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GOAL: Comprehend the possible dangers of assuming that even when…
GOAL: Comprehend the possible dangers of assuming that even when the same language is spoken, communication between patient and practitioner is nonproblematic; understand the range of potential barriers to verbal and nonverbal communication. GOAL: Define cultural sensitivity (also called cultural competence) and describe processes entailed in its implementation, including basic activities necessary for learning about the patient perspective.
GOAL: Examine socialization and motives of health care professionals to illuminate how patients can more productively interact with them. When we think of all [the] tasks in the consultation, what is surprising is not how often we fail, but that we ever succeed. Even when patients and doctors come from a common culture, neither participant has any idea what the other is talking about much of the time. In one sense, every consultation can be thought of as a cross-cultural one. (Fuller and Toon 1988, 27-28)
Because of the disease orientation of biomedicine and the tendency to medicalize or reduce problems to the organic level, recommendations for diagnosis and treatment within the biomedical system did not, until recently, begin to include the consideration of cultural beliefs, values, or practices. The great impact these have on health and illness has long been demonstrated by social scientists. Increasingly, MDs are getting social science PhDs tooand sharing social science insights within the biomedical community (e.g., Farmer 1999, 2005; Helman 2007; Kleinman 1980; Waitzkin 2001). Culture can no longer be ignored by biomedical professionals. While the nursing profession has for some time promoted the benefits of “culture care” (Leininger 1985), many physicians may still resist the suggestion that they should address a patient’s emotional and psychological needs as well as his or her physiological problems, and they may not see the benefits of doing so. As one physician asked Loustaunau, “Do you mean to tell me that when I’m trying to treat a patient or save a life, I should be considering their cultural values and attitudes? That is utterly absurd!” This viewpoint reflects the reductionist model of medical care, excluding the role of social and psychological factors in health and illness. It is true that being culturally sensitive can entail a great deal of extra study, effort, and time. But considering the multicultural nature of the U.S. population, and demographic projections for increasing multiculturalization, cultural sensitivity is a key prerequisite for effective treatment. In 2001, the U.S. government issued national standards for culturally and linguistically appropriate services (CLAS) in health care, and these included mandates for all recipients of federal funds as well as guidelines and recommendations. The mandates, based on Title VI of the Civil Rights Act of 1964, include directives to provide language assistance services, including bilingual staff and interpreters as well as signage and printed matter in languages common to groups in the service area. The accompanying guidelines and recommendations begin with the statement that “health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.” It is suggested that mandated linguistic services should be part of a larger effort aimed at the provision of culturally sensitive care more generally.
Developing Cultural Sensitivity
Commonly termed cultural competence, the approach is defined officially as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (Office of Minority Health, 2005, emphasis ours). As Brach and Fraser observe: “Cultural competency is an explicit statement that one-size-fits-all health care cannot meet the needs of an increasingly diverse American population” (2000, 183). Care that is sensitive to cultural background is required. Although more research is needed on actual medical outcomes for patients who receive culturally sensitive care and patients who do not, the research that has been done suggests that culturally sensitive care can affect patient compliance or adherence to a given care plan as well as patient satisfaction, comfort, and attitude toward the medical establishment. Organizational imperatives notwithstanding, such as the need for a more diverse workforce as well as for operational processes that reflect and support the tenets of cultural competence, for practitioners an awareness that the perceptions patients hold may differ from biomedical ones, and that patients need to be made to feel comfortable if they are to discuss their concerns, is key. Developing the ability to communicate is, therefore, essential (Sobo and Seid 2003). Another strategy for clinicians who would be culturally sensitive is to develop networks of contacts within the communities to be served. And most important of all, they need to develop sensitivity to health needs as defined by those communities. As Fuller and Toon have noted, “The greater the cultural distance between doctor and patient, the less likely their expectations of the consultation and its outcome are to be congruent” (1988, 27; see also Cockerham 2010, Chapter 9; Philipsen 2003). ISSUES OF COMMUNICATION THE PROBLEM OF COMPLIANCE Doctors often become frustrated when patients do not comply with instructions, and it is estimated that over 60 percent of patients who visit biomedical practitioners are to some degree noncompliant (DiMatteo and DiNicola 1982; also see Cameron 1996). The reasons for this are varied, but the rejection of or failure to act on instructions is generally not due to a patient’s unncooperative nature or ignorance, as some doctors conclude.
