13 I Chinese–Do you REALLY know how to talk about food as medicine (Roulan Liu)

• Timespan: 57:49 minutes
• Transcription Type: Cleaned Verbatim
• Speakers: (Roulan Liu & Raj Sundar)

00:00

Raj Sundar:Do you think about how much work it takes for someone who doesn't speak English to get the care they need?

00:06

Roulan Liu: Because some things that a lot of people don't realize is how difficult it is for Chinese speaking or any immigrant population to get to you in the first place. They have to navigate through a call center that they don't speak any language of, and then they're directed to log on they the apps don't make any sense. And they finally got to see a doctor. And they're always concerned that they will not be able to follow up. And if I continue to have abdominal pain, what do I do?

00:35

Raj Sundar: Hi, you're listening to healthcare for humans Podcast, the podcast dedicated to educating you how to care for culturally diverse communities, so you can be a better healer. This is about everything that you wish you knew, to really care for the person in front of you, not just a body system. Let's learn together. I'm Dr. Raj Sundar, a family physician, and a community organizer. Welcome to Season One, where we talk about the history and culture of immigrant communities. You just heard from Ruolan Liu, a primary care physician who cares for a large Chinese population and is fluent in medical Chinese. What did you think about when you heard that clip? We all know it's difficult to get the care you need when you don't speak English, when you're in a country where everything is in English. But this is a reminder about what it feels like to the patient to finally get to see you. When they're feeling vulnerable. Their body or mind is failing. And they don't know if they'll ever see you again. Ruolan Liu is going to tell you how you can care for the Chinese community. She has knowledge about traditional Chinese medicine and has studied integrative medicine in her career. She even worked as a medical translator before entering medical school. And she is going to give us a masterclass in culturally responsive care for the Chinese community. We talk about Chinese cuisine, food as medicine contending with patients experience back home where they can get an MRI, when ever they want. And yes, I noticed because in India, you can too. You just walk up to the MRI shop. And you can order yourself an MRI. And when you're talking to patients that expect that are used to that, what do you do? As I said, this will be a masterclass. If this is your first time joining us. This is part two of a four part series on the Chinese community. Listen to part one to understand the history of immigration of the Chinese community and go to health care for humans.org to sign up. And remember, you can listen on any podcasting platform, including Apple podcasts, and Amazon music. Here's your Ruolan. Welcome to the show, Ruolan.

2:54

Roulan Liu: Thank you. Thanks for having me.

2:55

Raj Sundar: So tell me about yourself. How did you end up in Washington?

02:58

Ruolan Liu: I was born in Chengdu, China, which is capital city of those Citron province, you probably heard of it from all the spicy food. And then when I was nine years old, my parents immigrated to the US specifically, Portland, Oregon. Both my parents are acupuncturists, and they came as part of an employment-based visa program. And they establish their own practice in Chinese medicine in Portland. So I moved here in the middle of third grade and attended elementary, middle high school, and then decided to go into pre-med and study Western medicine, to my slight dismay have very traditional parents.

03:41

Raj Sundar: Yeah, awesome. You know, my story is kind of similar to you, except from India and I moved here when I was in third grade. But I'll say, I grew up in a Hindu household, and I ended up going to a Catholic school. So I thought all of America was Catholicism cuz, doing maths on Fridays, but it's totally that culture shock when you come when you're that young, you're still open to things, but it's still like, your home feels like a different place. Right?

04:03

Ruolan Liu:Absolutely. My parents were very traditionally Chinese cultural wise, and also their profession. So a lot of interesting conversations at home now that I've studied more, but I'm more allopathic slash Western medicine. Right. So we'll see. Yeah,

04:21

Raj Sundar: Yeah and  I know you, you mentioned you take care of a large population of Chinese immigrants, too. And there was another way to categorize it to just at least for our mind, when we're approaching different kinds of patients. There was one group we could say like the older Chinese American immigrants who are the most traditional, then there's the immigrants of working class who are still embracing cultural values that are traditional, but are open to just a culturally raishin or are more American in many ways. And then there's the professionals who are highly educated people who came here as professionals or working in the large organizations in our state. And then the last group is American Born Chinese Americans, that was just one way of categorizing it to say, if we want to talk about certain cultural values, it's not going to apply to all groups equally. Like I'm not going to go to American Born Chinese Americans and talk about hot and cold food, right?

05:31

Roulan Liu: Right. Yeah that's because I'm in traditional Chinese medicine that's rooted in there. And, you know, thinking about this, there's so many different ways to categorize and that don't want to stereotype because there's a lot of overlap. But, the truth is that the Chinese Americans who came here in the late 1800s settle down in their generations of Chinese-Americans from that point on will be much more acculturated into the American culture than people who had come here in the mid 2000s. Usually, there is a difference in geographic location of where they settled within the Seattle area as well, the Chinatown portion. And Portland had a Chinatown, I remember as a nine-year old being really confused, because my dad brought me to Chinatown. And it wasn't the culture I was used to at all. For example, the 1800s people came from a coastal city called kin Tong, and Hong Kong in China, where they speak Cantonese sounds novel like Mandarin, and I couldn't understand a single thing they were saying in Chinatown, and I said, this is not my culture, versus you, if you're looking at the East Side, they'll view Kirkland Redmond, that area in the last 10 or 20 years have been more from the mainland, and Taiwan immigrants to the US, where they speak more Mandarin. So these two sides of the lake we always see a different culture already, not just within Chinese immigrant population. So that kind of separation is settled, and not something that I usually say you have to understand deeply to be aware of how to provide the care for these patients, my non Mandarin speaking colleagues, I just go over this a little bit of the concept. But there is still a lot of values that connect these groups that goes back 1000s of years. So we can talk about that a little bit more.

