Creating Moments of Cultural Connection and Joy with Patients - Dr. Raj Sundar, Family Medicine Physician and Host of the Healthcare for Humans Podcast

Michael Carrese: Hi, everybody. I'm Michael Carrese. Providing culturally competent care has gained a foothold in the conversation about improving the healthcare system in the wake of COVID. But what should that look like? And are we making progress on that front? Well, here today to provide an on-the-ground perspective is Dr. Raj Sundar, a full-spectrum family medicine physician with Kaiser Permanente of Washington state. 

Dr. Sundar is also a community organizer dedicated to improving health care for culturally diverse communities and to working with healthcare systems to prioritize the dignity of each individual. As the host ofHealth Care for Humans -- a podcast aimed at educating clinicians on cultural safety in healthcare -- Dr. Sundar has shared his expertise with community engagement to a wide audience. We're very happy to welcome you to the show today. Thanks for coming. 

Dr. Raj Sundar: Thanks for having me. 

Michael: We always start by asking our guests to tell us more about their background, and we're always interested to know what drew them to medicine in the first place.

Dr. Sundar: My story is in a way straightforward because doctoring was a family trade in my family. I actually grew up in South India, close to Chennai, and I left there when I was about eight or nine and came to the US. But I'll say my uncle's a doctor, my cousin's a doctor, my dad's a doctor, my mom's a doctor. 

Michael: Oh my gosh. 

Dr. Sundar: So, when I was growing up, the question was, “What kind of doctor did you

want to be?” not “What do you want to be when you grow up?” That led me to choosing doctoring as a profession and I ultimately chose to do primary care as a family medicine doctor. That's the straightforward story. The complicated part of that story is when you grow up that way, and it doesn't seem like you had a choice, what do you do in the profession that has a high rate of burnout in a profession that makes it difficult to sometimes find purpose? I had to do that self-work and understand what am I specifically providing to the community, to healthcare, and to my patients, not just do it because my family does it, and it seems like a sustainable career. 

Michael: But it also sounds like just providing clinical care was probably not quite enough. 

Dr. Sundar: Yeah, yeah, you're right. You caught on quickly.

Michael: Which is true of a lot of physicians. A lot of them have other dimensions to their life and theirinterests and the kind of impact they want to make. 

Dr. Sundar: Exactly. My dad is a full-time physician in rural North Carolina and sees patients all day long. And I don't know if it's a generational thing, but that is not the essence of what I wanted to do because there was meaning for me in providing care to patients directly in one-on-one consultations. But when you're working in a system that continually falls short every day, you want to also be part of systems change, advocate for things to be better, whether in your own institution or at a bigger country level. You want to be part of that change to feel like you're making a difference, and I really needed that. So, I have some leadership positions in my organization, and then I started this podcast as part of my story on finding that meaning for myself in this profession. 

Michael: Yeah, and I can't wait to get into all of that. But I do want to also ask you about full-spectrum family physician...that's what I called you. What does that mean exactly? And tell us about your patients.

Dr. Sundar: People define that in many ways, and in some ways it seems like it's a lost part of medicine, the idea that one person can do it all when there are so many specialties with so much knowledge generation occurring. Now that, with artificial intelligence, we can go down that rabbit hole, it's like, how can one person keep up with everything? 

But the idea of full spectrum is that I do care for people from the day they were born to my oldest patient is ninety something. 

Michael: Wow. 

Dr. Sundar: So, I take care of people through all phases of their life. I also do prenatal care, and I deliver babies as well. There's something called the conundrum of family medicine or primary care when you do all of this, because any given part of my life may be outsourced to a specialist. I do knee injections. I'm sure the orthopedics who does thousands of injections probably is better than me at it -- and that's probably true for OB care -- but there's a special part of medicine and caring for people through relationships and families that adds value in ways that no one else can. My favorite experiences are when I deliver a baby, and I also take care of the mom and the baby, but also take care of her parents. So, there are a lot of things unsaid in that dynamic because I already know, I learned it from one interaction, and that's informed a lot of how I interact with the whole family. I understand their worries better. I understand their values and beliefs, and that actually informs a lot of the care that I provide. 

So, in the technical part of my profession, maybe other people do it better. But when I holistically approach a patient, I feel like I can provide them with care that they can't get anywhere else because I know them in that way. 

Michael: So, the other term I threw out there at the beginning was cultural competence, which I think generally people have an idea of, but if you wanted to flesh that out some, and where you think we're falling short in medicine on that count...in creating culturally responsive care, which is the ideal. 

