The culturally competent pediatrician: Respecting ethnicity in your practice

The culturally competent pediatrician: Respecting ethnicity in your practice By Lori Taylor, MD, and Lindia J. Willies-Jacobo, MD The percentage of ethnic minorities represented in pediatric practice is on the rise. To deliver optimum health care to these patients, pediatricians should recognize and respect each family's unique cultural beliefs. The population of the United States is becoming more culturally and ethnically diverse each year. According to 1990 census data, more than 28 million peoplesignificantly more than reported in earlier census reportsspeak a language other than English at home. Of these 28 million, nearly 45% say they have trouble speaking English.1 In addition, a 1997 study by the Census Bureau revealed that one in every 10 persons in the US is foreign-born.1 People born in another country now represent a larger segment of the US population than at any time in the past five decades, and the trend is expected to continue. By 2010, the number of Latino children in the US is expected to rise by 5.5 million, the number of African-American children by 2.6 million, and the number of children of other non-white races by 1.5 million. In this same period, the number of white children will fall by 6.2 million.2 By the year 2020, an estimated 40% of school-age children in the US will be a member of a minority group.3 This degree of cultural diversity has implications for the health services that pediatricians and other clinicians provide. Cultural background may strongly affect health beliefs, healing practices, and how members of minority groups interact with providers of traditional medical care. Pediatricians who are aware of the major beliefs, values, traditions, and practices of their patients are likely to foster better adherence, successful therapeutic outcomes, and improved patient satisfaction. Failure to recognize and address cultural differences may result in misdiagnosis, decreased compliance, poor utilization of health services, and patient mistrust (see "Interacting with ethnically diverse patients").4 The American Academy of Pediatrics (AAP) has recognized the importance of "culturally effective pediatric health care," which it defines as "the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions . . . [taking] into account the beliefs, values, actions, customs, and unique health-care needs of distinct population groups."3 How does a pediatrician achieve such cultural competence? He or she needs to become familiar with the health-related beliefs and practices of the major cultural groups represented in a particular patient population. Of course, no two patients are alike simply because they are part of the same cultural or ethnic group. The many additional factors that shape a patient's belief system include age, immigration status, personal experience, and education. The pediatrician must, therefore, develop a system for incorporating cultural awareness into day-to-day interactions with individual patients. To illustrate these points, we discuss in this article the health-related beliefs and practices of two large ethnic minorities in the US: Latinos and Southeast Asians. In addition, we describe a model for putting cultural knowledge into clinical practice. The patient from Southeast Asia Most Southeast Asians who have immigrated to the US are refugees, having fled their native country because of war or persecution or out of fear for their life. It is estimated that, since the end of the Vietnam War in 1975, more than 2 million Southeast Asian refugees have resettled in the US.5 The Southeast Asian population is heterogeneous, comprising people from Vietnam, Cambodia, and Laos. Refugees from these three countries differ in religious belief, language, and certain cultural practices and traditions. Laotian refugees are themselves diverse, with three main ethnic groups: lowlanders, or "Lao Lum"; highlanders, or "Lao Theung"; and the mountain people, or "Hmong."6 The Hmong are often viewed as quite distinct from other Southeast Asians because they have strongly animistic beliefs and what many consider a "primitive" culture. They have had a written language since only 1954, and few Hmong are literate. Despite the differences among refugees from Laos, Vietnam, and Cambodia, they do share many interpersonal behaviors, health beliefs and practices, and perceptions of Western medical care. Cultural values. Clinicians who interact with patients from other cultural groups need to learn about these groups' normative cultural values. Cultural values are beliefs, behaviors, and ideas that a group of people share and expect to be observed in their dealings with