My journey toward multiculturalism in paediatric practice

By Dr. Alice M. Chan-Yip C.M. MDCM, FRCPC, FAAP, DSc (HC)

When I was invited to reflect on my career to help celebrate the Canadian Paediatric Society’s centennial year, I found it hard to do without acknowledging past mentors. They influenced my journey as a paediatrician and promoter of multicultural, integrative psychosocial paediatrics in an era before cultural influence on medical practice was clearly recognized or acknowledged.

As a young medical student at McGill, I was conscious of racial profiling, which could be a subtle but persistent factor among faculty at that time. Racial profiling between mentor and mentee often changed the dynamics of acceptance of teaching topics in research seminars and lectures, for example. One renowned teacher at Montreal Children’s Hospital, Dr. Alan Ross, made a difference, however. His kindness to me as a medical student and junior assistant resident fostered my confidence to pursue postgraduate training in paediatrics, despite my experience of racism from some other staff. After completing my paediatric residency, a combination of sound advice from Dr. Laurie Chute, a professor and Paediatric Chair at SickKids and U of T, and ongoing cultural factors led me to undertake clinical research work outside the tertiary care setting.

My two-year clinical research fellowship, supervised by Dr. Donald Fraser, was in a very specialized field of metabolism. The focus was on metabolic bone diseases and calcium metabolism in a time before commercial dairy products were fortified with vitamin D, when vitamin D deficiency (VitDD) rickets was still a prevalent condition in Canada. A high point was when Dr. Fraser put me as the first author of a paper titled “Hypothyroidism in cystinosis” ^[1]. This invaluable training fostered my growing interest in community research.

1968 marked the beginning of a period of political instability in Quebec, but I nevertheless decided to return to Montreal with my husband, Dr. Gar Lam Yip, who had been appointed as professor of computer science and engineering at McGill University. I spent a year learning laboratory techniques in steroid metabolism under the supervision of Dr. Jacques Ducharme, the Chair of Paediatrics and director of the endocrinology laboratory at L’Hôpital Ste-Justine. I observed that his lab activities focused primarily on the clinical evaluation of patients, and realized my interest was not in laboratory research. However, it was a good milieu for me to improve my French conversational and reading skills and facilitated my obtaining a license to practice medicine in Quebec. 

Through the ‘grapevine’ linking Montreal paediatricians, I was introduced to Dr. Brock Dundas, who was planning to relocate to Calgary. He offered me the opportunity to take over his well-established community practice and introduced me to colleagues sharing weekend coverage for paediatric care. His advice to me was simple, yet empowering, and his “Three A’s for being a good paediatrician: Be Affable, Available and Able”, set the tone for my community practice.

In the same period, Dr. David Lin, a surgeon at McGill, invited me to develop an ambulatory half-day paediatric clinic at the Montreal Chinese Hospital, a long-term care institution established by the Chinese community in 1961 under his leadership. Working independently in this clinic alerted me to the suboptimal health of Asian and ethnic minority patients I was seeing, and led me to research the cultural influences associated with health practices and disease prevalence in these groups. Being on the board of directors helped me learn about the influence of institutional health policy on community health services delivery. By comparing Chinese patient-families attending my clinic with more mainstream Canadian families in my private office, I was able to identify and minimize significant discrepancies in health status between these communities.

My husband and I were actively involved in academics and the social life of McGill University and Chinese community settings. We engaged in advocacy and participated in fundraising events. We both remained aware of ethnic profiling in various instances, but such experiences made us more active when volunteering or at work, as we strived to make a difference. By working within community organizations and interacting with diverse cultural groups and enthusiastic Canadians (both Francophone and Anglophone, many of whom volunteered for the Chinese community), I developed culture-specific health and social services for newly arrived Chinese immigrants and Asian refugees. My practice extended to second-generation families who still could not easily access culturally appropriate health care and psychosocial supports.

My community practice was further enriched by inspiring lectures and private consultations on patient care with a few avant-garde clinician-scientists at MCH. A few stories illustrate how these exemplary teachers helped me initiate clinical research within community practice:  

• In the 1970s, Dr. Ronald Denton, who founded the paediatric hematology/oncology department at MCH, sent me the lab report for one young Chinese patient with very low hemoglobin. With it was a microscopy photo showing marked hypochromia, microcytosis with a classic picture of severe iron deficiency anemia (IDA), and a comment regarding high racial prevalence rate. In conversation he mentioned that Chinese parents probably did not know where to buy baby food. My attempts to understand cultural infant feeding practice in Chinese families soon led me to request a 3-day infant feeding diary from caregivers at health visits between 9 and 18 months of age. This initiative subsequently became my routine practice, both for monitoring and prompting anticipatory guidance on how to prevent iron deficiency ^[2].
• In the late 1960s, the renowned geneticist Dr. Charles Scriver was engaged in persuading the Canadian dairy industry to fortify all commercial dairy products with vitamin D. He also advocated for population screening for genetic markers in his research seminars, which inspired me to combine screening for thalassemia minor and iron deficiency in young Chinese children, as both conditions are associated with microcytic and hypochromic anemia. I therefore embarked on a longitudinal survey of Chinese clientele in my clinical practice on IDA versus thalassemia carriers ^[2].
• Simultaneously, I had also observed low rates of breastfeeding ^[3] and other culturally influenced but less healthy nutrition practices in Chinese families. In response, I developed language- and culture-specific prenatal classes for them, and co-wrote and secured funding for a manual in Chinese: Family-Centered Child birth and Infant care ^[4]. The Montreal Chinese Hospital Foundation provided funding for its free distribution to health care providers.  
• When Dr. Barry Pless became the Director for Community, Developmental and Epidemiology Research at MCH, his teaching and advocacy for community research, and support from his team members, helped to guide statistical analysis of my clinical data for articles published in the CMAJ and Paediatrics & Child Health ^[2][5]. The ongoing problem of IDA prevalence in young, ethnic minority children prompted me to write “A letter to the Editor” for P&CH in 2013 ^[6]. I urged clinicians to screen routinely for nutritional risk by adopting my own 3-day dietary record method, which had helped me identify early risk for, and often prevent, IDA in patients over the years.