Dr. Sundar: At this point, I like to ask people who I'm talking to of what they think cultural competent care is because it helps me understand people's differing understanding of it. So, when you hear the word cultural competent -- you just said it, people are aware of it, and they've heard about it before -- what does it mean to you?

Michael: I think ideally it would mean anyone coming into a medical setting would not feel uncomfortable in any way or feel like they needed to explain themselves or feel any awkwardness or worry that something was going to be misunderstood because of their cultural background.

Dr. Sundar: Yeah, that's great. It's less academic and so real in that I think that's what people want to hear. But when we think about culturally competent care as a field, at least the evolution of it, that hasn't always been the intended outcome or how it's been operationalized. Because I remember, at least in my medical school, in the few modules on culturally competent care, I learned about listening to our communities. I learned maybe that some communities value families more than American cultures. Some are more independent and that was about it. That led me to now feeling like I'm not actually providing great care to my patients, because I spent a lot of my time in medical school understanding the body, the organs, how it fails, how to repair it, how to recover somebody from illness, but never the human part of how to care for people other than electives or some modules. 

So, when we talk about culturally competent care, it falls short primarily in that we've reduced it to components of what it means to care for people, but it doesn't seem holistic enough to achieve the intended outcome that you were talking about...that when somebody shows up, they feel known, seen, and heard. They feel like they can communicate with you and trust you. 

In culturally competent care, the three things that I often bring up are a manifestation of its shortcomings is one, it's stereotypical, or it can be. All cultural work can be that way. Some people may look at me and say, I'm Indian, and I love eating curry. So, they talk to me about diabetes. Let's say I had a high A1C, which is a marker for diabetes, and they want to talk to me about rice. I'm like, well, I don't eat rice. Why do you just assume I eat rice? All cultural work can be that way. But cultural competent training can make it even worse because we have a two-dimensional idea of what cultures are, and then we impose it on people. 

The second problem is it can sometimes feel like “othering.” I don't know if you've heard that term before. It's that I'm normal, and you all are different than me and a little exotic. I'm going to go study you, understand what your culture is, so that when I provide my medications, I can give it in a way that makes sense to you. So, there's this distancing that happens. 

And then lastly, it feels like a checklist. “Hey, I finished that module. I got that CME. I'm pretty good at taking care of all Asian communities” and that is the ultimate, I feel like, learning that some people come out of cultural competent work, which isn't the intent. 

Michael: So, what's the way around particularly that second point about the otherness and the distancing? How would you do the training to avoid that? 

Dr. Sundar: The field itself has evolved. It's moved from saying just cultural competent, and we can get caught up in the jargon, but I want to just focus on the reason why it was changed to cultural humility and people probably have heard of that too. Cultural humility is more about myself, are you reflecting on your own values, beliefs, and your background, and what you're bringing to the table? 

So, as an Indian American, I bring certain values to the table. I'm very open and clear about what my assumptions are when I'm challenging them and taking care of a patient. There is newer terminology, but a specific terminology that I really like is “cultural safety.” It was created by the Māori population in New Zealand, specifically with the indigenous population everywhere in mind, including the US and Canada. They've often disproportionately suffered, historically, and structurally they are marginalized. The care they receive often is suboptimal and not the way they want to get it. Cultural safety brings in the lens of power: who has the power in this relationship and what was the historical power within our communities? 

Now I'm getting lost in my own jargon when I talk about this. I like to use a specific example that I find that resonates with a lot of people. I use this as a starting point because people get it. I talk about Native Hawaiian individuals. There's a lot of Native Hawaiians that had moved to the West Coast. You may or may not interact with this specific population, but I want to talk about this community to make some of those points clear. 

A lot of clinicians are well-intentioned and they want to connect with the patients in front of them. The thing with Native Hawaiians is that often people bring up having a vacation in Hawaii. And yes, you can bring that up -- and you're trying to connect with the person in front of you with something you are familiar with, with the land that you know -- but if you understood the history and the structural components of how the community is experiencing life, you would realize how wrong that is. 

I say that because in episode three of the Healthcare for Humans podcast, Dr. Maile Taualii was talking about caring for Native Hawaiians, and she said, “This is so frustrating because people always bring up having a vacation in Hawaii, but do they know that I got kicked out of my land essentially because of tourism? I can't afford to live there, and then now I'm here and I can't even visit my family. Then I come in at place of vulnerability, I need your help, and the first thing you tell me is how you went to vacation in Hawaii. Now I have to trust you, think that you actually understand me, and then come back to you for care.” And that was all from a small comment, but it links all these different ideas together. 