other people.7 Health-care providers who are not familiar with certain Southeast Asian cultural values may inadvertently offend patients from this culture or experience poor outcomes from clinical encounters. According to Southeast Asian culture, the head is a sacred part of the body; casually touching or patting the head may be considered offensive.8,9 When we examine the fontanelle of a Cambodian infant, we proceed slowly and deliberately, explaining to the parent what we are doing. In contrast, the feet are considered the lowliest part of the body, and pointing them at another individual is perceived as insulting. We try to remember this and adjust body posture accordingly when we sit and interview parents. A Southeast Asian tries to avoid direct eye contact with a "superior" (such as a physician); averting one's gaze is a sign of respect.5,8,9 Before becoming aware of this custom, we spent much time trying to "catch the eye" of parents while discussing their children. After all, eye contact is equated with honesty and sincerity in Western culturesomething every physician wants to convey. We feared that some parents were not paying attention to the discussion. Now we understand that parents are, indeed, listening, and with respect. Many Southeast Asian parents, particularly the Hmong, believe it is bad luck to admire a baby excessively because "spirits" may hear the praise and come to take the baby away.5 So it's best, we have decided, not to sing the praises of a Hmong baby. How, then, should one act when greeting and interviewing Southeast Asian parents and children? The best advice is to be polite and formal. With the exception of handshaking, primarily between men, social exchanges should not include physical contact. Public displays of emotion also are best avoided. Health-related belief systems. Germ theory is notably absent among traditional concepts of disease in Southeast Asian folk medicine. A person is thought to fall ill because of metaphysical, naturalistic, or supernatural causes.10,11 Metaphysical causes of illness include any disruption in balance or harmony of the person or his surroundings. Although this imbalance is described in terms of "hot or cold," the concept has nothing to do with temperature. Rather, certain foods, parts of the body, and experiences are designated as having either hot or cold properties. Foods or experiences that are "hot" are considered energizing, while those that are "cold" are perceived as calming. Examples of hot illnesses are fever and joint pain, while cold illnesses include dysmenorrhea, diarrhea, and postpartum recovery.8,9,11 If a child becomes ill with diarrhea, for instance, the parent presumes that he or she is imbalanced, with too much "cold" in the body. Many Southeast Asians believe that illness can be caused by a shift in the balance of natural "forces" or "winds." At times, this description refers to actual changes in weather, such as heavy rains or high winds.11 Other times, the concept is more nebulous, relating to changes in energy flow in the environment. Southeast Asians believe that, at certain times, a person is more vulnerable to having these "winds" enter the bodysuch as during surgery or in the neonatal period.9 For this reason, many Southeast Asian parents heavily swaddle their babies when the weather is very hotto protect them from natural forces. Illnesses commonly thought to be caused by "winds" are rheumatism, headache, and respiratory diseases.11 Many Southeast Asians, especially the Hmong, think that supernatural forces are important causes of disease. A person's spirit is considered the guardian of his or her well being, and, with that person's ancestors, determine spiritual harmony. This spiritual harmony can be disrupted if a person suffers a great fright, experiences extreme grief, is the recipient of unkindly words, or fails to pay proper homage to ancestors.6,8,9,11,12 A disruption in spiritual harmony is believed to cause illness. In addition, because many Southeast Asians, including the Hmong, believe that malicious spirits can enter the body and cause harm, they take many measures to protect themselves and their children.12 To guard against loss of soul or evil spirits, many Hmong parents tie white yarn around the wrist of a newborn baby or a sick person. Older children may wear copper or silver bracelets, necklaces, or anklets to "lock" the soul and prevent it from leaving the child.12 Traditional remedies. Many Southeast Asians try folk medicine before seeking Western medical care.9,10 They rarely volunteer that they have been using such traditional remedies, howevereither because they do not want to show disrespect by suggesting that Western medicine is the last resort