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Hey everyone. Welcome back. Hey, I’m excited to share this episode with you. My guest was fantastic. Dr. Raj Sundar is a full-spectrum family physician and community organizer. He hosts Healthcare for Humans, which is a podcast dedicated to educating others on how to care for [00:01:00] culturally diverse communities so they can be better healers. He works with others to create systems that treat each person with dignity, respect their histories, celebrate their joys, and honor their hopes.
And if all that sounds too good to be true, I would just encourage you to listen to this interview. I think it will become clear very quickly that Raj is a kind, gentle soul with a lot of passion for caring for diverse communities and honoring individual differences, and doing the work that many of us aspire to do. We talk about many aspects of caring for diverse communities. We talk about specific communities that Raj has worked with. We talk about bridging the gap to community leaders and we talk about the similarities and differences in this kind of work [00:02:00] between mental health and the medical field. It’s a fantastic interview, and as always, I think there’s a lot to think about and take away from this episode.
Now, if you’re a practice owner and you’d like to connect with other practice owners in a small group retreat-like setting, work on your business, and get some clinical instruction, I would invite you to check out The Testing Psychologist retreat this summer. It’s called Crafted Practice, August 9th-13th. At the time of recording, there are 12 spots left, by the time this releases, I’m guessing that’s going to be far fewer, but you can get more information and check to see if there are spots left at thetestingpsychologist.com/retreat. Feel free to schedule a call to talk with me about whether it’s a good fit or not, and I hope I might see you there.
All right, let’s get to my conversation with [00:03:00] Dr. Raj Sundar.
Raj, hey, welcome to the podcast.
Dr. Raj: Thanks for having me here, Jeremy.
Dr. Sharp: Yeah, I am really excited to chat with you. When you reached out, I read through your material and was just instantly like, oh yes, this guy is coming on my podcast. This is great stuff. So I always ask just to get going, why do this? You’re a potentially very busy individual, why spend some of your life focusing on this kind of material on this work?
Dr. Raj: Yeah, that’s such a tough question to answer for me because I feel like I could go in so many different ways, [00:04:00] Jeremy but I’ll say one is for myself in attempting to find meaning and purpose for my life overall, but also this work that I’m doing. I’m a family physician. I see patients all day long, three days a week, and other times I do some leadership work. But in that work itself, it can be so, how can I phrase this? Like you’re a cog in the machine. I feel like we all have that sense in many ways because of the systems we’re in, and the incentives that are in place.
I had to ask myself, how do I keep going? An answer to that question was partly, how do I do what I’m doing better? I felt like I was falling short with many people that just had different world views than me. And we, your audience, and you have encountered this too, people are different. They have different beliefs, and different values. It’s [00:05:00] informed by their family, their culture, their history, who they’re around. And I just hit so many roadblocks in trying to care for them that I felt like I could do better. And trying to answer that question is what led me into this process of really digging deep into culturally responsive care, cultural safety, and all those terms we can unpack in a second too.
Dr. Sharp: Right. I think a lot of us have that experience of seeing the gap and knowing that we could do better work. And it can be really challenging to make the time for that and to make it enough of a priority to make it meaningful. So just a kudos, I suppose, that you’ve taken it to this level and it’s really growing.
Dr. Raj: I’m curious, this dissonance is what everybody feels being in healthcare in many ways, whatever role you are in. We all have this question and we choose to answer it in different [00:06:00] ways. I’m going to ask you a question. How did you answer it, Jeremy?
Dr. Sharp: It’s a tough question. You’re not allowed to turn a question back on me, by the way. That’s not what we’re doing here. No, I think I had a similar experience as you did. And like you said, just went about it in a different way. So sometimes it’s very pointed, I will notice that dissonance and then go immediately look up three articles and try to learn something about it. I think that’s honestly a big part of this podcast, is hey, here’s a vehicle for me to call up all the experts and ask all the questions I want to ask and learn that way. So yeah, it takes different forms, but I didn’t do very well sitting in that dissonance. I don’t do very well with that in general. There’s always some action to take.
Dr. Raj: Yeah, and I asked you that question, not to put you [00:07:00] on the spot, but that we all have a similar feeling and we answer it somehow. We need to. It’s uncomfortable, it’s painful. And for both of us, podcasting has been a way to do that. And it’s not always the question. Some people change careers, and some people choose to approach their work differently, but just finding the common humanity in that feeling that we all have.
Dr. Sharp: Yeah. I like that we’re highlighting this. I’m guessing there are folks out there who are like, yeah, there is a lot of dissonances there. How am I handling that? Because we have to find some way to do it. That’s the way, right? We come back to homeostasis, whatever means that takes.
So you’ve already opened this door a little bit. I’m curious, just as we get into this idea of caring for diverse communities and cultural safety and so forth, how do you fit into the rest of the medical community? Like “social justice” is [00:08:00] a big thing in mental health, for lack of a better term. Is it like that in medicine as well? Is this baked into everything y’all are doing? Is there a lot of energy around it or not so much?
