Effective clinician–patient communication involves verbal and nonverbal sharing of information across cultural and linguistic boundaries. In the medical arena, these boundaries are populated on the one side by clinicians who represent the esoteric world of biomedicine, and on the other side by patients and families who often lack familiarity with biomedical concepts and procedures and may have their own strongly held beliefs about illness—what it means, how it should be diagnosed, and how it should be treated. The goals of effective cross-cultural communication (or “cultural competency,” as it is sometimes called) are threefold: (1) to understand illness from the perspective of the patient; (2) to assist patients in understanding diseases and treatments from the perspective of biomedicine; and (3) to help patients and their families navigate, express themselves, and feel comfortable within large, complex, and often impersonal health care organizations. These activities require some awareness of the wider context of patients’ lives, and of how the worlds of biomedicine and the lay public interact and, at times, conflict and misunderstand each other.

Cross-cultural communication skills are best developed through practice, reflection, and reading about and interacting with diverse patient populations. Knowing a few facts about the illness beliefs of an immigrant group or ethnic minority is not enough. It is important to develop ways of perceiving and interpreting what individual patients say and do in the context of their previous experiences with illness, structural positions within society, and membership within particular ethnic and religious communities. True cultural awareness also involves understanding how biomedicine is itself a cultural system, and how it is likely to be perceived and (mis)understood by patients.

As the dominant form of health care in the United States, biomedicine is practiced by highly specialized professionals and relies on detailed, scientific information about the human body and the use of pharmaceutical and surgical interventions to prevent or treat anatomic and physiologic disorders and their associated symptoms. It has a definite body of knowledge, set of practices, strengths and weaknesses, nonevidence-based biases, and inherent limitations. Each of its many specialties and subspecialties has unique conventions, systems of knowledge, and ways of making sense of people and events. To patients of all backgrounds, much about biomedicine is obscure; difficulties agreeing with and accepting medical explanations and recommendations are commonplace. Therefore, the perspective that orients the discussion in this chapter is that although cross-cultural communication is especially important and challenging for immigrant and minority patients, it has relevance to all patients.

Culture

Culture refers to beliefs, values, rituals, customs, institutions, social roles, and relationships that are shared among identifiable groups of people. Typically, one’s own culture is taken for granted; it feels entirely natural, consisting of those assumptions and routines that make the world what it is “supposed” to be. Unconscious learning and modeling play important roles in the acquisition of cultural assumptions and routines. Within the family, one of the most influential cultural systems, there is generally a clear-cut division of labor, regular routines such as meal and work times, explanations (or myths) about family origins, and strategies for fulfilling common goals and passing down shared values. It is also within the family that beliefs are first developed about the causes of illness, acceptable ways of expressing symptoms, and strategies for diagnosing illness and restoring health. Individuals, of course, are also shaped by, and participate in, cultures related to work, school, worship, political affiliation, social clubs, and so on, each of which may also have important—and sometimes contradictory or inconsistent—influences on beliefs about and responses to illness.

Cultures are neither pure nor static, but constantly intermix and evolve. Particularly in the United States—a highly mobile, diverse, and media-saturated society—millions of people move in and out of multiple domains, borrowing and adapting ideas and customs from other groups. Because cultural change over time and across generations is considerable, it should not be assumed that particular patients have certain beliefs or engage in certain behaviors solely on the basis of their last name, physical appearance, or national origin. Inferences—always open to revision—should be based on detailed knowledge of patient attributes that go beyond race and ethnicity alone.

The Relationship of Culture to Race, Ethnicity, and National Origin

Some cultural competency training takes the approach that various racial, ethnic, and national groups possess distinctive cultural traits with which the clinician should become familiar to render more effective care. Commonly cited examples include beliefs in “fallen fontanelle” and “evil eye” among Latinos and “high blood/low blood” among African Americans, as well as values such as “individualism” among North Americans, and “family centeredness” among Asians. Although these generalizations (or stereotypes) may illustrate a wide spectrum of cultural influences on illness and healing, this approach is too simplistic. It implies that race, ethnicity, and national origin are the most important determinants of an individual’s understanding of and response to illness, and ignores the tremendous heterogeneity among individuals within these groups and among individuals who may inhabit multiple groups simultaneously. Common notions of cultural competency assume that culture can be reduced to a technical skill that clinicians can develop without necessarily engaging with people in their local worlds and understanding the ambiguity and ambivalence that many people feel as a result of living within these multiple worlds.

