The PLAIN Truth: Caring for the Amish: What Every Anesthesiologist Should Know

The 30-year-old Amish mother of 3 is waiting with her husband in the preoperative assessment bay before her scheduled surgery. Your medical expertise and confidence seem to evaporate as a host of social-cultural questions suddenly fill your head. “Do I shake hands while introducing myself to an Amish woman? Will she allow me to listen to her heart and lungs if she is enveloped in those drab plain clothes? Do I dare ask her about alcohol or other illicit drug use as part of my history? And what about her husband? Who is the decision maker? Is this a patriarch or matriarch-dominate culture? Does it matter?” The uncertainty grows. Culture is the cacophony of beliefs and behaviors expressed to define the values of a community, tribe, ethnic, or social group. It includes elements of gender, religion, sexual orientation, employment and trade, tastes, age, socioeconomic status, disability, ethnicity, language, heritage, and race.1 Increasingly, physicians around the globe are caring for patients from backgrounds very different from their own. Thus, practicing professionals increasingly recognize the requirement for cultural awareness and sensitivity—the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from a multitude of cultures. Fortunately, Weller shares his insights and experience regarding one unique social group that is easily recognized but little is understood in certain parts of the United States—the Amish.2 We first appreciate that there are more than 300,000 Amish citizens currently residing in 500 different settlements in 31 states (especially Pennsylvania, Ohio, and Indiana) and 2 Canadian provinces.2 Second, Weller highlights the historic origins of the Anabaptists during the Protestant Reformation, noting the schism that led to the separation of Mennonites (no, they are not the same!) and the Amish. Clinicians will be well served to understand the beliefs, traditions, and lifestyle of the Amish communities, as Weller illustrates where these beliefs may directly affect the incidence of disease, its presentation, and possible treatments. For instance, because of the relatively closed community, anesthesia professionals should also recognize the “founder effect” within the Amish that increases the risk of genetic disease by reinforcing recessive genes. This is of sufficient concern that a Genetic Disorder Database repository is available for the Amish, Mennonite, and Hutterite people.3 Finally, Weller highlights where the media portrayals of the Amish (in movies such as “Witness” or television series such as “Amish Mafia”) are accurate or if they are simply the product of good fiction writers. But the core message of Weller’s description of the Amish goes well beyond his insightful account of the Old Order Amish (or the “Plain People”).2 Rather, international migration has made intercultural interactions almost a routine part of daily practice for many anesthesiologists, and physicians are increasingly aware that these cultural interactions can positively or negatively influence health outcomes. Given the European heritage, most Western trained physicians readily accept the relatively mild cultural differences between the Amish and non-Amish. However, as the Table illustrates, even simple conversations, gestures, or touch can lead to unintended but very real negative medical care consequences across cultural lines.Table.: Clinical Scenarios Illustrating Cultural Misunderstanding in MedicineIn addition, core cultural beliefs can affect whether a patient actually appears for a scheduled medical appointment, their adherence to prescription recommendations, and, of course, end-of-life issues. For instance, the Amish believe that good health comes from God and that end of life is simply a passage to heaven, so aggressive life support is usually not embraced. Patients from other cultures may prefer never being informed of a terminal illness. And, of course, many cultures prefer traditional healers rather than Western medical practitioners. Thus, while caregivers may bring a family member to a Western physician, they often pick and choose which remedies to actually apply. Without cultural sensitivity and empathy, the Western physician may never know what therapies are actually implemented for a given patient. We must humbly acknowledge the truism that if a patient’s cultural beliefs are discrepant from our prevailing medical traditions and recommendations, the patient’s culture will almost always prevail. So what else can clinicians do to provide culturally sensitive and competent health care to achieve health equity? First, hospitals can invite community leaders of culturally distinct groups to educate staff on the basic cultural norms prevalent in their communities. Second, we should recognize that care inequity directly impacts the health and even life expectancy for population groups across the developed world. Clinicians must recognize and reconcile disparities directly at the point of care, and learn how best to navigate cultural disparities. The Institute for Healthcare Improvement recently published a white paper4 to provide guidance on how health care organizations can reduce health disparities related to racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion. The Institute for Healthcare Improvement White Paper includes 5 key components to improve health equity in the communities they serve: Make health equity a strategic priority, Develop structure and processes to support health equity work, Deploy specific strategies to address the multiple determinants of health on which health care organizations can have a direct impact, Decrease institutional racism within the organization, and Develop partnerships with community organizations to improve health and equity. Thus, we deeply appreciate the efforts of Weller to not only educate us about the Plain People, but also more broadly to enlighten us on culturally appropriate care in an increasingly multiethnic and multicultural patient population. Clinicians and patients will both benefit from this “Plain” truth. DISCLOSURES Name: Richard C. Prielipp, MD, MBA, FCCM. Contribution: This author helped identify the core content, and write and edit the manuscript. Name: Joyce A. Wahr, MD. Contribution: This author helped with additional content, and helped write and edit the manuscript. This manuscript was handled by: Jean-Francois Pittet, MD.

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