The Cultural Context of Health, Illness, and Medicine
For example, Snow tells of a young first-time mother whose baby was failing to gain weight. After numerous consultations and one hospitalization, the pediatrician recommended a special formula high in calories and nutrients. The mother began to cry. As Snow explains, “A few questions revealed that she had not had enough money to buy formula in the first place and, when told that her baby needed a certain number of ounces/day, she had diluted the bottles to make sure that he got the proper amount” (1993, 245). Current research continues to reveal similar findings. However, financial stress is not the only cause for noncompliance; if it were, we would expect to find total compliance among those with financial resources, when we do not (Cameron 1996). This is because factors other than money, such as cultural expectations for consultations or for medication’s effects, can influence care plan adherence. Information we have on this subject is limited mostly to biomedical consultations. Whether people comply more, or less, and why, to nonbiomedical practitioner recommendations definitely needs further investigation, as does the problem of patient reticence to share compliance (and other) information with providers. Much of this sharing problem has to do with people’s aversion to the possibility of being judged as inferior by providers who do not share their cultural background, or of being lectured by providers who do not understand the constraints of povertyor of religious rules regarding certain medical practices, and so on (e.g., Prussing et al. 2004; Prussing et al. 2005; Sobo, Seid, and Gelhard 2006). But other factors also are at work. Many patients have unrealistic expectations for providers’ intuitive ability to discern their problems, to determine exactly what they need, and for what medicine can reasonably accomplish. These perceptions have been encouraged by the idea that physicians are, or should be, infallible and all-seeing. The media has also encouraged the idea that there is a pill for everything, and that anything can be “fixed.” Because the term “compliance” implies a power differential between practitioner and patient, as the relationship changes, the enhancement of compliance requires mutual trust and cooperation in decision making and implementation of treatment. The remedy should then lie in the communication process. COMPLIANCE AND INTERCULTURAL COMMUNICATION A reasonable amount of time is necessary for good communication to take place but communication also requires a number of skills: One must be able to express oneself in a manner understood by others and one must be able to listen to and properly interpret information offered and questions others. Previous knowledge and experience can affect the efficacy of both expression and interpretation in both physician and patient. One of the measures of communication is how much information gets transmitted. The need for information rather than treatment may actually be what brings many patients to clinicians. Some people go only for a diagnosis. Further, some go only for ailments that are new to them. Others go to make sure a condition is under control or to confirm their own treatment regimen is working (see Cockerham 2010, 134-56; Snow 1993, 129). However much patients may desire information, findings from studies cited in Hahn’s 1995 review of the literature on patient practitioner interaction suggests that one in five patients ask no questions at all and that 13 percent of patient questions go unanswered (169). Patients in one study of biomedical consultations spent an average of only eight seconds asking questions. Physicians in the study believed that they spent an average of nine full minutes providing information when in actuality they spent an average of 1.3 minutes doing so (Waitzkin 1985, 89). Compliance based on maybe 80 seconds worth of information transmission may, by definition, be problematicespecially when patient recall of doctor’s explanations and instructions has been reported at only 50 percent (Hahn 1995, 168). Work done more recently has helped to flesh out the picture developed in the 1980s. As noted in Kessells’s 2003 review, “40-80% of medical information provided by healthcare practitioners is forgotten immediately. The greater the amount of information presented, the lower the proportion correctly recalled; furthermore, almost half of the information that is remembered is incorrect” (219). Recall will vary by condition, education level, linguistic issues, and so on. It also will vary by provider or educator characteristics, such as time spent with patient, completeness of information provided, whether or not visual aids were used, and the like. The power structure of many biomedical consultations compounds the problem by limiting the role of the patient. So do class differences: Waitzkin identified a class-based cultural communication barrier (1985, 98). American working-class patients may tend to communicate more with tone and gesture than directly. Physicians, who are mainly from middle- and upper-class backgrounds, may be accustomed to direct verbal inquiries and so may fail to hear the nonverbal questions.