07:04

Raj Sundar: I think it's helpful to acknowledge, both the diversity of that community. I mean, China's a large, large country with a long history. As well as trying to find commonalities. So we are better clinicians. And we're asking questions that are more informed and not offensive as we're not putting people into buckets. Okay, I think we'll start with diet, nutrition and food. Let's start with just the different kinds of food but then we'll go deeper into food as medicine because I think that's can be a big part of Chinese culture. Let's say up front that Chinese food is not deep fried shrimp, and sweet and sour pork that are part of just like an Indian food. It's like chicken tikka masala is not Indian food for me. I think it's important to say out loud because I think culture changes here partly to please  (quote and quote) "Western tastes" and make a business when the authentic cuisine or what people eat at home is not what you see at these restaurants that you go to. But the cuisine of China is also diverse. There's Shanghai cuisine, Szechuan cuisine, Cantonese cuisine. I think people think of Cantonese, most likely when I think about Chinese because such wide as the spicy the hot chili, right? It's that dishes that people think of, right?

08:17

Roulan Liu: Yeah, it's almost as a ying and yang of cuisines when you talk about Cantonese and Sichuan cuisine. One of them the cooking styles really subtle. The flavors are elicited through hours of making and building a broth. And the other one is really hot peppers. It just really stir frying and bringing out just all the aromatics in one pot. So the cuisine, yes, in Chinese cuisine, they're these two opposing sides as well. But you're right. There's a lot of amplification when it comes to Fortune cookies. My American classmates at age nine come up to me and say do you like which I was like, that's not my culture either.

08:56

Raj Sundar: Okay, it's good. And I don't like those fortunes.

08:59

Roulan Liu: Now. I can't read them. They're in English, the kind of foods that my patients tend to also you can imagine now in the last 10 years, there's so much more dedicated Chinese supermarkets and it's incredible the amount of imported goods available from China you can find a specific brand of a specific type of chilli oil that you are more familiar with in China. It's not completely the same, but still they do have a lot of these traditional types of vegetables. My husband who is actually Indian-American, always asked, you can buy a lot of veggies from supermarkets like Safeway or KFC, why do you go to the Chinese supermarkets because they have a different breed of cabbages or different species of cabbages that they don't normally sell here? So the Chinese community tends to use ingredients and things that are not so widely sold in other stores, but their style of Cooking also incorporates about how they grow up. It's, it's really a comfort making them back to what they're used to.

10:07

Raj Sundar: Yeah. And would you say that most meals or let's say lunch and dinner consist of rice, soup, and like a few side dishes, where vegetables are already a part of the meal and meat isn't like the main meal, it's like almost for tasty in different dishes.

10:24

Roulan Liu: Chinese cuisine and the kind of timing of food is still very traditionally, breakfast lunch and dinner. And rice or some form of starch is very important. Some of the younger generation who say I'm on a keto diet or low-carb, and that doesn't really work for the majority of my patients. My both parents, my mom was tested to have slightly higher blood sugar, you know, pre-diabetes. And her doctor said you stop eating rice and she said, it's not possible and suddenly tried things like brown rice, things that are a little bit healthier, comparatively, but the taste is different. So in northern China, there is more focused on wheat based products like noodles, dumplings, the wrappers. And then in southern China, where there is less wheat grown, naturally because of the climate, you have rice noodles, rice or in Cantonese, you have those like beef noodle soups, but that is some sort of starch is a staple in Chinese cuisine for breakfast, lunch and dinner. Absolutely. And we are questioned about whether or not there's a meat components soup. Soup is generally drink at dinnertime, not so much lunch, I would say meat is more incorporated in Chinese cuisine, than in others. It's something that generally at every meal, and also my patients would really try to balance that out with some sort of stir-fried vegetables. Stir-frying is a common way of cooking in Chinese cuisine. We don't bake a lot, or roast vegetables or, or grill them as much, you know, at least not at home, right have this food carts or street street foods. And so talking to my patients about not just the kind of food that they eat, but the oils used to stir fry is usually a high yield topic, they often sometimes use pork, like lard, that's a traditional, you save some other things that from the pork, or they use canola oil, neither of which are very good for your cholesterol. So transitioning to more some things they haven't heard about as much like olive oil, or avocado, neither of those are traditional plants and oils used in China, but weirdly widely available here.

12:36

Raj Sundar: Yeah. And we're a big proponent of I think when I do this podcast and show respecting people's culture in their own cuisine. Is there anything else that you do for counseling for diabetes, heart disease, high blood pressure, you know, the big three that we often see.

12:52

Roulan Liu: Right? I think the concept of eating three meals a day is really important in the Chinese culture, because it's the cultural part of this is you when you have people over or you talk about things, your position in the community is really represented by how you appear. Here, there is less immediate family. When you're looking at a culture, it's more rare for recent immigrants to have their cousins and second cousins and grandparents and everybody here, it's usually just the nuclear family. So they reach out to not specific members: just friends, your community of friends is quite large, is part of the Chinese immigrant population. And with that, when it comes to food, if you're saying, Oh, we're not having we're just doing two meals a day, like the intermittent fasting type of thing that's so popular that just doesn't quite work for a lot of patients and their children. So I tried to talk to him about just eating a little bit less in the evening, that maybe have a really good breakfast or lunch. But limiting portion sizes, a little bit is more high yield. And it's difficult though to I find this myself because when you're trying to say count calories, and there's an app that says "My Fitness Pal" you can enter in this, you know cereal, and they'll tell you a bowl of it is this much calories. Well, I don't really eat cereal for breakfast. But most of the Americanized apps can't tell you how much calories are in this one type of crackers that are only produced in China. So it's really hard to have the kind of ease of access to do that for my patients who have diabetes or heart disease, but really eating more of a balanced meal, limiting portion sizes, being more mindful about that is where I find the best results.

