Extract
The privilege of caring for patients from unfamiliar backgrounds often presents a dilemma for the treating physician and the health-care team. Each unique group of people values its beliefs and ideals, and these convictions often blend with native knowledge and practices to collectively reflect expectations of appropriate, culturally competent health care. These medical practices can echo religious, cultural, or environmental factors and may reflect a combination of all of these influences. The administration of appropriate care in the context of a culturally and religiously diverse society is dependent on a physician's knowledge of the basic principles of his or her patients’ practices and preferences. Misinterpretation, uninformed assumptions, or stereotypical behavior may lead to anger and misunderstanding and can create obstacles to the administration of ethical, informed, and professional health care.
The privilege of caring for patients from unfamiliar backgrounds often presents a dilemma for the treating physician and the health-care team. Each unique group of people values its beliefs and ideals, and these convictions often blend with native knowledge and practices to collectively reflect expectations of appropriate, culturally competent health care. These medical practices can echo religious, cultural, or environmental factors and may reflect a combination of all of these influences. The administration of appropriate care in the context of a culturally and religiously diverse society is dependent on a physician's knowledge of the basic principles of his or her patients’ practices and preferences. Misinterpretation, uninformed assumptions, or stereotypical behavior may lead to anger and misunderstanding and can create obstacles to the administration of ethical, informed, and professional health care.
The American Academy of Orthopaedic Surgeons (AAOS) has established a Diversity Committee to construct learning goals and educational tools to evaluate and teach cultural understanding and communication skills in residency programs1. Although the establishment of this curriculum is a key step in raising awareness of the importance of providing culturally competent care, there remains a lack of accurate and informative resource tools to which interested orthopaedic surgeons can refer. Orthopaedic surgeons must be able to provide patient care within the context of our evolving society.
The purpose of this paper is to review how cultural and religious considerations apply to the Muslim orthopaedic patient. Although a great amount of attention and awareness has been placed on Islam over the past ten years, there are many cultural stereotypes and misconceptions that may compromise the administration of appropriate care to this population. Understanding the fundamentals of their beliefs and maintaining empathy to their principles of practice will help orthopaedic surgeons to provide high-quality and culturally sensitive care to their Muslim patients.
Muslims are individuals who practice the religion of Islam. There are over 1.3 billion Muslims in the world today, translating to roughly one-fifth of the human race2-4. Within Islam, there is great geographic diversity among its followers, most of whom arise from Asian and African descent. Only approximately 18% of all Muslims are Arab3. Islam is one of the most rapidly growing religions in the world and is the fastest growing religion in North America5. Approximately seven to eight million Muslims reside in the United States today6. With these rising numbers, orthopaedic surgeons will no doubt see and continue to take care of more and more followers of the Muslim faith in their practices.
In order to best take care of Muslim patients, orthopaedic surgeons should have a basic appreciation of essential Islamic convictions. The foundation of Islam is based on the principle that there is only one God (Allah), and the Prophet Muhammed (may peace be upon Him [MPBUH]) is His Messenger. The word Islam means surrender and peace, and Muslims are followers who humbly and completely submit to the will of God. The Quran is Islam's Holy Book of scripture, and its content, along with the established teachings of the Prophet Muhammed (MPBUH), provides a blueprint for the manner in which Muslims conduct their daily lives. Muslims establish the foundation of their faith on five basic pillars of practice: the declaration of the belief in one God and his Prophet Muhammed (MPBUH), the recitation of five daily prayers, the distribution of charity to the poor, the observance of fasting and sacrifice during the Holy Month of Ramadan, and the pilgrimage to the Holy City of Mecca during a Muslim's lifetime if one is able to do so on the basis of health and finances (Table I)3,4. Although the customs may seem unfamiliar, basic beliefs in Islam are strongly related to Judeo-Christian practices. Muslims trace their origin to the same lineage as Judaism and Christianity, and many figures, including Adam, Noah, Abraham, Moses, David, Joseph, Jesus, and Mary, are not only respected but revered5,6. Their beliefs are deeply rooted in the traditions of an obligation to do good and the rejection of evil5. With the exception of isolated individuals, the vast majority of Muslims in the United States are loving fathers, mothers, sons, and daughters who value education, respect their neighbors and laws of governance, and treasure the freedom of the American society in which they reside.
