Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 217

Culture surrounds and defines everyone. Both providers and patients have their own national and ethnic cultures. These include their culture of origin and the cultural values, beliefs, language, and local culture (acculturation) skills they have adopted. The patients’ cultures will influence when they seek treatment, their expectation of care, and whether they will comply with the providers’ recommendations.²⁷ Health care providers have the culture of biomedicine and their specific profession (e.g. medicine, nursing, and pharmacy) and speciality (e.g. surgery, geriatrics, and rheumatology). In addition, both providers and patients have cultural ideas and values that relate to their social culture^28‐30 age,^31,32 gender,^33,34 and gender identity.^35,36 Finally, health care providers for older adults are almost always younger than their patients. This age difference also has ramifications for compliance based on trust and respect.³⁷

Finding a way to communicate effectively is critical to good patient care. Patient satisfaction and the likelihood of compliance with medical instructions^38,39 are linked to patient–provider communication. If cultural differences are not addressed, then poor health outcomes and limited quality of medical decision‐making may result.⁴⁰ Patient satisfaction with health care is affected by age, race, and literacy level. In low‐income populations, communication satisfaction may be lower for groups that are traditionally active in doctor–patient interactions (e.g. younger patients, patients with higher literacy skills). Health care providers should be aware that older, non‐white, optimistic, and literacy‐deficient patients report greater communication satisfaction than their younger, white, pessimistic, and functionally literate peers. Furthermore, they are more likely to cope with their illnesses by withdrawing rather than by actively pushing for a higher standard of care.⁴¹ Therefore, health care providers should continuously seek ways to facilitate dialogue with patients who are older and non‐white and have poor literacy skills. Thus, cultural sensitivity can help providers improve health care delivery in the clinical encounter. It can lead to better provider–patient communication, more accurate diagnoses, more effective treatment, higher patient satisfaction/compliance, and efficient use of medical resources.

For most adults who are not health care providers themselves, navigating the culture of biomedicine is challenging. These challenges are even greater for older adults who are handicapped with physical, mental, and/or social limitations. Most older adults have chronic diseases in addition to acute diseases. Health care providers often underappreciate the physical burdens of these chronic diseases. For example, community‐dwelling Korean older adults with low health literacy often have been reported to have significantly higher rates of arthritis and hypertension. After adjusting for age, education, and income, older individuals with low health literacy had more significant activity limitations and lower subjective health. Older adults with low health literacy were more likely to report lower levels of physical function and subjective health and higher levels of limitations in activity and pain.²⁵

Nor are older adults the only ones with challenges. Providers have their own challenges when applying their biomedical culture to an ageing population. They were taught ‘Primum non nocere’ (or ‘First, do no harm’, the origins of which are discussed elsewhere⁴²), but many cures are harsh. This is because so many cures are designed for younger, robust patients who are experiencing an acute illness and whose natural reserves allow them to overcome any debilitating effects of the ‘cure’. This is not true for the frail elderly. For them, multiple pharmaceuticals increase the possibility of lethal drug interactions and/or side effects. Surgery is dangerous, and the subsequent recovery can be debilitating. Medical care is often too costly. Sometimes care is available but not in a timely manner. This waiting period can be particularly problematic for an older person, especially if they lack a cultural understanding of the need for haste or confrontation. Finally, the culture of medicine often emphasises the quantity of life over the quality of life. However, older patients may insist on more autonomy than the culture of biomedicine encourages.⁴³ They do not always follow instructions, especially if they feel that quality of life is preferred over quantity of life. It is not uncommon for family members to decide that an older patient should not be treated for a serious disease such as depression²⁶ or cancer.^44,45 This makes treatment difficult, if not impossible.

These differences in the approach to the culture of medicine affect care. Being aware of the potential for culture‐related problems in the clinical encounter is the first step in developing strategies to deal with those problems when they arise. To address these differences, providers must learn to communicate effectively, provide evidence‐based medicine in a timely manner, be prepared continually to develop new health services that target older adults’ changing medical needs, and consult with the older patient and family as to their preferences for care. The delivery of optimal health care depends on understanding across all cultures.