending ordersappear on the computer screen. I can start a note in the morn-ing and finish it later in the day. Clinical reminders such as“colonoscopy due” pop up on the screen when the patient meetspreventative medicine guidelines for these procedures.

I would argue that EMR not only offer numerous advan-tages, they are crucial to how medicine should be practiced.Handwriting at Rhode Island Hospital, where I was a student

Letters To the Editor

on the psych consult service, made me feel like an archeologistdeciphering hieroglyphics. Medicine teams make recommen-dations, but the assessment and plan could be impossible toread. Health care workers seem to accept these limitations as“the way things are.” Instead of deciding that electronic medi-cal records are a middle ground, we should figure out how tomaximize our abilities with the best technology that is avail-able.

Doctors at the VA have taken advantage of this system.They write notes faster than they would if writing them byhand. They make good eye contact with patients and showthem x-rays and lab values as they pop up on the screen. Theyshow the patients trends in their weight, blood pressure, andcholesterol to improve health education. Some primary carephysicians do look at the screen more than they talk to thepatient, but I believe that it is our medical training that willneed to adapt, rather than EMR.

Please visit the VA in Providence and see how wonderfulelectronic medical records can be.

David Margolius

David Margolius is a student at the Warren Alpert MedicalSchool of Brown University.



Dear Editorial Staff:

I read the July 2008 issue of Medicine & Health/RhodeIsland about Lyme disease and would like to share a differentperspective of this disease and how the medical communitycould better serve the people of RI.

As a biostatistician, I interpret the results of infectious dis-ease clinical trials and assess the generalizability of the findings.I have followed the literature on Lyme disease for the past 3years and am aware of the controversy surrounding this illness.

I believe the medical community in RI should acknowl-edge that an infection with Borrelia Burgdorferi can be seriousand difficult to diagnose and treat, contrary to the opinionspresented in the Medicine & Health/Rhode Island issue. Insearching the literature, I have not been able to find proof thatthe Lyme bacteria is always eradicated following short-termantibiotic therapy.

Unfortunately in the writing of their diagnosis and treat-ment guidelines, members of the IDSA have ignored anddownplayed many studies that provide convincing evidence ofchronic and seronegative Lyme disease. A review article by Dr.Stricker provides 13 references describing Lyme serologic testsas too insensitive for diagnosis and 21 references documentingpersistent symptoms and/or evidence of continuing infectionfollowing antibiotic treatment (Stricker RB, Counterpoint: Long-term antibiotic therapy improves persistent symptoms associatedwith Lyme disease. Clin Infect Dis 2007; 45: 147-57).

In addition, the Stricker article provides evidence of thecomplexity of B. Burgdorferi, explaining that it has 132 func-tioning genes compared to the 22 found in syphilis and 3 timesmore plasmids than any other known bacteria. The article pro-

vides biological explanations (with citations) of how B.Burgdorferi can evade antibiotic therapy and why longer coursesof treatment can be helpful.

In this letter, I cannot provide a detailed critique of the threeNIH-funded randomized clinical trials studying re-treatment ofchronic Lyme disease. In summary, two of these studies demon-strate that symptoms can be measurably lessened by treatmentbut that a cure for the chronic stage of Lyme disease has notbeen found. Improvement of symptoms in the antibiotic treat-ment groups compared to placebo, but relapse upon discon-tinuation of antibiotic treatment, can indicate that the treatmentstudied, although helpful, was not curative and the infectionremained (Fallon BA, et al. Neurol 2008; 70:992-1003).

I believe it is the moral and ethical duty of the medicalcommunity to acknowledge the uncertainty and charged po-litical atmosphere surrounding this disease. Physicians shouldprovide patients with information on all viable treatment op-tions so they can make their own informed choices.

Availability of longer-term antibiotic therapies could makethe difference between a life of disability and a full and pro-ductive life for those not cured by an initial course of antibiot-ics or diagnosed months or years after the tick bite occurred.

Sincerely yours,Allison DeLong, MSe-mail: [email protected]

The author is a statistician in the Center for Statistical Sci-ences, Department of Community Health, Brown University.

Response from Drs. Jerome Larkin and Jennifer Mitty:

Ms. DeLong raises a number of issues warranting reply.We agree that characterizing B. burgdorferi as the “the lessdevastating relative of syphilis” is an oversimplification. De-grees of genetic relatedness, while fascinating, only rarely im-ply similarities in virulence or pathogenecity. The most thatscience can say about T. pallidum and B. burgdorferi is that theyare both spirochetes, of which there are literally hundreds ofvarieties, including many which are part of the normal flora ofthe human mouth.

