D John Doyle MD PhD Chief Department of General Anesthesia Cleveland Clinic Abu Dhabi Professor of Anesthesiology Cleveland Clinic Lerner College of medicine No Disclosures No Conflicts of Interest ID: 908819
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Anesthesia and Culture: Personal Reflections
D. John Doyle MD PhDChief, Department of General Anesthesia, Cleveland Clinic Abu DhabiProfessor of Anesthesiology, Cleveland Clinic Lerner College of medicine
No DisclosuresNo Conflicts of Interest
Anesthesia and Culture Rev 004
Slide2Outline
What is culture?What is medical anthropology?The challenges of cultural diversity(and the problem of cultural pathology)The Muslim worldLiving in the UAEMedical practice in the UAEConclusionsReferences
Slide3What is Culture?
A culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next. https://www.tamu.edu
http://www.driveactiondigital.com/our-team/our_culture/
Slide4Cultural Competence
http://media-cache-ec0.pinimg.com/736x/4c/0d/82/4c0d8210c01d27ee354196d5fa616fa3.jpg
Slide5What is Medical Anthropology?
Medical anthropology is the study of human health and disease, health care systems, and biocultural adaptation.
Slide6Slide7“In recent years, evidence-based medicine (EBM), clinical governance and professional accountability have become increasingly significant in shaping the organization and delivery of healthcare. However, these notions all build upon and exemplify the idea of human-
centred, individual action. In this book, Dawn Goodwin suggests that such models of practice exaggerate the extent to which practitioners are able to predict and control the circumstances and contingencies of healthcare. Drawing on ethnographic material, Goodwin explores the way that 'action' unfolds in a series of empirical cases of
anaesthetic and intensive care practice. Anaesthesia configures a relationship between humans, machines and devices that transforms and redistributes capacities for action and thereby challenges the figure of a rational, intentional, acting individual. This book elucidates the ways in which various entities (machines, tools, devices and unconscious patients as well as healthcare practitioners) participate, and how actions become legitimate and accountable.” (Amazon.com)
Slide8Smith AF, Pope C,
Goodwin D, Mort M. Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence. Can J Anaesth
. 2005 Nov;52(9):915-20. PubMed PMID: 16251555.PURPOSE: Although the importance of communication skills in anesthetic practice is increasingly recognized, formal communication skills training has hitherto dealt only with limited aspects of this professional activity. We aimed to document and analyze the informally-learned communication that takes place between anesthesia personnel and patients at induction of and emergence from general anesthesia.
METHODS: We adopted an ethnographic approach based principally on observation of anesthesia personnel at work in the operating theatres with subsequent analysis of observation transcripts.
RESULTS:
We noted three main styles of communication on induction
, commonly combined in a single induction. In order of frequency, these were: (1) descriptive, where the anesthesiologists explained to the patient what he/she might expect to feel; (2) functional, which seemed designed to help anesthesiologists maintain physiological stability or assess the changing depth of anesthesia and (3) evocative, which referred to images or metaphors. Although the talk we have described is nominally directed at the patient, it also signifies to other members of the anesthetic team how induction is progressing. The team may also contribute to the communication
behaviour
depending on the context. Communication on emergence usually focused on establishing that the patient was awake.
CONCLUSION:
Communication at induction and emergence tends to fall into specific patterns with different emphases but similar functions. This communication work is shared across the anesthetic team. Further work could usefully explore the relationship between communication styles and team performance or indicators of patient safety or well-being.
Slide9Pathological Altruism
Pathological AltruismBarbara Oakley et al. (Eds)Oxford University Press, 2012ISBN 0199738572 465 pages“ Pathologies of empathy, for example, may trigger depression as well as the burnout seen in healthcare professionals.”
