Keywords

FormalPara Case

Faith was a one-month-old girl with a diagnosis of trisomy 13 (Patau syndrome) admitted to the Newborn Intensive Care Unit (NBICU) at an academic medical center in Albuquerque, New Mexico. She had severe hypotonia, an atrial septal defect, microphthalmia, and cleft lip and palate. She was ventilator dependent and unable to be weaned. The overall prognosis was poor with only a 5–10 percent chance of living past her first year. The family lived in Tohatchi, NM, an extremely rural town in the Navajo Nation with no running water in their home and electricity provided by a diesel generator. In this town, there were very few medical services, and no home nursing care. The NBICU team offered several options to the parents. An alternative feeding route, tracheotomy, ventilator dependence, and a possible cardiac procedure would be necessary to consider discharge to home. The option of withdrawing care was also explained.

The health care providers were concerned about the 165-mile distance between the hospital and the home, a three-hour drive. The interventional teams were consulted, including Cardiology, Otolaryngology-Head and Neck Surgery, and Pediatric Surgery. When the providers attempted to discuss the benefits and risks of tracheotomy, gastrostomy, and cardiac catheterization, the family did not wish to hear the risks. The surgical teams were concerned about their ability to obtain a truly informed consent for the procedures and the difficulties in caring for a tracheostomy in a rural area with reduced access to emergency and specialty care. The parents became upset during these interactions and did not want to discuss any further. Since conversations with providers did not go well, the family was considering transfer to another facility for a second opinion.

The Neonatology team offered a family meeting. The parents requested the participation of extended family members. Contact was made with Native American Health Services through the hospital who offered a patient advocate and interpreter for the meeting. The parents invited the paternal grandparents, maternal grandmother, both great grandmothers, and 2 great aunts. Medical teams included Neonatology, Dysmorphology, Neurology, Cardiology, Pediatric Surgery, and Otolaryngology. The neurologist was also a member of the Ethics Consult service. A social-worker and discharge planner were included. The Navajo medical student on the Pediatric Otolaryngology service was also invited.

1 Introduction

Discussing complex medical and surgical information is difficult, but when required between people of different cultures, beliefs, and daily practice patterns, it is even more challenging. Understanding where differences are, on what they are based, and being able to employ and engage people competent in both cultures may allow true communication to occur.

This chapter explores the mores, traditions and customs, of the people of the Navajo Nation, the Diné . We outline a brief history of the Navajo Nation, present-day social determinants of health, structural and health inequities for Navajo residents, and some of the traditional and contemporary beliefs of some Navajo people (see Table 20.1. Navajo Vocabulary). Maintaining a positive outlook and hope through words and actions is central to Navajo culture. The traditional Navajo belief system holds the idea that thoughts and language have power to shape and influence reality and may affect the outcome of future events. The belief that thinking negative thoughts or speaking negative ideas or sentiments can be causative is held by many cultures and may influence discussions of surgical care, informed consent, and advance directives. The definition of “family” and who is involved with major healthcare decisions also varies across cultures. Some patients may wish to complement allopathic treatments with traditional healing methods or spiritual care based on cultural beliefs.

Table 20.1 Navajo words [1,2,3,4,5,6,7,8]
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There is very little written literature about Native American peoples’ beliefs and views on healthcare. However, there is more literature about the Diné, compared to other tribes, perhaps due to the unique geographic location and large size of the Navajo Nation, allowing greater language and cultural retention [9]. Based on the 2010 United States (US) census, the Navajo Nation is home to almost 50% of those who identify as Diné (Navajo) and the largest number of persons who associate with one tribe [10]. At least 50% of the population speaks fluent Navajo, and a high percentage of tribal members participate in traditional Navajo customs [9]. The relative concentration of healthcare services on and bordering the Navajo Nation also allows a focused population of patients to interview, care for, and foster relationships with. This can lead to a better understanding of cultural practices, which is helpful in developing culturally sensitive communication skills and surgical care.

In caring for people from some cultures, it may be necessary to further contemplate the four principles of biomedical ethics and how their application may differ with regard to communication and treatment to assure beneficence, non-maleficence, autonomy, and justice for all patients. With the use of an illustrative case, this chapter examines some culturally competent strategies to improve communication with and advocacy for patients. We also consider focused efforts to lessen the effect of cultural and racial discordance between patients and healthcare workers.

We hope that this chapter will provide a glimpse into the wonderful, rich Navajo culture, which is based on tradition and a belief system that may contrast with US healthcare education and policies and can be used to help guide surgeons and other healthcare providers to a better understanding of how culture and medical decision-making intersect. As we each strive to become culturally competent and practice cultural humility in providing surgical care, we can endeavor to improve healthcare for patients of all cultures and backgrounds and move us closer toward the goal of eliminating health disparities.

2 Search Strategy

Given the relative paucity of scientific evidence about the subject of this chapter, alternative sources of information were utilized, and timeframe was expanded beyond a typical evidence-based search, 1995–2021. Sources and methods used were PubMed, WorldCat, Google Scholar, official Navajo Nation websites, news interviews, and personal communication in the form of a grand rounds lecture. What is notable, yet not surprising, is that the themes and conclusions of the most recent articles have not changed in 25 years. The importance of integrating a culturally competent approach to treatment and communication with culturally diverse populations runs throughout the literature. We are still talking about the identical structural inequities leading to health disparities today.

3 Discussion

3.1 Background

3.1.1 Population Demographics

There are 574 federally recognized ethnically, culturally, and linguistically diverse Indian Nations in the US (variously called tribes, nations, bands, pueblos, communities, and native villages). Each has their own land base, culture, government, and language. Each is very distinct in every way. Additionally, there are state recognized tribes throughout the US acknowledged by their respective state governments [11].

The Navajo people are called Diné, which means “the People” in Diné Bizaad, the Navajo language. Anthropologists and historians believe that the Navajo first arrived in the southwestern US from what is now known as western Canada between 900 and 1300 AD. They came in contact with Pueblo Indians who lived in the area around 13–1400 AD, from whom they learned farming. The Spaniards made contact around 1581 AD and brought sheep, goats, and horses to the region. There is an extensive history of warfare with the Spanish and the Pueblo Indians. By 1700, the Navajo were living in the area of the present-day Navajo Nation (see Fig. 20.1) defined by Four Sacred Mountains created by the “Holy People”, Diyin Dine’é, for the Navajo people.