14:47

Raj Sundar: That makes sense. Okay, I think the other part of diet and nutrition is treating food as medicine. If you're feeling ill, changing the type of food you're eating can restore balance and make you feel better. But, I think that's a foreign concept for a lot of people, because I bring it back to also trying to identify our own culture and our expectation. In America, where there's no seasons for fruits or vegetables, like strawberries, like 12 months a year kind of thing. It's hard to imagine that you're trying to balance your needs with environments needs and the type of food and how you will react with each other. So I don't know, how would you explain the idea of hot and cold? Because I know certain foods are hot, and certain foods are cold. And I think also like, sometimes patients may ask you, like you say, Oh, you have an infection, they may ask you, what should I eat? It's probably not the right response to say, Oh, you can eat whatever you want. Because I don't think that's probably what they're asking you about. So how would you approach that too.

15:45

Roulan Liu: So if I were to explain this, to my colleagues at clinics about the concept of how food ties into health for my Chinese patients is really rooted in Chinese medicine. The idea with Chinese medicine is everything that you come into touch with impacts your health. We'll talk about how emotions plays into that but really, what you put into your mouth has different properties. And these properties can infect your chi or energy. And your body inherently is a cold and cold, warm chi type of like it has a warm energy, you're warm blooded. And so the eating of foods that are warmer for you are generally your spend less Chi in digesting that. And it's better for the movement of this energy through your body in general. To help along with this chi, there are different herbs that are often incorporated into soups or porridges. And we often eat both of those things when we feel ill or sick, or our parents feed us those.  The cold the concept of eating cold things, it's not part of my training, going through medical school and residency, but I can understand my patients said they oftentimes have a common thing is Gerd reflux. And as you know, treatment of reflux is at least 50% diet changes, you can put on the acid, reducers, and tons. But if you don't change your diet, you're going to have this recurrent problem. And so it's telling them not to drink coffee of alcohol. While most Chinese immigrants don't drink a lot of coffee, or alcohol, tea doesn't have as strong of an irritant effect, but telling them to maybe eat less, while spicy food can also trigger that but talking about it in terms of eating smaller portions and eating more warm foods. Although that does conflict with what I'm trained in. But it really gets the point across that you have to look at the food that you're eating. And speaking in that language to them is more helpful to understand how that relates to disease.

17:55

Raj Sundar: Yeah, I mean, our job is the job of healing and we meet people where they're at. I know, I totally get it like sometimes it feels like it conflicts with our trading. But I do feel like if we don't communicate where people are, they often just ignore us, or they don't come back to us, we think we've done our job, but you will never see them again. So it sounds like in your perspective, you do try to talk about the hot and cold food a little bit, but you're not trained in it. So you don't go into this specific like this foods hot this, but just acknowledging that it exists. And then maybe listening to your body and choosing the food that feels right to you and then reorienting towards the disease process itself like reflexes, this is what's happening. So this may be helpful for you to do. That sounds right.

18:37

Roulan Liu: Yes. So the understanding of medicine, now that we're talking about food as medicine is very different because of the influence of 2000 years of Chinese culture and traditional Chinese medicine. So when you are talking about, for example, you know, a certain illness, the general population, their understanding is some obstruction of chi, or maybe they have too much heat in their body, and they need to do some other treatments to tone down the heat or tone down the inflammation of some sort. I'm not trained in that. And I'm very upfront, some of my patients get confused because I do speak fluent Mandarin, they think that I am, or most medical training in China incorporates a little bit of traditional Chinese medicine. So I'm very upfront that I don't know that in detail, but speaking and understanding that they come from a position where they understand the body slightly differently, and just putting in some of those keywords will make them pay attention a little bit more to the ideas that you are (quote unquote) "selling or not selling".

19:39

Raj Sundar: But you understand, people want to feel like they're being understood. And when you do that, I think they feel bad. Do you refer to like a traditional healer or somebody who practices traditional Chinese medicine, if a patient brings that up, say Well, yeah, those are good questions. Let's work together with a traditional Chinese medicine practitioner if you want. Do you say that or do you have people that you refer to or organizations, just curious.

20:03

Roulan Liu: Absolutely. I mean, I have just a list of acupuncturist or traditional Chinese medicine.  As I was alluding to earlier, a lot of patients who are immigrants here have a huge community of friends, extended friends of friends, and extended family members in China that thanks to the ease of communication, like WeChat, which is a group chatting app that they use. They oftentimes when they come to see you already have had some sort of conversation about what they think this is, with friends, and then they will know a friend whose friend is a doctor. And then they would ask the doctor in China, what they think this rash is. And so I find it a lot easier to ask the question of what have you heard about within your community about what you think this is? So that we bypass a lot of, you can speak to an interpreter for 30 minutes about the Western understanding a reflex, but they will just nod and be politely agree with you. But that doesn't get you a lot of places.