Dr. Raj: Yeah, there’s definitely a lot of energy around it. The question is, how much change has that led to? Because people, especially after the murders of George Floyd and the protests and uprising, there’s a lot of momentum and self-reflection on where we’re falling short. And nowadays there’s so much polarization and I’ll say jargon around terms that sometimes it’s hard to communicate around this term.
I’ll be really specific in that within our population. If you’re a Pacific Islander, you’re doing worse, period. I don’t have to know anything about you. Your diabetes is worse. You’re dying earlier. Just your health is not as good as it could be, and we’re not able to support you in the way you need to. I can tell that by somebody’s identity. And [00:09:00] that’s the part where we have to self-reflect on, why is that? Because I think it’s easy to answer that question by blaming the community of a person saying, well, they just need to care for themselves better. Isn’t that obvious? But then we lose all accountability for ourselves. The question to ask then is, what should we be doing or could we do something differently to help this population?
So back to your original question, yes, there’s a lot of energy and then a lot of self-reflection, a lot of awareness of, hey, yes. Depending on your identity, it can be any kind of identity. We talk about race often, but it can be ethnicity, it can also be the geographic diversity where your community. So all of that can affect your health outcomes. Now we have a lot of awareness around it. I don’t think we’ve figured out how to change it. I think people have ideas, people have hypotheses, people have had successful ways of changing it in smaller places and people are thinking about it, but we’re nowhere [00:10:00] close to saying, hey, we’ve achieved health equity.
Dr. Sharp: Oh, sure, that seems like a long way away but you have to start somewhere.
Dr. Raj: Exactly. So hope energy but we’re still trying to figure out what that means, you think. It sounds like in therapy and psychology, it’s having the same kind of reflection and energy, am I saying that right?
Dr. Sharp: Yeah. I think so. There’s a lot of energy around it. And there has been, I think, for several years, certainly catalyzed by some of the, like you said, the George Floyd murder and many other things over the last two years. And we were talking, my wife is also in the mental health field, she’s a counselor, and we were talking just the other day about this dynamic of having [00:11:00] lots of training and lots of talk around culturally responsive care and maybe not landing exactly how we intended to and it’s not necessarily resulting in a whole lot of change.
Dr. Raj: Exactly. And maybe that’s what I was trying to communicate. Obviously, we haven’t achieved health equity, but the feeling of changing, it doesn’t feel palpable. It feels different. We’re actually providing better care. Partly that may be just my emotional reaction, what I’m witnessing but as you said, I can ask this question for anybody listening. How many people have done microaggression training or implicit bias training? Now it’s like an annual thing. It’s like, how many times should we have to hear about this? And then is it actually changing anything? Not dismissing the importance of understanding that topic, but is that actually changing outcomes? Are we providing better care?
The same thing with, you said you were [00:12:00] talking to your partner about culture-responsive care. That’s actually what started my journey because I was seeing let’s do like a Khmer woman who was struggling with somatic symptom disorder, which is that she was having pain everywhere. We didn’t have a clear cause for it. But she couldn’t express to me what she was really feeling, but she wanted help from me and I didn’t know how, and I didn’t really understand what was going on. Or I just mentioned the Pacific Islander community who came to me, was diagnosed with diabetes, A1C of 13.1. For people who don’t know, that’s really high because diagnosis starts at 6.5 and said, no, I don’t want insulin.
And then there was that gap on, I didn’t know how to help them. Again, this is the self-reflective part of yes, I could just say, okay, well, they’ll come to me when they’re ready. I can’t do anything for them, but I wanted to ask myself, could I be better in this situation and meet them where they’re at and help them through their health journey? And similar to many people, talk about [00:13:00] cultural responsiveness, I’ve done maybe a module a long time ago about it and like the basic concept of listen closely and acknowledge diversity, and you’re like, yeah, these all sound great, but what am I supposed to be doing right now?
Dr. Sharp: Sure. It’s such a good point. Oh my gosh.
Dr. Raj: And then I googled, we have our new medical encyclopedia textbooks, it’s all online. There’s a thing called UpToDate. You can look stuff up there either. It’s all medical algorithms. So then I googled and then there’s profiles of countries or people who have done cultural competency work for decades and a long time.
We always knew there was difference between different cultures and we need to address that somehow, but that work was so stereotypical sometimes, like, hey, this is where the country’s from, and these are the three values they hold. They like family, they like to live together, and they’re hierarchical. And I’m like, [00:14:00] okay. Still this isn’t really helping me. I’m going to show up for this patient and say what am I going to do?
Dr. Sharp: Right. Well, you brought that up as we were brainstorming ideas for the conversation around how it’s easy to be super reductive in our approach to this problem. And I get it because if you’re not super reductive, then it opens the whole Pandora’s box of, oh, well, I need to be aware and cognizant of these million different variables that real people might have. I get it but I feel like in this fear, it’s not doing us any favors. Like you said, maybe opens the door a little bit but then when we actually get in the room, it’s like, what is happening here and this isn’t working, how do I put this knowledge into play? And can even be dangerous if we’re [00:15:00] overly reductive.