Fig. 20.1
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Map of the Navajo Nation within the United States

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In 1864, they were forced from this land on the “Long Walk”, 300 miles to the Bosque Redondo Reservation in Fort Sumner, New Mexico (NM) and imprisoned by American soldiers. They were allowed to return in 1868, after a peace treaty was signed. Those who survived the imprisonment and travel returned to their sacred land [12]. The results of the “Long Walk” are still discussed today through stories and teachings to Navajo youth. “The physical genocide of the 1800’s, followed by the cultural genocide of the 1900’s left behind a tribe whose roots and foundation were shattered”. What has resulted is a deep historical grief, anger, mistrust, and misunderstanding [1]. Native Americans were not granted US citizenship until 1924.

Today, Navajo Nation (Naabeehó Bináhásdzo) is the largest Indian reservation. The sovereign nation, created in 1923, covers portions of northeastern Arizona (AZ), southeastern Utah, and northwestern NM, borders Colorado, and is over 27,000 square miles in size (over 17 million acres, approximately the size of West Virginia). The Navajo Nation is larger than 10 of the 50 United States (see Fig. 20.2). The Navajo people farmed and raised goats and sheep and eventually developed a barter economy, exchanging rugs and silverwork with white traders. In the Four Corners region, oil and mineral exploration began in the 1920s and uranium mining in the 1940s, which improved the wealth of the Nation but caused contamination of water and other environmental damage (see Fig. 20.3). The Navajo Nation now has a population of greater than 250,000 and serves over 300,000 registered tribal members and is the second largest Native American population after the Cherokee Nation [2].

Fig. 20.2
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Map showing the Navajo Nation and Hopi reservation and highlighting healthcare services

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Fig. 20.3
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Navajo Nation Flag. The Navajo Nation flag has a pale buff color background, bearing a map of the Navajo Nation in the center. The original area of the 1868 reservation is dark brown, while the much larger current borders are copper. Surrounding the map are the four sacred mountains in each cardinal direction: black (representing the north), turquoise (representing the south), white (representing the east), and yellow (representing the west). These 4 colors form a recurring theme in the legends of the Navajo, beginning with the Navajo creation story. In it, the world began as a black island floating in the mist. Above it are 4 clouds: black, white, blue (turquoise), and yellow. The story describes the colored clouds as successive worlds and narrates the themes of birth, propagation, flood, escape, and continuing life. Arching over the mountains and map is the rainbow of red, yellow, and blue, with red outermost in reverse sequence from the Navajo Nation seal. The rainbow symbolizes Navajo sovereignty. Centered on the map is a white disk bearing corn stalks and three domestic animals from the Navajo Nation seal representing the Navajo livestock economy. Symbols of other aspects of the Navajo economy: a traditional Hogan, modern home, oil derrick, forestry, mining (symbolizing the resource potential of the Navajo Nation), and fishing and hunting (recreational economy). At the top near the sun, the modern sawmill symbolizes the progress and industry characteristic of the Navajo Nation’s economic development [12]

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3.1.2 Social Determinants of Health

Social determinants of health are the nonmedical factors that impact health [13]. The Navajo Nation has poverty rates more than twice as high as the other portions of AZ. Forty-four percent of tribal members live in poverty and half were unemployed before the COVID-19 pandemic. The median income is $27,389 per year and 57% of individuals have an income less than $10,000 per year [10]. Thirty percent of households on the Navajo Nation lack running water, electricity, and/or indoor plumbing. Many members drive an average of 2 hours to obtain water. Sixty percent of residents have no internet, causing digital social isolation with no access to emergency alerts, public health announcements, news, virtual schooling, and limited emergency health care command operation responses [14]. To combat the COVID-19 pandemic , schools have tried to expand online learning through providing wireless hotspots to students. However, the fact that many students live in “dead zones” from the cellular tower highlights the serious disparity of education on the Navajo Nation. Families would have to travel several miles to a local town that provides access to internet. The infrastructure of Navajo Nation does not allow for a physical address for many, therefore limiting emergency services, routine postal routes, and contact tracing. Food insecurity on Navajo Nation is worsened by decreased farming, lack of water access, and lack of refrigeration due to no household electricity. There are only 13 full-service grocery stores on the Navajo Nation and residents need to drive an average of 3 hours to obtain groceries. The remaining food sources are fast food restaurants and gas station convenience stores, limiting healthy food choices [10, 14, 15].

3.1.3 Health Inequities

The Navajo Nation suffers from health disparities in addition to or because of poverty and its location in a water, food, and technological desert [14]. The Indian Health Service (IHS), established in 1951, is an agency within the Department of Health and Human Services that is responsible for providing federal health services to American Indians and Alaska Natives. The Navajo Area IHS (NAIHS) provides inpatient, emergency, outpatient, public health, and other services through 12 health care centers including 4 full-service inpatient hospitals with only 400 hospital beds and 40 intensive care beds. There is chronic underfunding of the IHS with yearly average per capita expenditure of $4,078, which is less than half of the funds spent for non-Native Americans. An average of $9,726 is spent for non-Native Americans, $9404 for Veterans Affairs patients, and $13,185 for Medicare patients [5, 14]. The people of the Navajo Nation also have poor health status with an average life expectancy of only 73 years (5.5 years fewer than other races) and unintentional injury, heart disease, and cancer are the leading causes of death [5, 13, 14]. There are also high rates of comorbid diseases with Navajo adults being more than 2 times more likely as white adults to have type 2 diabetes. In 2018, 48% of American Indians had BMI of 30 or greater [5]. In the Navajo Nation, there are 523 abandoned uranium mine and mill sites which have contaminated soil and water supplies and are implicated in high rates of cardiovascular disease, hypertension, diabetes, kidney disease, anemia, gastrointestinal cancers, and various pregnancy disorders, such as pre-eclampsia and preterm labor [16].