It is not surprising that she is unable to find evidence inthe literature for the eradication of infection with B. burgdorferi:it doesn’t exist. There is no technology, assay or culture methodto demonstrate such eradication. Most testing in the realm ofinfectious diseases is specific; it is rarely sensitive. It is indeed atricky business to disprove (as opposed to convincingly dem-onstrate the presence of ) infection and is not the standard weapply to the vast majority of infections in clinical medicine. Acommon error in practice is to follow “titers,” meaning theELISA or Western Blot, in a given patient with Lyme Disease,presuming persistence of antibody levels or bands on the West-ern Blot to indicate persistent, active infection. No data sup-port such a presumption. While antibody levels may declineover the course of years to decades, positive tests should be

expected in the short-term (< 5 years) at a minimum, includ-ing in the face of adequate treatment.

Stricker’s opinion piece from Clinical Infectious Disease isprimarily just that: opinion. This is true also of the rejoinderby Auerwater in the same issue (Clin Infect Dis 2007; 45: 143-8). Stricker’s references consist primarily of animal studies, casereports and molecular biology. While the last may be the basisfor furthering our understanding of Lyme Disease, none ofthe studies cited constitute a sound basis for the leaps he makes.First, do no harm. In the absence of a randomized controlledstudy demonstrating a benefit and given the trials of prolongedantibiotic therapy which show no difference compared to pla-cebo, we cannot in good conscience recommend prolongedantibiotic therapy for an unproven entity. Our moral and ethi-cal duty is not only to “acknowledge uncertainty,” but also topractice based on the best available medical evidence.

Ultimately, all patients make their own decisions. Physi-cians can only help guide them. If someone wants an antibi-otic, they can probably find a medical professional willing toprescribe it. This is as true of Lyme Disease as it is of the com-mon cold, but we all know that chicken soup would do just aswell and in all likelihood is in fact better.


A Purgatory of Ambiguous Words�

Physician’s Lexicon

Number (a)261188

373747

Number (a) Rates (b) YPLL (c)2,719 254.2 3,654.52,280 213.1 5,972.5

385 36.0 642.0516 48.2 8,078.5424 39.6 322.5

Reporting Period

12 Months Ending with December 2007December

2007

UnderlyingCause of Death

Live BirthsDeaths

Infant DeathsNeonatal Deaths

MarriagesDivorces

Induced TerminationsSpontaneous Fetal Deaths

Under 20 weeks gestation20+ weeks gestation

Number Number Rates1,082 12,736 11.9*

760 9,992 9.4*(4) (78) 6.1#(4) (58) 4.6#

437 6,372 6.0*179 2,863 2.7*357 5,047 396.3#

37 816 64.1#(37) (746) 58.6#

(0) (70) 5.5#

Reporting Period12 Months Ending with

June 2008June

2008Vital Events

Rhode Island MonthlyVital Statistics Report

Provisional OccurrenceData from the

Division of Vital Records

(a) Cause of death statistics were derived fromthe underlying cause of death reported byphysicians on death certificates.

(b) Rates per 100,000 estimated population of1,067,610

(c) Years of Potential Life Lost (YPLL)

Note: Totals represent vital events which occurred in RhodeIsland for the reporting periods listed above. Monthly pro-visional totals should be analyzed with caution because thenumbers may be small and subject to seasonal variation.

* Rates per 1,000 estimated population# Rates per 1,000 live births

RHODE ISLAND DEPARTMENT OF HEALTH

DAVID GIFFORD, MD, MPHDIRECTOR OF HEALTH EDITED BY COLLEEN FONTANA, STATE REGISTRAR

VITAL STATISTICS

Diseases of the HeartMalignant Neoplasms

Cerebrovascular DiseasesInjuries (Accidents/Suicide/Homicde)

COPD

Each of the noble professions has its ownvocabulary; and medical dictionaries attestto medicine’s awesome gathering of 25,000or so technical words. Certainly there areoverlapping terms [between surgery and car-pentry, for example] but words in the medi-cal domain are singular to medicine with butrare clusters of words shared with still othervocations. Some of the words pertaining togastrointestinal medications [purgative, ca-thartic], for example, are also employed bytheologians to signify the acts of cleansing,penitence and expiation.

Purge, in the sense of cleaning, appearsas a Latin verb meaning to cleanse, to pu-rify. In a document dated 1185, St. Bernardwas apparently the first to employ the Latinderivative noun, purgatorium, originallymeaning a specific place for physical cleans-ing, now to mean a station where dead souls,who had died penitent, are gathered; and are

then purified of venal sins or undergo pun-ishment for forgiven mortal sin prior totheir passage to heaven. In ecclesiastic writ-ing, Purgatory was then assumed to be a placeof great purpose and geographic specificity.The word, purgative, however, remains es-sentially medical, describing those chemicalagents which hasten the “cleansing” of thecolon. The word, expurgate, now also yieldsa narrower meaning: to amend somethingby erasing its offensive elements. The Latinverb, purgare, to cleanse, is closely related tothe verb putare, meaning to purify.

Purge, as an ideologically motivated so-cial action, defines an act of cleansing, butwith sharp and often, in certain Europeannations, mortal undertones.

