AMA Journal of Ethics^®

Case

Mary (her English name) is a bright, athletic young woman who maintains a high level of physical exercise and training. An exchange student from South Korea, Mary currently lives in Australia with a host family. Several months ago, Mary went to the emergency department with her host mother in a condition of extreme underweight and in a somewhat confused state. The emergency doctor decided to call in the Emergency Psychiatric Service to assess Mary's psychological well-being. Diagnosed as suffering from anorexia nervosa, Mary was kept in the psychiatric ward for 6 weeks where her weight, diet, and emotional state were monitored. During this period, she was extremely compliant with doctors and nursing staff and keen to gain weight. At the time of discharge, an appointment with a specialized counselor was set up to help her through the transition from the hospital back to her host-home environment. During several appointments, the counselor elicited Mary's personal narrative and determined that she was not suffering from an eating disorder at all. Her 6-week hospitalization on the psychiatric ward, the anxiety and fear she experienced, and the concern it caused both her host mother and Korean mother were the unnecessary result of inadequate cross-cultural communication.

Commentary

When Mary arrived in Australia some months ago to live with a host family to better understand English and the Australian lifestyle, her host mother treated her as a part of the family. This included feeding her typical Australian meals such as roast meat, potatoes, cooked vegetables, and fish and chips (the traditional and most popular fast food in Australia). After a while, Mary became constipated. She did what she had always done when feeling ill at home in South Korea—she asked her aunt for advice. Her aunt, who had adopted Mary at an early age, suggested that she take some laxatives. As most Korean children do, Mary followed her parent's advice and started to take the laxative, which she obtained from the supermarket without prescription. At the same time, she continued her intense physical training. As a result, she suffered great weight loss, lack of muscle tone, and general loss of energy. Her host mother became understandably concerned and took her to the emergency department.

As in so many other cross-cultural miscommunications, the problem did not arise from bad intentions. Rather, as life continually teaches us, good intentions do not necessarily bring about good results. In this case, there is no doubt that everyone involved had Mary's best interests at heart and acted accordingly. Physicians and other medical professionals in the emergency department and Emergency Psychiatry Service acted not only competently but also empathically. They followed guidelines and protocol for assessing, diagnosing, and treating her obvious symptoms. Moreover, to guarantee good communication and overcome possible language and cultural misunderstandings, an interpreter was provided as a part of the service, even though Mary's English was acceptable. The hospital took appropriate measures to keep her in a safe environment, stabilizing and nourishing her until she was able to live back in the community. As a part of outpatient service, a counselor was provided. On the social level, Mary's host mother treated Mary like her own daughter. Mary's "mother" (aunt), thousands of miles away, lovingly advised the use of laxatives to alleviate the discomfort her daughter was enduring.

So, what went so wrong? How did the unnecessary 6-week hospitalization with its associated distress (and cost) occur in spite of everyone's good intentions and actions? What the counselor identified after a number of sessions can be called "inadequate cross-cultural communication." Mary never really liked the food offered by her host mother, though it was wholesome and nutritious. But she never said anything unfavorable about it to her host mother or other members of her host family. Quite the opposite, she appeared to be always appreciative and uncomplaining. We all know it is not polite for a guest to say anything unfavorable to his or her host, and this is especially the case according to the cultural norms and customs in South Korea and other East Asian countries. The same applies to discussions of personal health, which are considered private matters in Mary's culture. She would never think it proper to mention her constipation to her host.

This case teaches a number of lessons. For example, it is crucial for medical professionals to be attentive to patients' personal narratives when diagnosing illness and providing care. Mostly, this case makes an important point about cross-cultural communication in medicine. Cross-cultural issues in medicine and health care are not always as dramatic and obvious as life and death situations. On the contrary, most of them are so basic that they can be easily overlooked. In Mary's case, the problem is captured by the Chinese phrase "shuitou bufu" (literally, water and soil not suiting), a situation so common that almost every cross-continental traveler has experienced it. That is, one has some difficulties in acclimatizing or being accustomed to the environment including, if not especially, the food. The experience is so common that, apparently, neither Mary's emergency room physician nor the emergency service psychiatrist asked her whether Aussie food agreed with her.