Further, even people who speak the same language or share the same language base can “talk past” each other. Cultural rules, including rules regarding doctor-patient consultations, are generally implicit or tacit and “each party assumes without discussion that it is their rules that both are using” (Fuller and Toon 1988, 28), even when they are not. The language of the biomedical culture is grounded in bodies and their mechanics, diagnoses, and repair. But the medical lexicon also serves to bind the medical community together and helps its members express the reality of their own lives and experiences; it also distinguishes them from nonmedical personnel and patients. Notwithstanding, the use in clinics of the biomedical slang referred to as “med speak” or “doc talk” and the rationalization by clinicians that communication is not important because patients could not possibly understand medical terminology adds to the communication gap. Patients also have their own culturally related lexicons. And even when they do have some familiarity with biomedical terminology, whether slang or technical jargon, miscommunication may occur. Patients and clinicians may use medical terminology in different ways. For example, people who report having “high blood,” “pressure,” or “high-pertension” do not refer to the same things that clinicians do when they say “hypertension” or “high blood pressure.” First, while the last two terms are the same to clinicians, for certain black people “high-pertension” means increased tension or stress, combined with increased blood volume. Pressure, or “high blood,” on the other hand, just means having too much blood, or blood that is therefore too high in the body (Heurtin-Roberts and Reisin 1990; Snow 1993, 117-34). Hypertension, biomedically defined, is something altogether different, so it is important to make sure that when similar terms are used that the meanings attributed also are the same. If not, adherence to clinician suggestions will likely be poor, as the physician will not address the problem that really concerns the patient. MEDICAL INTERPRETATION AND TRANSLATION People who do not speak the same primary or native language have an even more difficult time communicating in the clinic setting. The most obvious strategy when provider and patient do not speak the same language is to use an interpreter (an interpreter conveys meaning orally; a translator conveys meaning in writing). But, as demonstrated in early studies on the subject, simply finding someone who speaks the same language as the patient is not enough. For example, it is important that written material be translated for the patient or his or her family, as advice might not be fully remembered after a consultation (and it should not be assumed that people always can read the languages that they speak). It also is essential that instructions given (e.g., how to cleanse a healing wound at home) are given in logical sequence; if x precedes y, then instructions should be stated that way: “Do x and then y” (e.g., Fuller and Toon 1988, 46). Asking the recipient of instructions to repeat them back helps to confirm their comprehension. The interpreter must be perceived of as nonthreatening and encouraging to the patient (Fuller and Toon 1988, 45; Tseng and Streltzer 2008, 31-32). Moreover, the interpreter must interpret the clinician’s communications exactly, without editing or altering what is said. This means that idiomatic expressions, which may not make sense when translated literally into another language, must be converted so that their meanings remain intact in the target language. We are reminded of a friend who had a visitor from another country to dinner. Having eaten his fill, the man announced that he was “fed up.” Had the hosts not known about the man’s culture, they may have interpreted what he said as aggressive and insulting. Two more examples help illustrate the problematic nature of idiomatic expressions. Both are taken from Geri-Ann Galanti’s U.S. case study collections (1991, 2008), as are most of the other examples used in this section. The first example involves a mistakenly literal translation of “cold feet” or apprehension so that a Chinese-born physician suspected circulatory disease. In a different but similar case, a Korean physician who sought to reassure a patient when the patient nervously but jokingly asked if he would “kick the bucket” answered very positively, but to the wrong effect, ” ‘Oh, yes, you are definitely going to kick the bucket!’ ” (2008, 27). These examples are doubly significant. Not only do they demonstrate how nonsensical idiomatic expressions can be, but they also show that the linguistically divergent individual need not be the patient. And they show, also, that interpretation may be happening in an individual’s own thoughts and not just through a trained interpreter or translator. Some health care settings have paid interpreters and translators on call who provide professional and continuous service, resulting in a patient-interpreter/translator-clinician team that persists for the duration of the treatment. Such continuity is very important. Some clinics even have cross-cultural advocates or brokers: “trained members of a particular ethnic group who act as go-betweens for that group and the institution” (Fuller and Toon 1988, 37). Advocates interpret