3.1.4 Dikos Ntsaaigii-Na ha ́st’e ́ı ́ts’a ́adah (COVID-19)

The Navajo Nation led the country in per capita infections of COVID-19 early in the global pandemic, and the disease has devastated the elder population. Cases were at the highest per capita rate in the US in mid-May 2020 [2]. At that time, the Navajo Nation’s infection rate was 2,304 cases per 100,000 people, or one in every 43 persons had been infected with SARS-CoV-2. As of February 10, 2021, there had been 28,994 cases of COVID-19 and 1,075 deaths, or one death per 27 cases. As of February 2021, the NM cumulative age-adjusted case rate for American Indian or Alaska Native persons was 15,379/100,000 or one case per 6 to 7 persons, which is about 2–3 times higher than any other racial/ethnic group in NM [17]. In Arizona, only 5.3% of the population are American Indian or Alaska Native but 8% of COVID-19 deaths were in these populations [18]. In the state of New Mexico, only about 10% of the population are Native American but this demographic accounted for 33% of all coronavirus cases in May 2020 and 29% through February 2021 [10, 17]. All US indigenous tribes are disproportionally affected by COVID-19. For most Native American communities, including the Navajo, structural and health inequities are major factors, but cultural practices may also contribute to high rates of infection. For example, the importance and frequency of large gatherings for ceremonies and celebrations in addition to the handshake being the traditional method of greeting. These factors have aided in the rapid spread of coronavirus [13, 14]. Devastation from infectious diseases is not new to the Navajo Nation. Diseases that were introduced to Native American populations during European colonization were devastating due to immunological naivety. Smallpox caused mortality rates greater than the warfare and enslavement that followed [13]. The 1918 Spanish influenza pandemic infected 24% of Native Americans resulting in a loss of 2% of the Native American population, the highest death rate of any racial/ethnic group and thousands of Navajo persons were lost [13]. In 1993, the Sin Nombre hantavirus spread through Navajo Nation with a 75% mortality rate [1, 13]. During the H1N1 Influenza A pandemic, the Native American population had a 4 times higher mortality rate than all other US racial and ethnic groups combined [13]. For many communities including the Navajo people, structural and social factors cumulatively increase the transmission rates of infections. Frequent travel is essential to border towns, such as Gallup and Farmington, NM, Page and Flagstaff, AZ which provide employment and supplies for those who live on the Navajo Nation. Lack of delivery options for groceries or other goods and the need to travel outside the Nation increases contact and makes self-isolation difficult. Personnel are less able to work from home due to job types, such as blue-collar professions, and poor access to the internet [14]. Close-knit families living in multigenerational homes, lack of plumbing and running water for hand washing in 30% of homes, and a paucity of emergency services on Navajo Nation contribute. Many households lack physical addresses, and the telecommunication infrastructure is poor resulting in emergency medical services decreased ability to find homes. Poor access to health care, high rates of comorbid conditions, paucity of professional caregivers, deficient funding for health care centers, and a shortage of intensive care beds contribute to a high rate of mortality. Since the elderly are at higher risk of poor outcomes with COVID-19, there is intense worry among the Diné about losing elders with specialized knowledge. For example, each medicine person (Hataałii) specializes in different and unique ceremonies and this knowledge may die with the person and be forever lost, since wisdom is handed down only verbally to learners. Over the last several decades, the tribe has gone from 1000 Diné medicine people to just 300, and the coronavirus threatens the few who remain. The elders and medicine persons who depart take an encyclopedia of information with them, so the tribe is rushing to educate the younger population and reconnect youth with elders. Traditional medicine apprenticeships are offered through the 6 campuses of Diné College on the Navajo Nation and groups are creating digital files on cultural practices, so the expertise is not lost forever. Due to pandemic-related stay-at-home orders and curfews with difficulty accessing stores, there has also been a resurgence of farming to improve upon the scarcity of healthy food [19].

Although Native American communities have struggled with reducing the spread of COVID-19, they have exceeded other US states in vaccination rates, likely due to cultural cohesiveness and a centralized healthcare system, the IHS [20,21,22]. Almost every US tribal member has been affected by or lost family members in the pandemic and considers protecting family and tribal elders a cultural responsibility [20]. United, with a common goal, tribes are striving to inform members with consistent information regarding COVID-19 vaccine facts through coordinated public relations campaigns in partnership between government officials, IHS, tribal health care employees, and tribes [20]. There has been a unified communication process across the Navajo Nation with the Navajo President’s Office using social media, radio, and a bilingual approach [20]. Navajo Nation President, Jonathan Nez, publicly received the vaccinations to increase confidence in their safety for the Diné. Support for the vaccines has been discussed in public town hall meetings with tribal leaders and respected health experts to allow for questions [22]. Well-respected and trusted tribal elders and medicine men and women were enlisted to record radio broadcast messages to encourage vaccination [22]. A more streamlined Navajo vaccination program was made possible with the decision to use the centralized IHS system of hospitals and clinics for extensive vaccine clinics and drive-through sites [22]. Public health nurses and community health representatives are identifying tribal elders without transportation to clinic sites and are vaccinating them in their households [20]. By mid-April 2021, 86.5% of the Navajo population had at least one dose and 37% were fully vaccinated, and 12 of the 15 counties with the highest vaccination rates in the US contain Indian reservations or Alaskan Native communities where IHS or tribal clinics are the primary source of healthcare [20, 22, 23].

Due to the physical distancing requirements and decrease in health care providers in the Navajo Nation due the pandemic, the tribe has expressed interest in tele-education, tele-traditional medicine, and tele-monitoring to decrease health inequities on the Navajo Nation. Some traditional Navajo healers are using virtual platforms for tele-traditional medicine, however, concerns about barriers with internet access and technologic literacy remain [14]. While over 1.2 million persons on US tribal lands lack basic access to mobile technology and quality Internet capability, advancing tele-health services is improbable. The Navajo Nation has been allocated funds from the Coronavirus Aid, Relief, and Economic Security (CARES) Act to increase Internet services, broadband expansion and mobile towers, but much more funding for infrastructure is needed to improve health equity [14].

3.1.5 Cultural Difference

Culture is shaped by mores (values, beliefs, norms, and practices) that are shared by members of a cultural group and guide thinking, doing, and being. Culture becomes a patterned expression of who we are and is passed down from one generation to the next. Cultural values are unique principles of a particular culture that become acceptable as they are practiced over time. Persons in the general US society and many who work in the US healthcare system may have differing views based on cultural values related to health care decisions, life, and death.

3.1.5.1 Individuality

Health care providers should not assume that all patients from a particular group or culture are of the same mind [3]. Native Americans are not one people or culture, and we cannot generalize about individuals. Beliefs, traditions, rituals, and ceremonies among tribes vary widely. The culture of each nation or tribe also reflects the influences of assimilation and acculturation, which may be the result of relocation, forced education in boarding schools, and competing religious missionary efforts in American history. These events resulted in a heterogeneous belief system among the Native American community [9]. Based on the 2010 US Census population count, 47% of Navajo tribal members lived on the Navajo Nation, 10% in larger towns bordering Navajo, 26% in metropolitan areas throughout the US, with large populations in Phoenix, AZ and Albuquerque, NM, and 17% in other areas of the US [10]. Knowing whether a patient resides or was raised on the Nation of Navajo versus a large metropolitan area, may help to inform the approach a health care provider takes during interactions and difficult medical discussions. However, even if a person was raised in a large urban area, influences of culture may still have an effect on beliefs and identity [24].

Some Navajo patients have multiethnic and multicultural families with members of other Native and non-Native peoples who practice different religions. It is common to have a family in which some segments are Christian while others maintain traditional Navajo religious beliefs in the multiple generations of a matrilineal family [4]. An individual may also be influenced by the push and pull of traditional and modern beliefs. Allopathic therapies may be acceptable with the addition of traditional and/or Christian ceremonies to ward off evil, harm, and negativity to protect the individual and family [4].