Years of experience have convinced me that timely screening and culturally appropriate counselling can often prevent early childhood caries from developing through excessive bottle use, encourage strategies for parents coping with excessive infant crying ^[3][5][6], and even help prevent VitDD and related symptoms, which are still so prevalent in some ethnic minority groups and Indigenous communities.

In 1989/90, I was invited to join a sub-committee of the Quebec Mental Health Department that included anthropologists, cultural psychiatrists, and psychologists to study specific issues and service needs experienced by minority ethno-cultural communities in Montreal. Some advocacy projects to improve mental health maintenance in children and adolescents of ethnic minorities were subsequently published ^[7]. In office practice, I collaborated with a psychiatry colleague, Dr. Nathalie Grizenko, in leading a team on a pilot project to study acculturation styles and psychological functioning in children of immigrants ^[8]. In our study, we identified four distinct styles: assimilation, integration, separation, and marginalization. In acculturation, individuals can select different components of both the host and ethnic cultures, increasing identification with one culture while not necessarily decreasing identification with the other. Our research clearly showed that individuals with the most integrative style also experienced more optimal psychological function compared with marginalized individuals. These distinctions can help clinicians to recognize intra-familial risk as well as protective factors during acculturation and facilitate psychosocial counselling to avoid intergenerational conflict.

 After closing my community practice in 2005, I continued work as an attending staff member in the ER and Paediatric Consultation Centre at MCH until 2015. There I conducted a survey of patients presenting with medically unexplained symptoms or somatic symptom disorder (MUS/SSD) and multiple ER visits between 2006 and 2010, which revealed a prevalence rate of 4.2% for MUS specifically. Fifty patients with MUS were recruited for a subsequent study to develop diagnostic and therapeutic strategies. We used the Pediatric Symptoms Checklist (PSC)-17 ^[9][10] for psychological screening, which includes subscales for internalizing  (>5), externalizing (>7), and attentional deficit (>7) as clinically significant symptoms, with subsequent referral for psychiatric consultation. As the attending paediatrician, I identified psychosocial risk and protective factors in three life domains (home, school, and community) for each patient and offered on-site counselling for families. The data also revealed that most of our cohort were newcomers to Canada.

Paediatric practices that include developmental monitoring, evidence-based, culturally appropriate care, anticipatory guidance, professionalism, and empathy can help ensure early diagnosis and individualized therapeutic approaches for children and youth with MUS/SSD. Preventing chronic symptoms from developing and reducing health care costs are long-term benefits of multicultural health care.

References

1. Chan AM, Lynch MJ, Bailey JD, Ezrin C, Fraser D. Hypothyroidism in cystinosis: A clinical endocrinologic and histologic study involving sixteen patients with cystinosis. Am J Med 1970;48(6):678-92.
2. Chan-Yip A, Gray-Donald K. Prevalence of iron deficiency among Chinese children aged 6 to 36 months in Montreal. CMAJ 1987;136(4):373-77.
3. Chan-Yip AM, Kramer MS. Promotion of breast-feeding in a Chinese community in Montreal. CMAJ 1983;129(9):955-58.
4. Chan-Yip AM, Au OM, Chan L, Mok A, Hum HS, Sanh SL. Family-Centered Childbirth and Infant Care. Montreal, Que.: Montreal Chinese Hospital, 2002.
5. Chan-Yip A. Health promotion and research in the Chinese community in Montreal: A model of culturally appropriate health care. Paediatr Child Health 2004;9(9):627-29.
6. Chan-Yip AM.Letter to the editor: Culture, communication, negotiation: Preventing iron deficiency in children new to Canada. Paediatr Child Health 2013;18(9):407.
7. Bibeau G, Chan-Yip AM, Lock M, Rousseau C, Sterlin C; Le Comité de la santé mentale du Québec. La Santé mentale et ses visages: Un Québec pleuriethnique au quotidien.Boucherville, Qué: Gaëtan Morin editeur, 1992.
8. Pawliuk N, Grizenko N, Chan-Yip A, Gantous P, Mathew J, Nguyen D. Acculturation style and psychological functioning in children of immigrants. Am J Orthopsychiatry 1996;66(1):111-21.
9. Gardner W, Murphy M, Childs GE, et al. The PSC-17: A brief pediatric symptom checklist with psychosocial problem subscales. A report from PROS and ASPN. Ambul Child Health 1999;5(3):225-36.
10. Brief psychosocial screening at health supervision and acute care visits. Wagman Borowsky I, Mozayeny S, Ireland M. Pediatrics 2003;112(1 Pt 1):129-33.

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