but also educate health workers about their cultures and the economic and health problems typical among members of their group. They review health education materials that target their group; assist patients in understanding their options, for example, as in regard to surgery and its implications; and help staff members understand, and thereby reduce, institutional racism (37). Many clinics and hospitals cannot afford this service, let alone professional interpreters or translators, despite the government’s (unfunded) mandate for them, as per the CLAS standards (described earlier). If a member of staff speaks a language common to the patient population, he or she might be called upon. A friend or relative of a patient might also serve as an interpreter in an emergency. Despite their best intentions, relatives who volunteer do not always provide good translations or interpretations. Besides their lack of familiarity with medical terms and procedures, they have other roles to play in relation to the patient, and certain role expectations may conflict with the messages they are asked to relay by clinicians. Moreover, clinicians must think carefully about patients’ right to confidentiality, which should not be violated; patients may not wish to reveal certain details in the presence of family or friends. For example, a woman accompanied by a husband or boyfriend may not want him to know about past abortions, sexually transmitted diseases, contraceptive use, or pregnancies. Her concerns about self-presentation and preserving her self-esteem and that of others may override her interest in meeting the clinician’s need for accuracy. Talk of reproductive matters between children and parents also can be problematic, as the following example shows: A Hispanic woman, Graciela Mendoza, had to sign an informed consent form for a hysterectomy. Her bilingual son served as the interpreter. When he described the procedure to his mother, he appeared to be translating accurately and indicating the appropriate body parts. His mother signed willingly. The next day, however, when she learned that her uterus had been removed and that she could no longer bear children, she became very angry and threatened to sue the hospital. What went wrong? Because it is inappropriate for a Hispanic male to discuss the private parts of his mother, the embarrassed son explained that a tumor would be removed from her abdomen and pointed to that general area. When Mrs. Mendoza learned that her uterus had been removed, she was quite angry and upset because a Hispanic woman’s status is derived in large part from the number of children she produces. (Galanti 2008, 39) As Galanti has noted, “Even speaking the same language is not always sufficient. Cultural rules often dictate who can discuss what with whom” (1991, 16). Another important aspect of this case is the way in which the translator edited for the mother. Editing also can happen in the other direction: Some translators will consider themselves representatives of their culture or of the person for whom they are translating, and they will take pains to eliminate any statement that might reflect poorly on the patient or on their group.
NONVERBAL COMMUNICATION EXPRESSIVITY
Cultural rules dictate who talks about what, to whom, and also when discussion should take place to begin with, as well as at what pace it should proceed at and at what decibel (Kreps and Kunimoto 1994, 116). Members of some cultures tend to be loud and verbally expressive when they wish to demonstrates interest and concern. Silence is another form of expression, and its value is quite high in some cultures. This can have ramifications for provider-patient interaction: Ellen was trying to teach her Navaho patient, Jim Nez, how to live with his newly diagnosed diabetes. She soon became extremely frustrated because she felt she was not getting through to him. He asked very few questions and never met her eyes. She reasoned from this that he was uninterested and therefore not listening to her. Rather than signaling disinterest, however, Mr. Nez’s behavior demonstrated a respect for the nurse’s authority. The Navaho value silence. A person who interrupts while someone is speaking is perceived as immature. Most Americans are uncomfortable with silences and tend to fill them with words, making “small” talk. The Navaho use silence to formulate their thoughts. Words should have significance. (Galanti 1991, 16) Silence may signal respect, but again, it may not: It may reflect fear. A Laotian refugee being treated for stomach cancer refused to talk to a hospital social worker because, says Galanti, she seemed to “have feared that anything she said would have repercussions for her family still in Laos and Thailand” (1991, 28). Silence also may signal embarrassment at a lack of command of one’s host country’s language. In traditional Chinese and Japanese cultures, silence on the part of the speaker signals the listener to consider carefully the content of what was said before anyone goes on speaking. A black person may remain silent after being asked a question perceived as ridiculous. French, Spanish, and Russian people may interpret silence as signaling agreement (Fuller and Toon 1988, 4). Clearly, cultural context and individual acculturation levels must be taken into account when interpreting a silent reaction.