These factors may influence how a patient and family process medical decision-making and combine to define the individual’s preferences with regard to health, values, and behavior. A family may have traditional cultural beliefs combined with varying religious beliefs and a contemporary context, resulting in a spectrum that needs to be explored to provide good communication with each patient [5, 6]. Getting to know each patient and family will guide the methods for discussing medical information.

3.1.5.2 Positive Thinking

In the traditional Navajo belief system, thoughts and language shape and influence reality and may affect future events. For Navajo people, it is believed that your words carry power, hence the act of discussing something can make it happen and may influence the outcomes of medical interventions [3]. Hózhó or hózhóni is the central concept in Navajo culture and its meaning is approximated by combining the concepts of beauty, blessedness, goodness, balance, order, harmony, peace, and everything that is positive or ideal. Hózhó, the “beauty way of life”, defines the traditional Navajo way of thinking, speaking, behaving, and relating to other people and the surrounding world and living a balanced and harmonious life [1, 7]. In general, Navajo people believe health is maintained, or restored, through positive language, termed hózhoojí [7]. The Navajo phrases hózhoojí nitsihakees and hózhoojí saad literally translate to “think in the beauty way” and “talk in the beauty way”. Positive thoughts are important in all things and negative thoughts and ideas are avoided [5]. Many Navajo persons refrain from thinking or speaking in a negative way and maintain a positive outlook and hope. The Navajo phrase, “Doo’ájíniidah” has literal translation “don’t talk that way!” Speaking about potential future harm will either call upon the negative result that is discussed or will make it more likely to occur [8]. This positive thinking has sometimes been misinterpreted by others that the Navajo people are intensely afraid of death. On the contrary, they have tremendous respect for life and the preservation until old age would be ideal [9]. The belief that talking about bad things can be causative is held by many other cultures, such as people in Greece, China, Italy, Korea, Mexico, and the Horn of Africa [7].

3.1.5.3 Family Structure

According to laws in the US, there are strict definitions of “family”, k’é. Immediate blood-relations, family members by marriage or adoption, and legally appointed powers-of-attorney are allowed to make decisions about individual patients. Many cultures have differing family structures that do not adhere to these rules. Native American tribes may be matriarchal, bilinear, or patriarchal, but in most tribes, the wisdom and experience of elders are honored and respected. The Diné are a matriarchal and clan society, emphasizing the importance of the maternal lineage. The lineage of the clans is passed down through women and women have authority over property and are custodians of the children. A clan is a small tribe within a tribe [1]. The Navajo tribe has more than 100 clans from differing areas of the Navajo Nation with unique meanings and histories. Each person belongs to four different clans, derived from family linage. The individual’s primary (or first) clan is from the mother’s female linage (grandmother, great grandmother, etc.). The second is from the father’s primary clan, third from the maternal grandfather’s primary clan, and forth from the paternal grandfather’s primary clan. These clans are used to identify family members or establish kinship with one another. Therefore, a person/patient may have many “mothers”, “aunts”, and “siblings” who are influential in upbringing and decision-making throughout one’s life. Separate clans are interwoven by cross-membership in other groups, forming a complex network and may inform the decision-makers for health care choices. In each family or clan, one elder may be designated as the final decision-maker [6, 25]. The Diné also have a close-knit extended family with many multigenerational households due to culture but also structural inequities on the Navajo Nation. Extreme poverty necessitates shared homes or close proximity of small households on one plot of land owned by the family. The definition of “family” and who is involved with major decisions regarding health care varies across cultures. Allowing participation of non-conventional family members in decision-making is crucial to cultural competence in treating many patients [1, 6].

3.1.5.4 Traditional Medicine

The Diné value living in harmony with everyone and everything, people, the land, and animals [1]. This is called “Walking in Beauty”, a world view in which everything in life is connected and influences everything else and is a path to health, healing, and life [1]. Traditional Navajo religion involves worship of the winds and watercourses and a number of divine beings who are believed to intervene occasionally in human affairs. These entities are frequently invoked, offerings are made to them, and ceremonies are performed to continue to live a life of balance and harmony (hózhó). Songs, chants, dances, prayers, sweat baths, and sand paintings also form portions of the intricate religious rituals [6]. Traditional Navajo customs may partially or completely inform an individual patient’s culture or may have no influence at all based on individual and/or family belief.

Traditional Navajo healers are called Hataałii or “singers”, also known as medicine men (or women), and use chanting, singing, praying, and herbs to create medicinal elixirs or ointments, and “cleansers” to perform healing ceremonies and blessing rites intended to protect and cure the body, mind, and spirit. The Hataałii sees a person not simply as a body, but as a whole being, connected to other people, families, communities, the planet, and universe. All of these relationships need to be in harmony to be healthy [1]. In traditional Navajo medicine there are no disease names. Sickness is a result of things falling out of balance, of losing one’s way on the path of beauty. Religion and medicine are combined [1]. Illness is thought to be caused by transgressions against the supernatural, witchcraft, or violation of taboo [26] and by imbalance with an animal or bird or caused by the wind, dirt, or the season. The word “taboo” can be defined as not being acceptable to talk about or do and is a strong cultural warning or prohibition against an action [26]. Violating a taboo may have a negative effect on the family and community, not only the individual’s mores. Bilagáana (European-American or white man) illness are the names and causes of allopathic diseases. Diseases may be attributed to contamination and oppressive social conditions resulting in loss of traditions by having to live according to the “white man’s” philosophy, eating processed foods, or exposure to environmental pollutants. Traditional healers and ceremonial interventions may be needed to correct for contamination caused by contact with non-Navajo blood, breath, organs, and medical personnel. This type of background information for a particular culture may be beneficial in working with indigenous populations across the globe [4]. For Navajo patients, traditional healers may be requested to reverse taboo or for protection ceremonies. Patients or families may wish to consult with a traditional healer combined with contemporary allopathic medical treatments [27]. Often the songs of the medicine man can inspire hope and compliment treatment with biomedical medicine [1]. Having a ceremony before surgery or other treatment may result in a calm patient who is a better candidate for surgery. Navajo healers practice a viable and real medicine that works with the patient’s mind as well as the body [1]. It is therefore important to realize that using “science” to try to talk patients out of their beliefs will be ineffectual when used alone. Allowing traditional medicine to come alongside science may be an effective holistic approach.

