1) A brief clinical scenario and why it requires cultural awareness/humility.
66-year-old Catholic African-American male presents to his primary doctor with acute symptoms of blood in the urine, urge to urinate frequently at night, blood in the seminal fluid and weak interrupted urine flow. He has a positive family history of prostate cancer and his father also died of prostate cancer at the age of 70. His primary doctor informs the patient that based on his age, family history, and symptoms its recommended by CDC to perform a digital rectal exam to evaluate his prostate for any changes that could point to prostate cancer or BPH. Patient never had a digital rectal exam done before and it was the first time hearing how a DRE was performed. Being a devoted catholic man, patient believes that a digital rectal exam goes against his religious views and opposes the idea of having the doctor perform a DRE on him.
This requires cultural awareness/humility because although DRE is often done in patients who are suspected of BPH or prostate cancer, it can also violate a patient’s religious views or culture. It is necessary to accommodate this patient’s request while still providing the best medical assistance to him.
2) The cultural factors that need to be considered
Digital rectal examination cannot be seen only as a physical examination that can diagnose prostate cancer early. In some religions, a medical provider inserting a finger in the rectum of a patient (especially in a male’s rectum) can be seen as taboo and is not permitted. Being an elderly male who grew up in a religious catholic environment, a digital rectal exam could also bring shame and embarrassment to this patient as well. This is something the patient might not ever bring up in conversations with his family members or friends who also might share the same religious views. Another cultural factor that needs to be considered is that some religious patients might relate digital rectal exams to homosexuality which makes them very likely to decline DRE when its needed to be perform.
3) Any beliefs that might be different from western medicine beliefs or unique considerations that care of this patient might require
There are multiple beliefs of this patient that differ from western medicine belief. As mentioned earlier, religious views on DRE can delay an early prostate cancer diagnosis which only increases the mortality rate in these patients. The idea of a practitioner (especially a male practitioner) inserting a finger in their rectum can be viewed as a sexual act and is associated with homosexuality in different religions while in western medicine is just another physical exam to assess the prostate in men. Western medicine relies heavy on using drugs to treat diseases and in the case of prostate cancer they would also use chemotherapy as well. However, this is not always true in religious communities as they often first use herbs and other natural supplements to treat most of their diseases.
4) Areas where conflict might develop (e.g. for a Jehovah’s Witness patient or for someone who has strong beliefs about the healing value of prayer or traditional herbs)
1) Patient having an issue with medical provider performing a rectal exam.
2) Patient embarrassment and feeling ashamed about this whole situation could lead for less future visits and follow ups with their doctor which can lead to more complications with prostate cancer and METS.
3) Patient down-playing the severity of their signs/symptoms and not being truthful with the doctor to avoid DRE.
5) What would be expected of the student in demonstrating Cultural Competence/Humility – what things would the student be expected to say/do/avoid/suggest/consider in this scenario (these may not all be relevant). These would be the elements on which the student taking the OSCE would be graded
1) Don’t assume that everyone knows what a DRE is. Some patients may have never heard that before so this would be a good opportunity to explain and educate the patients why this is done and how.
2) After explaining what DRE is and why its done, and patient is still not willing to have a DRE then start suggesting other methods of screening for prostate cancer such as ordering PSA levels.
3) Make sure the patient is alone in the room unless they state otherwise and be respectful of their religious views on medicine.
4) If they were diagnosed with prostate cancer and would like to try natural supplements and herbs even after you explained the dangers and complications in doing so without chemotherapy or surgery, respect their wishes.
5) Always be respectful and never try to convince them for a DRE. Seek other options.
6) Any patient counseling or education that would be required in the situation
Explain why DRE’s are done in patients when prostate cancer is suspected.
Explain how they are done and what exactly are practitioners looking for while doing it.
Explain what the complications are if patient diagnosed with prostate cancer decided to use natural supplements and herbs instead of chemotherapy or surgery.
Source:
https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232008000600033
https://journals.sagepub.com/doi/pdf/10.1177/1557988308318686
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