or because they fear meeting disapproval. To find out whether a patient or parent has used the traditional remedies described in the discussion that follows (which is likely), the clinician must ask her directly. Illnesses with a metaphysical cause are treated by the principal of opposition: Hot illnesses are treated with cold foods, such as fruits and vegetables, whereas cold illnesses are treated with hot foods, suchas meats, wine, and foods thatare spicy, greasy, or salty.1012 In Cambodia, women who have just given birth spend the first postpartum month with lit fires under their bed to restore balance after their "cold" childbirth experience. One hospital in California was able to increase the percentage of Cambodian women in the community who sought Western prenatal and perinatal care by allowing the women to simulate their native tradition and operate a space heater under their bed in the postpartum ward.13 Physical treatments such as rubbing the skin with eggs or coins (cao gio, or "coining"), pinching the skin, or applying warm cups ("cupping") to the skin are often used to treat illnesses caused by winds.5,8,9 It is believed that these treatments "draw the bad wind to the surface" so that it can be eliminated. In cao gio, for example, a balm or ointment, such as eucalyptus balm, is spread over the chest or back; a coin is then pressed on the skin and drawn a short distance in one direction without breaking the skin. This procedure is repeated several times until blood appears under the skin (Figure 1).5 Of course, health-care providers who are unfamiliar with this practice may become alarmed when examination of an ill child reveals multiple bruises. This practice is not usually painful, however, and does not constitute physical abuse. Many Southeast Asians grow their own herbs to use during times of illness. Herbs are used to treat virtually all physical ailments. Most patients are unable to identify plants by name but simply use what their ancestors have designated as "good for hot illness" or "good for wind illness." Many communities have "medicine men" (or women) who dispense herbs, teas, and other compounds. Most of these substances are either innocuous or, possibly, helpful. One exception is "pay-loo-ah," a powder containing lead that is used to treat a variety of ailments, including headache, muscle ache, and abdominal pain. Clearly, this is one remedy pediatricians should counsel parents to avoid using on their children. Many Southeast Asians, especially Hmong, turn to spiritual healers to cure illnesses thought to be caused by an offense to the patient's spirit.6,8,11,14 Traditional spiritual healers, known as shamans, perform ceremonies at which they call to the spirits of ancestors or to those of sick people. Hmong families offer sacrifices to evil spirits in exchange for the soul of an ill relative. They offer food, money, and even live animals, such as cows, goats, pigs, ducks, and chickens.14 Beliefs about Western medicine. Many Southeast Asian refugees, especially the Hmong, were not exposed to Western medicine before arriving in the US. As noted, many are reluctant to seek medical care and do so only after exhausting traditional remedies. One patient told us, "I make him some herbal tea, then I do cao gio, then I go get some Tylenol, and then, if he still has fever, I come see you!" There probably are several reasons why Western medicine is a "last resort," including misperceptions about Western doctors and medicine and distrust or misunderstanding of the Western medical community. A common belief among Southeast Asians is that Western medicines are very potent and cure rapidly.5 Southeast Asian patients may give up on a medication if they do not feel better immediately, believing that it is not working. Compliance with a course of antibiotics, or with a chronic medication such as one prescribed for asthma, can therefore be a problem. Many believe that Western medicines are too strong for the relatively small body size of Asians, and cut pills in half or take a partial dose of prescribed medication.5,9 We try to address this concern by using a calculator in front of parents to figure out a dosage and then say, through an interpreter: "Based on his weight, your son should take 4 mL of this medication." Misperceptions about radiographs also are common. Some Southeast Asians believe that X-rays are meant to be curative; others believe that they are extremely dangerous.5,8 Surgical procedures are feared: Many Southeast Asian patients believe that cutting flesh may cause a person's soul to leave the body. Even drawing blood may be refused because it may be equated with withdrawal of the soul. Parents may be alarmed if the clinician draws