Cultural Issues in Medical Care
Physicians, trained in the American medical system, may make assumptions
about people’s behavior that are based on American cultural beliefs, values, and
practices that are not shared by members of other ethnic groups. Familiarity with
the beliefs, values and practices of specific ethnic groups, on the other hand,
may lead to stereotyping. Culture is best used to understand behavior, rather
than to predict it, since variation within a culture is usually greater than that
between cultures. Individuals, especially those living in the United States, may
hold a mosaic of cultural beliefs. It is literally impossible to predict for any
specific individual which beliefs they will hold.
As such, a realistic goal for physicians with regard to culture is to realize that
individuals from different cultures may react in ways that are different from what
is most typical of American society, that there are ways one might try to elicit
preferences, and that it's important to try to pick up on clues that an individual or
family may have been made uncomfortable by something which the physician
might never have imagined was anything but innocuous. Generally, the more
acculturated the individual, the greater the chance that they will have adopted
more American ways. A quick measure of acculturation is English language
skills. But, again, it is impossible to predict which aspects of American culture
any specific individual will have adopted, and which aspects of traditional culture
will be retained. It is also important to remember that cultures are not static, but
always in the process of changing.
Remember: every culture has certain values, beliefs, and practices, which may
be held to a greater or lesser degree by the individual members of that culture.
Major dimensions along which cultures vary include:
Desire for information
Response to authority
Decision-making
Emotional expressiveness
Time orientation
World view/beliefs
Patient /provider relationship
Gender Roles
Communication style
Racism
Listed below are some of the variations that are found. I have listed cultures
which exhibit one aspect of the spectrum or another, but this does not mean that
individual members of that cultural group will necessarily share that cultural
pattern.
Desire for information: Some may want a lot of information; others may
want very little. Some families may want information withheld from the
patient.
 In Jewish culture, for example, knowledge is often highly valued.
Knowledge = control. (Perhaps due to a history of being asked to leave
one country or another without much in the way of material possessions.
Thus, knowledge, which can never be taken away, became highly valued.
As a result, some patients may want as much information as possible up
front. E.g., they may want to know all the side effects of different
treatments prior to receiving the results of a biopsy which may determine
whether or not any treatment is needed.

In rural Vietnamese culture, for example, verbalizing something (negative)
may be believed to increase the chances that it will occur. Thus, someone
who held this belief may not desire very much information about the
negative consequences of their condition. It also makes signing informed
consent problematical if consent covers negative possibilities.

In many cultures which value the family over the individual (e.g., many
Asian & Hispanic cultures), it is seen as inappropriate to reveal a fatal
prognosis to a patient. Instead, the information should be given to a family
member, who will decide whether or not to inform the patient. It can be
thought to create a sense of hopelessness & hasten the dying process.
Others see it as insensitive. Those who are devoutly religious may
believe that only God knows when someone will die.
A culturally competent way to deal with this issue: Ask the patient how
much information they would like to be given. Ask if they want
information about their condition to be given to them or to some other
family member whom they designate.
Response to authority: Different cultures hold varying amounts of respect
for authority
 In traditional Asian cultures, which are hierarchical, respect for physicians
is high. In order to show respect, a patient may agree to whatever the
physician says, but may not follow through. The emphasis is on showing
respect to the individual’s face.
A culturally competent way to deal with this: to increase the chances
that a patient will follow through, ask them what problems they might
encounter in adhering to your recommendation. Ask them if there is
anything you can do to make it easier for them to adhere. Ask if they’ve
ever known anyone who did what you ask who later had problems as a
result. In other words, try to find out what concerns they may have to
adhering.

In many cultures where there is respect for authority (.e.g, many Asian
and Hispanic cultures) individuals may indicate comprehension &
agreement when it is not present. This can also be true in order to avoid
the shame of not understanding something.
A culturally competent way to deal with this: be sure to ask open-ended
questions to ascertain whether or not the patient truly understands what
you have said. Don’t rely on a yes or no response.

In cultures where there is an emphasis on individual autonomy (e.g.,
Anglo American & African American cultures since the baby boom
generation) individuals may openly challenge the physician.
A culturally competent way to deal with this: make the patient a partner
in the decision-making process. Ask what problems they might encounter
in complying. Ask them if there is anything you can do to make it easier
for them to comply.