3.1.5.5 Allopathic Treatments

Traditional Navajo believe that each person has a predetermined life span or limit. There is also belief in an afterlife in which a person returns to the spirit world to be with the “holy people or diyin dine’é” and will need the tools to reside there, including an intact, uncontaminated body, “the sacred gift”. Taboo procedures, such as autopsy or organ transplantation, either as a recipient or donor, may hinder the journey process after death. Organ transplantation, blood transfusion, cardiopulmonary resuscitation (CPR), and even some surgical treatments may be difficult to accept, because they may interfere with one’s predetermined life limit by extending it [4].

Organ transplantation is a particular conundrum. Belief that the body should remain intact to enter the spirit world, mistrust of the ethical process of organ procurement, and uncertainty about the safety and quality of deceased organs are concerns. On the other hand, patients have expressed that their family and loved ones were the primary motivation to pursue transplant, in addition to improved quality of life by avoiding dialysis and dietary restrictions. Although a more modern cohort of patients may accept transplants, there remains a resistance to organ donation. An organ, blood, or breaths received in CPR may be contaminated by the donor’s spirituality, personality, or physical ailments and may be acquired by the recipient. Donated organs or breaths given in CPR are also thought to give away a part of the Navajo donor, therein, a piece goes to and stays with the recipient. Navajo patients with traditional beliefs would rather accept blood or organs from someone living, as opposed to deceased, and in their own kinship, however, some may not wish to burden family members by taking an organ they may need in this life or the afterlife. Patients also express that some taboos of accepting allopathic treatments can be remedied with ceremony and asking for permission and protection and are, therefore, rendered less objectionable [4, 28].

3.2 Principles of Medical Ethics in Surgical Care and Cultural Difference

In caring for people from some cultures, it may be necessary to further contemplate the four principles of clinical medical ethics and how their application may differ with regard to communication and treatment to assure autonomy, non-maleficence, beneficence, and justice for all patients. Belief systems, family structure, communication styles, characteristics and temperament of individuals, and distrust of the healthcare system can position cultures such as the Diné in conflict with the classic intention of the four principles of clinical medical ethics as outlined by Beauchamp and Childress (see Table 20.2) [29].

Table 20.2 Ethical principles [29]
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3.2.1 General Concepts

Many aspects of surgical care, such as obtaining informed consent and advance directives, involve outlining negative consequences, risks, and possible dire scenarios. Having belief in the causal efficacy of stating future harms, some patients may ask that their healthcare providers avoid these negative discussions and doing so may uphold non-maleficence. Some traditional Navajo persons would like to avoid “Doo’ajiniidah”, negative thoughts, and wish for hózhoojí, positive language and thinking to maintain hózhó [8]. The belief of creating negative outcomes by voicing them also exists in other cultures and is known as the Nocebo Effect and refers to adverse outcomes produced by negative expectations for an event, procedure, or treatment [30]. This may lead to some patients experiencing anxiety or other adverse outcomes, if aware of serious side effects or risks of surgery [31]. Some patients expect to hear a complete list of possibilities and to be fully informed. Others wish only to gather basic information and avoid conversations about advance directives or specific scenarios and negative outcomes. This dichotomy may be particularly evident between Navajo patients with traditional beliefs and those from a more progressive background, emphasizing the need to individualize dialogue with each patient.

3.2.2 Trust

Historically, the education system was used to forcibly acculturate Native Americans by removing them from their families, tribes, and land, assigning them European-American names, prohibiting them from speaking their languages, sending children to boarding schools, and generally stripping away every aspect of indigenous culture [28]. Healthcare institutions, both historically and in the present, have not always shown themselves to be worthy of trust, which is a critical element in cross-cultural cooperation. Experimental treatments and inequity in medical and surgical care for ethnic minorities are well documented. Until disparities in access and quality of care are eliminated or at least greatly reduced, simply encouraging Native Americans and other ethnic minorities to be more trusting of recommendations provided by non-Native physicians is likely to fail [32]. Attention to culturally competent communication is a first step in inspiring trust.

3.2.3 Patient Autonomy

In the United States healthcare system, the value of autonomous decision-making is strongly held. Autonomy is defined as a norm of respecting and supporting independent decisions [29], permitting control over one’s body according to an individual’s personal values and beliefs. How does autonomy differ in a maternal, family-based culture? For many American Indians, autonomy is not an individual concept as decision-making lies in the community. Since the Navajo family composition can be quite complex and elders held in high regard, many health decisions may be made together with multiple family members, and families may make decisions for individual members (see Chap. 19).

3.2.4 Advance Directives

In 1991, the United States legislature implemented the Patient Self-Determination Act (PSDA) that requires health care organizations and encourages patients to create advance directives (ADs) [8]. Initially, ADs were viewed as a solution for decreasing the use of costly, life-sustaining technology, which did not maintain life at a quality level. Individuals, regardless of race, ethnicity, culture, and cultural heritage, fear that life-extending technology might increase suffering without ultimately resulting in sustained and prolonged life. The PDSA was adopted by the Indian Health Service in 1992 with the proviso that “Tribal customs and traditional beliefs that relate to death and dying will be respected to the extent possible when providing information to patients on these issues.” [8] However, if a healthcare provider honors her Navajo patients’ Doo’ajiniidah request, these patients may not receive sufficient information needed to make informed decisions. Navajo patients with traditional beliefs may not wish to participate in the discussions concerning dire circumstances necessary for advance directives that are mandated by the PSDA, for they may believe that talking about the possibility of becoming terminally ill and/or in a persistent unconscious state will either cause them to suffer this fate or make it more likely [8]. For some, an advance directive is considered a death warrant and a violation of fundamental tribal views and is perceived to be detrimental not only to the individual but to the family and community [7, 33].

3.2.5 Informed Consent

As surgeons trained in the US, we are taught to explain every risk and possible bad outcome of each treatment option. Not doing so can put us at risk for litigation, if complications occur. Fully “informing” our patients of not only the benefits and alternatives to surgery but also the risks involved in having or declining surgical treatment is the key portion of obtaining informed consent. In the same way discussing advance directive choices regarding end-of-life care may cause distress for those who wish to only discuss positive ideas, the informed consent process can be problematic and may result in a patient losing trust in their care. On one hand, most persons value autonomy, and so value giving informed consent to treatment to protect it. On the other hand, a view of causation may preclude a patient from talking or thinking about “negative things,” and so may prevent giving truly informed consent for treatment [8].