21:11

Raj Sundar: Yeah. That's a good takeaway, right? Like we acknowledge it upfront. We know what's happening, and that we don't dismiss it, but add to it, our understanding of what could be happening. And ultimately, it's the patient's choice to choose whatever that they want to do to help their condition, whatever that is. Okay. So part of this segment, we usually talk about substance use too. And one thing with many Chinese-Americans is that they have a variant of a gene called the ALD h2, which changes the breakdown of alcohol. So people get facial flushing, it's like the flushing response with nausea, headache, dizziness, rapid heartbeat. Do you feel like that actually affects the prevalence of alcohol abuse? Or do you talk about alcohol differently with your patients or Chinese immigrants?

21:56

Roulan Liu: I don't talk about that in a lot of detail. Chinese cultures, generally, really, we're a very conservative when it comes to any sort of substances, alcohol in Chinese medicine, as always been no knowledge as a detriment to your chi.

22:12

Raj Sundar: And I think this response probably validates it right. Getting heartbeat.

22:17

Roulan Liu: Exactly! My patients generally are very conscientious. They know that drinking alcohol is not a daily habit. But the idea is that you're bringing up of sort of public health concerns. There are different diseases that are more prevalent in the population. Hepatitis B being one of them, that a lot of patients are more concerned about. There's a link between Chinese-Americans and gastric disease, H. Pylori, cancers, those are areas as clinicians we should be aware of in that specific population. That is unique, that's not so prevalently taught in our US, PS TF guidelines. So the Chinese community are highly educated came here as part of an employment-based visa. And they have a lot of family members in China who are highly educated. So you have this combination of kind of highly educated but also difficult to getting, or understanding the American healthcare system, which is a whole other beast when it comes to getting the care that they're used to. What I say to my patients is the Chinese culture and American culture are different. And the Chinese medical culture and the American medical culture is also very different as well. So medicine, how is practice in China, in mainland China in parts of Taiwan and Hong Kong these days is very fast paced. The doctor will be seeing 50 to 80 patients a day. And they often will sit behind the desk and the patient would give one or two sentences of their thing. They would say, Okay, here's all the blood tests we need to do. Here's the images, because it does take time. There's never any opportunity for them to actually listen to your lungs. And so the patients are used to this type of interaction. When I took a year off between college and medical school and actually interned in one of these hospitals, working as a medical translator. A lot of students so I saw how reliant Chinese medical systems are in these diagnostic tests. And I tell my patients like in China, you're walking into Medical Center, kind of like a buffet, right? You have all these choices. I would like to get just my CBC, BMP all these panels done, but you also have the choice of getting CA-125. When you don't even have any ovarian cancer, you can have a CE-25 for pancreatic cancer and just add everything on. So that and the patients coming in to see an American healthcare system is so night and day.

24:54

Raj Sundar: People think our health care system is influenced by capitalism, but I can only talk about India where everything's unregulated. So you can, you know, if I want an MRI, I could just go and get an MRI, then patients start feeling like, oh, like, when I go to the doctor, I'll get a bunch of things done. And they'll give me blank antibiotic or medicine. And that's what doctors do. So this has come up and other episodes, too, they come to us, and we're like, we don't do anything, we listen to their heart and say, You're okay, you will get better, there's no better medicine or like, wasted their time coming here. And I haven't found a good way to approach that because that is what we do. But I think sometimes then it discourages them from coming to the doctor, like they won't do anything anyway.

25:36

Roulan Liu: Yeah, they'll do that buffet analogy, what I say to beginners, in China, they're like ordering off a menu, right? You can order the fries with your pizza with your lobster, if this is what you do in China, that's fine. But here in the American healthcare system, I'm more like a guide. You walk into my buffet and I say, "sure, you can get the fries. And you can get the cheeseburger and the pizza in one meal". But that's not going to be really good for you. And that kind of brings them into a context that this is what they're there for is for advice, and really being listened to. That there's a certain level of trust there that is hard to achieve. From an immigrant population to an American marriage system, not just culturally, but also with medicine, and even harder with an interpreter present, which I think within the interpreter, you can really use them to your advantage of they sometimes offer that gap in bridging that cultural gap. I, too often, even though I do speak live sometimes in Tokyo come in and I hear them try to explain to the patients now they did, that's the way to do it here. They just check your cholesterol and blood sugar. They don't order an MRI. But yeah, so it's really a different way of showing the patient that you do care. I don't know, I can't say that I found a perfect way each time it changes with a patient. That's something I struggled with a lot coming from my background because I can understand both ways of practicing what I learned in residency, but also reconciling that with my culture and some things I've grown up with. But I think initially, what I would do is, you know, find a middle ground, I wouldn't order MRIs, I would say, Well, maybe if you're really worried that you might have lung cancer, it will definitely show up if they constantly on an x-ray and just say let's meet in the middle and establish that former trust and over the years, they will listen to you more when they say we don't really need to check ovarian cancer marker for you today.

27:37

Raj Sundar: Yeah, it's a too complicated to go into. I mean, there's a reason why we don't do a lot of things sometimes unless it's fully indicated, both because of harms of over testing and over prescribing. Do you talk about that? I mean, I think there's already skepticism about Western medicine, I don't want to be disingenuous insight, these medicines are powerful. So we want to be careful when we prescribe it, and make sure you absolutely need it. I want to be honest, at the same time, meet them in their beliefs and their values.

