Cross-Cultural Care

Health care should be delivered with cross-cultural sensitivities. The quality of healthcare improves when doctors understand sociocultural differences between themselves and their patients. 

DEFINING CULTURE — Culture is a system of beliefs, values, rules, and customs that is shared by a group and is used to interpret experiences and direct patterns of behavior. Culture plays a large role in shaping each individual’s health-related values, beliefs, and behaviors, and clearly impacts clinical care.

When a clinician interacts with a patient, three cultures are juxtaposed: the patient’s, the clinician’s, and the culture of medicine. All three cultures influence the outcome of the encounter. To understand patients, it is first necessary to recognize our own cultural beliefs, values, and behaviors, as well as personal life experiences that have influenced the way we think about health care and make clinical decisions. In addition, the culture of medicine has its own particular beliefs, values, and customs (eg, the idea of patient autonomy and the value placed on scientific evidence). Finally, the patient’s social and cultural background affect the quality of understanding and communication that occurs in the clinical encounter.

The core values necessary for providing effective cross-cultural care are values fundamental to the practice of medicine: empathy, curiosity, and respect.

Clinicians increasingly see patients who may hold beliefs and values that differ from their own [3].

Effective communication — Effective clinician-patient communication is directly linked to improved patient satisfaction, adherence, and, subsequently, health outcomes. However, patients, particularly those from minority backgrounds, are often dissatisfied with their ability to communicate with their clinician.

Racial and ethnic disparities in health care — 

●African Americans are less likely than non-Hispanic whites to be referred for cardiac catheterization for coronary artery disease.

●Hispanics with isolated long bone fractures were twice as likely as non-Hispanic whites to receive no pain medication in the emergency department, in a study from one US academic medical center. Despite an increase in the past decade in opioid use for pain-related diagnoses visits in US emergency departments, disparity in pain treatment between ethnic groups has not decreased. Compared with white patients, the odds ratios for black, Hispanic, or Asian patients to receive opioid treatment were 0.66, 0.67, and 0.79 respectively.

●The risk of an African American developing end-stage renal disease requiring dialysis is four times greater than a European American. Once on dialysis, African-American patients are only 70 percent as likely to be referred for evaluation for renal transplantation.

●African Americans with hyperlipidemia, compared with non-Hispanic whites, are less likely to achieve target lipid levels, less likely to be using medication to control lipids, and less likely to be taking high efficacy statin drugs.

●Asian Americans, compared with non-Hispanic whites, have lower rates of cancer screening (colorectal and breast), adjusting for access to care and socioeconomic status. Foreign-born Asians, on survey, believed that cancer screening should be a response to symptoms and declined tests because of lack of symptoms.

●Minorities in the United States are less likely to seek mental health treatment when indicated than are white Americans; mental health providers (psychiatrists, psychologists, and social workers) are less likely than general medical practitioners to be Hispanic, black, Asian, or Native American.

Skills for cross-cultural care — Cross-cultural care is based on universal principles of patient-centered care.

Components of cross-cultural care include effective use of interpreters, familiarity with differences in disease epidemiology, and comfort level in working with patients who are culturally different than oneself. Additionally, cross-cultural care goes beyond learning about patients based on their racial, ethnic, or cultural background, to focusing on the skills required to follow the principles of patient-centered care.

Patient-centeredness encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient. Cross-cultural care aims to take this a step further to include skills that are especially useful in cross-cultural interactions but remain vital to all clinical encounters.

Styles of communication — Differences in styles of communication between patient and clinician, which can lead to discomfort and miscommunication, include both verbal and non-verbal communication: eye contact, touch, and personal space. Direct eye contact may be avoided in some cultures, while in others it is a sign of respect. Providers should be aware of their own tendencies and should be sensitive to the preferences of their patients.

Techniques for adapting to different communication styles and customs are as follows:

●Get a sense for the patient’s general communication style and adapt your style of communicating to fit best with his or hers.

●Try to draw out indirect or reserved patients by making them feel comfortable and asking open-ended questions. Do not assume that lack of resistance means agreement with your plan or recommendations.

●Determine how the patient prefers to receive information about results of testing.

•”I am going to check the report of your sonogram tomorrow and would like to let you know the results. Some of my patients want to be told directly, no matter what the test shows, even over the phone. While I don’t suspect that there will be anything serious, I would like to know how you prefer to hear the results.”

