PT Classroom - Through the Lens of a Hmong Therapist: A Cultural Perspective for all Healthcare Providers ׀ by Ying Xiong, PT, DPT

Physical therapists have a unique role in the mass confusing world of western healthcare. We have the job of ensuring patients can return back to their normal lives. We set up goals that we label, “functional.” Well what is functional? What is functional to you? To me? Now perhaps - there are some things that a majority of us can agree on – maybe standing, sitting, walking, getting dressed…….? Well what if the most functional thing for your patient was actually a combination of standing, sitting, chanting and “riding” a form of a chariot as a spiritual ceremony? This is the case for a patient who is a Hmong Shaman – whose community role, is to perform this important spiritual ceremony which can sometimes last for hours. How effective would interventions be if this vital piece of his/her life was left out?

Now don’t get me wrong – This image doesn’t represent all Hmong people. At least in America, there is a wide range of Hmong people who differ in age, identification, social-economic status, religious and cultural beliefs. I don’t understand all the practices of Hmong people, and I certainly don’t speak for all Hmong people. With that – this is a disclaimer – that this article is based on my own experiences and perspectives. It is not intended to pigeon-hole Hmong people into one homogenous group – but to shed some light on what things I have found important when dealing with Hmong (specifically the elder) AND other cultures.

I am not going to highlight specific practices or beliefs – because I think that is beyond the scope of this article – I will however, go over a few basic principles that I think are key elements for any good provider (PT or not) to get right the first time.

The first is – assumptions. Too many assumptions. I’ve come to understand that being bi-cultural, my life looks radically different than the average American. I can’t count how many times I’ve encountered the statement “everybody knows what that is.’ Well……No – everybody doesn’t. I’ll say it again, no, everybody doesn’t. Most of the time I’ve heard this statement applied to basic concepts, but sometimes, to things I consider advanced. For example, a colleague (PT) of mine said to me just a few weeks ago…”everyone knows what biomechanics is.” Excuse me – No. No they don’t. I’ve heard this too often, throughout PT school by students, and throughout my professional work. This type of thinking can lead to a lot of miscommunication. You might think this isn’t necessarily a cultural disparity, that, many people might feel this way regardless of culture. I’d agree with you, but when you compound this with someone from a completely different culture – you’re adding layers on layers of confusion. If you think the average American might not know what you’re talking about, then consider the person who lives in a different culture, and carefully assess what they know, and what you need to teach them.

Another issue I run into constantly is – “the doctor doesn’t respect us.” I get this all the time. When talking to my own Hmong patients or my family and friends. So what causes this? In my experience, it’s that these people feel they’re not being listened to. Their concerns are not taken seriously, they don’t know how to advocate for themselves, and thus action is not taken. Let me give an illustration. About a year ago, my brother (1yr old), became very sick, fatigued, and lost his playful personality. My parents took him to the doctor who diagnosed pneumonia. He was put on some meds and asked to follow up if symptoms didn’t clear up. After a few months, his condition did not improve. Again, my parents were told, “he has pneumonia, come back in a few months.” At this point my parents were confident it was more than pneumona – but they were unable to explain that to the doctor. To clarify, it wasn’t so much a language barrier, but typically, as a commoner, it is considered rude or disrespectful to tell someone like a “Doctor” – that they are wrong. So they have no choice and no way to advocate.

To finish the story, another few months past, his conditions worsens. This time I call the doctors personally myself to advocate for my brother. Finally- after a thorough evaluation, it was discovered he had severely low Hemoglobin levels, and was immediately air lifted to a large hospital and given multiple blood transfusions. His life is saved. What would have happened if that call was never made?

Third - Check for understanding and missing pieces, and fourth - Ask respectful questions. Hmong patients have become very good at shaking their heads and smiling at you – giving you the impression that they understand – whether they do or don’t. Please, take another minute to explain and listen. It’s simple, take some time, and listen to your patient, explain to them, in a way that they can understand.

Now the part about the missing pieces. It’s important to know that you probably won’t have the most accurate or detailed subjective history. Growing up, many of my elderly family members were afraid of doctors, and if they felt the doctor was going to be upset about something, they simply didn’t tell them. For example – I remember taking my grandma to the hospital as a teen. When asked about current medications, my grandma was able to provide a list to the doctor. She then whispered to me, “I’m also taking some Hmong Medicine – but don’t tell the doctor about that one.” I believe this arose due partially to a belief that taking those medications might anger the doctor, and a lack of understanding how important it is for the doctor to know – due to interactions with meds, and in the case of PT, indications for exercise.

In another case, it’s not purposefully withholding information, but not even realizing its relevant. For example, my father was recently diagnosed with a toxic goiter. He still does not know what that means. It wasn’t until I spoke with the physicans that they had an accurate history – that is, that there is a history of thyroid cancer in the immediate family. My point here is – in many cultures, especially Hmong, family plays a vital role, and gathering this data is no different, they should be involved whenever possible. Additionally, family is always involved in the decision making regarding interventions, it is rarely a one or two person decision.

Lastly, Ask good, respectful questions. I don’t expect healthcare providers to be experts on all cultures and peoples, that’s impossible- but please, take a moment to do some background research on the culture of peoples around your community. That will go a long ways to helping you to ask the right, respectful, non-ignorant questions, when the time comes. It will help you build rapport, gain trust, and have a much more effective intervention.

So to sum up my points – let go of your assumptions, listen to your patients, show them respect regardless of background, value their questions and concerns and, involve family for information and decision making, and ask respectful, educated questions.

Sounds like kindergarten lesson….in a nutshell, that is what it is. Nothing groundbreaking or earth shattering. These are the things we are taught as children but have lost along the way. In my opinion, they need to be a priority if we are to provide effective, culturally appropriate care.

I’ve been told by providers there isn’t enough time in the day to do this – my plea to you is, yes there is. If you consider it important and critical to your effectiveness, then yes, there is time, and please don’t delay another minute.

If you have any questions or would like to provide constructive feedback please contact me at: yxiongdpt@gmail.com Website: www.hmongpt.org 

Last revised: December 21, 2017
by Ying Xiong, PT, DPT