You need to know Native Hawaiians and their culture, but you also need to know the history of land displacement and colonialism, and the current structural forces, which is, I can't afford to go visit my homeland or my family. The small interactions with clinicians we think are small, but they add up to this mistrust and distrust we talk a lot about, of why certain communities don't like or trust healthcare systems. 

Michael: What's your advice to physicians? If you're going to be seeing, let's say, a pretty broad spectrum of cultures, what's sort of “step A” to practice that cultural humility, cultural safety philosophy? 

Dr. Sundar: Yeah. I haven't figured out the one specific way yet. I'll tell you how I've approached it, which is that when I bring this point up, people then respond saying, “But how do I learn about all the cultures? There are so many cultures out there.” I'll speak about being Indian...there's South Indian, North Indian, there's an Indian from the city, Indian from the village. There's an Indian who's second generation whose parents are really Indian, but I'm kind of Indian. There are so many manifestations of culture. But my hope is that you probably interact with certain communities more than others and it's worth it to build relationship with that community outside of the clinic walls and understand what it means to care for them. 

Yes, I care for a lot of different communities, but it's not a million. I don't take care of everybody in the world. I know some people in international clinics may have to, but maybe they should actually dedicate their time to learning about the cultures like they do continuing medical education. If we can learn about the Krebs cycle for so long and all the changes in algorithms, I think we can learn about other people's culture. But it's usually more manageable for most people because it's actually a few communities that have moved into their neighborhood or their state because we know communities tend to go where they're already communities of them. 

So, the first step is being aware: what communities are you taking care of? The second step would be, what does it mean for you to learn about that community and not place the burden on them? Because sometimes people show up saying, “Okay, tell me about the history of your community.” I'm not saying they do that, but implicitly, like, I don't know anything about you. But if a patient has to go through every doctor and explain that, you can imagine why they get frustrated. 

Then third, just be patient because this work is messy as we talked about, and it sometimes doesn't have a black or white answer. It can shift it within the appointment itself. It can provide moments of joy, but also moments of conflict and we can talk a lot more about that too, if you want. But no, there's not an easy answer. It's not an algorithmic answer. 

Michael: You know, as I listen to you, I'm thinking about a physician that I worked with. I was at an academic medical center in Burlington, Vermont for a bunch of years doing communications and Burlington has a federally designated refugee resettlement program. This physician was sort of our point person interacting with that community and providing care for that community. A couple of things stuck out from my interactions with her. One is that she never wore a white coat and nobody on her staff ever wore a white coat dealing with a patient because she really wanted to neutralize that power dynamic. She also said that it's so important for providers to learn as they're trying to become familiar with another culture, how that culture defines health, because it can be very, very different from how Western medicine defines health. I'm wondering what you think about those approaches?

Dr. Sundar: I think that's true. That was well said. That's one big component of meeting people where they're at, and that combats the idea of the othering that we talked about, because you're actually getting the definition of health from the community or patient you're taking care of, and also giving them the opportunity to define what this relationship could look like. So, I'm not studying them, but they're telling me from their perspective what it looks like to care for them, and health does mean a lot of different things for people. 

Right now, in the US, there's a whole wellness industry about drinking green smoothies and wearing yoga pants and that is the epitome of quote-unquote health, right? That's not necessarily true from a Western healthcare perspective, but there is a culture around wellness that defines it that way. From a Western perspective, it's often all your lab values are okay and that's actually the thing that we anchor onto, because...hypertension is a good example. If it's high blood pressure, we want to treat it, but if a patient feels okay, we have a hard time communicating that. 

With a lot of cultures that I interact with, health means I feel okay and I can take care of my family. I can go to work and I'm not hurting. That's what health means to me. Not all my vitals are okay and my lab tests aren’t normal, and this is where we get into the conversation of how do we honor people's cultural values and beliefs, but also inform them of a different way of looking at health and way of life? But the first step is always meeting them where they're at, because if we challenge them from the beginning saying, “I know you feel well, but there's a lot of things wrong with you,” 

Michael: Yeah. 