Dr. Raj: Yeah, exactly
Dr. Sharp: Yeah. So I imagine there’s so many layers to this, just thinking about how to get to a behavior change place where there’s the layer of finding physicians or practitioners who can acknowledge this ambivalent or this dissonance rather and be willing to do something about it. Then it’s like finding the information, then it’s actually delivering the intervention. Then it’s being with patients who are receptive to that. There’s a lot of layers that make it challenging.
Dr. Raj: Yeah. Our work is complex because we work with people and people are complex. That’s an understatement. Identity is complex because it’s dynamic. I didn’t present myself to you as an Indian but circumcircles that’s the primary identity I hold. And when I’m with my family in India, I’m going to highlight my Indianness. [00:16:00] But in this clinic, I mostly hold onto my identity as a physician. There’s also a part of my identity where I’m from North Carolina, I’m from the South. I liked iced tea and sweet tea. I played lacrosse. Can hold onto that identity if I’m there.
And then there’s this philosopher who said, we have a hierarchy of identities. What is most apparent is the one that’s being most threatened. So if I’m the only dark-skinned person in a group of white people, that identity is the most obvious to me because it feels the least comfortable holding that identity in that space. So it’s like when you stand out or that part of your identity is being threatened, that’s what seems like the most important to you, although we’re complex.
I think in our conversations, wherever you are in delivering healthcare, when people feel like they don’t feel understood, that identity becomes really salient. Like, yeah, he’s talking about depression [00:17:00] but does he really understand what I’ve been through in the history of my community? Because I understand the concept of it but just doesn’t seem like he understands this part of my identity, which is important to me right now.
Dr. Sharp: Yeah. I was going to ask if there, that’s a good example, are there other ways that you see that coming up with your patients and what identities tend to feel threatened the most in a healthcare setting?
Dr. Raj: It’s often when your humanity isn’t acknowledged. That’s a big sentence. I like to use examples because part of my journey, because I don’t have answers, I’m just looking for answers and part of it was through podcasting as you know. And when I’ve interviewed people from different communities, they often tell me because they’ve had bad experiences or good experiences and they highlight what it means to them.
I’ve really focused on ethnicity right now. Obviously, there’s so many layers of identity. Hopefully I’ll [00:18:00] get to unpack and discuss in the future, but I’ll use an example, I think I shared with you earlier, the Native Hawaiian community, because I take care of Native Hawaiian community here. One thing they shared with me or this community leader shared with me was that, hey, there’s one thing doctors and clinicians wherever I go do all the time. And it’s really frustrating to hear it. And that is, they tell me about their vacation in Hawaii and I was like, oh, like I didn’t know. I was like, I think I did that the other day. What are you talking about?
She was like, well, I’m coming to you for help. I moved here to this state because Hawaii became unaffordable because of tourism. And then I’m here, I can’t even visit my family because it’s too expensive. And then the first thing you say to me is that, hey, I’m going to vacation there. I was just on vacation. That doesn’t feel great. And my identity is Native Hawaiian. It’s [00:19:00] clear you don’t understand it. And the ways we have suffered and the why we’re here. And now I have to tell you all the things that are bothering me, be vulnerable, and then trust you. That’s going to be hard, right?
Dr. Sharp: Yeah. That’s a powerful example and one that is probably obvious to some folks, not so obvious to me.
Dr. Raj: Yeah, exactly. And it’s things that I may have done. It’s the little thing that sometimes makes a big deal. I want to acknowledge the point that you made earlier that seems like we’re opening up a box of, how can I know about all these things of every community? My journey was just, I’m going to start with the communities that I’m interacting with and the communities around me. It’s the few people. It seems like there’s enough of them and I’m taking care of them. So I’m going to talk to this community leader and go out and have a conversation.
I also take care of the Somali community and this [00:20:00] Community leader was telling me, one thing that I hear about a lot, it’s a small thing, but it’s annoying thing, is that when we go with our babies, the doctors are sometimes complementing our babies. Like, hey, your baby’s so cute, they’re doing so well. It’s like, yeah, what seems wrong with that? And we’re like, well, there’s this thing about the evil eye, and it seems like doctor’s always trying to bring the evil eye on us. And then we’re always like, stop saying that. We don’t want to hear that. It’s not helpful for us. We say this thing called Mashallah that can help mitigate that or lessen that but that’s one thing you should know.
It’s such a small thing but our relationships are built out of these moments and connections. The more of those moments you have, the less you feel like this person cares enough about me to know this thing that seems important to me. And part of my journey is finding out what’s important to this community. I try not to answer for myself. I ask them directly.