several vials of blood because they believe that such loss is permanent.8,9 The Latino patient Latinos account for approximately 13% of the US populationa percentage that is expected to rise over the next few years.15 The term "Latino" refers to people in the US whose backgrounds can be traced to Spanish-speaking regions of Latin America.16 Their roots are in Mexico, Central America, the Caribbean, and South America. In California, 32% of the population is Latino, nearly half of whom are children younger than 18 years. Latino children are at higher risk than other children for a variety of health problems, including obesity, asthma, and type 2 diabetes. In addition, Latino children receive, on average, lower quality health care than their non-Latino counterparts.17 Many variables account for this disparity, and cultural and language issues are believed to be among them. Although all Latino groups cannot be lumped together with regard to all issues, they do have many similar health beliefs and practices. Cultural values. The five normative cultural values of Latinos are simpatia (kindness), personalismo (formal friendliness), respeto (respect), familismo (collective loyalty to the extended family), and fatalismo (fatalism). The pediatrician who does not know about familismo may be baffled when the parents of a 3-month-old Latino who has a fever without a source respond to the news that their child will need a sepsis work-up by saying that the child's grandparents will need to be consulted before the parents permit any testing. The clinician shows respeto by using appropriate titles (Mr./ Señor and Mrs./Señora) when addressing the child's parents and by using "usted" (the more courteous form of "you") instead of "tu." Pediatricians do not often encounter fatalismo in practice but should keep it in mind whenever the parent of a Latino patient seems less concerned than expected when faced with a difficult diagnosis. In short, Latino families expect the physician to treat them in a warm, respectful manner and to know that many family members will need to be part of important decisions. When we see Latino families, we sit somewhat closer to the family than usual and end the visit not simply with a handshake but also by patting the caregiver's shoulder. Health-related belief systems. In addition to certain unique cultural values, Latinos have their own health-related belief systems. Some Latino parents believe that three primary forces contribute significantly to the illnesses of their children: hot-cold imbalance; drafts or winds; and decomposed foods.1820 In a study of 100 Latina mothers who were asked about the cause of their child's illnesses, 80% believed that an imbalance between hot and cold forces was responsible for cough.19 A balance between hot and cold is believed to be important in maintaining health. Illness is therefore believed to develop when these forces are in disequilibrium. Cough is considered a "cold" illness, and treatment is aimed at restoring balance with traditional "warm" home remediesfor example, herbal tea.19,20 About 36% of the Latina mothers also believed that their child's diarrhea was a direct result of "something that they ate," and 53% believed that their conjunctivitis was caused by "an air."19 This particular concept of disease is unclear, but is believed to be associated with pollutants and dust in the air. Many Latino families put no stock in germ theory. By knowing this, the pediatrician can have a much better dialogue with the family and educate patients and parents about modern concepts of disease. Folk illnesses and remedies. A folk illness is a distinctive ailment associated with a particular cultural group. When asked, a large percentage of Latino caregivers acknowledge a belief in folk illness.1820 The four common folk illnesses of the Latino community are empacho, mal de ojo, mollera caida, and susto. Empacho, or blocked intestine, is believed to develop when foods stick to the walls of the intestines, causing obstruction. Symptoms include abdominal pain, vomiting, and diarrhea. A variety of folk remedies are used for this condition, including herbal teas and abdominal massage with oils. The goal of therapy is usually to dislodge the offending agent from the intestines. By far the most problematic treatment for empacho is to administer substances containing lead, such as greta and azarcon. These products are readily available to Latino families at botanicas or drug stores in border Mexican cities. These substances can ultimately cause lead toxicity. Mal de ojo, or evil eye, is believed to result when a person with "strong eyes" looks at a child. Latinos believe that strong eyes heat up the child's blood, leading to