Dr. Sundar: Again, I'm being facetious a little bit and a little blunt, but that's the message they receive. They go in for a checkup and they're saying, “I'm feeling okay. I just wanted to see the doctor” and they walk out with four new diagnoses. “I was feeling okay before I came in. Supposedly I'm dying. I didn't know.” So there's an art to bridging that gap.

Michael: Boy, you have a complicated job. That's for sure. You also are interested in getting healthcare systems to prioritize focusing on the dignity of the individual. Tell us about that. 

Dr. Sundar: I think a lot of people feel this. It comes out in a lot of the conversations that I have about what it means to feel like you're cared for in a healthcare system. Because sometimes our healthcare system feels so industrialized and corporate in doing all the right things. I'm part of it. I know I am going to give you a questionnaire to diagnose depression and anxiety for you. I have an algorithm. I keep bringing that up, but there’s one for hypertension. I give you these three meds. If you don't get better, I give another med, I refer to cardiology. So, there's all these steps we have, but we end up implementing it in a way that sometimes feels like the humanity of the person's lost because however our financial incentives are set up, it's often not set up to help people feel like we know them well and respect their values and beliefs. 

So, when I say we want to acknowledge people's dignity, we want to acknowledge that health is not the ultimate value for many people. Health is a path to something else. It could be family. It could be your legacy, like passing on generational wisdom to your kids. It could be finding purpose in life and doing the work that you wanted to do. It could be any number of things, but it's often not just health. My ultimate goal in life is not just to remain healthy, but our healthcare systems often feel that's the only goal, so we diminish the importance of all the other values, whether intentionally or unintentionally. It often doesn't matter because when you're a patient, it just feels like nobody cares. 

Michael: So, how do you make that a reality in big healthcare systems that, as you know, are kind of hard to move and change? They can be slow to react. How does that not just become a memo from the department chair and not actually end up happening in the visits? 

Dr. Sundar: Yeah. I talk to a lot of different people, so I want to be cognizant of audience members who have different levels of power. I think if you're a practicing clinician, which I am, when I'm doing that work, my singular goal is how do I create moments of connection so that patients feel like, ‘hey, this person cares about me.’ If you set that intention, it's possible to do. In culturally responsive care, any little thing matters. I think this is something people are taught a lot, which we don't do every time, but saying hello in other people's languages. We just think it's a good way to say hi and connect with people, but it means so much more. 

When I do that, people smile so much, and they're really forgiving when you say it wrong. I know you can do this wrongly, right? You're not trying to come off as making fun of somebody's language or do it intentionally wrong, but you have to understand people spend twenty-four hours a day, seven days a week, trying to fit into a new culture and changing how they speak, learning a new language. At every step of the way, they have to dismiss or diminish their own cultural identity. When somebody else does the work to learn their identity or language, it's a big deal and that one step matters.

Another example is -- I was thinking about this the other day, and I brought it up to somebody -- we all say Happy New Year to everybody until we don't know when to stop. They just keep saying it. I knew for the Ethiopian community, the calendar was different. It was actually their Christmas for a lot longer. I said, “Merry Christmas” and this patient I was interacting with was a little surprised because I'm sure everybody was saying happy New Year, and then I said, “Merry Christmas.” It's like a small nugget that I learned because I was learning something about Ethiopia at that time. Then he opened up and told me so much about what he was doing, which he probably didn't share with other people. 

What I sensed was that -- and I talked to not him specifically, somebody else in the community -- and I was like, “Wow, he really opened up, I was surprised.” They're like, “Yeah, for most people, it just feels like they don't care enough to learn about us, so why did we spend our time sharing it? It doesn't seem like you cared enough to know in the first place. Do you care enough if start talking about this? I don't know, but I don't want to take the effort.” 

I took the first step and said, oh, I'm interested in that part of your life and know something. I don't know everything. We already talked about those challenges. Then that gave them an opportunity to connect at that level. 

Your question of what can we do to change...I think as individuals, we can probably do a lot more than we're doing -- even in that space of burnout and being overwhelmed that we're in -- because I think these moments of connection can sustain us because connecting with other people sustains all of us. 

When you have more power organizationally, I would say, how do you make this work less jargony and more meaningful? I feel like any time we gain momentum towards a specific initiative like equity or anti-racism, people just keep saying those words over and over until nobody's actually clear on what we're talking about or what's actually changing. So, being really specific about the change and then making sure people who are affected most are driving that change, too. Sometimes that challenges our fundamental assumption of healthcare. 