In cultures where social status is highly valued (e.g., many Middle Eastern
cultures), individuals who share this value may insist on speaking with the
“top man.” Males may also be preferred since males have higher status
that females.
A culturally competent way to deal with this: this is a tricky one. One
way to deal with it is to emphasize your knowledge and status with regard
to the particular issue. Another way is to make a referral.
Decision-making:
 In cultures where an egalitarian social structure is seen as the ideal, even
if it is not the reality (e.g., Anglo American culture), individuals may want to
be a partner in making decisions about their own life & health. Since this
is in alignment with the values of the medical profession, it should not
pose a problem, except among more authoritarian physicians.

In some Arab cultures, it is believed that since the physician has the
expert knowledge, he should take responsibility for making the decision.

In hierarchical cultures (such as many Asian cultures) where the physician
has a great deal of authority and often acts in a paternalistic manner,
some patients may expect to be told what to do.

In cultures where relative sexual equality exists, at least as an ideal (e.g.,
Anglo American culture since the feminist movement) women may feel
comfortable making decisions by themselves.

In cultures where men are dominant (e.g., many Hispanic, Asian, & Middle
Eastern cultures), traditionally oriented women may defer decision-making
to their husbands, whether it be for themselves or their children. (In many
Middle Eastern cultures, which have a patrilineal kinship organization,
chidlren “belong” to the father, not the mother, and thus it is appropriate to
defer to the father.)

In cultures where the family is the primary unit (e.g., many Hispanic and
Asian cultures), individuals may prefer to have decisions made by the
family, rather than the individual.

In Romany (“Gypsy”) culture, where the clan is the primary unit, and
decisions may be deferred to clan elders.
A culturally competent way to deal with this: when decisions need to be
made, ask the patient how they would be most comfortable arriving at a
decision. Do they want to consult with family members. Sometimes the
physician must be willing to take a more active role if the patient wants
that. One study (Browner, et. al. 2003) indicated that Mexican patients
interpreted the shared decision-making approach of the physician in
determining whether or not to get prenatal testing as an indication that
it wasn’t important. “If it were important, he would have insisted upon
the test.”
Expression of emotions: Different cultures allow or encourage a greater or
lesser expression of emotion; individuals vary along these lines as well.
 For example, most Asian cultures – especially Japanese—see emotions,
particularly negative ones, as something private and not to be shared with
strangers. Native American, Northern European, and American WASP
cultures tend to encourage greater stoicism and emotional control.

Many Hispanic, Middle Eastern & Southern European cultures allow more
emotional expressiveness in their members.
A culturally competent way to deal with this: make no assumptions about
an individual’s level of pain or distress based upon their verbal
expression. Do not make the mistake of ignoring, for example, a Middle
Eastern woman crying out in pain by stereotyping her as “just another
Arab woman exaggerating her pain.” Her expressiveness may indicate a
serious problem. Nor should you make the mistake of assuming a
Japanese patient is not in pain, simply because he is quiet.
Time Orientation: planning ahead
 Many individuals who are either poor or come from 3rd world countries
tend to be present oriented. Poverty often forces one to live in the
present; planning for the future is a luxury of wealth. This may impact
their health care behavior; if they feel fine now, they may resist preventive
care. They may not want to know what the future holds (in terms of
genetic testing) because the future is not as real to them.
A culturally competent way to deal with this: When it comes to
preventive behavior, this may require more patient teaching. In terms of
genetic testing, see below.

Middle and upper class individuals from 1st world countries tend to be
future oriented and may be concerned with the future. They may be more
likely to want to know whether or not they have a genetic disease which
could manifest sometime in the future, so that they can plan their life
around knowing.
A culturally competent way to deal with this: First, make no assumptions
as to whether or not someone would want to know their genetic risk of
getting a disease. Second, ask whether or not they want to know. Third,
do not impose your own biases on them. Some people may want to know
only if they can change the outcome, and if it cannot be changed, they
don’t want to know. Others may want to know because the knowledge will
lead them to make different life choices.
World View: controlling nature
 Some cultures, particularly those that are industrialized, manifest a belief
that humans can control nature. This is reflected, for example, in the
American assumption that given enough time and money, any disease
can be cured. An individual holding such a belief may be more likely to be
proactive in their health care.