●Get a sense for whether the patient is more stoic or expressive of pain and symptoms. Avoid judging patients based on your own cultural perspective.

●Pay attention to cultural differences in personal space, eye contact, body language. Try to be flexible, and not to be misled by misinterpretation of communication cues.

Trust — Trust is a crucial element in the therapeutic alliance between patient and health care provider. It correlates directly with adherence to clinician recommendations and patient satisfaction. Mistrust of the health care system also affects patient’s use of services and results in inconsistent care, doctor shopping, self-medicating, and an increased demand for referrals and diagnostic tests by patients.

The provider should be aware of cues that may indicate some degree of mistrust. Patients may express concerns about whether a particular test is necessary, or they may mention a bad experience in the past. These should lead to direct efforts at reassurance and trust-building. Suggestions for building trust with patients, especially across cultures, include:

●Discuss mistrust openly. If the patient seems open to it, discuss why they might feel mistrustful of doctors or medical care. Reassure them of your intentions to help.

•”You’ve mentioned that you don’t really like coming to doctors. Was there anything in particular that led you to feel that way? (Any bad experiences or concerns?)”

●Explore the patient’s perspective. Ask what’s important for him or her.

•”What are your thoughts about having this operation?”

•”What were you hoping that I could do for you today?”

●Provide focused reassurance. After determining the patient’s perspective and concerns, focus reassurance on those concerns.

•”You’ve told me that the pain is what you’re really worried about so I’m going to make absolutely sure that you’ll have enough pain medication after the operation.”

●Build a partnership. Many mistrustful patients respond well to being given options and some control over their health care decisions.

●Communicate clearly. Listen carefully, avoid medical jargon, and check in regularly for feedback from the patient.

Techniques for understanding cultural differences in decision-making and family dynamics include:

●Introduce yourself respectfully to the patient and others in the room and determine their relation to the patient, keeping in mind that in some cultures it is appropriate to speak only to certain individuals.

●Find out if the patient prefers autonomy or would want the family, or someone in particular, to be involved in medical decision-making.

•”How much do you want your family to be involved in making decisions regarding your health care (such as tests or medications)?”

●Find out if there is an authority figure in the family, community, or religious group to consult and involve in important decisions.

•”Is there anyone in particular whom we should talk to about your health care besides you, someone who makes decisions in your family (or community)?”

●Consider allowing a patient to waive their right to know (legal documents can be signed in this case) when the family wants to withhold information.

●When a dominant family member is not allowing direct communication with the patient, explain the situation tactfully. If this fails, try ways to obtain information directly from the patient without offending the relative. However, if there is any concern for domestic abuse, laws protecting the patient should supersede issues of cultural sensitivity.

•”I appreciate what you’re saying, Mr./Ms. ——, your input is very important. From a medical standpoint, though, it’s also very important for me to hear a description of the problem from the patient herself, so I can make a more accurate diagnosis.”

●Realize that in many cultures it is typical (and important) for family members (as many as 5 or 10) to stay with the patient in the hospital at all times. If this leads to difficulty for the staff, it should be negotiated openly.

Many of these health-based traditions and customs are directly related to the patient’s worldview, religion, or spiritual beliefs. Illness and death are among the most powerful and mysterious phenomena in our existence, and people often seek meaning in these experiences through spirituality. Clinicians may undervalue the importance of addressing spiritual concerns with patients in the primary care setting. Patient expressions of spirituality should be discussed when appropriate and relevant to the clinical interaction.

Questions for clinicians about customs, religion, and spirituality include:

●Can you tell me anything about your customs that might affect your health care? What about your diet?

●How important is religion (or spirituality) in your life?

●How important are these beliefs to you, and do they influence how you care for yourself or what type of care you might receive?

Techniques for understanding sexual and gender issues, customs, and taboos include:

●Be aware of the different ways that patients and families view gender roles and try to accommodate them when feasible.

•”Unfortunately, we have no female obstetricians in clinic today, but if you are willing to reschedule your appointment, I can make sure that your wife will see a female doctor next week.”

●A judgmental attitude toward patients is unlikely to change behaviors and values, but may compromise the clinician-patient relationship and the ability to provide good health care.

●Ask patients/family what is acceptable to them, rather than making assumptions based on limited information (name, clothing, etc).