“Hyperempathy - an excess of concern for what others think and how they feel - helps explain popular but poorly defined concepts such as codependency.”“ …pathological altruism, in the form of an unhealthy focus on others to the detriment of one's own needs, may underpin some personality disorders. ”
Slide10Slide11Slide12Medicine and Culture
Folk healers / ShamansTolerance of pain and sufferingWomen as “impure”Religious influencesReligious medical ethicsversus secular medical ethics
Slide13Medicine and Religion
EuthanasiaSuicidePain and sufferingBlood transfusionsFaith healingAbortionBrain deathContraceptionPregnancy / Obstetrics
Organ transplantation
Slide14Medicine
and Religion
“The physician, taking nothing for granted, reasoning deliberately, prolonging life by every means in his power, stands out in contract to the priest, whose mind is bent on the future, and who regards the body as of secondary importance.”
Slide15“Although America is the most medically advanced place in the world, many people disregard modern medicine in favor of using their faith to fight life-threatening illnesses. Christian Scientists pray for healing instead of going to the doctor, Jehovah’s Witnesses refuse blood transfusions, and ultra-Orthodox Jewish
mohels spread herpes by using contaminated circumcision tools. Tragically, children suffer and die every year from treatable diseases, and in most states it is legal for parents to deny their children care for religious reasons.”
http://paul-offit.com/booksby/bad-faith/
Slide16Simpson JY. Notes on the employment of the inhalation of
sulphuric
ether in the practice of midwifery.
Monthly J Med
Sci
1847-8;7:721-8.
Simpson JY. On a new
anaesthetic
agent, more efficient than
sulphuric
ether.
Lancet 1847;
ii:549-550.
Simpson JY. Answer to the religious objections advanced against the employment of
anaesthetic
agents in midwifery and surgery. Edinburgh: Sutherland & Knox. 1847.
After learning of the use of chloroform by Queen Victoria at the birth of Prince Leopold,
The Lancet
in an editorial challenged the accuracy of the information, and then condemned the Queen's physicians and Dr. John Snow (although not by name) for even considering anesthesia.
http://www.ph.ucla.edu/epi/snow/lancet1853reaction.html
John Snow
Queen Victoria
James
Young
Simpson
Slide17Slide18“Pain is a gift from Allah”
Dutch Islamists Refuse Pain TreatmentRecalling that the Koran says one must be alert before Allah, some Muslims are refusing palliative care, fearing that it would leave them drowsy on their death beds. Prof. Wouter Zuurmond of the Vrije
Universiteit Medisch Centrum in Amsterdam has seen this pattern while working at the Kuria Hospice, which he manages. He finds the situation frustrating, knowing as he does that pain management need not make one drowsy. Accordingly, VUMC organized a symposium on March 29 about providing palliative care to Muslim patients. (March 31, 2009)
http://www.danielpipes.org/blog/2005/06/islamists-in-the-hospital-ward
Slide19What is Cultural Pathology?
Cultural beliefs or practices that if widely held and acted on inevitably results in injury, misery, suffering, despair or death.
Slide20Some Examples of Cultural Pathology
Slide21Slide22Her royal boat capsized. Despite the presence of many onlookers, they were forbidden on
pain of death to touch the queen – not even to save her life!
Slide23According to Wikipedia,
homosexuality is a capital offense in the UAE but in a recent Amnesty International report, the organization said it was not aware of any death sentences for homosexual acts. In the UAE
all sexual acts outside of marriage are banned (creating a problem for preoperative pregnancy testing programs).
Slide24Gun Violence USA
Slide25Ritual Female Genital Mutilation
Slide26The Muslim Faith
Slide27The Muslim Faith
Monotheistic / Abrahamic religion based on the Quran, which muslims consider to be the verbatim word of God as revealed to the prophet Muhammad.Five pillarsOriginated in Mecca and Medina at the start of the 7th century.
1.6 billion Muslims world-wide. Sunni Muslims are the largest denomination (85%) with Shiites at about 15%. The two denominations don’t always get along.Other denominations (e.g., Druze) also exist.
Slide28Five Pillars of Islam
Shahadah: Declaring there is no God but Allah, and Muhammad is His Messenger.Salat
: Ritual prayer five times daily1.Sawm
: Fasting and self-control during the holy month of Ramadan2 .
Zakah
:
Giving 2.5% of one’s savings to the needy
Hajj:
Pilgrimage to Mecca at least once in a lifetime (if able to).
