Every clinical encounter is influenced by three cultures: the patient’s, the clinician’s, and the culture of medicine. Each person’s culture is also shaped by many factors – their place of origin, education, religion, race, gender identity, ethnicity, sexuality, profession, and so on. Cultural practices and beliefs are dynamic and ever changing, and most people participate in multiple cultures simultaneously.

Culture can be defined as the shared language, practices, visible and invisible routines of a social grouping.Given this complexity, our goal as physicians is to approach clinical encounters with cultural humility and to create a space of cultural safety.  Cultural humility is a life-long approach acknowledging that we as providers have limited knowledge of our patients’ beliefs and values and must bring curiosity, empathy and respect to every encounter. Within this construct, we engage in self-reflection to increase awareness of our own assumptions and prejudices, and act to redress the imbalance of power inherent in provider-patient relationships.

Cultural safety describes “an environment that is spiritually, socially and emotionally safe, as well as physically safe for people; where there is no assault challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience of learning together.”

Cultural competence is an earlier approach that emphasized knowledge about other cultures and cultural practices and implies that “mastery” of others’ culture is possible. While it’s helpful to know some general information about shared values, language, and practices within specific communities, remember that, for individuals, many separate identities intersect (e.g. eldest child, Vietnamese-American, lesbian woman, lawyer).  It is important that we avoid generalizations. There are inherent problems in trying to stereotype or generalize about an entire culture (e.g. not every American likes apple pie and baseball), leading to the shift toward cultural humility.  As a practice, we should work to recognize our biases and challenge ourselves to get to know our patients’ stories more deeply to better understand their self-identified cultures.  Genuine curiosity and a willingness to ask about the details of a patient’s life can help us avoid making assumptions about patients based on their ethnicity or race or other visible identifiers.

Part of the process of providing cross culture care is to recognize and reflect on our own cultural beliefs, values, and behaviors in addition to those of the culture of medicine and how these influence clinical encounters.  Empathy, curiosity and respect are fundamental to providing effective care for all patients.

Introductory reading

Cross-cultural care is based on the universal principles of patient-centered care: providing care that is respectful of, and responsive to, individual patient preferences and needs and ensuring that patient values guide all clinical decisions. Exploring the meaning of illness, understanding the social context of the patient and illness, and engaging in negotiation take on particular importance when our patients’ culture is very different from our own.

Before our workshop on this topic, please read this excellent chapter from UpToDate:  Cross-cultural care and communication.  UpToDate 2021.  It reviews the literature on disparities created by differences in culture and language, identifies common issues in cross-cultural care, and recommends strategies and questions you might use in cross-cultural encounters.  Important considerations for clinical encounters – as framed in the chapter- are summarized below for your later review.

Common issues that arise in cross cultural encounters

Styles of Communication

Verbal and nonverbal communication, levels of assertiveness and how much information should be shared can differ across cultures.  For example, in some cultures direct eye contact is a sign of respect while in others it may be avoided.  Preferences for personal space and touch also differ. Be aware of your own tendencies, be sensitive to the preferences of your patients, and adapt your style to fit your patient’s needs.

• Adapt your use of touch and personal space to patient preferences
• Use open-ended questions to draw out indirect or reserved patients.
• Don’t assume that a lack of resistance means agreement
• Recognize that people may differ in expression of pain – some more stoic, some more expressive – and avoid judging based on your own cultural perspective.

Mistrust

Mistrust of the healthcare system or providers is common and negatively impacts patient satisfaction, adherence and clinical outcomes. Watch for cues that may indicate some degree of mistrust and explore these concerns with respect and empathy. You may learn something that allows you to provide much better care.

• Discuss mistrust openly if your patient is receptive
  • “You’ve mentioned that you don’t really like coming to doctors.  Was there any bad experience or concern that leads you to feel that way? 
• Reassure of your intent to help
• Communicate clearly – listen carefully, avoid jargon, check in and adjust.
• Explore the patient’s perspective
• Build a partnership, emphasizing options and control over healthcare decisions.

Decision-making and family dynamics

In the United States, the culture of medicine emphasizes autonomy in the medical decision-making process.  Autonomy is not the norm in all cultures and family members or others may be very involved in the decision making process.  In some situations, family members may wish to exclude patients from decisions or may choose to withhold a terminal diagnosis from a patient in order to prevent undue stress. This can be hard when the predominant culture emphasizes that the patient “has a right to know.”

• Introduce yourself respectfully to everyone in the room and determine their relationship to the patient. In some cultures it may be appropriate to only speak to certain individuals.
• Determine whether patient prefers autonomy or would prefer to have family or someone else involved in medical decision making.
  • “How much do you want your family/loved ones to be involved in making decisions regarding your health care (such as tests and medications)?”
• If your patient prefers that others receive information and make decisions on their behalf, consider allowing them to waive their rights to know.  Legal documents are sometimes signed in this situation.
• Find out if there is an authority figure in family or social network to involve in important decisions.
  • “Is there someone in particular whom we should talk to about your health besides you, someone who makes decisions in your family or community?”
• If family members or other decision makers are not allowing direct communication with the patient, explain the situation tactfully. If this was not helpful, you may need to find ways to obtain information directly from the patient attempting to not offend the relative or decision maker.  Remember to assess for intimate partner violence and if this is a concern the laws protecting the patient should supersede issues of cultural sensitivity.  We will be addressing intimate partner violence in a separate workshop.
  • “I appreciate what you are saying Mr/Mrs/Ms _____, your input is very important. From a medical standpoint, though, it is also very important for me to hear a description of the problem from the patient themselves, so I can make a more accurate diagnosis.”
• In many cultures/families having multiple family members at the bedside while in the hospital may be typical.  Negotiate openly with the staff on ways to accommodate this request while maintaining ability to provide safe care.