inconsolable crying, fever, diarrhea, and gassiness. In a survey of 51 caregivers, this was the folk illness experienced most often.20 Latinos often turn to curanderos, or "folk healers," to cure mal de ojo. Having the child wear an azabache, or seed-like charm, on a necklace or bracelet is believed to protect against this illness (Figure 2). Many children come to their visits wearing such charms. We usually ask the parents if the child is wearing the azabache for protection against mal de ojo, and they readily acknowledge that this is so. The most commonly used treatment for mal de ojo entails "sweeping" the child's body with an egg. The egg is later broken into a glass of water and placed under the head of the child's bed overnight. If the egg appears solidified and milky white in the morning, the child is thought to have had mal de ojo.19,20 Mollera caida, or fallen fontanelle, is believed to result when an infant pulls away from the breast too quickly, or when a bottle is pulled away from the infant too quickly. The soft palate is thought to sink in, leading to difficulty feeding and swallowing, as well as fussiness, fever, and diarrhea. Therapy is aimed at "realigning" the fontanelle. Some of the folk remedies for mollera caida include sucking on the fontanelle or pushing up against the soft palate. The most dangerous remedy is hanging the infant over a basin of hot water and tapping the feet. The medical literature contains a report of a Latino infant who died from subdural hematomas after his grandmother held him by the ankles and partially submerged his head in boiling water, while shaking him and tapping his feet.21 The symptoms of susto, or fright, which is triggered by a scary experience, are usually insomnia, nightmares, fevers, and diarrhea. A variety of rituals, such as applying holy oil and water to the forehead, are performed and prayers said to rid the child's body of the so-called fright. (The chart "Eliciting health-care beliefs from parents," in the print edition is adapted from Kleinman, A, Eisenberg L, Good B: Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research Ann Intern Med 1978;88:251.) Incorporating cultural competence in clinical practice Once we learn more about the value system of a particular culture and examine some of its health beliefs and practices, how do we incorporate this knowledge into daily practice? Pachter proposed one model of cultural competencythe awareness-assessment-negotiation model.22 This model can be used for all patients, but is especially helpful for dealing with patients who do not fit a standard biomedical model, such as a member of an ethnic group. This model has several components: The primary care provider first develops cultural awarenessthat is, becomes knowledgeable about the commonly held beliefs and practices specific to the patient population that he or she serves. Without such cultural awareness, it would be difficult, for example, to understand why Vietnamese babies are often overbundled or why a Latina mother may attribute her child's conjunctivitis to playing at the park on a windy afternoon. A search of the medical anthropology literature is one way to obtain information on a variety of cultures and their distinct health beliefs and practices. The National Center for Cultural Competence ( http://www.georgetown.edu/research/gucdc/nccc ) is also a helpful resource. The second part of the model calls for assessing whether the specific family in question relates to the particular belief system associated with the cultural group of which it is part. One cannot assume, for example, that everyone who is Latino believes in the existence of empacho. To explore a family's health-related belief system, the pediatrician should ask general questions to tactfully and nonjudgmentally elicit health-care beliefs. Some pediatricians, once they are aware of health beliefs common to the particular family's culture, may prefer to ask more direct questions. For example, a pediatrician who wants to know if a certain Mexican family believes that empacho is the cause of their daughter's abdominal pain may say, "Some families tell me about a disease called empacho that causes pain in the belly. Are you aware of this disease?" The third part of the model relates to negotiation.23 For example, when parents are concerned that their child has empacho and the actual diagnosis is viral gastroenteritis, propose a safe, traditional intervention such as abdominal massage with oils while firmly discouraging the use of substances that contain lead oxide. (Remind the parent about the importance of hydration as part of supportive care.) For an appraisal of the case vignettes presented below in the context of this