3.2.6 Treatment

3.2.6.1 Pain Assessment

There are several studies that show ethnic disparities in assessment and treatment of postoperative pain [34]. Expression of pain is a complex interaction between biologic, psychosocial, and cultural factors and may be more subtle in Navajo and other Native patients. Commonly used assessment instruments may not accurately reflect the degree of experienced pain. While various pain scales exist, their reliability and validity across different racial/ethnic backgrounds remains to be determined [34]. When given numeric pain scale options, some Native American patients may tend to choose favorite or sacred numbers instead of the number that accurately indicates their level of pain. There can also be a difference in communication of pain. Many indigenous tribal beliefs about causes of illness and pain are related to imbalance between the spiritual, mental, physical, and social interactions of the individual and are to be endured. Courage and humble, soft-spoken stoicism should not be misconstrued as absence of pain. There is also evidence that subtle symptoms and the use of descriptive words by Native American patients to describe pain can be used as an indicator for the presence of pain. Due to the combination of the above factors, there is a need to assess acute postsurgical pain differently for some patients to avoid maleficence by undertreating pain. Attention should be given to nonverbal cues, as well as universal objective indicators of pain, such as tachypnea, tachycardia, diaphoresis, pallor, or increasing blood pressure [34].

3.2.6.2 Withdrawal of Treatment

As in our case of Baby Faith, families are often opposed to withdrawal of treatment for diagnoses with poor prognosis and limited life expectancy. People of many backgrounds prefer to choose life-sustaining treatments, including surgery, which may allow for improvement of disease or discharge home. It was difficult to find evidential information in the literature concerning this subject with regard to Navajo tradition. There are some reports about other cultures that approximate the Navajo concept of avoiding interference with one’s predetermined life limit and preserving hope in deciding to continue treatment [4]. Many Christian religions also discourage withdrawal of care or hastening death. Since it is difficult to provide a definitive prognostic estimate for a diagnosis due to phenotypic variability and severity of disease processes, life expectancy projection cannot be exact, complicating decision-making for patients and families. Families have stated that letting a patient die is not their decision to make, which has been expressed by other groups who have beliefs that “only God has knowledge about and power over life and death” [32]. Despite the reasons, we should attempt to understand and accommodate desires for continued or more aggressive care, and use respectful negotiation when treatment is contraindicated or seems medically futile [32].

3.3 Cultural Competence and Cultural Humility Improvement Strategies

Physicians frequently care for patients whose cultural, religious, or social backgrounds differ from our own. If these differences are not attended to, the substantial variety in patient values, beliefs, and behaviors related to health and healthcare may result in conflict, misdiagnosis, poor adherence to recommendations, suboptimal outcomes, or decreased patient satisfaction. Cultural, ethnic, or racial discordance between patients and physicians has an impact on communication related to healthcare, and barriers can be due to differences in language, religion or spirituality, family involvement in decision-making, responses to inequities in care, and lack of trust. Biases in treatment recommendations, pain assessment, and outcomes can be mitigated if we use an individualized, culturally competent method of providing care, which has been shown to improve outcomes in many disciplines and should be a part of modern-day medical care [3, 35]. Focused improvement strategies for individuals, medical education, hospitals and health systems, and the broader society can be used to improve culturally competent communication and care for patient populations. “To effectively reach populations affected by disparities, providers need to have a personal understanding of the communities and people within those populations—who they are, what matters to them, and how they can be supported in building a stronger foundation for health.” [24]

3.3.1 Individual Provider Strategies

3.3.1.1 Unconscious Bias Awareness and Training

Individual surgeons and other healthcare practitioners should familiarize themselves with cultural competence and cultural humility and strive to understand and practice both. We should embrace implicit bias training, awareness of biases, and make a conscious effort to lessen them and endeavor to be knowledgeable about and accepting of other cultures. Lead by example with professional behavior and compassion for cultural difference with emphasis on beneficence, non-maleficence, autonomy, and justice [3]. Implicit bias is likely the most common form of bias among healthcare providers, but explicit bias is also persistent, and efforts are needed to minimize its occurrence as well. We also need to enhance structural competence among healthcare providers, which refers to increasing awareness of how racism is embedded in our culture and institutions and shapes not only behavior of individuals but also the ways in which policies and procedures in medical and other social institutions have initiated and sustain racial inequality. Therefore, effectively addressing implicit bias also requires identifying and dismantling institutional legacies and social consequences. This will require changes not only in the individual behavior of providers but also policy changes across many domains of healthcare and other social institutions [36].

3.3.1.2 Communication Strategies and Ethical Principles

Good communication is critical for caring for all patients but can be more difficult with those from different cultural backgrounds. Cultural differences can lead to the need to alter the typical manner of pre- and post-operative discussions, which are often blunt and directly goal oriented. Awareness of the differences between cultures can enhance communication and using interpreters and lay medical advocates improves quality of care. “Increased awareness of social cues that communicate respect to Indigenous people, attending to these during medical history-taking, physical exams and delivery of treatment, ensuring that patients will be treated with respect and dignity, and that there will be time to answer questions” are helpful practices [24].

3.3.1.2.1 Four-Step Approach

Carrese’s 2000 article describes a four-step guide for communicating with Navajo patients based on conversations with Navajo informants and can be adapted for use with many patients of differing backgrounds (see Table 20.3) [3]. The overarching premise of the approach is to interact while applying the Navajo concept of k’é, compassion, caring, kindness, and respect, especially when discussing negative information. Getting to know the patient and family and communicating awareness of potential differences in culture will allow them to have more confidence in the care. These methods can be beneficial in connecting with all patients.

Table 20.3 Carrese’s four step approach [3]
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The first step in the guideline is to ask permission to discuss negative information, which goes hand in hand with the second step of rapport building. Rapport is cultivated by (1) establishing a trusting relationship, (2) facilitating involvement of family members, (3) warning the patient about the nature of the discussion and communicating that no harm is intended while asking permission to discuss negative things, and (4) facilitating the involvement of a patient advocate and interpreter and traditional healers, if the patient desires. The third step involves specific techniques for communication. (1) Communicate information in a caring, kind, respectful manner, k’é. (2) Do not rush the interaction and allow enough time for the conversation and questions. (3) Maintain a positive focus, keeping in mind hózhoojí, using positive concepts and words. (4) Refer to third parties rather than to the patient directly when discussing prognosis, risks, or other potentially negative information; “Some people with this diagnosis had these treatments.” “The types of problems we have seen may include bleeding, transfusion, or need for more surgery.” (5) Review the patient’s story in a circuitous route from symptoms, physical findings, and study results, then meander to the most likely conclusion, rather than stating the facts and diagnosis bluntly. Use positive language for wishing these things were not happening. Using positive action words and third person language are techniques that uphold non-maleficence. The fourth step involves follow-through and the physician’s responsibility to the patient and family after negative information has been shared. Continue to care for the patient, communicate hope, and invite traditional healing and other methods of care, especially for those with a poor prognosis. Outline the options and continue to convey a positive message in positive language to maintain hózhó. “In the Navajo way there is always something to be done” [3]. As an example:

If you say, “This medicine is for your high blood pressure, and you’ve got to take it like this, and if you don’t, one of these days you’re going to get worse, and maybe a year later or two you’re going to be dead,” then right there, that guy’s going to back off from you. That’s the negative aspect. If instead you say, “If you follow this example, you will get better, you will feel better, you will feel good.” Then the Navajo patient may actually follow the recommendation to take the medication. “Mention the positive thing. That’s what people want to hear. (Traditional healer) [3]

3.3.1.2.2 Hypothetical Case Approach

Another strategy to preserve non-maleficence is using a hypothetical case to inform the patient and family about the procedure, treatment plan, or prognosis. This technique acknowledges the patient’s and family’s realistic fears, respects the need for indirect discussion, and invites further questions. Direct confrontation may frighten or offend the patient, and sensitivity and skill are essential to gauge the degree of information sought. Responses to inquiry may be indirect or phrased as hypothetical, according to the wishes of the patient and family [3].

