I am just Indian enough to keep the patients with whom I share an ethnic background coming back for more.
There is a large body of academic work showing that patients from minority, under-reached and under-represented backgrounds prefer doctors from the same background.
Women have better health outcomes when their surgeon is a woman. Black men and women have higher satisfaction with healthcare when their doctor is of the same race. Lack of a common language between the doctor and patient is a major barrier in quality healthcare universally.
Of course, none of these are universally definitive or insurmountable to overcome – it is just to say that sharing qualities or lived experiences with our patients can improve their health and experience of healthcare. Instinctively and intuitively, don’t we know this to be true?
Most of my patients are women, and mostly of reproductive age. And many of the similar-aged women patients of mine are ethnically Indian, like me.
But unlike me (a first-generation migrant from Bangalore raised in Melbourne), many of my Indian patients are adult or new migrants who moved to Australia for university, work, marriage or some combination of the above. They grew up in a westernised, young, modern India that I know nothing about because the problem with migrants is that we imagine our motherlands as static, captured in time, unchanged from when we left it.
My parents and I left India in the early 1990s. How I grew up in Melbourne (and admittedly I was quite removed from the Indian community here) was completely foreign to the experiences of my adult-migrant Indian patients, and yet we intersect here in this clinic room.
I always wonder what draws my Indian patients to me. I do not speak my languages (Tamil and Kannada) fluently enough to conduct medical appointments in them. The patients do not know me socially from community events or cultural groups; I am not involved with any of those. We don’t have mutual friends or friends-of-friends or any association that would have brought a recommendation to see me. It’s just my Indian name that drew them in, I suppose, and then somewhere over the years, there was some commonality or trust that maintained the relationship.
But what? And why? What makes my Indian patients relate to me?
My parents have had the same GP for 34 years, an Indian man. I know why they relate to him – they have the same holy worship and deep sacred reverence for cricket. He has the same accent as them, grew up in India just like them, speaks the same languages as them. He has the gruffness and firm no-nonsense bedside manner that they are culturally familiar with and respect. They cross paths with his family occasionally at community events, or the Indian grocery shop, because they also live in the same area.
But I am not so good an Indian. My only Indian friend is my brother, I think. I loathe cricket. I loathe it so much, and the pain of being an Indian-Australian who loathes cricket as much as me is indescribable.
I am an extremely conservative prescriber and firmly wave off desperate requests for antibiotics for common colds, although I know many of my Indian patients were raised in a country with abysmally high antibiotic resistance and where antibiotics are available over-the-counter at local pharmacies, so the patients are used to liberal antibiotic use.
Many of them will see another GP, a kinder one, a more generous prescriber, if they believe themselves to need antibiotics. It will be a waste of an appointment with me – their usually preferred doctor – to be told to rest, take paracetamol, de-snot and wait it out. But I’m still there for all the other issues; the shoulder pain and the headache and the rash and the chest pain. These things I am still deeply trusted to manage, but I perhaps am not Indian enough to appreciate our culture’s use of antibiotics on compassionate grounds.
Related
I am, though, a very generous prescriber of medication for menstrual management. My culture doesn’t do this well. There is a great deal of hush-hush and period stigma, and I am frequently surprised by the conservative beliefs of my otherwise progressive patients in relation to this and only this.
The contraceptive pill won’t make your teenager suddenly start having sex. It won’t make you infertile. It won’t make you obese. It won’t interfere with your natural menopause, 20 years in the future.
I’ve seen teenage girls bucketing blood during their periods, anaemic and miserable, and still their Indian mothers are reluctant to allow the pill, or the IUD, or the Implanon. Or worse, their mothers are supportive of treatment, but the fathers are not. Or worst, the mature minors themselves reject their capacity for decision-making because in our culture that is not done; parental approval is required for medical care.
It frustrates me, because I don’t know how else to reassure my patients. After all, aren’t I Indian, too? Am I not an Indian woman, acutely aware of the cultural barriers and stigma, and I, of all people, still believe this treatment is both necessary and safe.
But when it doesn’t work, when my convincing and rationalising and shared decision-making and active listening fails, then I must accept I am simply not Indian enough to understand the reluctance. I do my best by offering an iron infusion and refer to an Indian gynaecologist, one with an Indian accent. Sometimes she succeeds where I do not.
The same conversation I have about diet. There are many wonderful things about being Indian, but the risk of metabolic syndrome is not one. We are not advantaged phenotypically. Our fat is held centrally, our plaque is held tighter, and our insulin resistance occurs earlier. We must work so much harder to avoid the spiral of high blood pressure, diabetes, high cholesterol, obesity and heart disease. And our diet – our reverence for food as powerful as reverence for cricket – feeds disease.
Please don’t feed the children sweets and chocolate and ice cream daily, I beg. I know that is how our Indian culture expresses love – through rich, nutritionally deficit, ghee-filled carb-heavy food – but it is more detrimental than loving. It normalises these food choices. It normalises disease. Your children will still feel your love through fruit, or nuts, or god forbid, by vocalising it. Change your white rice to brown or red. Stop the sweet biscuits with sugar-heaped chai three times a day; these are empty calories. I know you grew up buying boiling tea from the roadside stalls in India every morning, hot and sweet. I know I did not, but the sugar is damaging. You’ll get used to the taste without it, I promise. But how would I know? I have never added sugar to tea.
So still my patients’ HbAIcs increase, and the medication doses increase, and I realise I am just not Indian enough to convince them. I do my best by suggesting edamame instead of peas in upma and refer to an Indian dietician. Sometimes I refer to an accented middle-aged Indian male cardiologist, for a more informed discussion about ethnicity and metabolic risk. Maybe to the patients he looks and sounds more authoritative than me.
Then I wonder, truly, where do I meet my Indian patients from my experience of our culture? I do not feel Indian enough for them, but still, they choose to see me, dogmatically and loyally, year after year. They tolerate me, and my “Australian” views. They know I have trained here, I was raised here, I am different. They know I practice differently to the doctors they were used to, that I have no interest in small talk about the cricket.
But all of that is untrue and unfair, and I have reduced brilliant, trusting, meaningful, satisfying, caring and enjoyable therapeutic relationships with my Indian patients to a pathetic collection of frustrated interactions. Actually, the patients don’t tolerate me, they choose me. They pay to see me, to hear again and again and again my long-winded lectures on the harms of fat-filled ultra-processed frozen parathas. Because seemingly these frustrations are allowed when it is from a doctor who looks like them, and knows the brands of the parathas, and knows exactly where to get healthier alternatives for pre-made roti.
Because despite all of the differences and all of the ways I think I’m not Indian enough for them, in fact I am just Indian enough. The lived experience I have, however meagre or diluted or different, is enough for my Indian patients to relate to their Indian doctor. And the best I can hope for is that this eventually does bring them better health outcomes, and a better experience of healthcare.
For another year, Happy Deepavali.
Dr Pallavi Prathivadi is a Melbourne GP, member of the Eastern Melbourne PHN Clinical and Practice Council, and GP Lead of the RACGP Academic Post cohort support and education program. She holds a PhD in safe opioid prescribing and was a Fulbright Scholar at the Stanford University School of Medicine. She is studying creative writing at Harvard University’s Division of Continuing Education.