EXPRESSING PAIN
Pain is one of the symptoms used by biomedical practitioners in diagnosing illness; it is perceived as a signal that something is wrong. However, classic studies by Zborowski (1952) and Zola (1966) found that cultural ideas about expressiveness and stoicism influenced the expression of pain responses for several ethnic groups. Although this knowledge is important, with it as with other generalizations presented in this chapter and elsewhere, there is a consequent danger of inadvertent stereotyping and false expectations in physicians who treat these patients. Numerous other variables may intervene, such as age of patient, educational background, and personal experience. Still, such research shows that, to a significant degree, people may be willing to tolerate pain as a function of cultural expectations, sometimes even refusing medication. One such case is described by Galanti. A Nigerian farmer was in the United States for surgery on a knee injury: “His nurse waited for him to request pain medication, but he never did. Mr. Seisay was Muslim, and he offered his pain to Allah in thanks for the good fortune of being allowed such specialized surgery” (Galanti 2008, 56). Another case demonstrated how clinicians trained in one culture may easily misinterpret pain expressed in another: [Mary Carroll] was scheduled for surgery at the end of the week. Her family became very concerned when she suddenly started complaining of pain. They knew Mrs. Carroll was typically Irish in her stoicism. They spoke to her doctor, who was from India. He was not worried. In his country, women were usually vocal when in pain. He ignored their requests that the surgery be done sooner, thinking it unnecessary. When he finally did operate, he discovered that Mrs. Carroll’s condition had progressed to the point that she could not be saved. (Galanti 2008, 53-54) These examples make clear how important it is for medical staff to be culturally aware of the relativity of the expression of pain. OTHER MODES OF COMMUNICATION Eye contact is another mode of communication that can have wide cultural variation. Patients may read a physician’s gaze as reflecting knowledge and caring, which can inspire trust and reassurancebut not always. The patient gaze may also be misinterpreted. Aversion of the eyes can signal respect, as in the case of many Asian and West African cultures: “An English doctor with a West African patient may therefore feel that she or he is depressed, hostile, or not being straightforward, when in fact there is merely a difference of cultural convention. Conversely, the African patient may experience the English doctor’s eye contact as excessive staring” (Fuller and Toon 1988, 51). Sometimes, eyes are seen as spiritual windows, and so direct eye contact can endanger those involved. Other times, direct contact signals intimacy. Eye contact with certain patients might be misinterpreted as sexual interest; this can be distressing for all involved (Galanti 2008, 46). Other forms of nonverbal communication that might become important during a consultation include one’s physical proximity to patients. For instance, while many Americans, Canadians, and British people require substantial space between themselves and other people (Gross 1992, 109 reports this at about four feet), Latin American, Japanese, and Arabs prefer very little (about two feet for Latin Americans, according to Grosswho also cautions that most evidence on distance is anecdotal; and see Bente et al. 2008 regarding methodological problems in cross-cultural research on nonverbal behavior overall). Patients may attempt to pull clinicians intoor push them out ofpersonal space in order to make themselves more comfortable. Habitual gestures also must be taken into account; they might have different meanings cross-culturally. While a nod of the head means “yes” to most Americans, Greek and some other Mediterranean people traditionally say “no” by a similarly vertical movement of the head (Gross 1992, 109). An American clinician might beckon a patient forward by wiggling the index finger out and in with the palm up and other fingers and thumb closed or bent in toward the palm. But this gesture is used in the Philippines to call animals (Galanti 1991, 22). Information on gestures relevant to the population(s) served by a clinic can help to avoid embarrassment. COURTESY AND CIVILITY Courtesy and civility can do much to enhance a relationship and improve communication. However, this form of expression too may be culturally relative. For example, some people may not wish to bother nurses, even when in pain, for to do so would be disrespectful. A sense of politeness also might lead patients to answer “yes” when they really mean “no” or “maybe.” For example, “rather than refuse to the physician’s face and cause him dishonor” (1991, 21), a Chinese woman described by Galanti told her physician that she would return for follow-up treatment and then never did. Here is another example of this kind of situation: Jackie, an Anglo nurse, was explaining the harmful side effects of the medication Adela Samillan, a Filipino patient, was to take at home after her discharge. Although Mrs. Samillan spoke some English, her husband who was more fluent, served as interpreter. Throughout