Traditional family

I do not know what a traditional family is, even though “family” is a key part of my job title. If you were to ask an Inuit, a Jew, and a member of the Mafia, each of the 3 would have very different definitions of the word, and which people should be included under its umbrella. And, as my anthropology professor would have been quick to point out, none would be wrong.

I also do not know what a “race” is. Biologically, there is no such thing: as PJ O'Rourke wrote, “If we were dogs, we'd all be the same breed.” Yet the topic of race remains hot and uncomfortable. I am not old enough to remember segrega- tion, but I am old enough to remember when rap artists Public Enemy released their album “Fear of a Black Planet,” and to remember when Flava Flav's jeering litany, “black man, black woman…black babies. Black man, white woman…black babies” was edgy and controversial. It was in the early 90s and I lived in D.C., a racially tense enough city that a male friend of mine who is African American was uncomfortable being seen out in public with me, a white woman. At the time, I thought he was being ridiculous and paranoid. I was probably being naïve.

Over 20 years later, I guess I still am. If the family on the cover of this issue does not look familiar, look more closely at the little girl on the right. Her name is Grace Colbert, but you probably know her better as “the Cheerios girl,” who shocked the nation earlier this year by appearing in a cereal commercial in which her TV-land parents, much like her biological ones, were of 2 different races. A pretty girl promoting heart-healthy cereal does not seem either radical or inflammatory, but it was apparently a big enough issue that it was the subject of national news commentary and Facebook posts. The word one anchor used to describe some viewers' reaction was “outrage.”

Specific detractors were not named, but I did have to wonder how they would have fared in my office, in which, literally the day after I saw the commercial, I met with a biracial teenager who announced that she had no gender preference in whom she dated, but that she was a “sapiosexual,” meaning she is interested in people who are intellectually stimulating. Before her mother could speak, the girl preemptively asserted, “Don't start, Mom, it's not a phase.” A few weeks earlier, the Defense of Marriage Act had been ruled unconstitutional and a number of my friends were already sporting new wedding rings. I have also been helping an 18-year-old college freshman make the necessary hormonal adjustments as he transitions from his birth identity as a female to his true identity as a young man. His mother comes to office visits and is completely supportive, as was the public high school from which he graduated. And a biracial Cheerios model is “nontraditional”?

We all think we do a good job with cultural sensitivity, and many of us are probably wrong about that. When you are speaking to a deaf person, do you remember to look her in the face when speaking, even when an interpreter is the one who is actually hearing you? How about when you are communicating with a Chinese man through his English- speaking daughter? When you enter a room with a new pediatric patient, do you tend to address the oldest woman in the room as “Mom” even though she may be a foster parent or an older sister? Is every father in the delivery suite a “husband”? Which groups of people really, really do not like to shake hands? Who finds it rude to make eye contact? I have fumbled these matters one way or the other, and as

I mentioned, I have a degree in anthropology. There are many more opportunities to get it wrong than to get it right, particularly if the patient comes in with a chip on the shoulder because of all the other professionals who have gotten it wrong in the past. My residency attending had a great opening gambit, “Now, how is everyone here related to each other?” which usually keeps me out of trouble, at least in terms of family dynamics. International matters remain tricky.

The implications of our own hang-ups or discomfort can go beyond being offensive; they can also lead us to do bad work. My son has fallen off the growth curve for a few years, and I got small window into being on the receiving end of cultural bias when his father and I took him to an endocrinologist. The doctor did not ask about nutrition, physical activity, or even take a review of systems, which might have been pertinent to a hormonal disorder. What he did do was spend a lot of time discussing the fact that my son's parents are no longer married, and that I was in a new relationship. He also wanted to see pictures of the sisters and, for some reason, of my partner. After I read the consult note, in which frequent mention was made to “the child's parents are divorced and Mom already has a new boyfriend,” I realized that he was pursuing the hypothesis that my son was short because he had been fathered by someone else. He later told my son's dad, “I can check growth hormone, but you are setting yourself up for disappointment.” We can only imagine what my ex would have inferred from that information if we were not still friends.

I am an Irish American physician who is effective at advocating for my children and me. If this is how he approaches the workup on my family, what baggage must this physician bring to families that fall even further outside of his comfort zone? What important data does he ignore because of it?

If you think cultural sensitivity does not matter in medicine, consider that patients are more likely to get adequate pain management in the emergency department if they have the good fortune to be Caucasian, male, and middle aged.1 If you think social mores are irrelevant to the practice of medicine, consider how long it took us to realize that the opinions of a same-sex life partner are more likely to reflect a patient's wishes than are the opinions of an estranged brother who has not spoken to the patient in years but who is biologically related.

‌In this issue of the Osteopathic Family Physician, Drs Cianciaruso and Zavala review culturally competent care.

Although a comprehensive review of every possible culturally based land mine would be impossible, this piece starts the conversation in a positive direction. Peter Zajac, DO, FACOFP, has also created a patient education handout for the purpose of assisting the parents of an adolescent who may be having gender or sexual-orientation questions.

I will never be completely comfortable with every possible permutation of the word “family,” of every single choice of lifestyle. I am easygoing and hard to shock, but like everyone else, I am human and most comfortable with what is familiar to me: eventually, someone will find it possible to knock me off balance. And when that happens, I hope I have the ability to recover gracefully, and to remember that it is not the patient's job to help me to feel comfortable: it is my job to get over it.

Merideth Norris, DO, FACOFP

Editor, Osteopathic Family Physician

Reference

1. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. J Am Med Assoc. 2008;299(1):70