Take the case of the United States, in which the primary racial/ethnic categories include African American, white, Asian, American Indian, Pacific Islander, and Latino. Some people may self-identify using these terms, and the labels are often important politically, but there are significant differences among people within each of these categories in terms of age, place of birth, religion, social class, sexual orientation, level of education, and so on. Conceptualizing differences in health beliefs and behaviors on the overarching levels of race and ethnicity promotes stereotyping and does little to advance more effective medical care. In general, assumptions about cultural beliefs and practices should be based on more specific identification of group membership, such as recent immigrants; particular US subpopulations such as the homeless, southern rural African Americans, or inhabitants of particular city neighborhoods.

Social Location

As we move beyond ideas of culture determined solely by race and ethnicity, knowledge of patients will be enhanced by awareness of their social location. Social location specifies one’s position in society relative to others and is based on an amalgam of characteristics that include not only race and ethnicity, but also gender, age, immigration status, language(s) spoken, neighborhood of residence, length of time and number of generations in the United States, educational attainment, income, occupation, religion, sexual orientation, and prior experiences with racism. Gender and age are two fundamental variables that influence how patients give meaning to illness and express themselves in relation to it. Men and women, and people over the age of 50 years and under the age of 20 years, although from the same city or region, will generally belong to distinctive subcultures: they may share certain core beliefs, values, and customs, but not others. Another fundamental influence on disease risk, health behaviors, and familiarity with biomedicine is degree of acculturation. One’s neighborhood of residence, with its quality of housing and schools, population density, associated level of crime, and access to public transportation, also dramatically shapes one’s understanding of the world and strategies for dealing with adversity. Religion, spirituality, and membership in a community of like-minded believers also have significant bearings on attitudes toward health and illness. Historical experiences of racism can engender feelings of helplessness, anger, and distrust that may, in turn, significantly affect attitudes toward medical providers as well as interpretations of illness. Finally, the elements of social class—education, income, and occupation—have a profound influence on beliefs about illness and opportunities and strategies for restoring health.

The attributes of social location are more complete, specific, and clinically relevant than race and ethnicity alone. In this way, a clinician will not simply note that a patient is Latino, or even Mexican American, and then attempt to remember “typical” cultural traits that apply to members of this group. Instead, they will observe that the US-born patient is 20 years old, unemployed, has completed high school, speaks little Spanish, and lives with her Mexican-born, primarily Spanish-speaking, rural-origin parents in a mixed race, working-class neighborhood. Each of these characteristics, alone and in combination, provides important clues about this patient—clues that help in interpreting the patient’s statements and symptoms and that facilitate patient education and tailored treatment.

Of course, the more experience that practitioners have with patients from a specific, narrowly defined population or community, and the greater the language concordance between practitioner and patient, the more they are likely to become aware of the health problems and themes important to that group as a whole. The ability to communicate effectively with patients from such groups can be enhanced by spending time in the local community—in senior citizen centers, at cultural and sporting events, churches, and schools—as well as by reading relevant neighborhood newsletters, ethnographies, social histories, census reports, novels, and biographies. Although such activities and materials do not constitute the normal corpus of medical duties or references, they can sensitize the clinician to the issues that are important to patients—in their own terms and from their own points of view. Detailed knowledge of a specific population as well as the ability to communicate in the patient’s native language can also help the clinician understand not only the literal sense of a patient’s words, but also other kinds of meanings contained in what the patient says (or chooses not to say), and in what the patient does (or chooses not to do), such as adhere to prescribed treatments.

Recent immigrants bring a number of unique issues and challenges to medical cross-cultural communication. Relocating to a new country often results in dramatic alterations in social status, occupation, and daily routines; isolation from previous friendships and networks of social support; and the upending of traditional roles as older individuals rely on those who are younger to support the family, locate housing, and interpret local events. Anomie (a sense of purposelessness) and alienation (lack of feelings of belonging) can contribute to anxiety, depression, and a decreased ability to cope with the new stresses of daily life. Refugee experiences of war and natural catastrophe exacerbate these problems. The astute clinician will be aware that many individuals somatize this distress.

