How I Got Over: The Journey to Cultural Competence

They always say, “The hardest part is getting them in.” It’s not; that’s almost the easiest part. You can get somebody in here because certain things happen, whether they got hospitalized or whether they just found out about their infection. So you’ve got them at that one, what I call “teachable moment,” where they’re just kind of scared so they’re going to come in. But then how do you get them to come back? My name is Dr. Tony Sillemon. I work for East Bay AIDS Center. I work as a psychological assistant and a medical social worker. I was often just overcome with just feeling really distraught about having to see a patient with HIV. I didn’t particularly care for seeing HIV-positive patients because they were very, very difficult to take care of. And there were things about the illness and what brought people to the illness that I really didn’t understand. My name is Lisha Wilson, and I am the Medical Director of the AIDS Healthcare Foundation Healthcare Centers here in Oakland. As you go through training, it’s much kind of like an imprinting where you follow the senior doctors and actually are rewarded when you act like them. And it’s very much a directive, paternalistic kind of training. “You do as I say, do as I do; and if you don’t, I don’t want to hear about it.” I’m Dr. Virginia Cafaro, and I work here in San Francisco at the WellSpring Medical Group. I’m an internal medicine physician, and mostly I specialize in HIV medicine. There are not enough doctors to match everyone on all of the race, ethnic and social sexual orientation criteria that people have. But being a good doctor is not predicated on being a member of that group that your patient is part of. And you can be a good doctor to somebody very different than you. My name is Hyman Scott, I’m an HIV provider at UCSF 360 Clinic. I’m originally from Chicago, and I was raised in a lower middle class family by my grandparents. From the time that I was in medical school and started learning about medicine, HIV care was very appealing because it incorporated all of the very interesting aspects of medicine, but also all the vital aspects of the social lives and the social situations in which people live in. And so for me when I thought about the type of doctor that I wanted to be, that was the type of doctor that I envisioned becoming. “Your blood pressure is normal.” “This is Dr. Cafaro; yes, I got your results.” I’m originally from Brooklyn, New York, and traditional Italian/Irish upbringing. And I’m actually the first in my family who has completed college and actually gone on to medical school. I really got into medicine mostly watching my sister go through an illness and dealing with multiple physicians, and realizing that none of them actually talked to her and dealt with her as a young person and really finding out what she was feeling and going through. So I did my training in the Bronx, which was pretty much under siege, either medically from HIV, from drug abuse and from violence. So what drew me to working with MSM and the entire gay community in general was realizing that they needed someone who they could talk to and trust and felt safe with. I was born in Portland, Maine. My parents were both from the segregated South; they were both from Mississippi. So we were a black family in Portland, Maine, which wasn’t very integrated at the time. So my experience as a child was growing up and going to school mainly as the only Black kid, along with my brothers and sisters, in my elementary school. I always felt different because of having to deal with sometimes feeling like an outsider. And as I look back on it, I think it’s those experiences that have really made me be able to sort of be the empathic provider that I’ve become. I’m from Washington, D.C. My mom is from Morocco, and my dad is from Jamaica. I identify as African American. I have eight brothers; six sisters; three kids, two boys, one daughter; and three grandchildren, two girls and one boy. One of the things that kind of drew me to work in this population was I had a brother who actually passed away from HIV AIDS, so I just wanted to kind of get into the field and learn more about it and kind of get back and kind of pay it forward. I mean, I’ve got to be honest; I’m pretty naive myself. I wasn’t comfortable working with the population. The way I grew up, it was all about masculinity. If you are bisexual or homosexual, you’re not a man. It just was looked really down on in my culture. When my brother passed away, I think it came to realization that something needs to be done. You know, the way to deal with things is to talk about it, which is really hard in the African American community because we grew up saying, “What goes on in this household stays in this household. You don’t share with other people.” And so to try to change that whole mindset now and to tell a young African American male, “Okay, let’s talk about it. Let’s talk about how you’re feeling.” And they look at you crazy, “What do you mean how I’m feeling?” So to really make that okay to do to me is huge; it’s a huge shift in culture. We’ve all grown up somewhere that you’ve got a prejudiced against somebody, somewhere because Grandma used to say. And then you go, “Oh, my god, I really have that in the background; never thought about it.” So if they can admit to themselves what they’re not comfortable with and say that to the person, the person will get it. Listening was a way for me to step past those barriers because when you can hear, when you can truly hear and listen to people, you can learn things. I think it’s very important to maintain an open and honest dialog, even if it is somebody who is different from me in some way, whether it’s age, race or gender. I think it’s maintaining an ability to have a conversation with that person about their lives, about how their identities impact the way that they interact with other people and connect with other people. And it allows me to be a better doctor for them. It allows me to provide some guidance and some recommendations if there are places where they