Jackie’s explanation, the Samillans nodded in agreement and understanding and laughed nervously. When Jackie verbally tested them on the information, however, it was apparent that they understood very little. What had happened? Dignity and self-esteem are extremely important for most Asians. Had the Samillans indicated that they did not understand Jackie’s instructions, they would have lost their self-esteem for not understanding or they would have caused Jackie to lose hers for not explaining the material well enough. By pretending to understand, Mr. and Mrs. Samillan felt they were preserving everyone’s dignity. (Galanti 2008, 30-31) SHAME One of the quickest ways to injure patient dignity is to write off their statements as old-fashioned or superstitious. When a Mexican American mother says that her infant has cai´da de mollera, one group of physicians “would tell the mother not to believe in that kind of ‘superstitious nonsense’ ” (Robert Trotter, as quoted in Arellano and Kearny 1992, 49). We hear this kind of comment today still, even though this is not an effective strategy. Cai´da de mollera, or mollera cai´da, is a condition in which, among other things, an infant’s anterior fontanel (the soft spot on the front of a baby’s skull) is visibly depressed or has sunken or fallen in; the condition also is called “fallen fontanel.” Other symptoms include excessive crying, reduced appetite, diarrhea, vomiting, restlessness, and irritability. The condition can be fatal without timely proper treatment; Trotter believes it is what biomedical specialists would call “severe dehydration.” But because the women in Trotter’s research knew that the clinicians would ridicule them, they would not bring the condition to the clinician’s attention until it was very severe (as cited in Arellano and Kearny 1992, 49-50). Likewise, many do not tell clinicians about home remedies or complementary or alternative medical treatments they may be using (see Chapters 4 and 5). Patients’ use of their own terms should not be denigrated but rather encouraged if clinicians are to provide adequate care; a patient’s use of the term cai´da de mollera can serve as a “good screening device” and a “significant indicator” that a child needs immediate attention (Arellano and Kearny 1992, 50). But how can clinicians find out about illnesses such as cai´da de mollera, let alone learn the terms for such illnesses, if patients are made to feel ashamed of them and then keep quiet? The idea of becoming culturally sensitive may seem overwhelming in the face of all the possibilities. However, some common ethnographic methods can be incorporated into medical training, and adapted and utilized by health care professionals to enhance relationships and care, as well as to complement medical science with medical art. Ultimately, even mistakes will be much less serious if there is an open, trusting, and mutually respectful relationship between practitioner and patient.
ETHNOGRAPHIC TECHNIQUES: AN INTRODUCTION
Cultural sensitivity to communication practices, such as the ways in which the body is used or the people with whom it is appropriate to speak, is a first step in building sensitivity to other realms of culture as part of a culturally competent approach to the provision of health care. It is the first step in collecting and assessing further cultural data on a given aspect of a given way of life. In order to enhance and facilitate communication, clinicians can try to gain an understanding of the particular cultural factors, which include ethnicity, sex, age, and social class, profession, and the like, to which different patient populations they serve subscribean ethnographic understanding. Technically, ethnographies are written accounts (-graphy) about certain peoples (ethno-). Libraries are full of such accounts, and this literature can be extremely helpful in familiarizing oneself with the culture of a patient population. In addition to library resources, original research can also be useful and rewarding. A growing number of clinicians are joining or forming study groups specifically interested in doing research on the populations they serve. There are also a growing number of resources and manuals directed to health care providers that summarize and give general information on techniques of rapid assessment (e.g., Fuller and Toon 1988; Kreps and Kunimoto 1994; Tseng and Streltzer 2008; Srivastava 2007; Ring et al. 2008). Bernard (1995, 2001) provides a full discussion of the methods professional ethnographers might use, as do Pelto and Pelto (1996). Sobo (2009a) focuses specifically on ethnographic approaches in regard to today’s health care challenges.
THE ETHNOGRAPHIC ASSESSMENT While clinicians generally will not conduct full-fledged ethnographic research, they can collect ethnographic information by listening to what patients say about their lives. To gain insight into local social structures, clinicians should pay attention to the household forms most often described by patients. They also should attend to the types of individuals most often referred to by patients as emotional, social, and financial supports, and those most often cited as barriers, troublemakers, power brokers, or purse-string tighteners. Sometimes, in add
