CASE 5

Jon Le

A 48-year-old Korean man with cerebral hemorrhage

Scott Kasner, MD, and Horace DeLisser, MD

University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Educational Objectives

TACCT Domains: 1, 3, 4, 6

Case Summary, Questions and Answers

Mr. Le is a 48-year-old Korean American engineer who has been a U.S. resident for the last 20 years. His wife died 10 years ago and he has one daughter, age 26. He develops a sudden headache and left-sided facial drooping with left arm weakness while having lunch with his daughter. His daughter insists (to the point of tears) that he should go immediately to the hospital, but he first seeks treatment from a practitioner of Chinese medicine for “moxibustion” heat therapy.

Moxibustion

Moxibustion, or moxa, is one the major healing modalities of traditional Chinese medicine. It involves the application of heat generated by the burning of mugwort, a small, spongy herb, at targeted acupuncture points. As with all aspects of traditional Chinese medicine, the goal of this therapy is to strengthen the blood, stimulate the flow of qi (also known as chi, the energy of life) and support overall health. It has been widely used to treat a variety of diseases and conditions, including breech birth, Hashimoto disease, rheumatoid arthritis, menstrual cramps, and musculoskeletal pain or inflammation.

There are two types of Moxibustion: direct and indirect. In direct moxibustion, a small cone-shaped amount of the ground-up mugwort is placed over an acupuncture point and burned on the skin. The ignited herb may be allowed to burn itself out, resulting in blistering and localized scarring after healing (scarring moxibustion), or it may be extinguished or removed before injury to the skin (nonscarring moxibustion). In indirect moxibustion, the mugwort does not have direct contact with the skin. Instead, a burning, cigar-size stick of the mugwort is held close to the area being treated until the skin turns red, or an acupuncture needle is placed into an acupoint and the free end of the needle is wrapped with the herb and ignited. Indirect moxibustion is more popular because of the lower risk of pain or burning.

1 How does this patient’s heritage and culture affect his decision-making process with regard to his current medical condition?

Acculturation describes the process by which the values, attitudes, and behaviors of individuals from one culture are changed over time as a result of contact with a new and different culture. Regardless of how it is conceptualized, acculturation occurs across multiple domains (e.g. attitudes, values, self-identification, language/communication, customs, etc.), the pace and pattern of which is dependent on many factors, including age, gender, length of time in the U.S., literacy level, language proficiency, and the nature of contacts with the host culture. Although Mr. Le has been in the U.S. for 20 years and is employed as an engineer, it should not be assumed that he has completely assimilated into American and/or Western culture. Traditional Eastern concepts of health and healing might still be significant and relevant to him. Given the large number of factors that influence rates of integration or assimilation into the dominant culture, it is not surprising that differing patterns of acculturation among family members can occur, leading to intergenerational conflict between parents and children.

The impact of acculturation on health-related outcomes is complex. Low levels of acculturation may compromise access to, or utilization of, effective Western treatments, potentially leading to health-related disparities (as in Mr. Le’s case). In addition, individuals who have experienced a high level of acculturation, particularly with respect to adopting a Western diet and sedentary lifestyle, typically have poorer outcomes. Studies of first- and second-generation U.S. immigrants have demonstrated that acculturation is associated with increased morbidity and mortality from a number of chronic degenerative diseases.

Assimilation and Acculturation

There are a number of assimilation models; two such models have been proposed to describe the process of acculturation. The first is a unidimensional, zero-sum scheme model in which individuals adopting host culture values and behaviors simultaneously discard or relinquish the corresponding attributes from their native culture. This model of acculturation is conceived as a single continuum of change, in which some will quickly and strongly adopt the cultural values, practices, and behaviors of their new country, readily relinquishing their original culture (assimilationists), whereas a number of them (at least initially) will choose to hold tightly to the culture of their origin, despite daily contact with the host culture (separationists). Between these low and high levels of acculturation are others who, to varying degrees, will try to maintain their culture of origin while selectively embracing elements of the host culture (integrationist).

