Keywords

Case Scenario

A 42-year-old male presents to the emergency department for evaluation of a nonhealing laceration on his lower leg. The patient is accompanied by his girlfriend, who is employed at the hospital as a medical assistant. The doctor learns from the girlfriend that the patient was very reluctant to seek medical attention. He currently lives in Jamaica, is a practicing Rastafarian, and is only visiting the United States. Per the girlfriend, the patient was given a “savve” for the cut, but it has not helped with healing. The patient is a thin, well-groomed male with shoulder-length hair (dreadlocks) who appears older than his stated age.

Engaging the patient in a meaningful conversation is very difficult. Although the patient is pleasant, he appears very suspicious of the questions he is being asked and answers every question with an additional question [1]. Despite the challenges, the doctor is able to obtain a few meaningful pieces of information concerning the laceration from the patient that makes the doctor very concerned for a serious underlying infection and undiagnosed metabolic abnormality. The doctor, believing the patient to be minimizing the potential seriousness of the situation and trying to embarrass him in front of the staff, becomes more impatient with the patient. He assumes that the nonchalant attitude of the patient may be due to his use of “ganja” (also known as marijuana). The doctor, believing that the patient is “impaired,” begins to discuss his working differential diagnosis and treatment plan with the girlfriend. He intentionally positions himself between the patient and his companion and turns his shoulder slightly away from the patient. Although the doctor received no confirmation from the patient that he has recently smoked marijuana, his assumption is based on the general appearance of the patient, preconceived stereotypes about “practicing Rastafarians,” and the perceived widespread use of marijuana among this group of individuals [2]. The doctor suggests to the girlfriend that the patient’s complaints could be limb-threatening and “it may already be too late.” Specifically, the dialogue is as follows:

  • Physician (enters the room and immediately begins with his questioning): “Hello sir, how long has that laceration been present on your leg?”

  • Patient: “Well, doctor, it has been there for quite a while. Why do you ask?”

  • Physician: “Well, it doesn’t look like it is healing well from here.”

  • Patient: “How can you say that Doc?”

  • Physician: “I understand that you have been putting an ointment on it. How long have you been using it, and do you know what type of ointment it is?”

  • Patient: “I’m not sure, but it has been off and on. In my line of work, I always have a cut or scrape here and there. Why does it matter? They typically come and go.”

  • Physician: “Have you had fevers, weight loss, or tingling in your legs?”

  • Patient: “Whoa Doc, is this a fishing expedition? How does that relate to the cut on my leg, Doc? I only came because my girl insisted. I am very healthy and active.”

  • Physician: “Okay, sir.” The physician repositions himself and begins to address the girlfriend more directly. “Based upon the appearance of the laceration, it looks infected. I am concerned that the infection has spread to the bone. This can be very serious and he could lose his leg, especially if he has an underlying problem such as diabetes.”

  • Both the patient and his companion are shocked, evidenced by the puzzled looks on their faces, and are speechless.

  • The physician, feeling that he has gained control of the situation and effectively “put the patient in his place,” continues to speak with the patient’s companion. However, now he is entirely using medical jargon. “Yes, if he has osteomyelitis in addition to undiagnosed diabetes that is out of control, then he may be looking at a below the knee amputation in the worst case scenario. This is a very serious situation. We will have to be aggressive if the infection has spread to your bones.”

  • Physician: (feeling superior and victorious, turns to exit the exam room) “I’ll have the nurse come in and draw the blood, get the x-rays ordered, and start fluids and antibiotics. Once we get some results, I can answer any additional questions.”

Review of Symptoms

Provided by the girlfriend: The patient has experienced increased thirst and has had frequent urination . These symptoms are attributed to his line of work in Jamaica as a roofer where he works long hours under the sun. There is no history of vomiting or documented fevers.

Past Medical History

Unknown; the patient routinely sees a “healer” in Jamaica and has not been formally diagnosed with any illnesses [1, 3,4,5,6].

Family History

Strong family history of diabetes on both paternal and maternal sides.

Social History

Smokes marijuana, no tobacco, no alcohol.

Physical Exam

Vital Signs

Temp, 99.8 °F; pulse, 121; respirations, 22; BP, 100/72; O2 Sat 98% on room air.

General

Thin male, well-developed, appears generally healthy

Cardiovascular

Tachycardia rate and rhythm, S1 and S2 normal

Respiratory

Clear to auscultation

ENT

Pupils equal and reactive, extraocular movements’ intact

Neck

Supple, mucous membranes moist

Abdomen

Soft, flat, +normal bowel sounds, no rebound, no guarding

Extremities

There is a 3 × 2 cm irregularly shaped chronic appearing ulceration with surrounding erythema, warmth, and purulent drainage. There is tenderness to palpation. Pulses are palpable. There is a trace amount of pretibial edema. No clubbing of nails.

Skin

Warm, dry, intact, clean

Neuro

Alert and oriented × 3, cranial nerves II–XII intact

Questions for Discussion

  1. 1.

    Why did the physician-patient relationship suddenly change to an adversarial one?

Attitudes/Assumptions: The Physician

  1. (a)

    I am the doctor, and I have a medical degree. You came to me for help. Don’t challenge my knowledge or pretend that we are on the same intellectual level.

  2. (b)

    Based upon the patient’s repeated questions as answers to my questions, the patient is trying to embarrass me in front of my staff and thinks I am incompetent.

  3. (c)

    The patient is a practicing Rastafarian, which means that he smokes marijuana frequently and most likely is always under the influence of marijuana.

  4. (d)

    The patient’s chronic use of marijuana has impaired his ability to understand the seriousness of his illness.

Attitudes/Assumptions: The Patient

  1. (a)

    The doctor is trying to manipulate me and manufacture illness.