1
Logistical implications for anesthesia
2
Clinical implications
Slide29Slide30Muslim Forces Anesthetist from Operating Room
Doctor Philippe Becx from Bree, Belgium, was called to the hospital in the middle of the night because a woman had to undergo an emergency caesarean section. However, her husband blocked the door and demanded a female anesthetist. The latter was unavailable.After a two-hour discussion proved fruitless, an imam was summoned. The imam permitted the doctor to apply an epidural injection, but only if the woman was fully covered with only a small area of skin showing.
During the surgery itself, performed by a female gynecologist, the anesthetist was to remain in the hallway. Through a door that was slightly ajar, he shouted instructions to a nurse who was monitoring the anesthesia.
According the hospital’s directors, the doctor acted with ‘admirable understanding.’ He would have been in his right to have the man removed by police.http://www.religionnewsblog.com/19778/islamic-extremism-13
Slide31Life in the UAE
Composed of seven emiratesOnly 44 years oldBenevolent monarchMost progressive culture in the region (some exceptions)In 2013, the UAE's total population was 9.2 million, of which 1.4 million are Emirati citizens and 7.8 million are expatriates.
Despite the sunny environment, there vitamin D deficiency is epidemic. Inshallah [God willing].
Slide32Slide33Slide34Cultural Contrast — Two Emirati women stare at a foreigner wearing a revealing dress at horse racing's Dubai World Cup.
Slide35Anesthesia Practice in the UAE
Long delays to recruit new doctorsConsultants
vs specialistsSupply chain challengesFrequent last-minute cancellationsMust return spent opiate ampoules and vialsStrange drug restrictions (e.g., flumazenil is a controlled drug but
naloxone is not)HAAD largely opaque and not accountable to the clinicians they regulatePregnancy testing potentially hazardous
Slide36Anesthesia and UAE Culture
Distrust of the medical systemPregnancy testing a problem in unmarried womenModesty issuesLate arrivalsDelays to allow prayersMost women are brought to their appointments by their sons, brothers, fathers, or husbands. “It’s in God’s hands” / fatalism
Slide37Anesthesia and UAE Legal Issues
End-of-life decision makingNo DNRInformed consentBrain death only recently establishedControlled drugs in the OR / ICU Criminal vs civil actions following adverse clinical outcomes (see cautionary tale)
Slide38Amanda Morris Report: Cancellation of elective cases in a recently opened, tertiary/quaternary level hospital in the Middle East
Slide39Amanda Morris Report: Cancellation of elective cases in a recently opened, tertiary/quaternary level hospital in the Middle East
Patient reason
N
%
Patient cancels
43
38.1%
Patient wants to reschedule
30
26.5%
No show, no communication
19
16.8%
Patient refuses
5
4.4%
Preop instructions not followed
4
3.5%
No show, patient wants to reschedule
3
2.7%
Patient transportation
2
1.8%
Patient wants to go to another hospital
2
1.8%
Patient's family wants to reschedule
2
1.8%
Procedure already completed
2
1.8%
Patient's family does not consent
1
0.9%
Total
113
100%
Slide40A Cautionary Tale (UAE)
The Guardian 2013 A South African doctor detained in the United Arab Emirates on a decade-old manslaughter charge has returned home after nine months in limbo, declaring: "It's wonderful to be out of that bloody place."
Cyril Karabus, 78, had been convicted without his knowledge of killing a young
leukaemia patient in Abu Dhabi in 2002. He was arrested in Dubai last August while in transit to South Africa from Canada. Karabus
was acquitted in March but endured countless setbacks and bureaucratic wrangling before finally boarding a flight to Cape Town, where he was greeted with wild cheers and tearful hugs from family members and supporters.
"It's fantastic," said
Karabus
, meeting his three-month-old grandson, Gabriel, for the first time. "I didn't
realise
what the welcome would be. It's unbelievable the number of people who are at the airport.“
A leading
paediatric
oncologist, he helped save the lives of black cancer victims during the apartheid era and pioneered treatment for cancer and blood disorders at the Red Cross hospital in Cape Town, where he worked for 35 years.