In contrast to this unidimensional model of acculturation, a second model has more recently emerged that conceptualizes acculturation as more often a bidimensional process in which there is high adherence to both the native and the host culture and that both the old and new cultures for the individual may change independently of each other, so changes in one may not be associated with reciprocal changes in the other. For example, the Korean immigrant becoming “less Korean” over time does not necessarily mean that s/he has become more American; or that, as the immigrant becomes “more American,” s/he may still maintain a high identity to Korean culture. Because self-defined identity is not the same thing as behavior, many immigrants identify as being American and maintain family traditions and values. Evidence of this comes from studies of the use of traditional health care among Korean Americans, which have shown that the most educated and acculturated Korean immigrants are actually more likely to seek traditional healing than those less acculturated and of lower socioeconomic status. In fact, the majority of users of alternative medical care in the U.S. are white, college-educated individuals.

Several hours later, when moxibustion therapy did not improve his symptoms, Mr. Le agrees to go to the Emergency Department (ED). As the ED resident evaluates Mr. Le, he notices first- and second-degree burns on his arms and legs. The physician wants to treat the burns, but Mr. Le is hesitant, fearing that this will counteract the beneficial effects of the moxibustion treatment.

2 How should the physician approach Mr. Le about his use of alternative medicine?

Complementary and alternative medicine (CAM) encompasses a diverse group of treatments currently not included in conventional medicine. When combined with conventional interventions, these approaches are referred to as “complementary medicine,” whereas “alternative medicine” describes modalities that are used in place of conventional medicine. Various personal, societal, and cultural factors may lead a patient to seek CAM. The National Center for Complementary and Alternative Medicine has separated CAM into five domains:

The use of these modalities, particularly when they involve the use of alternative medical systems, may be part of a strong cultural identity. When the physician learns about the patient’s CAM usage, if he or she responds with visible shock, amazement, or disgust, it is likely to alienate Mr. Le. Although there is obvious concern about injury or harm from Mr. Le’s use of CAM, the physician needs to initiate a nonjudgmental, respectful conversation with the patient. In the end, the goal is to develop a relationship in which the patient is willing to be candid with the physician about all aspects of his/her health. The patient and his health care providers will need to try to develop a consensus regarding a realistic and achievable treatment plan. Fundamentally there is no interaction between antihypertensive therapy and moxibustion, so they can be used simultaneously. However, the key to prevention of recurrent cerebral hemorrhage is aggressive blood pressure control. It is possible that other traditional Chinese medicines could interact with his prescribed antihypertensive agents, so again, a relationship with open and ongoing communication is critical to ensure optimal care.

Mr. Le overhears the resident explaining his case to the attending physician outside his door. On more than one occasion during the conversation, the resident refers to Mr. Le as a Chinese man, even though he is Korean. When the attending enters the room, Mr. Le is noticeably angry and hostile and therefore not forthcoming with any answers to the attending’s questions.

3 Why is Mr. Le angry and how could this have been avoided?

Individuals who trace their origins to the Far East, Southeast Asia, or the Indian subcontinent now comprise 5% of the U.S. population (or nearly 15 million people). This “Asian” population, like all ethnic groups, is not homogenous, but instead constitutes several diverse and culturally distinct subgroups, each with specific identities. Some Asian groups, such as the Japanese and Chinese, have had histories in the U.S. that go back several generations, whereas others, such as Koreans, Vietnamese, Hmong, Cambodians, and other South Asians, are more recent arrivals. Suffice it to say, respecting the diversity of patients of Asian ancestry by asking and identifying based on the patient’s preference is essential. Historically, and especially for first-generation immigrants, lingering tensions from previous conflicts, such as that between the Japanese and Chinese or Koreans during World War II, may create added sensitivity about being ethnically misidentified. Where there is uncertainty, simply ask the following questions to avoid an unintended insult:

Mr. Le undergoes a CT scan that reveals a small intracerebral hemorrhage. He is subsequently admitted to the neurology service and found to have significant hypertension, which ultimately requires three medications to control. Mr. Le is reluctant to take them but eventually agrees. Prior to his discharge, he asks his daughter to call his traditional Chinese medicine (TCM) practitioner to prepare herbal remedy, as he does not plan to take any of the blood pressure medications he is receiving in the hospital after he is discharged. His daughter informs the physician of his intentions.

4 How should the physician approach Mr. Le about his plan to work with a TCM physician?

In responding to Mr. Le, the central tasks are to first obtain a real understanding of the patient’s worldview with respect to health and healing and then use that information as a basis for dialogue and negotiation with the patient. For facilitating these kinds of potentially challenging cross-cultural conversations, Berlin and colleagues have offered an approach that goes by the acronym LEARN:

Questions that can be used to initiate the process of “LEARNing” and to begin to explore the meaning and significance of disease to the patient include:

References: Case 5

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