28:05

Roulan Liu: Yeah, it's something that I will continuously explore. And always something that challenges me and my daily practice of how to reconcile that I try my best to. And I can also understand where the doctors in China are struggling, because you can spend 10 minutes explaining why you don't need an MRI or 10 seconds, you can write MRI order. When you're seeing 50 patients a day, what are you going to choose, but the crux of it is showing that you do care, and then we're going to follow up, and we're going to check and setting up follow up appointments. Because some things that a lot of people don't realize is how, how difficult it is for Chinese speaking or any immigrant population to get to you in the first place. They have to navigate through a call center that they don't speak any language of and then they're directed to log on, the apps don't make any sense. And they finally got to see a doctor. And they're always concerned that they will not be able to follow up. And if I continue to have domino pain, what do I do? So another way is to say, we're going to schedule a phone call with me in two weeks to check and see. And oftentimes they said, Okay, that's my lifeline. I know that I'll speak to you again. And I will bring up any issues at that time. So that oftentimes works. Although you're right, I haven't unlocked that level where I have a spiel that works for everyone.

29:28

Raj Sundar: But it has to be individualized. But rather than focusing on why we're not doing it, we could try to talk about our strengths because we know the context of why there's so much imaging and usage saying this buffet of ordering is that oh look like we have time to listen to you. And I can learn a lot from that. And then we'll also have a follow up so don't worry if things aren't going as expected. We'll obviously get this imaging too.

29:51

Roulan Liu: And I'm aware of just, because I speak the language it is a lot easier for patients to bring up these concerns to me. Sometimes patients will ask for thing and then shoves it or will say something doctor say, blah, blah. And then they wouldn't ask again, because a lot of Chinese values is tied to you know, heard about Confucianism and Taoism being the two great concepts that came from 1000s of years ago. Taoism talks about humility being a virtue, that you don't rock the boat, you don't speak up, you just accept, and you almost are grateful for what comes at you. And that also, you know, in recent years kind of ties into the concept of the model minority, why are we the model minority, not just because a lot of us are highly educated, but as a culture, we're very humble. We don't try to complain about anything. Even the Japanese-Americans, the concept of, you know, always been passed into all the East Asian countries that during their internment, not a lot of them complained that while they're being stripped of their belongings and put into these concentration camps. So the idea of humility will prevent your patients from really saying, No, I don't agree with that. They wouldn't really challenge the doctors. And just because they, they have that barrier, and they don't feel like that's their place.

31:12

Raj Sundar: That's a good transition to culture. Because let's talk about values. Religion is a big part of it. You mentioned Confucianism, and Taoism, even if people aren't actively practicing it, because of its history within Chinese culture, and mainland China, like it's actually been incorporated into just the value system. So people don't say, Oh, I practice Taoisim. So it's like just part of how you live your life with the values that you hold on to. So the main, I think the four traditional religions slash philosophies, maybe that's a better way to say it that way than just to religion is Confucianism, Buddhism, Taoism, and sometimes ancestor worship. Obviously, many Chinese Americans also practice Christianity, too. So we'll just acknowledge that, but Confucianism emphasizes, like social order, and fulfillment of responsibilities. Even those are important to know, because everybody has a role. And this informs some of like why people protect their families from knowing certain things. And then Taoism on this, like conforming humility, emotional calmness. So when people are experiencing hardship. You're supposed to experience it with calm and composure and equanimity. And then the Buddhism, that's probably a hard one to capture. It's obviously complicated. But I think those two religions, as you mentioned, informed the cultural values. Now transition to just digging deeper into the value system, and you just brought up I think, the idea of deference to authority, I think I would capture it that way. I don't know if this is related. But I think there's a belief about face saving, I don't know how to say this, and you helped me like Bianchi, NC, let's talk about that. Because I think that is an important concept for people to know. For sometimes why people don't express their questions or concerns.

32:58

Roulan Liu: Yeah, it's really sort of capturing the way to say that. The answer is it seeps into everything. Growing up as a Chinese-American girl, the concept of DNS is faced like you, the Chinese society, thanks to Confucius, who is this philosopher 3000 years ago, talks about a way of life like he has a social moral code and harmony. And this sort of permeates into values in the way of life of your family where you are in terms of the hierarchical structure. And he took that eventually to apply to our governmental system tried to sell these ideas to different kingdoms throughout China at the time, but that didn't really stuck around. And so you are seen as part of a community and a part of a hierarchy. And your face is how you present yourself and that can be determined by your income, or your status, your job. And that kind of hierarchy. Also, in more applicable to Chinese American immigrants is about your children's well being and your parents well being to Confucius talks about a concept of filial piety, which is the respect for your elders, but much more than respect, it's obedience to your elders, obedience to authority. And part of the concept of saving face is if you go through a hardship, hard time, it's hard to talk about without losing face, without exposing that vulnerable side, you have to present your family as having it together to some form, even to close friends, that your troubles are behind closed doors in a sense, and you don't ever break up the filial piety. You must respect your parents, you must make sure that your children are well taken care of. And your struggles are sometimes put aside in the bigger setting of this harmony and the structure. So, that idea of saving face I see in my practice come to play so much with mental health. And it's getting better definitely in China, mainland Taiwan and Hong Kong, recognizing mental health issues. And speaking about it is not considered something that's shameful. The concept of saving face is tied a lot to shame and guilt. Well, I read a lot of Brene Brown talking about shame and guilt. And that's not something I feel like the Chinese community has yet exposed yourself to, that it's okay to experience those emotions. But certainly, there's a knowledge meant of anxiety, as a disorder, a clinical disorder, clinical treatment needed for that instead of just, I'm weak or there is something organically wrong with me. I think more people tend to focus on it's not my anxiety, it's really that I have diarrhea 10 times a day or something like that. So if you're trying to up end 3000 years of Confucianism, teaching, in 10 minutes of clinical practice, that's not going to be very successful. But it's just talking about how I say, How do you feel like your emotions are impacting you in that open ended way? Because alongside Confucianism, let's talk about Taoism. Taoism is a similar general philosophy and China that actually takes form nowadays in Chinese medicine in general, that ying and yang that comes from Taoism, the balance between the two. So, when my parents when I was growing up, I never took an antibiotic until I got to college.