Recent immigrants are more likely to hold beliefs and practices that to “Western” trained physicians may seem colorful or strange. These illness beliefs and behaviors are often cited in discussions of cultural competence but are generally most applicable to elderly and/or recently arrived immigrants. Processes of globalization, including the growth of tourism, the opening of commercial markets, and the spread of popular culture from the United States and Europe, have familiarized large numbers of third-world immigrants with life in industrially advanced, capitalist societies. In addition, a substantial proportion of first- and second-generation residents quickly assimilate into US society, often because of a keen desire to “fit in” or “become American.” Even among individuals who speak English poorly, are poorly assimilated, or actively resist assimilation, many will have had a significant amount of experience with biomedicine in their countries of origin. Although they may not have previously encountered the technological and organizational complexity that characterize biomedicine in the United States, they may be familiar with its reductionistic, scientific foundation, status as a profession, and its conventions for diagnosing and treating illness. It is difficult, if not impossible, to accurately gauge a patient’s level of sophistication about biomedicine and “Western” disease categories through visual inspection or knowledge of the patient’s race and ethnicity alone; the clinician should avoid assumptions and instead learn by observing and asking questions of the patient.

Developing cross-cultural communication skills may involve a transition from having no insight about the role of patient culture on medical care; to accepting that a patient’s culturally informed beliefs, values, and behaviors have an important influence on health, disease and treatment effectiveness; and, finally, to unconsciously integrating attention to patient culture into all areas of clinical practice. Equally important, however, is that clinicians develop an awareness of their own cultures and the unquestioned assumptions that are informed by their personal histories, the nonprofessional aspects of their daily lives, and the socialization imparted by their significant, lengthy engagement in biomedical training and practice.

Focusing on “culture” primarily in relation to immigrant or minority patients may convey the notion that biomedicine is itself without culture. In fact, although biomedicine is informed by scientific knowledge (a “culture” with its own values and beliefs), it is also shaped by the politics of government funding, insurance reimbursement, rivalries among specialties, as well as by competing ideologies of profit versus altruism, changing fashions and trends, best guesses, and regional biases. Biomedicine comprises many cultural worlds and languages—primary care, cardiology, surgery; the hospital, the clinic; nursing, physicians, pharmacists; and so on—that for many patients are strange, potentially threatening, and difficult to understand. Awareness of how different kinds of patients are likely to experience and interpret biomedicine is essential to enhancing cross-cultural communication. It is equally important for clinicians to be aware of their own roles in perpetuating the culture of biomedicine, and to realize the extent to which they are both the products and practitioners of this cultural system.

Table 15-1 lists several characteristics that have been associated with biomedicine and its practitioners. Tensions and misunderstandings between practitioner and patient are often strongly rooted in many of the attributes listed under (A) in Table 15-1. Often most problematic from the perspective of patients is biomedicine’s tendency to sharply differentiate body from mind and to emphasize organic pathophysiology over the psychosocial ramifications and origins of illness. Nonetheless, many of biomedicine’s major successes have been achieved despite—or often because of—such tendencies. These are the characteristics that set biomedicine apart from other systems of healing. They are also quite resistant to change. The clinician’s goal should be to act as a cultural broker, making these features of biomedicine more accessible and understandable to the patient while at the same time exploring and attending to the psychosocial dimensions of illness from the patient’s perspective.

Individual practitioners vary greatly in the degree to which they conform to the attributes of professionalism listed under (B) in Table 15-1 (see Chapter 46). Although common, none is a predictable feature of biomedicine in the same way as those listed under (A). A central problem, however, is that many patients have difficulty understanding or sympathizing with the attributes in either category, compounding communication difficulties and leading some to hold many of the negative impressions listed under (C) in Table 15-1. This is especially true when patients desire a more personal and less professional relationship with their physicians, or when social distance compounds the patient’s feelings of powerlessness. The culturally competent clinician will understand these common features and negative patient perceptions of biomedicine, recognizing when they contribute to misunderstandings and impair a patient’s ability to feel at ease, communicate, and benefit from a biomedical approach.