  2. (b)

    The doctor is arrogant and believes I am inferior to him.

  3. (c)

    Western medicine practitioners in general are not trustworthy.

  4. (d)

    The doctor does not understand Rastafarian culture and attitudes [5]. He probably thinks I am under the influence of ganja.

Gaps in Provider Knowledge

  1. (a)

    Lack of knowledge of health beliefs/customs by the provider: Rastafarians place a high value on maintaining one’s health. It is part of the foundation of Rastafarian ideology. Rastafarianism involves a holistic approach to healing , and Rastafarians often seek “remedies” as part of their healing regimen. There is a strong belief in the body’s natural ability to heal itself. These “remedies ” involve tonics comprised of “herbs, barks, and roots” [1, 6]. Remedies are passed down within families. The usual sequence of managing illness/ailments involves (1) self-diagnosis and self-medication with herb tonics, followed by (2) recommendations from family and friends, (3) a healer visit, and finally (4) seeking professional medical assistance. Western medicine is utilized to treat diseases, whereas “Jamaican folk healers” are utilized primarily for treating “illness problems” [1]. Nonetheless, because of the underlying distrust of western medicine, seeking medical attention is often facilitated by close family and friends and usually not by the individual themselves. In addition, there is often a great deal of suspicion toward plans that involve invasive or aggressive forms of medical treatment because of Rastafarians’ strong belief in the body’s natural ability to heal itself.

  2. (b)

    Lack of knowledge of Rastafarian as a religion : Rastafarians see themselves as very spiritual individuals. Ganja is regarded as a herb that aids religious mediation and is a “medical food” not for recreational use. Smoking ganja is optional for Rastafarians, and some Rastafarians choose not to smoke weed at all. Those who smoke do so for the perceived spiritual benefits gained by smoking [2].

  3. (c)

    Lack of knowledge of disparities/discrimination : There is a misbelief that marijuana or “ganja” use is widespread in Jamaica, especially among Rastafarians. Dreadlocks are stereotypical of affiliation with Rastafarian beliefs [2, 5].

  1. 2.

    What actions could have been taken by the physician to avoid/prevent this negative change?

Cross-Cultural Tools and Skills

  1. (a)

    Greetings or acknowledgment of an individual’s presence is an important cultural value. Absence of the greeting implies a lack of interest in the well-being of the individual.

  2. (b)

    Listen carefully to understand what is being said. Many Jamaicans may speak with an accent. Simply clarify what has been said in order to prevent any misunderstanding on your part or the part of the patient. Make sure that efforts to achieve clear communication and dialogue are not conveyed in a condescending manner.

  3. (c)

    Remember that Rastafarians bring with them a cultural history and that “one size does not fit all.”

  4. (d)

    Be understanding of cultural norms and tendencies without imposing judgment.

  1. 3.

    What medical issues concern you about this case?

  1. (a)

    The patient is concerned about his health and condition and attempts to engage the physician by asking his own questions in response to the physician’s questions. However, the engagement is ineffective and interferes with the ability to obtain a good history from the patient.

  2. (b)

    Most Rastafarians are unsure whether their beliefs will be respected while in the hospital [6]. It is therefore important to create an environment where the patients will feel comfortable to ask questions and engage in dialogue.

  3. (c)

    Discuss or explain the reasoning behind your questions. This may help improve the quality of the patient’s responses. For example, explaining why the type of herbal ointment used by the patient and the duration may be important in establishing what type of treatment exposure has occurred. Many herbal ointments do not contain antibiotics, and many contain barks and roots that may be irritants to the skin.

  1. 4.

    Which components of the Emergency Medicine Milestones of the ACGME competencies [7] are incorporated in the case?

  1. (a)

    Patient Care : Establishes and implements a comprehensive disposition plan that uses appropriate consultation resources, patient education regarding diagnosis, treatment plan, medications, and time- and location-specific disposition instructions.

  2. (b)

    Patient-Centered Communication Skills : Demonstrates interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families. Taking the time to introduce or greet the patient can serve to set the tone for a good physician-patient relationship and a potentially positive service outcome. For example, by asking the patient specifically if there are any concerns related to his religious practices that the physician should be aware of would go a long way in establishing a trustworthy relationship. Ask when in doubt. Most Rastafarians are proud of their religion and are happy to talk about it [3, 5].

  3. (c)

    Professional Values : Demonstrates compassion, integrity, and respect for others as well as adherence to the ethical principles relevant to the practice of medicine. Listen carefully to the patient’s concerns. Communicate openly in a nonjudgmental manner, and do not minimize the patient’s participation in the conversation.

Case Outcome

Diagnosis

Infected diabetic ulcer complicated by osteomyelitis of the fibula.

Disposition

Admit for hyperglycemia control and intravenous antibiotics.

After an appropriate history and physical examination is obtained utilizing the principles above, screening laboratory studies revealed glucose of 320 mg/dl, urine negative for ketones and evidence of infection, and white blood cell count of 18,000 with no previous baseline. X-ray of the left fibula demonstrates deep soft tissue swelling, a periosteal reaction, cortical irregularity, and demineralization. Based upon the X-ray findings consistent with osteomyelitis, the physician concludes that it is secondary to infected diabetic ulcer from undiagnosed type II diabetes mellitus. The physician explains his concerns to the patient, his companion, and his family and provides the correlation between the patient’s symptoms and the physician’s findings. The physician provides recommendations for admission to the hospital and discusses in detail the proposed treatment plan and the expected hospitalization time frame. The patient is allowed to ask questions and conference with his family. The patient is concerned about a prolonged hospital stay and agrees to a 24-h observation admission to receive intravenous hydration, glucose management, and intravenous antibiotics while arrangements are made to continue treatment on an outpatient basis.