Chapter 6 - High-Velocity Transcortical Lead Therapy

The Hmong in the refugee camps in Laos told terrible stories about the dangers of life in America, but in reality, their deepest fears about life in the United States fixated on doctors. The question for the author was - why? It soon became apparent to her that medicine was religion, religion was society, and society was medicine. She concluded that the Hmong preoccupation with medical issues was nothing more than a preoccupation with life and death and life after death. A Hmong walking into MCMC complaining about a stomachache was actually complaining about an imbalance in the universe. With this, there was no way for the young residents to succeed in satisfying the Hmong. None of them had had a single hour of instruction in cross-cultural medicine. “What the doctors viewed as clinical efficiency the Hmong viewed as frosty arrogance.” And no matter what they did, the Hmong inevitably interpreted it in the worst possible light. ‘

The author interviewed the most educated and most Americanized segment of Hmong society, the segment most likely to understand and value Western medical care. They found nothing but fault with how doctors treated them. Their version of reality failed to match that of their doctors. The doctors certainly knew the Hmong did not like them and that rankled, because most of the residents had chosen family practice - a specialty that was the lowest paid and offered the most difficult hours - for altruistic reasons. It was Bill Selvidge, MCMC’s former chief resident, who first told the author about the doctors’ description of how challenging the Hmong were as patients. The doctors joked that the preferred method of treatment for them was “high-velocity transcortical lead therapy,” which meant the patient should be shot in the head.

Other problems that cropped up with the Hmong were the gongs, the chickens, the amulets, bringing their own food and medicine to the hospital, making a lot of noise and even trying to slaughter animals for their own purposes. Neil and Peggy also discovered quarter-sized round lesions on the abdomens and arms of the Hmong children. They called in Children’s Services and were proceeding to remove the children from their parents until a San Francisco doctor explained that the lesions were the result of dermal treatments like cupping, a treatment common among Southeast Asian ethnic groups. This stopped the removal of the children from their homes. It made Dan Murphy and the other doctors realize how high the stakes were if they made a tactical error in dealing with the Hmong. They needed to bend over backwards to be culturally sensitive and that didn’t always work!

Compared to other patients that came to MCMC, the Hmong were not only trickier, but also sicker. They had many more diseases and conditions dating from their time in Laos during war. Add to that the process of being screened for health problems when they came into this country. The process was so short and so cursory that it was one more reason for the Hmong to fear American doctors. Then, when they arrived in American, they were not required to see any doctor for post-immigration screening, so their first real experience with American medicine would be the ER. Merced’s ER became responsible for dealing with problems that no one else in the community wanted to dirty their hands with. In addition, each year brought new residents to the hospital who had to learn and deal with the idiosyncrasies of the Hmong which the older residents had become used to.

When an interpreter was present in the ER, the doctor would try to interview the patient. “It was typically Hmong for patients to appear passively obedient - thus protecting their own dignity by concealing their ignorance and their doctor’s dignity by acting deferential - and then, as soon as they left the hospital, to ignore everything to which they had supposedly assented.” When no interpreter was present, the doctor and the patient stumbled around in a dense fog of misunderstanding. Also the interviews between doctor and patient doubled or tripled in time involved, because the Hmong language had such long descriptions for simple words like parasite which is 24 words long in Hmong. However, the biggest problem was still the cultural barrier. They expected to leave the ER with some kind of medicine even if it wasn’t required. Meanwhile, the doctors who were dealing with a Hmong patient whose complaint was pain, tried to find out what kind of pain, only to be told repeatedly that “it hurts.”

One of the greatest problems among the Hmong was that their complaints had no organic basis though their pain was perfectly real. They were feeling somatization, emotional problems expressing themselves as physical problems. As a result, the doctors prescribed the “Hmong Cocktail” - Mortin (anti-inflammatory), Elavil (an anti-depressant), and vitamin B-12. Unfortunately, this usually didn’t work and the doctors at MCMC came to realize that because of the Hmong’s underlying problems, there was no treatment that was in their power to offer. Then, of course, there was the problem of getting permission for surgery or any other invasive treatments. The Hmong would debate and debate and then refuse. “That attitude had been very culturally adaptive for the Hmong for thousands of years and . . . it is still culturally adaptive, but when it hit the medical community, it was awful.”

The Hmong always married early and had many years where they were able to bear children. As a result, they often had as many none or ten children or more. They loved children and they viewed large families as proper and good. Unfortunately, that did not endear them to those staff members at MCMC who had strong ideas about family planning. The Hmong women also preferred to wait at home until the last moment before the birth and often gave birth in the parking lot or the elevator. They refused, however, to have their babies at home, because they believed the children would then not be an American citizen. The women made so little noise during labor that the doctors and nurse could not tell when it was time. It made the medical staff anxious and nervous. The author was struck at the staggering toll of stress the Hmong exacted on the doctors and nurses. They could not understand why the Hmong rejected what they had to offer, because it intimated that what Western medicine had to offer was not much. However, the Hmong did have one doctor at the MCMC that found acceptable. His name was Dr. Roger Fife and he was not held in very high esteem among the other doctors. The Hmong liked him, because he didn’t cut and he allowed the Hmong to practice all their own rituals when they wished. It was galling to the other residents and staff to realize that the Hmong overwhelmingly preferred a doctor whose standards of care they believed to be inferior to their own. Roger just believed that of his patients didn’t comply with standard American medical practices, it was because “it’s their body.”

Notes

This chapter is so intriguing, because it presents not only the frustrations of the Hmong with American medicine, but also the terrible stress it created within the medical staff. It was the most terrible of cultural clashes.