Dr. Sharp: Sure. [00:21:00] I want to dig into two communities that I know that you work with and before we totally do that, I know you used this term cultural safety a little bit ago, and I would love to hear just a working definition of what you mean when you say cultural safety in this context of caring for individuals.
Dr. Raj: Yeah, and I’ll acknowledge that this terminology, cultural safety, was created, defined by the Māori population in New Zealand because they were attempting to create a concept of how to get care from a healthcare system that has often harmed the indigenous community. So that’s where the terminology comes from. That terminology is prevalent in Canada, Australia, but not in the US as much. Clearly, some people talking about it.
So I want to go back a little bit about terminology that we often use, which is cultural competence. [00:22:00] Two things I want to say; language is important and language is not important. Language is important because we want to communicate the way we want to, but I don’t want people to get caught up in the theories and not understand the practical implications. So what I mean is, you can use whatever word you want to define, I want to care for this relationship between us in a compassionate way so I’m going to learn about your community. That idea.
But there’s terminologies to unpack because they have come with baggage for decades. Cultural competence specifically, we’ve all heard about it. We’ve all thought about it. As we talked about historically, it’s been applied in a way of othering communities, which is that I’m the normal person and these people are different than me. I’m going to study them so then I can understand their values, then I can do what I want, which is, they can listen to my recommendations because I can figure out how to convince them.
There’s this inherent distancing [00:23:00] font part of it that comes with that terminology. We talked about the stereotypical part of it, and the third is it seems like a checkbox, hey, I’ll do this module and then I’ve achieved cultural competence. I’m competent. I get it. Now I can take care of the community and you lost all that humility that comes with it.
Dr. Sharp: That’s the part that gets me, the competent. It just built into it is this idea that you can achieve it and then it’s done. That’s not how it goes.
Dr. Raj: Exactly. So overall, the field has transitioned to using cultural humility which is more of a self-reflection on your own values and beliefs and how that’s affecting the interaction. What I really like about the cultural safety term is that it brings in the relationship and really focuses on the relationship, on acknowledging that we all have power differences depending on where we’re interacting with folks. And that we have a relationship that has a history, even if it’s not us individually, or communities do, or [00:24:00] countries do. And that can also affect our dynamic.
So it’s important to understand the context of people, communities and countries because that’s going to inform the relationship and the power dynamics of this thing that we’re building together.
Dr. Sharp: I like that. The relational component is so important in the work that we do and that really does a nice job pulling that in. I know folks, part of this process is doing the work and that it doesn’t happen overnight. And I know folks are like, okay, I want to do this somehow. I want to learn more. You strike me as someone who’s done a lot of self-reflection and self-work on this journey. I’m curious for you, are there any practices that you’ve engaged in that you have actually found to be helpful in self-reflection as you [00:25:00] do this work that might translate for other folks, other practitioners?
Dr. Raj: Yeah. There’s so many, I’ll say practices that’s informed by principles. Principle being, I want to be able to slow down and listen. That’s a common thing that we tell people but I think it’s hard to implement. So one of the practices, I like to “write a letter” to myself not read a letter. I have it on my phone, on the things that felt painful to me today, especially with people that I didn’t connect with. Because I think we lose it in that flow. So it’s a letter to my future self because I’m going to read it later. And then it’s going to help me think about this in a different way or reflect on it.
And there’s such an example of things that I’m always thinking about because life feels so crazy and uncontrollable sometimes. The other approach is not relying on myself to solve this feeling because we’re so [00:26:00] individualistic in our country and you hear this out, we just have a hard time asking for help or looking to others for answers. So when I was in these situations, I was like, well, I don’t really know. And these modules and these websites aren’t cutting it. So I’m going to actually talk to the people in the community and it’s going to be a leap of faith.
This is a random person reaching out. What does he want from me? Because communities often feel like they’re being extracted from, so that’s other principle, don’t try to extract from community, meaning I want to learn from you so I can benefit my organization and get more patients to my practice. That’s not the goal.
You have to be really approaching in a humble way. And say, hey, I’m taking care of many members of a community and I want to do this better. How can I do this better? And then you build that relationship with that small community. So people listening, you might not take care of Native Hawaii and you might not take care of Pacific Islander. It could be migrant farm workers. It could be somewhere rural that [00:27:00] people are traveling to your clinic for, but you don’t know what the town feels like there.
I find that podcasting, what we’re doing now is able to capture some of the nuances better because it uses voice conversation and stories more, and it can get deep into it. So these things that feel abstract and conceptual, like listen deeper, understand the nuances of culture, you can get specific about those. As I gave you an example, a Native Hawaiian and Somali community. But there’s something like that for every community.
I just talked to somebody from the Chinese community and we talked about the model minority myth. For people who haven’t heard that term before, has some historical connotations where some immigrants are good immigrants, others are bad immigrants. The immigrants that are good or the model minority, which are typically seen as East Asians because they don’t cause a lot of [00:28:00] trouble, they work hard and make a lot of money and then they don’t end up in leadership positions, but they don’t complain about that too much. That that’s all in that terminology. You can certainly read about but when you hear it from somebody who’s experienced it and felt it, it’s a whole different feeling.