A cathartic, medically speaking, de-scribes a chemical agent designed to enhancebowel activity. The word derives from theGreek, catharos, meaning cleansing, purify-

ing; and perhaps from an earlier word mean-ing tree-pruning. Psychiatrists often employthe word, catharsis, to denote a purification[or clarification] of human emotions. TheCatharists [the pure ones] were a hereticalChristian sect of the 12th and 13th Centuriescentered in the Languedoc region of FrenchProvence; the sect was destroyed in theAlbigensian Crusade.

A laxative, meaning a purgative or ca-thartic, is the most common word to de-scribe a bowel-cleansing agent. It stems fromthe Latin, laxus, meaning to loosen, to widenor to open [cf. words such as relaxation].Commercially offered laxatives have beengiven names as explicit as Ex-Lax; and as am-biguous as Serutan [the word, Nature’s,spelled backwards.]

– STANLEY M. ARONSON, MD


�

�

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�VOLUME 1 PER YEAR $2.00NUMBER 1 SINGLE COPY, 25 CENTSPROVIDENCE, R.I., JANUARY, 1917

The Official Organ of the Rhode Island Medical SocietyIssued Monthly under the direction of the Publications Committee

NINETY YEARS AGO, DECEMBER 1918From October 1918 through December 1919 the Rhode

Island Medical Society suspended publication of the journal,because key staff members were serving in World War I.

FIFTY YEARS AGO, DECEMBER 1958In “Panel Discussion: Prevention and Treatment of Car-

diac Emergencies,” J. Scott Butterworth, MD (New York Uni-versity Postgraduate Medical School), James V. Warren, MD(Harvard Medical School), Allan Friedlich, MD (HarvardMedical School), and Louis Dexter, MD (Harvard MedicalSchool) traded opinions.

Harold W. Williams, MD, in “The Clinician: In the Modeof Today’s Thinking,” opined on modes of analysis. “The clini-cian emphasizes. He recognizes overlooking and neglecting todo is a reality of his human nature.”

Arthur B. Kern, MD, in “Treatment of Cutaneous Reac-tions to Antibiotics,” noted that the key was “elimination ofcause and secondarily treatment of the skin.”

C. Aguillera Maruri, MD, in “Riehl’s Melanoma of Emo-tional Origin,” described the case of a 60 year-old woman whohad had vitiligo since age 22. One winter day, she “opened thedoor to her brother who fell dead in her arms. The followingnight her face became red and swollen, with severe itching.” Afew days later, the erythema subsided, replaced by darkeningof the skin.

TWENTY-FIVE YEARS AGO, DECEMBER 1983Charles P. Mosher, Administrative Director, Rhode Island

Blood Center, contributed an Editorial: “Blood Use in RhodeIsland.” “Rhode Islanders use more blood transfusions per per-son than the residents of any other state.” The author attrib-uted this to the “complexity of cases” in the state’s acute carehospitals. Since 1980, red cell transfusions increased 16%; redblood collections increased 36% (twice the national average,four times the rest of New England). The use of platelet con-centrates and fresh frozen plasma increased 45%. The authornoted: “A transfusion of blood or blood components is per-formed every 5 minutes in Rhode Island.” The editorial em-phasized the need for blood-donors.

On the President’s Page, Charles P. Shoemaker, Jr, MD,discussed “Medicare: Usual, Customary and Reasonable andthe Prospect of Medicare Assignment.” Medical societies op-posed mandatory assignment.

Erminio R. Cardi, MD, FACS, in “Choledochoscopy,”explained “The flexible fiber optic choledoscope promises toreduce significantly the incidence of …common duct stones.”

David M. Barry, MD, FACS, in “Microsurgical Removalof Ruptured Lumbar Disks”, cautioned: “While early excel-lent results appear likely to be permanent, long-term studiesare needed.”

Robert E. Newhouse, MD, John R. Stuart, MD, andJoanne Baldwin contributed “Blood Usage: Physicians’ OrderProvides for 4 Elective Surgical Procedures.” An audit of hos-pitals in Rhode Island revealed a high incidence of unneces-sary routine blood cross-matching “due to lack of awareness ofthe problem by surgeons as to procedures which do not com-monly require transfusions.”

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101 Airport Rd • WesterlyT 315-0095 F 315-0092

Rhode Island Medical Society and 30 other medical and professional societies endorse NORCAL as the professional

liability insurer for their members. That’s because they know that 9 out of 10 claims NORCAL processed last year were

closed without indemnity payments. They also know NORCAL has returned $358 million in dividends to our policyholder

owners since 1975. Visit www.norcalmutual.com today, or call RIMS Insurance Brokerage Corporation at 401.272.1050. NORCAL. Your commitment deserves nothing less.

It’s Good to Have Endorsementsin an Election Year

You practice with passion. Our passion protects your practice.

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