Southeast Asian Patients

They tend to say what they feel the physician wants to hear.

I WAS A PHYSICIAN in the Vietnam Army until Vietnam fell, in 1975, when I came to the US. After the required examinations for foreign medical graduates, I enrolled in a family practice residency at Louisiana State University's Affiliated Medical School Program.

About two years after the residency, in 1981, I came to Sacramento, attracted by the large Southeast Asian community of Vietnamese, Chinese from Vietnam, Cambo-dians and Laotians, the latter including Hmongs and Miens. This is where I wanted to practice.

There were about 10 physicians and a few clinics dedicated to serving this population of about 30,000. I was familiar with the Vietnamese patients, but initially had some difficulty taking care of the others, as did my colleagues.

Most difficult was the language barrier. In the beginning, we had no interpreter and communicating with the patient was almost impossible. I still use multi-language staff, but the problem is less important today because patients already speak some English or are accompanied by a family member who can translate for them.

Because Asians traditionally respect authority, they can usually be trusted to take the physician's advice seriously. On the other hand, the physician must be aware that they tend to say what they feel the physician wants to hear.

Most non-compliance occurs in older generations. It is not unusual for a patient to stop all medication, or to refuse recommended surgery, to seek treatment common to his or her culture.

Most non-compliance is about diet. Asians consider two sauces, "nuoc mam" or "xi dau," a regular and indispensable part of food-not a violation of a restricted-salt diet. The same is true of rice, a basic of meals, for the diabetic patient.

Home accidents are frequent, usually due to poor safety precautions. We see eye injuries from sanding without goggles; scrapes and breaks from falling from a chair placed atop a chair (instead of using a ladder); body injuries from using power equipment. We have seen gas poisoning from people fixing their car in a closed garage. A few deaths occurred in the past when people burned charcoal for heat in an enclosed space.

TB is widespread in Asia and is still a threat to the immigrant Asian patient. We approach any report of chronic respiratory symptoms or an abnormal chest x-ray with high suspicion. Some of these patients had BCG, which the CDC advises we disregard because the patient is as likely to be unprotected as to be protected. We find rare cases of non-pulmonary TB in the kidneys or vertebrae, causing abcess in the ilio-psoas muscles-a challenging diagnosis.

Hepatitis B is endemic in Southeast Asia and spreads in local households through the common practice of "coining," abrading the skin with a contaminated object, like a coin. The Vietnamese seem increasingly aware of the risks and are asking for screening tests. Early detection and treatment of active HBV and HCV in asymptomatic patients has proven beneficial for many.

Tapeworm is a common parasitic disease. Asian immigrants often kill their own cow or pig for meat in large community gatherings, such as funerals, or to share with several families.

Emotional stresses are very common. Asians who were fairly active in their native country are now more sedentary, especially the women, who rarely drive. They become bored and depressed, leading to breakup of the traditional family. All family members work, often in multiple jobs, and sometimes while starting businesses.

Children get little adult supervision and are often the interlocutors connecting their non-English speaking parents to the English-speaking community. This upsets traditional parent-child relationships, leaving parents and children with a poor understanding of each other when the children are grown.

Post-traumatic stress may be a problem for older Vietnamese patients. Torture and brutal hardship, displacement, confinement, loss and upheaval are likely parts of their war experience. For the Hmong immigrant, who is likely to be in an urban environment for the first time, culture shock may be most intense emotional stress.

One special problem is unreal expectations. A patient who had traumatic nerve damage 20 years ago may expect a "cure" now; a post-polio patient now expects a normal leg after treatment.

For physicians who do not share the background of their Southeast Asian immigrant patients, resources are available. The County Chest Clinic provides the best help and screening for the newcomers, and can answer questions. UCDMC also provides translation services for its patients. Health for All used to be available for phone consultation about Asian patients, but became less available as it developed more clinical services, including day treatment.

Many community-based organizations can help with translation and other services. One of them, Asian Resources, can provide a list of health and social service agencies that work with physicians serving Southeast Asian patients.