3.3.1.2.3 Ask, Tell, Ask Approach

The physician should regularly seek feedback from the patient and family to assess their understanding of the proposed treatment plan or progression of the disease and to determine need for additional information [32]. Ask patients what they want to hear, tell them what they are comfortable hearing, and then ask what they understand and repeat as the conversation progresses [37].

3.3.1.2.4 Modified Informed Consent

There is some literature proposing modifying informed consent (IC) by withholding negative information, such as risks, out of respect for the wishes for some people to avoid negative thinking, including in Navajo culture [8, 30, 38]. Some authors recommend either providing only basic information about a treatment unless asked for more [30] or tailoring a discussion to each specific patient, termed “contextualized informed consent” [39]. Asking about the preferred mode of decision-making will allow the patient to know you are aware of potential cultural differences. The patient may wish to have family, tribal elders, and/or a spiritual healer or Hataałii participate in the discussion. Determine and document who may not want to hear about the negative risks. Prioritize positive thinking during discussion of risks and document any modification the IC process. Customizing the information given to provide maximal transparency with the least potential harm may uphold non-maleficence and avoid the nocebo effect [31]. Since the primary motivation behind informed consent is the protection of patients, then through the principle of beneficence, withholding nocebogenic information may be appropriate. Clinicians should be aware of the impact of their conversations on patients’ experiences and endeavor to shape their discussions to optimize outcomes while maintaining patient autonomy [39].

3.3.2 Medical Education Improvements

Improving diversity in the healthcare workforce will likely need to start with societal changes and improved institutional inequities in the US education system. Medical schools should strive for admissions that reflect the diversity of the population served. Mentoring and recruitment needs to begin in early education, high school or earlier, to attract students to medical disciplines, especially surgical specialties, by developing mentorship and pipeline programs to foster diversity. The diversity among surgical residents and practicing surgeons should be a focus in residency recruitment and admissions, since there continues to be a paucity of black, indigenous, and people of color (BIPOC) in surgical residencies and, subsequently, surgical practice [40]. A diverse workforce improves patient-provider racial and cultural concordance. Research indicates that racial concordance between a patient and a clinician is associated with better communication, overall health outcomes, higher levels of patient satisfaction with care, and superior adherence to provider recommendations. Therefore, as the US population becomes increasingly diverse, with the current BIPOC populations becoming the majority of the US population in less than 25 years, ensuring the increasing diversity of health care providers is in the best interest of national health care delivery [36].

3.3.3 Health Systems Strategies for Cultural Competence (see Table 20.4)

3.3.3.1 Diversify the Workforce

Hospitals and health systems should increase educational opportunities in medical disciplines for diverse populations and recruit actively for medical providers, physicians, and nurses with differing backgrounds that reflect the local population and/or population at large. Hospitals should recruit and cultivate a diverse workforce with intention and provide educational competencies not only in compliance, HIPAA, patient safety, but also in cultural competence and communication. They should require courses on common cultural traditions in the region and emphasize using customized techniques with patients. Diné College offers cultural orientation courses for non-Navajo medical workers, as an example. Outline potential differences in various patient populations and emphasize the need to inquire with the patient and family their preferred communication style, type of care, other healing methods or holistic care they prefer. Require that staff are educated on implicit and explicit biases and cultural and structural competence. Maintain ongoing evaluation and training on potential for bias and strategies to eliminate or diminish the influence of biases on behavior and patient care. Deliberately recruit and hire health care workers who strive for inclusion and cultural openness. Be sure this is part of the interview and hiring requirements with ongoing training and evaluation.

Table 20.4 Healthcare systems strategies for cultural competence and humility [1, 4, 5, 7, 8, 21, 24, 30, 31]
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3.3.3.2 Interpreters and Patient Advocates

Hospitals should hire bilingual, bicultural staff and train them in medical translation/interpretation for the common racial and ethnic groups in the region of practice. Create paid job positions for patient advocates with background and understanding of the patient populations cared for. Assure that these positions are paid and not on a volunteer positions to promote longevity and provide income [24]. Providers should always avoid the use of family members as interpreters and insist on using medical interpretation during interactions with Navajo and other non-English speaking patients. Many patients may speak English, but pride may impede the request for an interpreter [5]. Patient advocates and interpreters understand the Navajo positive speaking and culture and can enhance interactions [32].

3.3.3.3 Traditional Healing

Healthcare facilities that care for populations of American Indian patients should employ and/or development consultation contracts with traditional healers and provide spaces for traditional healing. Hospitals should facilitate the use of traditional Native healers as a complement to allopathic medicine and recognize the importance of spiritual traditions when setting up prevention programs, screenings and health care services [24]. In 1996, the Navajo Nation was granted funds from the US Department of Veterans Affairs to finance traditional healing services. The Indian Health Service (IHS) has made efforts to incorporate Navajo opinions into its operations to make facilities more accessible to Navajo practitioners. One of the first examples of this cooperation is the Chinle Health Care Facility in AZ which created an Office of Navajo Healing to build a bridge between biomedicine and traditional Navajo medicine. They offer traditional counseling and care and arrange herbalists and ceremonial practitioners and have a hogan (traditional dwelling and ceremonial structure) at the facility. Other centers have integrated traditional practices in treatment with medicine persons as permanent staff members, hogans and healing rooms on site, facility doors facing east, Navajo artwork, and Diné Bizaad signage [1, 4]. At the University of New Mexico Hospital, there is a non-denominational meditation space with respect for differing religions and beliefs. There are Native American patient advocates and interpreters on staff through the office of Native American Health Services.