I was talking to the Pacific Islander community, and they said, “Hey, Raj, this is great what you're doing, but really just give us the money and we will start our own clinic and take care of our people because we know what we're doing.” I'm like, “Yeah, that sounds great. I wish I could.” But now that I know, I can say when I'm at tables of power, “Listen, we know our Pacific Islander population have the worst quality outcomes. I wonder if we can give them some autonomy to design care in the way they want to.” I can speak that language and be that bridge and say, “How do we make that happen? Maybe their health outcomes will improve. Is it possible for us to do something like that?” So, I can become a better advocate in that way, too. 

Michael: Yeah. That's a great point. As we get toward the end here, I did want to give you a second to talk about the Healthcare for Humans podcast. I'm biased. I think podcasts are interesting, right? So, how did that get started and what kind of conversations are you trying to have on that show? 

Dr. Sundar: Well, it started because I really got into murder mystery podcasts. I know that's not what we're doing here. 

Michael: It is the number one category. True crime. 

Dr. Sundar: Yeah. Exactly. We're always competing against true crime, aren't we? But you probably know about Serial, the Sarah Koenig podcast. If people don't know, it was a big series hosted by Sarah Koenig and one season that I'm talking about was with Adnan Syed and the whole idea was going over a case that Adnan Syed was accused of murder, but there was a lot of uncertainties about it. What I really loved about that series is one, it gave voice to the person most affected. It wasn't just the journalist reviewing some articles and speaking for it. And then, Adnan, they actually gave him the mic and he was able to speak for himself. 

Second, the podcast could go into the nuance and uncertainties of the case when things were contradictory. We don't know if it was true or not. We just knew people were saying different things. But voice and conversation can make space for that in ways that sometimes the written article or words can't. And then three, it went into the depth of the uncertainty. You could spend forty minutes talking about one specific incident of the day. 

I realized listening to Serial, that culture fits into this category. It would be nice to give voice to the community to prevent that sense of othering. It would be nice to explore the contradictions because culture is contradictory. People say different things and it's always changing depending on where you are and I could really go deep into certain things that I felt like wasn't doing justice for the community and it helped me do all that. It started as a hobby and then I just kept going because it felt, as I said, meaningful for me. 

Michael: How have you found the experience? I mean, obviously it's a positive one. You're going to keep it going? 

Dr. Sundar: Yeah. Yeah. It's positive and only podcasters know how hard podcasting is and the work behind it. 

Michael: Amen. Yeah. 

Dr. Sundar: The goal is to make it sound like a natural conversation, but you have to do a lot of work to make it a natural conversation. So, it is a lot of work at this time, but it fills my cup to do the other work and I think I shared with you earlier, I'm doing an episode every two weeks and always learning something new and shifting my perspective in ways that are better for me as a clinician, and for my listeners. I mean, I get positive feedback from a lot of the clinicians that are listening, so it feels like I'm making change in the community, too. In that way, I think -- even though I spend a lot of energy and time doing it -- it's a net positive for now, so I'm going to keep going. 

Michael: Well, everybody's learning. You're learning and so is the audience, and that's great. As we wrap up here, we always like to give our guests a chance to provide advice to our audience -- which is mostly learners, med students, nursing students, allied health profession students -- about approaching a career in healthcare particularly at this time when things are really pretty tumultuous, and we've been through some unprecedented waters. So, what's your go-to advice? 

Dr. Sundar: My advice is that change is here to stay. There's so much uncertainty for every healthcare system and we're beholden to the capitalistic structures, if I can say that, of our country. And it's hard. But I want to end on a note of hope that I actually like my job, believe it or not. I like taking care of my patients and I like the work I'm doing to further how healthcare is providing care for culturally diverse communities, because I feel like I'm making a difference. I think everybody brings something unique to going through medical school and residency. Sometimes there's just not time for it, but there are opportunities after you go through those phases to cultivate it again. And you heard some snippets of my podcast today, but take a listen to it and see if that helps you think of other topics, especially if you are coming from a culturally diverse community. I want to know what it is that you're experiencing, because I want to make healthcare better for everybody, too. 

Michael: Well, that's a great message and as a reminder, folks, it's the Healthcare for Humans podcast and we've been speaking to the host, Dr. Raj Sundar. I want to thank you so much for being with us today. It's been a fascinating conversation. 

Dr. Sundar: Yeah, thanks for having me. 

Michael: I'm Michael Carrese. Thanks for checking out today's show and remember, as always, to do your part to raise the line and strengthen the healthcare system. We're all in this together.