In contrast, in cultures with a particularly harsh environment, or where
there is much poverty, people are more likely to take the attitude that
humans are powerless against the forces of nature and the supernatural,
except as their prayers & beliefs can cause higher forces (e.g., god(s)) to
act on their behalf. This is reflected in such sayings as, Que será, será
(Hispanic – what will be, will be). Bahala na (Filipino – what will be, will
be). Inshallah (Arabic – God willing). Although individuals who hold such
a belief may have less faith in scientific medicine to provide a cure than
someone who believes that we can control nature, they may also have
more hope if they are religious, for in most religious traditions, God can
cure anything. Such a belief may also develop as a result of life
experiences and can be found among individuals of any culture.
A culturally competent way to deal with this: it may be especially
important to address the patient’s spiritual needs. Encourage prayer
when appropriate. Consider involving religious practioners in the decisionmaking process.

Another perspective is one held in cultures where people have traditionally
lived close to the land. This is the view that humans are a part of nature.
It is not unusual to find such a belief in Native American cultures and
Chinese culture. Disease may be interpreted as a lack of balance
between natural forces (yin/yang in Traditional Chinese Medicine; hot/cold
in many Latin American systems). Individuals who hold such a view may
prefer natural, herbal-based remedies.
Patient/Provider relationship: the expected nature of the relationship
between provider and patient may vary according to culture.
 One dimension along which this may vary is related to degree of personal
familiarity – e.g., many Middle Easterners may expect a personal
connection with their physician. Providers often have a close, warm
relationship with family, & get involved in their personal life. That kind of
relationship is often seen as unprofessional in the US, and thus American
health care providers may be perceived as cold and uncaring to someone
who expects personal involvement.

American physicians are trained to ask many questions of their patients. It
is a way to gain information and to develop rapport. In some cultures, for
example some Native American and Asian cultures, the “competent”
physician will know through observation and intuition what is wrong with
the patient. Only the “incompetent physician” will ask a lot of questions.

In some countries, such as the Philippines, it is seen as inappropriate for
nurses, for example, to ask any personal questions of the patient. They
are not trained nor are they expected to deal with psychosocial issues.
That is the job of the family, and it would be seen as intrusive on the part
of a nurse. Nurses from such a background may sometimes be perceived
by American patients as “good at providing technical care, but cold &
unfriendly.” From the perspective of the nurse, her behavior is
“professional.”
A culturally competent way to deal with this: If you are having trouble
developing rapport with your patient, it may be because you are perceived as
either uncaring or as too intrusive. If you are comfortable doing so, you may
want to adapt your style to show more or less familiarity. There is not too
much that can be done with regard to asking “too many questions” other than
have an assistant ask them.
Gender Differences:
There are numerous issues raised by gender differences in various cultures.

Gender of the physician: In some cultures there is strict sexual
segregation (e.g., Muslim and Orthodox Jewish cultures).
A culturally competent way to deal with this: female patients should be
treated by female physicians and male patients by male physicians
whenever possible. Rules against opposite sex touching and eye contact
may impede good health care delivery. If it is not possible, respect
requests that male physicians where gloves when treating a female
patient, and that the woman be kept covered.

Gender preferences: In some cultures there is a strong preference for
one sex over the other, due to the role of one gender in carrying on the
family name or providing for elderly parents. In most cases, if one sex is
preferred, it is usually the son. In countries such as China, which has a
one-child-per-family policy, this has led to an increase in abortion and
infanticide of daughters. If a child is born with ambiguous genitalia,
parents may be biased toward raising the child as a son.
A culturally competent way to deal with this: Ask the patient if they have
a preference for a son or daughter. In the case of a child with
ambiguous genitalia, a great deal of explanation may be required if you
think it is best to raise a child as a daughter.
Communication Styles:
 While many individuals may prefer direct communication, some may
prefer an indirect approach. For example, among traditional Navahos,
there are many taboos, which can make direct communication
problematical.
A culturally competent way to deal with this: If you have a Navaho
patient who appears traditional in dress, talk in the 3rd person. For
example, rather than say, “X will happen if you don’t do Y,” say you knew
someone who didn’t do Y, and X happened. It’s safest to present
information by telling a story.
Fear of Racism
 It is not uncommon for individuals who belong to oppressed minorities to
show a lack of faith in the American medical system, which is largely
perceived as a white institution. A long history of racism and daily
experience of discrimination have left many African Americans, for
example, with a highly sensitive “radar” for racism. Many suggestions on
the part of white physicians may be seen as racially motivated, even when
they are not.
A culturally competent way to deal with this: Be especially sensitive to
how your patient may perceive any suggestions that could be interpreted
as racially motivated. E.g., suggesting a woman with ten children limit her
fertility may be seen as rational and objective by the white physician
suggesting it, but be interpreted as a plan of racial genocide by the
African American patient. Preface any such suggestions with your
reasons for suggesting it.