By the time Mrs. Zhang came to see me, her headache, left-sided weakness and facial numbness were two weeks old. Like many Chinese immigrants in this country, she’d hesitated to seek medical care because of language and cultural barriers and her apprehensiveness about Western medicine. In fact, she hadn’t seen a physician in the ten years since she and her husband had come to America. Only after a friend told her about me, the sole Chinese primary-care physician in a small Pennsylvania town, did she and her husband come to see me.
Mr. and Mrs. Zhang struck me as a typical older Chinese couple. With smiles on their faces, they bowed repeatedly to everyone in my office. Mr. Zhang spoke English reasonably well, but Mrs. Zhang spoke only Chinese. She grasped my hands and kept telling me how grateful she was to be seen; after several moments, her husband had to gently remind her to let go of me.
Although Mrs. Zhang’s other symptoms had resolved, her blood pressure was significantly elevated. Suspecting a stroke, I recommended a CT scan of her brain and medication for her hypertension. I also advised that she monitor her blood pressure at home and follow up with me in a couple of weeks. As I do with most of my Chinese patients, I wrote her instructions in a mixture of Chinese and English.
Seeing Mrs. Zhang reminded me of my own early experiences in this country. Shortly after I’d arrived, seventeen years ago, I’d had a bicycle accident and injured my ankle. Facing the same challenges as Mrs. Zhang, I didn’t seek care until several months had passed. Unfortunately, this delay resulted in ankle pain that troubles me to this day.
A few days prior to the follow-up visit, Mr. Zhang called and requested his wife’s CT-scan results. He hadn’t been able to sleep, he said, for fear that she might have a brain tumor. “I don’t want her to know the bad news,” he said.
Suddenly I felt caught between two worlds colliding–worlds with different cultures, different expectations and different health-care delivery systems. In China, there is little concept of patient confidentiality. The family shields the patient from bad news, and the doctor joins in this “protecting” process. The patient is the last person to learn of an unfavorable diagnosis or prognosis and often never hears of it at all.
As a fellow Chinese, I understood and respected Mr. Zhang’s wishes. As a physician practicing in the United States, however, I also had an ethical obligation to protect my patient’s confidentiality.
When I told him that I couldn’t divulge the information without his wife’s consent, Mr. Zhang was shocked and bewildered. Nevertheless, after I explained about patient confidentiality, he agreed to provide a form, written by his wife in Chinese with an English translation, giving me permission to discuss her medical condition with him. Although not a typical informed consent, it served as a compromise solution in this difficult situation, and I was able to ease Mr. Zhang’s worries–at least concerning cancer.
Mrs. Zhang’s scan did show a hemorrhagic stroke. When they came to the office, I explained the cause of her stroke and the importance of treating her hypertension. Her home blood-pressure measurements had fluctuated significantly, and she admitted to taking her medication only every two or three days. “I feel fine. I have never taken Western medication before,” she told me. The only reason she took the medicine at all, Mr. Zhang said, was to avoid disappointing me.
Although Mrs. Zhang’s blood pressure was not optimal, it was better than before. I knew that it would take lots of education about her illness and about Western medicine before she would feel at ease with the treatment plan.
One of the nicest things about this story is that it has a happy ending–for the patient, the family and the physician. Over time, Mrs. Zhang has become comfortable taking Western medications. Her hypertension is under control, and she leads a full and active life with her husband. Recently I received a thank-you letter from Mr. and Mrs. Zhang: “We are grateful to have a Chinese doctor like you here in this small town.”
It was written in Chinese and in English.
About the author:
Juan Qiu MD PhD is an assistant professor and clinical faculty member in the Department of Family and Community Medicine, College of Medicine at Pennsylvania State University. “In addition to delivering patient care and teaching third- and fourth-year medical students, I participate in cultural-diversity awareness programs in the local medical community. I love caring for my patients, and I became interested in writing because I want to share what I have learned from them and be their advocate. I believe that both patients and providers need cultural-diversity education so that people of differing backgrounds can get equal access to quality medical care.”