feel torn or have questions. If I understand where they’re coming from, then I can be a better doctor for them. I have a woman who was born a man, and I’ve worked with her for years. And I think she’s worked with me in a lot of ways to become more sensitive, or just more aware of what different people are going through. They want to know that you understand. They don’t want to know that it’s all about book smarts. They want some real life experiences. You know, “How are you going to tell me about, you know, using protection?” Some people are very open and you can walk in the door and you can talk about things sexually, and you don’t have to worry about sort of monitoring your steps. But there are other people, if you’re able to read their body language, there are other people where you know that you have to step back and maybe not open the door so quickly. I had a gentleman recently who was just going through a divorce and announced that he was coming out. And he goes, “So what do I need to know?” And I’m like, “Do you want the gay handbook now, or are we talking about safe sex? I mean, how much of a conversation do I have to have?” And he goes, “No, I’m not 13; I figured out most of that.” So I said, “Okay, safe sex talk, good, this is what we’re going to talk about.” It is something that gets addressed on every visit, discussion of sexual partners, disclosure, serostatus, so what is the status of your partners? Do you talk about your status with your partners? STD screening, and beyond the testing and preferences and behavior, it’s also about satisfaction. How satisfied are you with your sexual life, your sexual health, and helping people to navigate those types of issues as well. And for me being from a family of eight brothers/six sisters and I’m the youngest, you would think I would know a lot about sex. Well, I had my first child at 13; and so that’s why you’re talking about a 40-year-old man with a 27-year-old daughter and 23- and 21-year-old child, with three grandkids. I think, you know, I actually grew up really, really fast. And I think if I had somebody actually come talk to me back then, I think I would be in a different situation. If you’re already HIV-positive, people choose not to necessarily have safe sex or protected sex with condoms with somebody else because they’re already HIV-positive; but there are certainly so many other things that you can get. Syphilis is epidemic right now. Gonorrhea is at a point where it’s resistant to a lot of medications. So you want to either prevent these or catch them early enough so that they’re treated simply, and you don’t give them to anybody else. So you have to be able to talk about sex. We’re all so very much the same and realizing that sexuality is just such a normal part of who we are. In the situations in which something is discussed around sexual practices or behavior that I don’t understand or know much about, I use it as an opportunity to learn. So I ask my patient to describe what it is that you are doing, like, how does that work? Why is that enjoyable? Who are you doing it with? What are those situations that you are in when you’re doing that particular behavior? You know, I’ve been really lucky to have patients who are willing to teach me. I mean, that’s it. If I, like, have a blank look on my face, they’ll fill in the blank, sometimes more than I want, but they’ll fill in the blank. And, you know, let me ask questions and be a little stupid. Ask your patient what makes them who they are. Ask them what they like to do. What did they do on the weekend? If they have children, ask them how they’re children are doing. If a parent died, three months down the road ask them, “How are you doing after the death of so-and-so?” If a parent is sick, check in with them. And all of those things really help make connections and ones that are really, really valuable. And sometimes it’s really not about any of the exams, not about any of the fancy tests. It’s really just about sitting down and listening. Tell me about yourself. Tell me what’s important to you. Tell me what you’re hopeful for. Tell me what you’re afraid of. It’s me talking and not passing judgment because I think we all have to learn from our mistakes, and also how are we going to change what we did? Not blame ourself for our mistakes, but to move forward and to make sure we make healthier decisions. One of the things that I do with my patients is try to meet them where they are. And in particular for my younger patients, they like to text. So, I text with them; and I text them with questions that they may have; I text them reminders that they have a clinic appointment. And that is a way that I’m trying to meet my patients where they are so that I can maintain them and keep them engaged with the care that we’re providing for them. A simple follow-up call, just checking on you, say, “Hey, this is Tony. I’m just calling to see how you’re doing, how you’re coping, if you have any questions.” I mean, just keeping the communication open because what happens is — and especially from what I’ve seen in my experience when you’re talking about young African American MSMs, is that they feel really ostracized with the medical field. They already feel discriminated walking into a clinic, so to kind of reach out and let them know that you’re welcome and to keep the communication open is key. I think that’s where you keep ’em. I have knowledge that I can help you with, and you have knowledge about you. You’re the only one that has the owner’s manual for your body, that knows what goes on in that brain. You’re the programmer. So unless you tell me it, I can’t help you. Anybody you deal with, any client you deal with, if they know that you’re not really there because you care for them, they’re going to see right through you. If I can help one young person, and I’m going to be real specific, an African American person, not die of this disease — again, I’ve seen it firsthand, I do, I feel good. And I think, “I want to pay it forward.” Nobody should have to die from this disease, especially today.


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