model, see "Commentary: Interacting with ethnically diverse patients". The last word Like the AAP, public agencies such as the Maternal Child Health Bureau and private accreditation entities such as the Joint Commission on the Accreditation of Healthcare Organizations have begun to emphasize the importance of cultural competence in the delivery of health services.1 This importance can only increase along with the growing percentage of children in pediatric practices who are from an ethnic group. To provide the best medical care to all their patients, pediatricians need to be aware of the specific beliefs, values, and health practices common to various groups and individual families, respecting these traditions while applying traditional biomedical practices. REFERENCES 1. Rationale for Cultural Competence in Primary Health Care (policy brief). Washington, D.C., National Center for Cultural Competence, Georgetown University, 2002 2. A Vision for America's Future: An Agenda for the 1990s (policy statement). Washington, D.C., Children's Defense Fund, 1990 3. American Academy of Pediatrics, Committee on Pediatric Workforce: Culturally effective pediatric care: Education and training issues (RE9753). Pediatrics 1999;103:167 4. Shapiro J, Hollingshead J, Morrison EH: Primary care resident, faculty, and patient views of barriers to cultural competence, and the skills needed to overcome them. Medical Education 2002;36:749 5. Lindsay J, Narayan MC, Rea K: Nursing across cultures: The Vietnamese client. Home Healthcare Nurse 1998;16:693 6. Voices of the Lao community. Cross Cultural Health Care Program, Pacific Medical Center, Seattle, Wash., 1996 7. Flores G: Culture and the patient-physician relationship: Achieving cultural competency in healthcare. J Pediatr 2000;136:14 8. Voices of the Cambodian community. Cross Cultural Health Care Program, Pacific Medical Center, Seattle, Wash., 1996 9. Mattson S: Culturally sensitive perinatal care for Southeast Asians. JOGNN 1995;24:335 10. Hoang GN, Erickson RV: Guidelines for providing medical care to Southeast Asian refugees. JAMA 1982; 248:710 11. Frye BA: Use of cultural themes in promoting health among Southeast Asian refugees. Amer J Health Promotion 1995;9:269 12. Rairdan B, Higgs ZR: When your patient is a Hmong refugee. Amer J Nurs 1992;3:52 13. Mattson S, Lew L: Culturally sensitive prenatal care for Southeast Asians. JOGGN 1992;21:48 14. Nuttall P, Flores F: Hmong healing practices used for common childhood illnesses. Pediatr Nurs 1997;23:247 15. U.S. Census Bureau: Current Population Reports Washington, D.C., US Government, March 2000 16. Aguirre-Molina M, Molina C: Latino populations: Who are they?, in Molina C, Aguirre-Molina M (eds): Latino Health in the US: A Growing Challenge. Washington, D.C., American Public Health Association, 1994, pp 322 17. Flores G, Fuentes-Aflick E, Barbot O, et al: The health of Latino children. Urgent priorities, unanswered questions, and a research agenda. JAMA 2002; 288:82 18. Flores G, Vega LR, Barriers to Health Care Access for Latino Children: A review. Fam Med 1998;30:196 19. Mikhail BI: Hispanic mothers' beliefs and practices regarding selected children's health problems. West J Nurs Res 1994;16:623 20. Risser AL, Mazur LJ: Use of folk remedies in a Hispanic population. Arch Pediatr Adolesc Med 1995; 149:978 21. Guarnashelli J, Lee J, Pitts FW: "Fallen fontanelle" (caida de mollera): A variant of the battered child syndrome. JAMA 1972;222:1545 22. Patcher LM: Culture and clinical care: Folk illnesses beliefs and behaviors and their implications for health care delivery. JAMA 1994;271:690 23. Pachter LM: Practicing culturally sensitive pediatrics. Contemporary Pediatrics 1997;14(9):139 DR. TAYLOR and DR. WILLIES-JACOBO are assistant professors, department of pediatrics, University of California, San Diego. They have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article. Interacting with ethnically diverse patients Case 1 You are seeing a 1-year-old Hmong (Laotian mountain people) boy for a well-child exam. You note that, during his mother's pregnancy, she tested positive for hepatitis B surface antigen. The child received hepatitis B immune globulin and vaccine at birth as well as follow-up doses of the vaccine. You recommend performing a blood test to confirm that the infant did not contract the virus and that he has responded appropriately to vaccination. Because the parents balk at this suggestion, you try to convince them of the necessity of the test. As the discussion proceeds, the family grows more and more agitated until, at last, the father rushes out of the clinic with the child in his arms. Case 2 A 6-month-old Latino infant is brought in for a well-child check. You