I think it’s easier for me to build those moments of empathy to really carry that with me when I’m talking to somebody who comes in, a professional working East Asian, who feels the burden of having to meet their parent standards. There’s lot to unpack but there’s underlying disbelief that’s prevalent in the culture too that may be helpful for you to know, to ask the right questions, at least. Like do you feel like you’re living up to a standard? Do you feel like you can’t veer off this path that you’ve established for yourself? And why is that? Because you have this underlying conceptual knowledge about a topic that you [00:29:00] heard somebody else from the community talk about.
Dr. Sharp: Yeah. I’m going to take a little detour just for a second because it just occurred to me, we struggle with the relationship building in the sessions that we have, which are much longer than the time that you typically get with patients, I would imagine. And so I’m just curious from a logistical standpoint, what this looks like in the room when you have 15 minutes with someone or maybe longer. Maybe I’m making some assumptions there but you tell me, how’s this working in a compressed timeframe.
Dr. Raj: Jeremy, I can solve all of world’s problems in 15 minutes. Do I need more than that? That’s what everybody tells me.
Dr. Sharp: Silly question.
Dr. Raj: You show up. I’ll put minutes. I constantly feel I’m [00:30:00] doing all this work trying to be better and I implement it sporadically and that’s my journey too, in doing that better within the constraints that have been placed on me. So best case scenario, I know I’ll see this person again and I try to take a long view of this relationship. It’s not just this 15 minutes but it’s the cumulative 15 minutes over the next year that I’ll have. I don’t know what that looks like. So I’m going to suspend some of my agenda. We’re going to focus on certain things, just try not to focus on other things and take time with things that could take longer than maybe this visit was intended to be.
So shifting perspective like that helps. And then these small ways that we actively dismiss people’s identity, I stopped doing that. I talked about saying hi to the Native Hawaiian community, someone from the, let me see if I can choose a different community. I’ll use the Pacific Islander. I didn’t say anything specific about them from their episodes, [00:31:00] but the community leader said, no, I haven’t gone to the doctor in four years. And this was somebody who was advocating for better health for the community and he wasn’t going to the doctor. And he said, because I go there and all they ever see in me is the fat body. They talk about how I’m overweight, obese, but I came in for a different reason. They didn’t even answer my questions. They talked the whole time about that.
And there’s a specific about just body size we can talk about in that comment right there but also we missed the historical context because he talked about how, hey, the US came in there, tested all these nuclear weapons, destroyed our food sources. We don’t even eat any of our native foods. We got kicked out of our land. And then all of our diet, nutrition, capacitor exercises changed. And then you’re blaming me for this body that has all these causes. So we’re sometimes actively dismissing people’s experience. So I can stop doing that and that doesn’t take time away from me. [00:32:00]
Dr. Sharp: That’s great. No, that’s just another fantastic example, context that we need to be aware of. So maybe we dive into one or two of these communities and love to just hear your perspective on care for some of these specific communities that you work a lot with.
Let’s take a quick break to hear from our featured partner.
The PDDBI can be used to assist with diagnosis and treatment of autism spectrum disorders. It was developed to assess both problem behaviors as well as appropriate social language and learning/memory skills. The PDDBI Score Report was recently enhanced and now includes a new interpretive guidance section, a revised look, and an optional items and responses section. More updates are coming later this year. Learn more at parinc.com/pddbi.[00:33:00] All right, let’s get back to the podcast.
Dr. Raj: Yeah, I’ll try to keep using different communities so maybe people don’t see certain communities, but do see others. Let me bring up the Khmer community. And with the Khmer community before I started talking to them directly, which gave me an impetus to really understand the history because I had to talk to them in a meaningful way, I didn’t realize the trauma they hold and what they’ve done with the trauma. And specifically for the Khmer community, which is the community from Cambodia, they experienced the Khmer Rouge. Khmer Rouge is linked to communism where essentially there was mass killings, thousands, I think some people even put it up to a million, maybe more people died.
In my episode with the Khmer community, James [00:34:00] Heng, a community leader he’s in Khmer Health Board, shared his story. The story was how he came on a boat and witnessed people’s deaths. And he said it so apathetically, casually. I thought about that a lot because on a follow-up conversation with one of the co-leaders of the Khmer Health Board, she talked about, hey, no one’s listened to us enough to understand what this means and what it means to process community trauma because our healthcare system doesn’t value answering questions like that.
This community has suffered massive trauma by witnessing death, losing family members, experiencing famine. A lot of countries have but once they come here, we just treat them as individuals without the support needed for them to heal because they left their country for a reason. We talk about asylum refugees, there’s work being done there, so I don’t want to discount that. But for this community, their lived experience was they were saying, hey, we didn’t [00:35:00] know what to do with this and we’ve just internalized it. So when you tell us we need surgery, all of this comes back, our vulnerability, what we’ve witnessed, and we’re going to say, no. We’re not speaking for the whole community because everybody’s different. We all hold different identities but many of us hold this trauma and we’re terrified of surgery and people don’t understand that.