When considering how to address a Muslim orthopaedic patient in the clinical context, physicians must realize that, within the religion of Islam, there is a high degree of heterogeneity. Religious practice and observance can vary on the basis of geography, culture, age, and sex just as in other religions. Although their essential beliefs are the same, individuals may display them differently. Many cultural practices can be hard to differentiate from religion but must nonetheless be respected. Additionally, in Islam, religion and society are viewed as being one and the same, and elements of belief are strongly interwoven in a Muslim's daily life. As previously mentioned, Islam dictates how its followers act, and these specific recommendations permeate all facets of life including states of health and sickness. Understanding this all-encompassing nature of belief can help orthopaedic surgeons to construct relevant plans of care and provide effective treatment for their patients.
One major factor that must be considered in the care of Muslim patients is the importance of family. The family is the basic structural element and foundation of a stable Islamic society4,5. The fundamental roles of education, spiritual growth, and dissemination of traditions and practices are shared within the context of a stable family. This unit provides both security and support for its members and often includes relatives and even close members of their Muslim community5. Elders are treated with kindness and respect, and children are loved and cherished.
One specific consideration when treating Muslim orthopaedic patients includes caring for children and parents. Even in the context of a hospitalization, parents often assume direct responsibility for the care of their children. This sense of commitment is often independent of age and may also stretch to extended family. It is not uncommon for elderly parents to care for their sick adult children, or for distant relatives to assume care of their ill nieces and nephews. Additionally, one or both parents often request to remain with the child at all times. Likewise, adult children are also obliged to care for their infirm parents, and this responsibility frequently is shared by both in-laws and grandchildren. Accommodations such as the provision of additional bedding and meals or allowing relatives to remain with their family member after visiting hours would allow parents or children to fulfill their sense of family obligation. Additionally, permitting a parent or family member to be present for simple procedures or to accompany his or her loved one to tests and surgeries may also be of benefit. For example, permitting a parent to accompany his or her child in the preoperative area to the farthest point that is safely allowed or be present for procedures such as closed reductions and casting allows the family to closely participate in the child's care. During these events, relatives often busily recite prayers or read verses from the Quran, appealing for the safe and expedient care of their loved ones. These prayers can be viewed as being as important as the procedures, and family must not be denied this freedom. Recognizing these issues and validating their importance is a key step in caring for Muslim families.
Additionally, visiting family and friends in the hospital is extremely important in Islam. Muslims are required to visit those who are sick or injured and provide patients and their families with comfort and support. The teachings of Islam dictate that Muslims not only meet with those who are ill but also converse with them, provide words of encouragement, and pray for their well-being and prompt recovery5,7. This important obligation is vital to the care of Muslim patients, and measures should be taken to accommodate these visitations. However, it is important to recognize that these events may provide additional stress to the nursing staff or adjacent patients sharing semiprivate rooms. In a recent survey of an intensive-care-unit nursing staff caring for Muslim patients in Saudi Arabia, families and friends were viewed as providing additional demands and distractions to the nursing staff7. One possible way to address this issue is to have a specific time when community members can visit the sick. At that time, all communication of health-related issues could be addressed through a family liaison. Also, anticipating this visitation and placing the patient in a private room may avoid disturbing other patients and their families. Appreciating this important Muslim duty and acknowledging the demands that it may place on the health-care team are vital to caring for both the patient and his or her loved ones.
Prayer is an important part of Islam and is a vital ritual that links the identities of Muslims all over the world. Performing daily prayers is one of the fundamental pillars of Islam and is a duty for Muslims3,5,7. Five times a day, which roughly correlate with early morning, afternoon, evening, sunset, and night, Muslims perform a cleansing of their body called wuduh in preparation for prayer8. They then direct their attention to the Holy City of Mecca and participate in a ritual, which includes recitation of Quranic verses coupled with prostration. After the completion of each prayer, Muslims ask God for forgiveness, thank Him for the bounties they receive, and request assistance in their everyday lives, including desires for health and well-being. These five daily prayers help Muslims to focus their faith and refine their relationship with God. It is important to note that for prayer, Islam has made provisions for the sick. If individuals are unable to physically assume a praying position, they may lie in bed, sit in a seated position8, or use furniture as support to assist them in prayer. However, despite these allowances, the majority of practicing Muslims aspire to participate in physical prayer as fully as they can.
