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Stanford Report, October 29, 2003

Film series illustrates gaps in cross-cultural communication in medicine

By ERIC WEISSMAN

An immigrant from Afghanistan refuses chemotherapy because it conflicts with his daily prayers. A toddler with a hole in her heart may not receive a lifesaving operation because her grandmother believes the scar is a mutilation that will stay with her into her next life. An African-American man who will die without a kidney transplant argues that the way the medical establishment allocates organs makes it harder for minorities to receive them.

These scenarios and others illustrating a cross-cultural disconnect between patients and their doctors unfold in a series of short films called "Worlds Apart."

Produced by Maren Grainger-Monsen, MD, senior research scholar and director of the Biomedical Ethics in Film Program at the medical school’s Center for Biomedical Ethics, the films and a soon-to-be-released facilitator’s guide are now available to medical schools for educational purposes.

The films follow real patients over a two-year period, alternating between the patients interacting with their doctors and with an off-camera interviewer or with their families.

Mohammad K. is one of four patients featured in "Worlds Apart," a series of films about cross-cultural communication in medicine. Maren Grainger-Monsen of the Center for Biomedical Ethics directed the series. Photo: Courtesy of Maren Grainger-Monsen

"I always thought that patients trusted me when I talked with them," said Grainger-Monsen. "But what I’ve learned after working on this project is that when you first meet patients, they are waiting to see if they should trust you. They don’t trust you right off the bat as a matter of course; you have to earn their trust."

This concept plays out in each of the videos, directed by Grainger-Monsen and filmmaker Julia Haslett. Patients attentively nod in apparent understanding while listening to their doctors, but later, once home or otherwise out of earshot, it’s obvious the message didn’t sink in, or if it did the message was irrelevant. The patients likely have other concerns, more immediate and pressing in their day-to-day lives, that remain unknown to their doctors.

For example, one video depicts "Alicia M.," an immigrant from Puerto Rico living in New York City, who has diabetes, hypertension and asthma. The viewer watches Alicia sitting with a translator, several bottles of prescription meds and her increasingly exasperated young doctor, a woman focused on the clinical aspects of Alicia’s care. When discussing through the interpreter why Alicia has trouble taking her medication, monitoring her blood sugar and sticking to her follow-up appointments, there’s a fleeting reference to problems in her life.

Unknown to her doctor is the severity of those vague "problems." Alicia has been evicted from her apartment of 18 years and is embroiled in a lawsuit with her former landlord. The upheaval and uncertainty has flung her into a depression that is somehow lost in the translation between doctor and patient. Alicia also has a closely held belief that prescription medications hastened her own mother’s death years earlier, leaving her deeply suspicious of the treatment course her doctor has urged.

Alicia’s story, like those of the other patients in the series, is not completed in the course of the video; the viewer never learns how the problems were resolved. Instead, the goal is to prompt discussion among medical students and health-care providers about the cases themselves — what they believe the nature of the disconnect is and how they would address the issues raised. The producers hope the films will trigger awareness and problem solving around issues of cross-cultural communication and cultural sensitivity.

"People who have seen these films have been very enthusiastic," Grainger-Monsen said. "There’s been a lot of interest in them because they’ve said there’s nothing else like them available."

Two of the films will be expanded into a longer format and presented for a general audience on PBS in 2004. Grainger-Monsen noted that those stories will be more traditionally narrative, walking the viewers through the cases and explaining how the situations finally played out.

Funding for the project came from the California Endowment, the Commonweath Fund, the Greenwall Foundation the Arthur Vining Davis Foundations. "Worlds Apart" is being distributed by Boston-based Fanlight Productions (http://www.fanlight.com).



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