And we’ve talked about healing, but what we really need is a community center because there’s community centers, places to gather for all these communities, but we don’t have one. So there’s so many facets to this:
1) Healing for this community means processing this trauma. What does that look like? How can we create that in our system?
2) The community’s telling us what the solution should be, which is, let’s create a community center, which is not the answer for everyone but it is for this one or in this moment, people who’ve been doing this work for 20 years and talking to the community.[00:36:00] So for me personally, I feel like it’s informed how I communicate with patients because now I can sometimes when I hear reluctance of like wow, that’s a big hernia. You probably should have a surgery. And they say, no, I don’t just give up there. I say, hey, surgery can be scary and it can often seem life-threatening but listen, Mike, I have had personally a lot of patients who’ve gone through this and they’re okay.
So I’m trying to find moments of connection with the background knowledge. I don’t have to say, hey, Khmer Rouge must have been hard on you, that’s not what we’re going for, but I understand that may be informing this patient and it’s a hypothesis. So now I have a place to start and then keep talking with the patient.
I’ll use the metaphor of dancing because sometimes conversation is a little like dancing. Trying to figure out where can we meet common ground here. And then when I’m in meetings where we’re trying to support or say like, hey, [00:37:00] we want to invest in the community, what we should do? Well, I just talked to this person. I have a relationship with them and say, this is what the Khmer community needs. So I have something very specific to advocate for because as clinicians, no matter who you are, you have power. Not always enough power to make change but more than most of the world.
Dr. Sharp: That’s such a good point. Well, and that story makes me think too of how healthcare is very individualistic in our country and for many folks it maybe makes more sense to think about a community-based approach. I don’t know how that would logistically work but to care for people in groups versus one-on-one in the office. I’m not sure what you think about that.
Dr. Raj: Exactly. Yeah. This is across communities where there’s a dichotomy with Westernized values versus Eastern values. Obviously some diversity there of our [00:38:00] individualistic approach versus a community approach, because when I talk about diabetes, so many people that I’m talking to are like, you’re always talking to one person, but it’s a family thing because my partner’s cooking and if they don’t know how serious that is, I’m going to keep eating the same thing because if I say no to that food, that’s really rude and it’s going to really hurt their feelings and I don’t want to, and that’s what matters to me most. That is the thing and you’re saying change your diet. Okay. I’m going to say yes to you, but you don’t really get it
Dr. Sharp: Right. That’s such a great example. Yeah, we talk about that a lot too in just intervention. We typically see people one-on-one or maybe we see families in isolation where we work with the kid and have to translate interventions to the parents and things like that, but then they go back into the community [00:39:00] and real life happens for every other hour of the week. And that’s really challenging to take all those factors into account. But just knowing that there is that other world out there and there are other factors and being willing to explore it. I think that’s something that I take away from these discussions often is that there’s no, I don’t know that it’s about solving the problem. It’s just being curious and being willing to ask that extra question like what would that be like to try to change your diet at home? Who’s doing the cooking? Who would actually make that change? Would that disrupt your family relationships? What would that be like?
Dr. Raj: Yeah. And this isn’t relevant for everybody, it just has been helpful for me. I’ll bring, let’s say the Ethiopian community, for example. And we’re talking about nutrition. We love a healthcare making these broad claims about diet, which is really complicated too. Like just eat less of this and then you’ll [00:40:00] feel better. Okay. But especially with people who are eating different food, and food means so much more than nutrition: It’s like your memories, what your mom made when you grew up. You’re so much there. We’re not gentle about telling people to just stop doing something.
But for the Ethiopian community, I feel like their diet is different enough and sometimes our recommendations don’t make sense. Like we could talk about lowering carbohydrates but like what do carbohydrates even mean? And then we can talk about rice and bread but they teff and injera, does that make any sense? How do they bridge that gap?
And there’s a lot of work on just culturally responsive nutrition, but for me personally, I’m not going to change their entire diet. It just has led me to connect with them differently again, because when I talk about diet can say, hey, I know some people use white flour to substitute for teff and injera, which injera it’s this flat bread that’s made from this grain called teff that’s native to Ethiopia but it’s really expensive [00:41:00] here so people use white flour and it’s what one of the community leaders said when I talked to them. When we talk to them, we talk about can you change it into whole wheat or bulgar? And that may be a different place to start. So I say that instead.