As previously mentioned, the principles of Islam permeate all facets of life, and prayer is considered an obligation even if one is hospitalized. Postoperatively, Muslim patients may want to participate in these prayers, and it is important to direct the health-care team to provide the support necessary to allow them to do so. One key consideration is assisting patients in performing wuduh. Impurities such as stool, urine, or blood must be cleaned off a Muslim's body, and it is important to direct nursing staff to assist in this washing for patients who cannot do so independently5,8. Also, assisting patients by placing them in a position to face Mecca for their prayers is helpful7. During these prayers, physicians, nursing staff, and other hospital personnel should provide the patient with privacy. Whenever possible, rounds and clinical duties should be scheduled to provide a quiet and peaceful environment8. Awkward interactions or uncomfortable interruptions of prayer may be avoided by directing the patient to indicate when he or she is praying. For instance, shutting the lights off in the room or posting a sign may be a good signal to specify a state of prayer. Additionally, providing a portion of the room or a designated area in the hospital for patients and families to pray is important. A clean corner of the room or a portion of the hospital chapel may be a suitable place for Muslim prayer and meditation, even if objects reflecting other faiths are present5,8. Providing prayer rugs or copies of the Quran can assist Muslims in fulfilling their religious duties comfortably in the environment of the hospital.
Additionally, preoperative counseling before an orthopaedic intervention should educate Muslim patients about the impact of their injuries or treatments on prayer. A chief consideration is the orientation of one's body during worship. Prayer involves multiple changes in position including standing, bending, kneeling, and rising from a genuflected position. The kneeling position necessitates a high degree of flexibility, and the lower extremities are often placed in >140° of knee flexion for several minutes (Fig. 1). This posture can place a substantial amount of stress on the patellofemoral articulation, and multiple concerns should be considered prior to treating or operating on Muslims who wish to continue with physical prayer. The stress of kneeling may lead to an exacerbation of anterior knee pain and subsequent patient dissatisfaction. Thus, for patients who participate in these activities for vocation or recreation, the appropriateness of the use of a patellar bone-tendon-bone autograft for knee ligament reconstruction should be carefully considered9. Additionally, diagnosing and alleviating patellofemoral symptoms in active Muslims may be difficult to do if the practice of prayer is not considered. Recognizing that this behavior and positioning are potential factors for knee pain may provide the patient with a greater insight into the source of his or her condition.
When knee or hip arthroplasty is discussed, it is important to consider prayer positioning in patient education, surgical approaches, and postoperative outcomes. Muslims must be made aware of the potential for limitations in range of motion that may affect their ability to perform prayer in their customary way10. These considerations may influence the type of surgery or prosthesis that one may choose for Muslim patients11. In a scientific exhibit at a recent AAOS meeting, a group from Dubai, United Arab Emirates, presented a specific surgical technique and protocol for a total knee replacement that allowed 62% of their patients to obtain full knee flexion, which was defined as >140° of flexion and thigh-to-calf opposition for at least one minute12. Additionally, they noted no increase in component loosening or damage resulting from full flexion13. These strategies may be valuable in treating osteoarthritis in Muslims who desire a greater range of motion for prayer. Also, instructions given to orthopaedic patients undergoing spine surgery or hip replacement about taking precautions to avoid compromising forward flexion or bending activities that may occur during prayer must be aggressively and repeatedly reinforced. In all of these cases, patient expectations must be balanced with anticipated realistic orthopaedic outcomes through detailed patient education and preoperative counseling. Having a thorough discussion about how a surgical or therapeutic intervention may influence a Muslim's practice of prayer will lead to better satisfaction for both the patient and the surgeon.
Modesty is extremely important to both men and women in Islam, and Muslims are often uncomfortable with unnecessary physical exposure. Dress is influenced by culture, sex, and age and can vary on the basis of the degree of faith and practice. However, regardless of country of origin, modest dress is valued, and unnecessary physical contact between members of the opposite sex is discouraged5,7. Women often wear a head scarf called a hijab, and some, on the basis of cultural but not religious mandate, may elect to cover their faces, hands, and feet.
