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Right Side Down: Why Doctors Need to Respect Patients’ Cultural Beliefs

A recent interaction with a Muslim family reminded Dennis Rosen just how critical it is that he incorporates cultural and religious beliefs into treatment plans whenever possible.
(Photo: michaeljung/Shutterstock)

(Photo: michaeljung/Shutterstock)

M, a bright-eyed six-year-old boy from the Middle East, came to see me because of his obstructive sleep apnea. This is a condition in which the muscles of the throat relax during sleep to the point where it collapses repeatedly, blocking air entry into the lungs.

Two years earlier—when first diagnosed—M was prescribed the use of a CPAP, a machine that blows pressurized air through a mask worn over the face and into the throat to keep it propped open. Unfortunately, as is often the case with children who require CPAP—and many adults as well—M didn’t tolerate the mask and wouldn’t keep it on his face at night during sleep.

After arriving in Boston for further care, M underwent another sleep study that confirmed the persistence of his apnea. An otolaryngologist felt that there were no easy surgical fixes, and so M was referred to me to see if I could help.

"Permitting" M to sleep as his mother believed he should not only validated the entire approach but also motivated her to do whatever she could to make it succeed going forward.

M arrived with his mother. Almost immediately it became clear just how frustrating the last two years had been for her. Worn down by the nightly struggles to get her son to wear the CPAP, she was also consumed by guilt and worry about the possible long-term effects of the untreated apnea.

“Doctor, how serious is it?” she asked.

“It’s serious,” I answered. “But there was something interesting about his sleep study. For much of the night, M slept on his left side, and he had very little apnea in that position. Almost all of the obstruction occurred while he slept flat on his back.”

Tilting her head slightly and leaning forward on her chair, M’s mother regarded me intently.

“It’s very possible,” I continued, “that if your son sleeps with his left side down and stays off his back, most of his apnea will resolve and he will no longer need CPAP.”

Her face lit up, and it was obvious that this was as thrilling to her as it was unexpected. I described different ways of keeping M from rolling from his side onto his back while asleep, including sewing a tennis ball into the pocket of a T-shirt worn backwards as a nightshirt and propping him up with a wedge-shaped pillow.

As I spoke, however, I could sense a clear shift in the mother’s demeanor. Something had begun to trouble her.

“What are you thinking?” I asked, wondering if perhaps she was concerned about where she might buy a wedge pillow back home.

“Doctor,” she hesitated. “Will his breathing also be OK if he sleeps with his right side down?”

This seemed terribly important to her. “Why do you ask?”

“Our Prophet instructed us to sleep on our right side, with the right hand underneath the cheek.” After studying my reaction and apparently finding it satisfactory, she continued: “Did you know that scientific studies have proven that this sleeping position is also, in fact, the healthiest?”

No, I hadn’t known that, I told her. And Yes, I thought that M would do just as well on his right side as on his left.

“Thank you!” she exclaimed, smiling broadly and hugging her son tightly.

Although I have been treating patients with sleep disorders for many years now, this was the first time that I had heard right-side-down described as the ideal sleeping position. It is well known, for example, that babies should sleep only on their backs to reduce the risk of sudden infant death syndrome. Likewise, pregnant women are often counseled to lie with their left side down to avoid compression of the inferior vena cava that can compromise blood flow. Curious, I did a literature search, and was surprised to learn that there is indeed evidence that some adults with certain types of heart disease may benefit from sleeping on their right side.

In the end, however, the tangible benefits of faith-based imperatives such as this are less important than the intangibles. Observant Jews, for example, shun pork not because it is unhealthy, but because they are commanded to do so. Likewise, fasting, a practice common to many faiths including Islam, Judaism, and Jainism, is not undertaken to promote weight loss, but rather in order to reach a higher spiritual plane.

“Permitting” M to sleep as his mother believed he should—and making this a central component of his treatment—not only validated the entire approach but also motivated her to do whatever she could to make it succeed going forward. Medically, it was inconsequential on which side M slept; for his mother, however, the difference was huge.

During my pediatric residency in Israel, while caring for the sick children of ultraorthodox Jews, I frequently had to speak with the parents’ rabbi in order to get his blessing—figuratively and on occasion literally—for the treatments we proposed. Invariably, I received the utmost respect from the rabbis I spoke with, and never felt that there was really any question that a child with suspected meningitis, for example, might not get the antibiotics she needed. Rather, it was a matter of framing the biomedical within the religious and cultural frameworks that the parents could relate to, and engaging their rabbi to bring the parents on board both reassured them and made it more likely that the child would receive the treatment she needed.

This principle remains relevant to my practice here in Boston. While it may be more commonplace to have to consider the cultural aspects of care instead of the overtly religious, in a multicultural society such as ours, neither is ever far from the surface, as the case of M and his mother illustrates. Demonstrating a respectful curiosity toward patients and their beliefs and treating these with respect even when it is not possible to integrate them into treatment plans, are key to increasing patient engagement and medical adherence that in turn result in better—and usually less-expensive—health outcomes.