36:41

Raj Sundar: I had a resilient immune system.

36:45

Roulan Liu: Sometimes I think about the times, I'd be like, I have a fever for a week, and my parents are just forgiving me. I was like, what probably should have had antibiotics. But anyway, I don't bring that up to them. So they teach me these concepts of balance and harmony. Interestingly, when you talk about Western philosophy, you don't have philosophers prescribing medicine.  But in China, that separation doesn't happen as much. All Chinese medicine practitioners will know the town, will know the ying and yang very well. So that's how the philosophy kind of translates even into physical ailments. Just like they do, acknowledging the Taoist tradition that your own emotions can translate into bad chi. That your emotions can impact the flow of chi in your body. That's one way that I feel like you can get through a little bit more on these hard to swallow concepts to have that balance of physical forces, but also the energy and emotions.

37:43

Raj Sundar: Let's review because we've talked about a lot. And we're trying to do this more. So with respect to face-saving and filial piety, I think there are a few ways that we probably see it all for all the reasons that you talked about. One is patients not verbalizing doubts about their medical care, or challenging diagnosis or treatment plans, right, this deference to authority that you talked about. And then also this filial piety probably links into not informing family members of illnesses to protect them, quote, unquote, or like being sure who has a decision-making authority in the family, like it might not be the person you're talking to, it might be a family member. So when you're taking care of folks like one is not to misinterpret some of this as non-compliance. That's it like that big category, or people not wanting to engage. And then two, maybe involving family more being clear about, like, how are we going to come up with this plan together? I don't know like, how do you incorporate family members into care when there are all these higher care positions, and maybe what you're saying should actually be set to a  certain person of the household in order to make a change in the household about whatever you're trying to make either care for something as serious as cancer or maybe even just dietary changes of what you should be eating?

39:01

Roulan Liu: Right. Oftentimes, I older Chinese speaking, patients will come with their children, and their children oftentimes serve as more of a decision maker, although there is that feel like they have their parents best interests at heart. And it's assumed that they should, and they be an active participants. So it is finding that balance of talking with the children about the diagnosis, or sometimes they would say, Let's talk outside the room. Let's make sure that my mom is this way or that and they're very particular about certain things. They always will have family members in China, as well. So your presentation of your treatment plan will get discussed with a whole community of people.

39:49

Raj Sundar: That's important to highlight because I think people underestimate how much people are connected to their communities in their home country. Because it happens for me and WhatsApp too, right like people talking to a family member be hospitalized and they will pay. This is what the doctors doing the labs they're ordering is this, okay?

40:06

Roulan Liu: My mom will send reports to me right from the end. It's the crowdsourcing that happens now in the technological age. So that I would say, in general, follow ups are important.  They probably won't come to a big decision right then in there, they will need to ask their entire extended family and their extended families. But they will really make sure that their parents are very well taken care of that their priority. Thanks to the filial piety part of Chinese culture.

40:34

Raj Sundar: Yeah, but I think that's an important point is that time to make decisions, like you're gonna say this and say, you could even maybe a theology, I know, you will have to think about it, there's probably a family and community we'll talk about. But let's talk about this again, maybe in a week or two, and come up with a next step together, or something. And I think you also mentioned anxiety and talking about mental health. There's, I think, one component of the shame associated with it that links to Confucianism and Taoism of not showing the world, your internal troubles. But also, I think, that in traditional Chinese medicine, there's more psychosomatic integration, there's not as much of this binary of the mind and the body, it's so separate. So people may default to just experiencing anxiety or depression as heaviness or pain in the body, which I don't necessarily think is wrong, I think people do feel that here too. But they just articulated differently.

41:28

Roulan Liu: The concept of what you feel can translate into how your body behaves, is much more clear if you tie it with Chinese medicine and their concept of how the energy goes through your body. That in some degree, I feel like my Chinese immigrant population does understand. I try not to immediately be dismissive and just say, this is just your anxiety. And there needs to be some work on my end, to build that trust, and to listen and to say, I hear you, here's what we did, and you don't have any stomach cancer that we can see. And so let's talk about what are your thoughts about other things that can be acting, we're getting to know them, how have things been at home? Do you think there's a lack of sleep? Sometimes I use to sleep, and a part of it is as introduction to people do feel more tired, and physically tired from lack of sleep, and it's a bridge between that and knowing most people feel too anxious to fall asleep. And that could really tie in that mental aspect to sleep than to a physical ailment, make that transition a little bit easier to swallow. But one of the things that I try to emphasize is, people think that because of a mental disorder, oftentimes in China, they'll just put them in a mental hospital. But a very worried that there might be stigmatized in that way. And normalizing that. And especially say, we're not going to need to go to any specific medication treatment. But I'd like us to think about how this chronic stress and not taking time for yourself can affect your health overall, I do think that those two things are connected.

43:14

Raj Sundar: So interesting. I meditate and do yoga. And we talked about how the breath is the only conscious and unconscious control of our body is trying to find that bridge. Same thing with like mental and physical. I think it's like a pro tip from you about sleep, like yeah, like I can talk about sleep, because it's a physical thing. But it's also clearly related to your thoughts and anxiety, that can help there can be like a way to approach that in a way that is productive. Let's say that

43:42

Roulan Liu: Let's say that people recognize that when they're anxious, they don't sleep well. Nobody will say I don't sleep are not because of my anxiety, but because of just my stomach acting up. So there's always people see that when their minds active, they can't fall asleep. But it is challenging to speak about that with an interpreter present. Because here we go back to saving face, and not having shame because the interpreter is a part of the community too.