There are many issues to consider when examining and treating a Muslim woman in the orthopaedic clinical or hospital setting. As previously mentioned, Muslim women often choose to cover their hair with a scarf called a hijab, and it is essential that physicians respect this decision and allow them to do so whenever possible. For example, even when going to the operating room for surgery, it is preferable to allow each woman to wear her hijab in addition to the hospital gown. If this is not permitted, utilizing a surgical head and neck covering can allow a woman to maintain her sense of comfort and dignity without compromising hospital and operating-room policy (Fig. 2). When a patient is alone or in the company of immediate family or other women, she may elect to remove her head scarf. When entering a hospital room, it is important for all male staff and visitors to knock and allow the patient adequate time to reapply her hijab when necessary. Placing a sign on the door requesting all men to knock before entering the room may avoid uncomfortable interruptions or embarrassing situations for the patient8.
Avoiding unnecessary exposure is an important priority. In the clinic, asking a Muslim woman to undress and apply examination shorts or a robe may place her in an uncomfortable position. Measures should be taken to recognize and balance her sense of modesty with a thorough and proper standard examination of the extremity or back. One way to do so is to encourage Muslim women to wear baggy or loose fitting clothing that can be dynamically positioned and stretched to allow adequate exposure for examination while maintaining as much coverage as possible. Also, offering individuals the option to double gown in the clinic or the hospital to provide maximum coverage can help to alleviate patient anxieties. Lastly, although a patient may be unconscious, covering the genital area intraoperatively with a surgical towel during skin preparation is also encouraged and conveys an additional element of trust between the patient and the orthopaedist.
Physical contact between members of the opposite sex is discouraged, and women may feel uncomfortable having a male orthopaedist examine them. If possible, it is preferable for female patients to be examined by female doctors or cared for by female nurses in the hospital setting5. However, if this is not feasible, then having a female chaperone available for examinations may help a Muslim woman to feel more at ease. Communicating to a Muslim patient that you recognize and understand her concerns about modesty is invaluable in developing the physician-patient relationship.
Another important issue when dealing with Muslim orthopaedic patients is physical contact or touch. Although citizens in certain Muslim societies use physical contact as a gesture of greeting among members of the same sex, unnecessary contact between men and women is often not approved. For example, Arab Muslim men often kiss each other on the cheek to communicate greeting, but public displays of affection between men and women are discouraged. Likewise, physical interactions in the clinic or hospital between staff and their Muslim patients may prove to be uncomfortable. For example, some Muslim women choose not to shake hands with unrelated males, even in the context of business and health4,8. This abstinence is not a sign of disrespect or disapproval but is simply an expression of a Muslim woman's display of discreet reserve. One way to deal with this issue in the clinic is to simply ask a Muslim woman how she would like to be greeted much as a physician would ask a patient how he or she wishes to be addressed. This introduction can avoid potential embarrassment for the patient and misunderstanding by the doctor. It has also been noted that, when caring for Muslim patients, health-care staff have identified descriptions of "instrumental touch" or task-oriented physical contact7. These interactions focus on the goal of objectively caring for the patient and avoiding unnecessary contact between members of the opposite sex. Thus, comforting gestures or reassuring touch may not have the intended consoling effect anticipated by thoughtful and caring physicians or nurses. Understanding the boundaries of physical contact between Muslims can help physicians to provide appropriate individualized care.
One of the most important roles for a physician is facilitating communication. The effective transfer of information from the doctor to the patient for his or her full understanding is vital to the success of a healthy physician-patient relationship. Many barriers to information exchange can arise when Muslim patients are treated in the clinic or hospital. One obstacle may involve language. Depending on their country of origin or duration of residence in the United States, Muslims may not be fluent in the English language. If this is the case, it is crucial to have an interpreter available to fully translate the conversation and explain any questions or concerns that the patient may have. In certain institutions, translators for languages such as Arabic, Urdu, Punjabi, or Hindi may not be readily available and employing telephone interpretation services or utilizing family participation may be the best options. Even with full fluency in English, patients may find musculoskeletal terminology to be difficult to understand. Regardless of the means, overcoming language barriers is mandatory for effective communication.