So there’s one point here, which is that, oh, I’m being culturally responsive. The second point is that the patients are surprised. They get this’s so little. They’re surprised that I knew something like this. And then they’re open to sharing more because now they know I cared enough to learn about this thing that’s in their community, because most of the time they’re just being shuffled around. It doesn’t seem like anybody cares about them enough to know and understand but since I’ve taken that first step, they’re like, oh, he would be interested in hearing more. I can tell them a little more. So they are able to open up a little more. Again, these are all broad strokes, but I’ve had moments like that more now, and I think that’s [00:42:00] been really helpful too.
Dr. Sharp: Yeah. As you tell that story, I’m reflecting on this and what this would be like, and just knowing myself, I think I’d be very self-conscious of coming across as performative in these situations, like deliberately trying to work in this knowledge that I have. I’m curious just me projecting or if that’s a real thing that you or maybe your colleagues have struggled with, finding that balance between, okay, how to do this in a natural way that communicates care versus, hey, look at me, I’m a white person who knows things about non-white people.
Dr. Raj: Yeah. There’s so many ways to do this wrong, and I think people give me probably a little more grace because I’m a darker-skinned man and I think there’s that assumption but I will say, the approach is, I [00:43:00] don’t go in saying, you’re probably eating white flour within injera and you should probably decrease that. The knowledge doesn’t lead to assumptions, but just leads to questions to be more precise. Like, hey, I’ve heard of people doing this, is this true for you? So then people can say yes/no. They can respond in any way, but it changes that approach a little bit.
And it’s not trying to say, I know this, I heard it, or somebody told me like I just know this thing. It may not be true for you. You’re not imposing that reality on them because a lot of people who, that’s part of the problem with cultural competence, you think you know this community, so then you impose this two-dimensional view of them in every individual, and they’re different. So I try to ask more questions rather than assume something about them and it gets me out of that situation of being stereotypical introductory, but also feeling like I’m being [00:44:00] performative. I’m not saying this randomly. I just talked to this person and they said this and it could not be true. So I’m maybe completely wrong.
Dr. Sharp: Yeah. So working some humility into the process. It goes a long way. I hear you. I wonder if you’ve run into situations where gosh, I’m trying to phrase this the right way but essentially the idea that someone’s cultural values directly contradict medical intervention- what you know or we think we know would be most helpful from an intervention standpoint. Maybe there’s some urgency to it. Maybe it truly is life-threatening. I’m not sure, but I’m curious how you approach something like that where there’s a real clash there at least on the surface between someone’s values and the intervention [00:45:00] that they might need.
Dr. Raj: Yeah. And those are, I feel, the moments that stick with us the most because they’re so uncomfortable. They’re so vivid. Maybe I’ll ask you, have you had a situation like that? I’m curious.
Dr. Sharp: So the one I could think for a long time about this, but I’ll just go with the top-of-mind example, which is I think a common one is running into families who believe in spanking their kids. And that’s a cultural norm. I grew up in the South. I got spanked, I got hit with a lot of things. It’s a norm and we’re pretty clear research-wise that is not a helpful parenting strategy. So that’s one that comes to mind right away.
Dr. Raj: Such a great example. I want to use one that is familiar to me, and then let’s see if we can navigate that territory together. So I also deliver babies, so I do prenatal [00:46:00] care and then deliveries. And certain communities have religious beliefs and personal beliefs that they really want to have a vaginal delivery. No Cesarean-section.
So for this woman who was Somali, who was fairly religious, again, not everybody in the Somali community does this. Got to say that over and over. But for this person, when we were in labor, we were chasing the fetal heart rate. There’s a monitor that they put on you, some people may know this, and it was showing signs of what we say is distress, that the baby isn’t doing well in labor. And more and more it seemed obvious that hey, we should move towards Cesarean-section because that’s the standard of care. We can do that. Have both mom and baby safe. We don’t know if this vaginal delivery is safe, but she said no, because it’s in God’s hands. And she’s going to trust that God is going to keep her safe and agree to a [00:47:00] vaginal delivery.
So there was a lot of conflict. People come in, scolding her and then accusing her of not caring of her baby. And then just a lot of anger and eventually she got, she got a Cesarean-section, but she was psychologically a little bit scarred and carried some trauma from that experience.
So one thing to highlight there is there’s one way to approach it. We’re accusing the person of not caring, hey, you’re spanking your kid, you must not love them. And you don’t want to have that message because that’s not going to help move us anywhere because that’s essentially not what they believe. This person loves her so she wants her baby to be safe.
So one is just not going down that path, which is so easy to, because we hear the so strong professional duty and to protect our patients, our families, and feel like, hey, we know, research shows you’re harming your [00:48:00] child. And that poll is so hard to not confront them and start conflict. Not saying people do, you’re trying to check yourself, but it can come out in subtle ways. So not doing that.
The second is the harder question is that, I try to honor cultural preferences as much as I can but when do we challenge those preferences or values because they’re leading to either bad health outcomes for you or the person you’re caring for or your family. And that’s a tough ethical question because a professional duty is going to conflict with this person’s cultural values. And I haven’t found an answer to that. I just know that’s oftentimes we’re not approaching it in a very, I don’t know what the word is, in a very compassionate way because I think if we did, there’s possibility for change there [00:49:00] because I do want to point out that it is okay to challenge cultural beliefs.