•”I perform breast examinations on all of my female patients to look for signs of breast cancer or other problems. Is this okay with you?”

●Be particularly sensitive to patients’ views on discussing sexual issues openly. State that you will be asking about some personal issues and explain why, especially in interactions where you are unfamiliar with the patient’s cultural background.

•”I generally ask all patients about some very personal matters at this point, which are important for doctors to know about. Are you comfortable talking about these things with me?”

●Recognize that patients’ views and language regarding sexuality and sexual orientation may differ. Ask whether patients have had sexual partners who are men or women rather than whether they are gay, bisexual, etc.

●Be open to and learn appropriate terminology for patients whose gender identity does not fit into the traditional male or female categories.

There is individual variation in how tightly people adhere to their beliefs. Some will be happy to learn “the truth” from a clinician. Others will ignore whatever they are told if it doesn’t take into account their own particular perspective and respect their common sense.

Techniques to understand the patients use of complementary/alternative medicine include:

●Ask patients in a non-judgmental, open-minded way about non-medical, alternative practices (can be asked after “medications” in the medical history).

•”A lot of my patients use other forms of treatment, like home remedies, herbs, or acupuncture, that can be helpful. Besides the medications that you mentioned, have you used any other types of therapy?”

●Check to see whether alternative therapies are safe and look for any interactions with medications.

●Negotiate the use of alternative therapies along with standard medicine when safe and important to the patient, and discuss reasons to discontinue any dangerous ones.

Questions regarding environment change include:

●Where are you from originally? When did you come and why did you decide to come?

●How have you found life here compared with life in your country (city, town)?

●What was medical care like there compared with here?

The following are some basic tips for working with interpreter services:

●Introduce the interpreter to patient

●Position the patient, interpreter, and yourself in triangle so each can see each other’s face

●Address and make eye contact with the patient, not the interpreter

●Ask one question or express one idea at a time and keep phrases short

●Encourage the interpreter to clarify terms with you and confirm understanding and agreement with the patient

●Empower team members (including the interpreter) to speak up when they notice a communication problem

●It is your responsibility to ensure that the medical interpreter and patient understand what is being communicated – avoid medical jargon, idiomatic expressions, and acronyms

●How well do you speak English: Not at all, not well, well, or very well?

If the patient responds “not at all” or “not well,” an interpreter is appropriate; if the response is “very well,” interpretation is not necessary; if the response is “well,” a second question should be asked:

●In what language do you prefer to receive your medical care?

Questions that may be asked to evaluate literacy include:

●Do you have trouble reading your medication bottles, instructions, or other patient information?

●Do you have trouble with reading in general?

Social stressors and supports, also described as social determinants of health, may have strong impact on a patient’s illness experience. A socially isolated patient may manifest more symptomatology related to a given illness than a patient with a broader set of social supports.

Questions helpful to gain understanding of issues related to life control, social stressors and supports include:

●What is causing the most stress in your life? How do you deal with this (ie, family, friends, activities, religion)?

●Do you ever feel that you’re not able to afford food, medications, or other medical expenses?

●Do you feel that you have the ability to affect your own health (or particular medical condition) or is it out of your control?

The following steps are helpful in the negotiation process:

●Step 1: Explore the patient’s perspective – Ask open-ended questions about the patient’s understanding and concerns about the illness and its treatment.

●Step 2: Explain your perspective – Provide the patient with an explanation in terms that are understandable and familiar, sharing what you hope will be beneficial for them if they follow your recommendations.

●Step 3: Acknowledge the difference in opinion – Do this in a way that is non-judgmental and accepting of difference.

●Step 4: Create common ground – This may mean offering a compromise or asking the patient what they are willing to do. This often requires some back and forth discussion in an environment where the patient feels they can be open.

●Step 5: Settle on a mutually acceptable plan – Once a plan is developed, check in with the patient again to make sure that it is acceptable. Look for any sign of hesitation on the part of the patient and discuss this openly. Ensure that the patient understands and has retained the plan that has been negotiated and articulated by the provider in language that is plain, simple, and understandable to the patient.

If conflict remains after initial negotiation, it may be helpful, if the patient is willing, to involve other individuals who the patient trusts. When a mutually agreeable plan or understanding cannot be reached with a competent adult patient, it is important to document the negotiation process in the medical record and acknowledge that the patient has the ultimate decision in his or her health care.