44:08

Raj Sundar: Yeah. And I also like the idea of, maybe you do a little more testing than you normally would to gain that trust. But then you have their buy in and build that relationship with a long term goal of maybe reducing testing overall, but getting them to understand their body in the way at least we've understood it so far here in western medicine, and the path forward in a way that's helpful. Do you think people are open to therapy? Or is that also really hard to engage in?

44:36

Roulan Liu: Some people are so definitely with the therapist speaks their own language. I have had a few cases before and a lot more throughout the pandemic of adolescents with eating disorders and talk about how difficult it is already to address this in our society without the language barrier without the cultural expectation. And there has been an instance where we had the children there who speak English went to see an English speaking therapist. The mom had a translator with her for part of those sessions. And they felt like you worked, okay. And they felt like they got some benefit from there. But most of my Chinese speaking patients will say, No, I don't want to speak to an English speaking therapist by goodwill to do. So I do have lists of Chinese speaking, therapists in the community. Some people find it more palatable to talk about, or I would encourage them to speak to their friends, because overcoming that sense of saving face is a huge deal. They often can find support in their community, if they open up, but just going through that process of No, everything is good. Yeah, we're one big happy family. Nobody is getting hospitalized for eating disorders. Nope.

45:54

Raj Sundar:  Okay. Anything else that you want to talk about with values or beliefs, that's important to know, before we transition to the next part? Okay, so the next segment that I wanted to do was just to cover Traditional Chinese Medicine a little bit more. We know your parents are acupuncturist. We talked about food as a medicine a little bit when we talked about the Yin and Yang and the Chi can be sometimes defined as the vital energy within your body. But there's different components to traditional Chinese medicine, there's food, but there's also herbs that you mentioned earlier. And what I've read is that usually the herbs that are prescribed often consist of four to 12 ingredients, and they have a primary effect. And then they have other things that balance the side effects and augments certain things. So it really is an art that is done in a specific way. But how do we acknowledge that patients may be taking this and not telling us because I think there's some statistic that most patients don't tell us when they take herbs, because they are afraid that we will dismiss them or judge them? And then how do you think about you making a treatment plan that doesn't interact with this herbs that you may, but as you said, most of us aren't trained in traditional Chinese medicine, so probably don't know, all the herbs and how they function?

47:05

Roulan Liu: I would definitely start out with that lead of what have you read about or heard about from within your community, about this illness? And how to treat it? And then follow up? Have you started treating this on your own? Because it's not just herbs, many patients would have antibiotics already they bought from China, which is over the counter, if you could,

47:27

Raj Sundar: if I'm lucky, they have the bottles in their bag, and they show me but they're just telling me they took something

47:34

Roulan Liu: Like we have four UTIs a year you took something but you know, what is it? Yeah, so they already have been self-treating at home. If it is something more herbal. Again, very often than not an herbalist or acupuncturist, I recommend seeing someone here, because the concept of diagnosing people in Traditional Chinese Medicine contains you feeling the person's pulse, and looking at their tongue, the process of diagnosis is looking at their facial color and things and I don't generally put a lot of I don't say fake, but I'm a little wary of diagnosing things over WeChat of just describing a few words of the symptom. And each of these herbs is so individualized to the person itself. And my parents often adjust these herbal formulas every week, or every two weeks depending on response. So I would encourage them to see an acupuncturist or a traditional practitioner here, so that they also are more aware of the types of treatments. I've spoken with some of our oncology colleagues, over the last few years are built up like my colleagues who do speak in Mandarin or Chinese to see their experience. Because I think in more serious cases of chemotherapy, that will be something that they're much more wary of, than let's say if I were to prescribe an antibiotic or something like that. And generally, I think our oncologists are more open to it than I thought they would be. That the interactions from data are not as horrible as we thought. And I'm not going to say just stop taking all of those. But be careful, because we've got to make sure that you are not causing yourself a lot of harm by drinking or doing anything in excess.

49:30

Raj Sundar: Yeah, yeah, I think that's helpful. No, no, I think that there was a good point you made about people who are trying to sometimes compromise because they don't have access to a traditional Chinese medicine practitioner or acupuncturist, so they just do the WeChat and get an herb. So like maybe bringing that up, maybe saying it can be helpful if you're actually actively working with the traditional Chinese medicine practitioner because they change herbs every week. So if you're wanting to do that we should connect you with somebody.  But if you're just getting it over WeChat maybe we can think about how to better approach it or something? I don't know. I don't know if I have the right words for it. But it seems like important to say. One thing that I was reading about how do we approach people who are taking traditional Chinese medicine, herbs, or getting herbs from wherever it doesn't matter. How is how do we jointly work with them, because clearly, they're taking the herbs because they either had a bad experience with what was prescribed through us as Western medicine doctors, so they had side effects and believe it, or just believe that herbs are more natural and are going to affect their Chi in a different way than Western medicine who have certain energies. I think the whole point is, you acknowledge it, and then ask them to actually track it. So if you think this is going to make you better, let's make sure it is. And then also make sure you track your side effects. So then we know this is causing it before we start putting in western medicine, you don't know which one is causing which. So really, just getting them to follow their symptoms and side effects closely and having close follow-up.