Orthopaedic surgeons must also ensure that each patient is able to make informed decisions with regard to his or her musculoskeletal health. Although a patient may choose to heed the influence of family and friends, the ultimate decision to participate in treatment or surgery must be made by the patient. When the orthopaedic surgeon meets and examines a patient in the context of his or her family or friends, the conversation must focus on the needs of the patient and the patient's priorities, which may include immediate return to child-care activities or to serving as the primary earner for the family. External influences must be carefully dissected and analyzed. The role of the family should be affirmed and respected, but this recognition must be balanced with the priority of patient autonomy. It is not uncommon for a spouse or elderly parent to direct the conversation or speak on behalf of the patient. In this situation, an orthopaedic surgeon must be able to identify possible external pressures and utilize mechanisms to overcome them. Situations involving informed consent and the full communication of the risks and benefits of surgery must be understood by the patient. It is not acceptable to have a surrogate provide consent for a capable and thoughtful adult patient unless the patient chooses to allow it. It may be useful to ask to speak to the patient in private (or with a chaperone from the health-care team when appropriate), to provide the patient with an office e-mail address, or to supply contact information of patients who have had a similar procedure and are willing to discuss their experience. These measures can provide a great deal of information about individual opinions and expected outcomes. Regardless of methods, orthopaedic surgeons must ensure that each patient is informed about treatments and how they will affect his or her life.
Muslims believe that dietary restrictions and allowances encourage healthy living5. Certain foods and drinks, such as pork products and alcoholic beverages, are prohibited. Additionally, many Muslims only eat meat products from animals that have been slaughtered according to Islamic law8. Regardless of culture or country of origin, healthy eating is a religious duty. In the context of an inpatient hospitalization, it is essential that orthopaedic surgeons notify dietary services of restrictions that may apply to Muslim patients. Vegetarian meals and kosher meat are acceptable substitutions in prepared entrees. Additionally, encouraging patients to bring healthy foods from home or from ethnic restaurants may also be suitable options. If an orthopaedic surgeon is not confident that a patient can receive adequate nutrition within the context of his or her dietary restrictions in the hospital, consulting nutrition services may be a welcome alternative5.
In accordance with their dietary regulations, many Muslims abstain from utilizing products or devices derived from restricted substances. For example, alcohol-based medications, porcine devices, or bovine items not prepared in accord with the rules of Islam cannot be used unless there is no alternative and the adverse outcome would lead to great harm4,8,14. In this context, orthopaedic xenograft supplements used for reconstruction, avian hyaluronic acid derivatives, animal thrombin gel, or porcine insulin and erythropoietin may not be welcome options for Muslims. However, this choice should be individualized to each Muslim, and his or her own spectrum of practice dictates these specifications. Nonetheless, when options arise for the use of such products, it is important to have an extensive discussion with the patient about their use and how they may affect his or her religious standards. Placing an animal derivative in an unknowing Muslim patient may not only adversely affect the individual's religious identity but may greatly compromise the trust and relationship that an orthopaedic surgeon has with the person to whom he or she is providing care14.
In conclusion, with the growth of Islam in the United States, orthopaedic surgeons will no doubt see increasing numbers of Muslims in their clinics and hospitals. Not all Muslims are the same, and it is important to recognize that, although the fundamental teachings of Islam are uniform, there is a high degree of diversity among its followers. It is a mistake to simply make assumptions of a Muslim's practice or knowledge of Islam on the basis of his or her appearance or initial actions. Just as in other religions, many Muslims are strict adherents to the teachings of Islam, while others are more flexible with their beliefs and practices. One way to differentiate among such individuals is to incorporate a section in the social history during the encounter to gain such important information. However, if there is ever any doubt as to what a patient prefers in the context of his or her culture and religion, the orthopaedic surgeon should simply ask. It is far better to ask sincere, straightforward questions instead of ignoring uncertainties and making inaccurate or ignorant assumptions. Most Muslims in the United States are accustomed to discussing and defending their beliefs and practices and often welcome the opportunity to share them with others.
Orthopaedic surgeons should not hesitate to utilize leaders in the local Muslim community for advice on uncertain issues or religious concerns. Most communities have established mosques, and encouraging hospital chaplains to maintain good relationships with local religious leaders, called imams, can help to open channels of dialogue in the community8. If these local resources are not available, utilizing reliable Internet sources or contacting national organizations for advice can also be done (Table II)4. Regardless of the problems, there are many constructive and welcoming resources that can serve to address them.
It is important to have a high degree of patience and flexibility when treating Muslim patients. Although providing informed and culturally competent care may necessitate extra effort and attention, it offers an unparalleled sense of satisfaction and brings honor to both the surgeon and the patient.
Note: The authors acknowledge Dr. Zulfiqar Ali Shah, Dr. Farooq Selod, Dr. Tariq Cheema, and Dr. Shahid Athar for their acquisition of information, professional expertise, or miscellaneous contributions to the development of this manuscript.
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