The hard part is there’s historical component to this because we’ve challenged cultural beliefs that just don’t seem great to us. So I’ll go back to the example of this baby. And many people may not know this, fetal heart monitoring is notoriously bad for actually predicting health outcomes. It’s like, okay, we just think it works. It’s the only thing we have. So we say it doesn’t look great, we want to do it. But it’s not great.
Part of it is our risk tolerance. Going back to humility, we as healthcare providers institutions don’t want to have any risk. Cesarean section is so easy. It’s this next door. So we’ll just take them. So we have to acknowledge that maybe the patient is just willing to bear more risk than we do, and she may have in her own country because she may not have had all these services available to her.
So I’m not getting to a specific answer because there are all these components, but I think it just leads to a different approach where we can hopefully still [00:50:00] challenge what’s happening. And in this specific situation with this patient, I’m going back to, I think what would’ve been better than what happened was being more empathetic, saying, hey, this is what we see. I know you don’t want this right now, but I wonder if you’re really understanding everything from our perspective and maybe we need a doula or somebody from the Somali community who can also help us at this moment. We can tell her and then she can communicate it to make sure you understand. And at the very least, we have the same understanding of what’s going on because I know you care about your baby. You love your baby. We think this is the right decision right now. We know that we have a low time for risk, so maybe we can wait a little longer, but we are worried and I want to be direct with you.
Dr. Sharp: I love that. I think down similar paths with my hypothetical but real [00:51:00] example as well. I think the thing that we want to prevent is divergence. I don’t know if you’ve read or seen the book, Mistakes were made (but not by me). It’s all about cognitive dissonance and how we rationalize our choices and things like that. But they give this visual of, we all start at the top of the pyramid, at the point but as soon as one person takes a step on either side, they start sliding down the sides of the pyramid and end up at the base, which is very far apart. And trying to keep that in mind, like, hey, like we both want everybody to come out of this healthy, we want your kid to have the best outcomes possible. I know that’s where you’re starting, that’s where I’m coming from too, is there room for discussion here around how this works and what you might be doing and [00:52:00] you open to hearing ideas, things like that?
Dr. Raj: Yeah. At the bottom of the pyramid, I can imagine. Parents could say they’re not spanking them and still go home and do it. You can’t control it. They could do whatever they want at home ultimately regardless of how this conversation goes.
Dr. Sharp: Exactly. And just doing our best to not polarize ourselves because that’s so easy to do.
Dr. Raj: Yeah.
Dr. Sharp: I appreciate you talking through that. I just love the humility throughout this conversation and willingness to say the answers are not obvious in many of these cases, and all we can do is be open and do the learning that we can and try to connect with folks and hear what they’re going through.
Dr. Raj: I know. I feel like at least in medical training, we’ve been so focused on what the answer is, what we should do, that we don’t highlight the how, [00:53:00] how it goes even if the why is uncertain, right? How are you actually having that conversation? What is the tone of your voice? What are you doing in that moment? And then are you anchored to your why? Like this purpose that you’re saying, the shared purpose of we’re both trying to get you and keep your family healthy and coming back to that over and over but it’s so easy to get caught in what research says blank. That’s what we’re doing today.
Dr. Sharp: Yeah. In our world, we call that process versus content. It’s the why versus the how or the what versus the how. Yeah, I’m with you.
Well, our time has flown by. I would love for you to share more about your podcast with folks. I think it’s super cool and you’ve shared some stories, but tell folks what this podcast is all about.
Dr. Raj: I host Healthcare for Humans podcast. The goal is for clinicians to hear directly from community leaders on [00:54:00] how to care for culturally diverse communities through voice, story, and conversation. As we talked about the nuances, the contradiction sometimes but the voice is directly from the community, and it’s also accessible for the community leaders to voice their opinion because they feel like giving voice to the voiceless is a mission in itself and trying to help them feel heard. And that’s my hope.
So if people are out there that match what you want to do in your values, go ahead and take a listen but more importantly, I do want to build a community around this kind of work because there are no right answers. So if you have thoughts on topics or people like this person does it so well, everybody should know, I want to know who they are because I would love to amplify their voice.
Dr. Sharp: All right. Yeah, that’s fantastic. Everybody, you hear the call, answer the call. [00:55:00] Okay.
Raj, I’m super grateful for your time and the conversation. This was different than a lot of my interviews and I really appreciate it. I’m glad that we were able to do this.
Dr. Raj: Thanks so much, Jeremy. Sorry, I had a pop-up. You can edit that out, now you disappeared for a second.
Dr. Sharp: Sounds good.
All right y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
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And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of [00:56:00] practice development; beginner, intermediate, and advanced. We have homework, we have accountability, we have support, and we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you.
Thanks so much.
The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute [00:57:00] for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.