51:05

Roulan Liu: Yeah, I think the reason people turn to Chinese medicine is it's familiar in terms of their culture. They feel they're more supported in that way that it's like speaking the same language. When I talk to patients about inflammation, for example, that they have joint inflammation or arthritis, that term is not as familiar as ever to say that you have excessive heat in your joint dog. Okay, I understand. Yeah, yes. So that is literally just a change in phrasing, by job to get that point across. So they take herbs for familiarity, they understand it, but also it's hard to get in to see us. And then those also that trust and language barrier. So I don't think there are a lot of people in China who say we don't believe in western medicine at all, or else they wouldn't be sitting in front of you. They, in fact, do believe it, that they buy antibiotics on their own, to try to treat it from China. So they do know that it's just making sure that you have to follow up with them from some focusing on you know, I know you're treating it your way, just like people are treating you with food every day. They're changing our food. But I'm gonna make sure that in my scope, I take care of you. I can't tell you to cut out the Jameson and this formula, because I don't know what that is doing. But within my scope, this is what I'm going to recommend.

52:26

Raj Sundar: Yeah. Okay, so we talked about traditional Chinese medicine, herbs, foodist, medicine, and a few other things that came up, I don't know how important it is or how often you bring this up, but cupping acupuncture. I think acupuncture is big. And it's often I think how why to convince other clinicians that alternative treatments are okay because acupuncture is one thing where they've done RCTs with like real needles and shaved needles, and acupuncture still makes people better. And Western medicine has no idea why it works like our understanding of the body like what we know it does for so many conditions over and over. How do you incorporate that into the counseling or when you give treatment plans?

53:06

Roulan Liu: So there are traditionally trained acupuncturists in China but you know, that school has expanded to the US where my dad and my father taught at for many years and they do teach cupping, they teach quassia which is a type of I think chiropractors picked it up I'm blanking on the name but type of cupping that you scrape the skin and elicits a bit of bruising underneath the skin looks awful but supposed to release the pent up stagnation of the chin. That's the technical term of it and then the acupuncture two points a meridian not following any nerve or any blood vessel but the meridians where the Chi flows. So those are all combined into a visit if the practitioner feels like this is needed depending on the patient's condition. So I am very much in favor of them seeking out agriculture for knee pain or joint picking. Some of them there's a little bit of hesitancy because there's some of my patients who think acupuncture is trading here may not know as much as the acupuncturist in China. They don't necessarily want to go see a white person's shirt faded, I've pinched like way could do. I don't know if you can't even pronounce the meridian points. So but then so that's my list is more traditional trade acupuncturists but they can certainly augment a lot of and give patients that sense of activity and control and not feeling so unplugged from their own health and so isolated and that's one of the things I think immigrant populations can feel with a smaller nuclear family here just having crowdsourcing from distant across the Pacific Ocean here feeling like they have an active role in their health will promote them to do engage more and that eventually leads to better health care outcomes too.

54:56

Raj Sundar: Okay, and then the question that I usually end the episode with. Was there an encounter with the clinician for you personally, where you felt seen your different identities? We learned a lot about you today. What you're like? Yeah, like that is something we should aspire to.

55:11

Roulan Liu:  When I was about a tool, my mom was diagnosed with breast cancer. She's doing well now by she had gone through chemotherapy, and she had gone radiation and before that of lumpectomy, so surgery, and I remember going with her in some of the appointments, and it was very overwhelming concern to the fact that besides my shots, I had never gotten into a pediatrician growing up, my parents were my health care providers. And suddenly, it's all of these specialists. But I remember meeting her surgeon who is African American, and we were all really nervous because she was going through the first surgery of her life. So their surgeon, contrary to our expectations was not in a rush at all. She was mostly sitting and just she held my mom's hand, those are translated there. But she still was talking to my mom face-to-face. And it just made us feel really safe at that visit. And I think a lot of this is not that the surgeon did a lot of speaking in Chinese or did a lot of cultural things, but just being present. I also think that goes back to what we saw that which is interesting. She had you that was coming after the surgery, and she had learned one phrase to say, which is just me how just Hello, right? She's like, Oh, yeah, they're Chinese speaking out, just reach out. And they may seem to us like, Oh, it's just one word. That shouldn't matter that much. But even if there's an interpreter present to us at one word, to just break the ice to connect to reach out, even if you're not pronouncing it in a certain way that it made a difference. But mom felt, really we all felt really happy. And with that, oh, that's so cute. They're trying to learn about our culture.

56:55

Raj Sundar: Yeah, because I think many immigrants experience is trying to fit into American culture and change their identity to fit into our systems. So people acknowledge and make an effort to learn their culture or see where they're at and communicate in the way they want. It's very important to help you feel seen and present, no matter how rushed, you feel. So thanks for sharing that. Thanks for this episode, Roulan. Thanks for joining us today. And I'm sure that we have a lot to think about and our listeners will learn a lot today.

57:28

Roulan Liu: Yeah thanks for taking your time as well. I'm sure I'll see you at some meetings or projects in the future.

57:32

Raj Sundar: Sure. Thank you for joining us on another episode of the healthcare for humans podcast. And if you'd liked this episode, go to Amazon music and share it with one other person and sign up at healthcare for humans.org to join our community. See you soon.

57:49

Speaker 3: This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participants' past, current or future employers unless explicitly expressed so, always seek the advice of your physician or another qualified healthcare provider with regard to your own personal questions about what medical conditions you may be experiencing. This Healthcare for Humans project is based on Duwamish land that makes a regular commitment to Real Rental Duwamish.

The transcript ends here.