notice a red string tied around his wrist with a large seed-like charm dangling from it. Viewing this object as a choking hazard, you tell the parents that it needs to be removed. They appear surprised and offended by your request, and later tell the nurse that you treated them rudely. Case 3 A 10-year-old Vietnamese girl in your practice has type 1 diabetes. You receive a note from the frustrated endocrinologist indicating that the patient has failed to achieve adequate control of her glucose level despite an adequate dosage of insulin. You schedule an appointment with the family and ask them to bring in their medication and syringes. Through careful interviewing and the help of an interpreter, you discover that the parent is administering only half of the recommended dosage because she fears overmedicating her child with this "strong medicine." Case 4 A 2-year-old Latina girl is brought to the clinic with a one-month history of abdominal pain. Upon questioning, the patient's mother reveals that she has been giving the child a "powdered substance" for the abdominal pain but that it has not produced any improvement. You immediately become concerned about lead toxicity and obtain a lead level as part of your work-up. The result comes back high: 67 mg/dL. For an appraisal of these interactions, see "Commentary: Interacting with ethnically diverse patients". Commentary: Interacting with ethnically diverse patients The four case vignettes on which this commentary is based are presented in "Interacting with ethnically diverse patients". Case 1 A pediatric clinician who is familiar with Hmong culture would recognize that the parents probably were reluctant to have their son's blood drawn because their culture holds the belief that withdrawal of blood can equate to withdrawal of the soul, or that the blood drawn would never be replaced. Belaboring the medical necessity of the tests, therefore, would be unconvincing. Instead, the best approach would be to assess this family's belief system by asking them about their concerns about blood drawing. Are they worried about the amount of blood to be drawn? Are they concerned that the child's spiritual welfare will be harmed? Once the underlying concern is elucidated, you can attempt to negotiate with the family, explaining, first, that only a small volume of blood will be drawn and, second, that the body has the ability to replace blood cells. Perhaps you could even use terminology such as "restoring balance," so that the intervention is placed in a context that is familiar. If the parents' concern is spiritual, it may be impossible to come to an agreementbut the interaction will still be better for your effort. Case 2 Awareness of mal de ojo would have allowed you to recognize that the charm worn by the boy was placed there to protect him. With this knowledge, you would have been better able to negotiate with the family, perhaps by suggesting that the string be used by itself (as is sometimes done), instead of asking that the entire bracelet be removed. This would have greatly enhanced your interaction with this patient, and the ultimate outcome may have been better. Instead, his parents leave the clinic angry and offendedsevering the doctor-patient relationship Case 3 Being familiar with Southeast Asian health beliefs, you correctly suspect why the glucose level of this Vietnamese girl with diabetes is not under control: Her parents have been reluctant to administer a full dose of insulin because they believe that Western medicines are too strong for Asian body size. By carefully interviewing the parent and using an interpreter, you are able to confirm your suspicionand then act by explaining that the dosage of insulin is a personalized one that was calculated based on the girl's weight. You are then able to negotiate with the parent to administer the appropriate dose. Over time, the patient's glucose level falls to an acceptable level. Case 4 You are aware that substances containing lead oxide are used by the Latino community to treat abdominal pain (empacho). Given your high index of suspicion, you know that it is important to obtain a lead level as part of the work-up. Because the diagnosis has been made at this visit, the child undergoes chelation therapy promptly and the outcome is good. Without your cultural awareness, the diagnosis may have been delayed, with a bad outcome. This vignette illustrates the importance of a good history and reinforces the notion that many patients' beliefs (and their parents' beliefs) do not fit the mainstream biomedical model. Lori Taylor, Lindia Willies-Jacobo. The culturally competent pediatrician: Respecting ethnicity in your practice. Contemporary Pediatrics June 2003;20:83.