Karabus
had gone to Abu Dhabi for a six-week stint during which he treated a three-year-old Yemeni girl. She had a form of
leukaemia
with an 80% death rate at the time, he recalled. "It happens. I've had a lot of kids dying of cancer. It wasn't me that killed her, it was the disease.“
He left the UAE because his contract had finished and resents that the charge sheet later described him as a "fugitive" who jumped the country. "
The case record had 16 lies in it
. It's absolute garbage. You cannot believe the rubbish written there. It's not exactly the best legal system.“
That would have been the end of the matter but for a fateful decision to travel through Dubai when returning to South Africa after attending his son's wedding in Canada. Ruefully explaining his choice of airline and route,
Karabus
said: "The Emirates fares are usually better than most.“
With time to kill before their connecting flight,
Karabus
and his family went through immigration to look for an airport hotel. It was then he suddenly found himself under arrest. "You're totally shocked and you're not sure what the hell they're talking about."
South African doctor Cyril
Karabus
, 78, greets well-wishers as he arrives at Cape Town airport. He was acquitted in March over death of a
leukaemia
patient.
http://www.theguardian.com/world/2013/may/17/south-africa-doctor-uae-death
http://www.theguardian.com/world/2013/mar/20/south-african-cancer-doctor-uae
http://www.theguardian.com/world/2012/oct/03/south-african-doctor-abu-dhabi
Slide41Conclusion
The practice of anesthesia, like the practice of medicine in general, requires a working understanding of the cultural issues (“cultural competence”) that medical anthropologists have been bring to our attention for many years.Failure to recognize this reality can harm our relationship with our patients.
Slide42Selected References
1: Dahlander A, Jansson L, Carlstedt K,
Grindefjord M. The influence of immigrant background on the choice of sedation method in paediatric dentistry. Swed Dent J. 2015;39(1):39-45. PubMed PMID: 26529840.
2: Snelgrove H, Kuybida Y, Fleet M,
McAnulty
G. "That's your patient. There's your ventilator": exploring induction to work experiences in a group of non-UK EEA trained
anaesthetists
in a London hospital: a qualitative study. BMC Med Educ. 2015 Mar 17;15:50.
doi
: 10.1186/s12909-015-0331-4. PubMed PMID: 25890264; PubMed Central PMCID: PMC4367902.
3: Livingston P,
Zolpys
L,
Mukwesi
C,
Twagirumugabe
T,
Whynot
S, MacLeod A. Non-technical skills of
anaesthesia
providers in Rwanda: an ethnography. Pan
Afr
Med J. 2014 Sep 26;19:97.
doi
: 10.11604/pamj.2014.19.97.5205.
eCollection
2014. PubMed PMID: 25722770; PubMed Central PMCID: PMC4337347.
4:
Paradis
E, Leslie M,
Puntillo
K, Gropper M,
Aboumatar
HJ,
Kitto
S, Reeves S. Delivering
interprofessional
care in intensive care: a scoping review of ethnographic studies. Am J Crit Care. 2014 May;23(3):230-8. doi: 10.4037/ajcc2014155. Review. PubMed PMID: 24786811.5: Shattell MM, Nemitz EA, Crosson N, Zackeru AR, Starr S, Hu J, Gonzales C. Culturally competent practice in a pre-licensure baccalaureate nursing program in the United States: a mixed-methods study. Nurs Educ Perspect. 2013 Nov-Dec;34(6):383-9. PubMed PMID: 24475599.6: Wright SM. Cultural competency training in nurse anesthesia education. AANA J. 2008 Dec;76(6):421-4. PubMed PMID: 19090309.7: Smith A, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth. 2003 Sep;91(3):319-28. PubMed PMID: 12925468.8: Chong N, Elisha SM, Maglalang M, Koh K. A successful partnership to help reduce health disparities at kaiser permanente: the institute for culturally competent care and the kaiser permanente school of anesthesia. Perm J. 2006 Spring;10(1):53-5. PubMed PMID: 21519458; PubMed Central PMCID: PMC3076986.
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