3.3.3.4 Hospital Policy Considerations

Health systems should consider policy revisions to incorporate a culturally competent organizational strategy [7]. Revising policies on requiring advance directives, family member definitions, and requirements for decision-makers may be appropriate. Some patients may want an advance directive and others prefer a more stepwise decision-making algorithm, making choices as only necessary. Policy should allow patients to designate decision-makers and how involved they are in healthcare choices. Some elders of many cultures will prefer to have a designee hear the “bad news” and make decisions about informing the patient.

3.3.4 Societal Advocacy

Healthcare leadership, especially physician leaders, in medical schools and hospitals should (1) work to increase diversity in the health system, intentionally and actively, (2) take a proactive role in learning, researching, publishing, and educating others about structural and institutional racism, cultural competence, and cultural humility, (3) use knowledge learned to inform health policies and for advocacy and mentorship to ensure and improve justice and equity in medical care, and (4) continue to support elevation, appointment, and election of persons underrepresented in medicine to medical leadership positions and elected offices.

3.4 Return to the Case

The Navajo patient advocate, Diné interpreter, and the medical teams met for pre-conference planning and various aspects of communication with Navajo families were examined. The advocate stressed the importance of shaking hands with a light touch, as opposed to a vigorous tight firm grip, as a necessary and respectful greeting in Navajo culture. The concept of positive thinking and avoidance of negative thinking and ideas were discussed. Use of the third person when naming risks was emphasized to avoid seeming to wish harm on the patient [3]. The Navajo medical student was elected to take the lead on discussing the proposed procedures. She was given the risk and benefit information and was assured the specialists would be present to answer more detailed questions.

The family meeting began with a prolonged introduction of all the participants to the family by the Diné interpreter. The interpreter, advocate, and medical student were noted to shake the hands of all of the family members before beginning. The dysmorphologist began with a detailed description of Patau syndrome. The interpreter repeated the details in Navajo for the elder family members, as the parents spoke both English and Navajo. She also occasionally paused to explain some Navajo traditions and common wishes to the medical team. In discussing the symptoms and prognosis of the syndrome, the team was very careful to frame the information and statistics to a third party. “Some patients have a short life and develop very serious medical problems.”

The baby’s current problems were outlined and described. The potential future associated problems were explained very delicately in the third person, prefacing each problem with “some patients have developed…”. The discharge planner and social worker clarified requirements for care at home with regard to plumbing, electricity, home care services. They offered to help obtain housing in Albuquerque, close to the medical center. The family stated that this was not an option due to their wishes to stay close to their extended family and community.

The benefits of tracheostomy and gastrostomy surgery were listed. The medical student then asked permission to discuss the risks of the surgical procedures. The family granted this discussion. Each statement was prefaced by positive action words and was stated in the third person. “We do not wish for any of these problems to happen, but some patients have had bleeding, collapse of the lung, infection, and the trach tube can get plugged or fall out.” With the “stomach feeding tube, in other patients we have seen infection in the belly, leakage of stomach fluids, infection of the skin. We hope that none of these difficulties will happen.”

The subject of an advance directive was brought up, and the family did not wish to make specific plans for negative outcomes and preferred to make decisions in a stepwise fashion at the time choices are needed. Withdrawal of care was also mentioned. “In similar situations, some parents have chosen to remove the breathing tube and let nature take its course.” The parents asked, “Let her die? We cannot let her die. This is not up to us. We need to do everything we can to take her home.” The family did not wish to discuss this any further. The family members had many questions, which were slowly, thoughtfully, and comprehensively answered.

The family stated they would like some time to think things over and asked the patient advocate about the availability of a traditional healer who could go to their daughter’s bedside. This was not available, therefore they wished to consult with a medicine woman at their home in Tohatchi.

The medical team members continued to round on the patient and visit with the parents daily, answering questions about the medical status and potential surgeries. The team members kept in mind the methods of discussing the negative information in the third person and emphasizing that they did not wish any poor outcomes and hoped for only benefits. The care teams and family all perceived improved communication and trust.

After discussion with extended family members and consultation with a traditional healer, the parents decided to stay at the facility, again expressing wishes to do anything necessary to take Faith home. They gave consent for the surgical procedures. They had discussions with the social worker about the availability of extended family members to help with 24-hour care and their comfort with their local health facility and transfer to Albuquerque, if necessary.

The medical team members felt satisfied that the family understood the benefits and risks of the recommended treatments, giving true informed consent. The individuals learned valuable skills in communication with Navajo families, but more importantly, culturally competent skills that may be applied to all patients.

4 Conclusion

Medical decision-making can be incredibly complex for patients and families as many belief systems, traditions, fears, and hopes combine. As surgeons and other healthcare providers, we should listen, learn and gather liaisons, interpreters, family members, and any other tools at our disposal to assist in understanding and communicating with patients. Further, we should treat every patient as an individual and keep an inclusive attitude to maximize beneficence, minimize maleficence, support and encourage autonomy, and protect and enhance justice and equity for those we care for. Deliberate attention to inclusion and embracing cultural difference will allow for improved care for marginalized populations.

We hope that the ideas and evidence presented in this chapter can inform surgeons and other health practitioners how to tailor discussions regarding surgical care to the individual, taking into account the background, culture, and belief-systems of the patient. The people of the Navajo Nation are the most written about US indigenous group, therefore, discussing some aspects of this unique culture can serve as an example in the examination of communication approaches that can be used with patients. This informed methodology can be applied to every encounter with patients and families in medical practice. Cultural competence and humility can and should be learned, taught, and customized for a surgeon’s patient population and practice setting (see Table 20.5). Ask respectful questions, listen to answers, keep a receptive mind, communicate in a kind and thoughtful manner, and walk gently during difficult conversations. The use of interpreters, patient advocates, consultation with traditional healers, and being open to perspectives divergent from our own beliefs will assist us in providing culturally competent care. As we each strive to become culturally competent and practice cultural humility in providing surgical care, we can endeavor to improve healthcare for patients of all cultures and backgrounds and move us closer toward the goal of eliminating health disparities.

Table 20.5 Cultural competence versus cultural humility [41,42,43]
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5 Selected References

  • Alvord LA, Van Pelt EC. The scalpel and the silver bear. The first Navajo woman surgeon combines western medicine and traditional healing. Bantam Books;1999.

    • The first Navajo woman surgeon takes us on her journey to combine modern medicine and traditional healing while working in the Navajo Nation in Gallup, NM.

  • Bird ME, Bowekaty M, Burhansstipanov L, Cochran PL, Everingham PJ, Suina M, eds. Eliminating health disparities. Conversations with American Indians and Alaska natives. ETR Associates; 2002.

    • Interviews with public health experts provide background information on existing disparities and recommendations to improve future practice and outcomes.

  • Navajo Traditional Teachings, youtube.com. https://www.youtube.com/c/NavajoTraditionalTeachings/videos. Accessed 1 Mar 2021