Traditions, customs, religion and spiritual beliefs

These may play a significant role in health and illness. These may include but are not limited to religious customs, spirituality, folk remedies, and dietary practices.  It is impossible to describe or be familiar with all of these customs however it is necessary to have an awareness of their importance and an openness to explore them further with individual patients.

• “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?”
• “Some patients have spiritual or religious beliefs that prevent them from having certain tests or treatments, such as blood transfusions.  Do you have any specific concerns or beliefs?”
• How important are these beliefs to you, and do they influence how you care for yourself or what type of care you might receive?”

Sexual and gender issues

Gender roles are strictly defined and enforced in many parts of the world.  In some cultures the male role may be seen as the protector and spokesperson for the family.  Issues that may arise include the provider and patient being of different (or same) gender. This can be particularly challenging when addressing sensitive topics such as sexual health or performing the physical exam. Being open to understanding the different ways that your patient and their families view gender roles is important and to try and accommodate them when feasible.

• Familiarize yourself with different ways that patients and families/loved ones may view gender roles. Try to accommodate when possible
  • “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 is unlikely to change a patient or loved ones behaviors or value but it can compromise the clinician patient-relationship and impair the ability to provide good care.
• Ask patients/family/loved ones about what is acceptable to them rather than making assumptions based on limited information.
  • “I perform breast exams on all of my female patients to look for signs of breast cancer or other problems. Is that okay with you?”
• Some topics such as sexual health can be particularly sensitive to discuss openly. Explain why it is important to ask about these personal issues so as to have a better understanding of their health care issues or needs.
  • “I generally ask all patients about some very personal matters at this point, which are important for doctors to know about as we consider your health.  Are you comfortable talking about these things with me?”
• Views and language regarding sexuality and sexual orientation may differ.  Ask patients about the sex/gender of their partners rather than whether they identify as gay, bisexual, etc.
• Be open to and learn the terminology that your patients use when their gender identity may not fit into binary male/female categories.

Exploring the meaning of illness

As consumers of healthcare, we all come with certain beliefs about the cause of our symptoms, concerns about treatment and treatment expectations.  Eliciting a patient’s understanding or attribution of their illness can impart considerable insight and help to develop a treatment approach that fits your patient’s beliefs and needs and will likely improve adherence.  Challenging yourself to ask the following questions during all clinical encounters is a great place to start.

• “What do you think is going on (or causing your symptoms/the problem)?”
• “What are you most worried about/concerned about /afraid of?

Determining the social context

A patient’s illness does not occur in isolation. It is intricately linked to the individual’s social environment.  Three particularly important aspects to consider include a change in environment; literacy and language; and life control, social stressors and supports.

Migration from any location to a new environment is stressful whether this means moving to a new country, city, town or neighborhood. The reason for migration may add another level of stress if patients were forced to move due to persecution or torture, loss of job, intimate partner violence among other reasons.  These migrations may also involve a change in economic or professional status.  Not only can it be challenging to learn to navigate an unfamiliar medical system, often in a different language, but patients may also be suffering psychological consequences from the stress.

Assessing language and literacy barriers can help determine best communication practices and the appropriate resources to access.

Utilizing resources such as interpreter services for patients with limited English proficiency and eliciting the support of a cultural navigator when available can help to decrease stress and improve care outcomes and patient satisfaction. Tips for working with interpreters will be discussed in a separate chapter.

Patients may differ in the level of control they have over their environment and their ability to seek care.  Many patients may not be able to take time off work to come to a medical appointment or be burdened by the cost of medical care.  Learning about patients’ levels of social support or isolation is also important.  Awareness of these challenges helps when formulating a diagnostic and treatment plan and allows for the opportunity to access social services and financial supports.

Knowledge Check

Engaging in Negotiation

Exploring patients’ perspectives is a key aspect of cross-cultural communication. The art of negotiation is about developing a plan that respects patient’s values and beliefs and not trying to convince a patient to accept a treatment plan that we think is right for them that doesn’t take into consideration their perspectives.  The following steps may aid in reaching common ground. If conflict still exists after attempting this approach consider involving others who the patient trusts into the conversation.

Using the “teach-back” method to assess the patient’s understanding of their medical illness and treatment plan is particularly effective to help avoid miscommunications, misunderstandings and disagreements which can impact patient adherence and outcomes.

• “In order to make sure that we are understanding one another and to make sure I have done a good job explaining things, can you tell me in your own words what the plan is for addressing X?”

Communication and clinical decision making may be influenced by sociocultural differences between patient and provider.  Failing to recognize and understand these differences may result in provider-patient miscommunication, conflicts and lower-quality care. Utilizing the principles of patient-centered medicine when providing cross-cultural care helps to prevent these challenges and works toward the practice of cultural humility and cultural safety.

Knowledge Check

References & Resources

Betancourt JR; Green AR; Carrillo JE.  Cross-cultural care and communication.  UpToDate 2021

Stubbe DE  Practicing Cultural Competence and Cultural Humility in the Care of Diverse patients. Psychiatry On-line.  Published Online: 24 Jan 2020: doi.org/10.1176/appi.focus.20190041

Williams R.  Cultural Safety. What does it mean for our practice?  Australian and New Zealand Journal of Public Health 1999 vol. 23 no. 2 (Williams, Aus NZ J Pub Health, 1999)

“What You Don’t Know”  a segment from NPR’s This American Life. American film director Lulu Wang tells the story of an elaborate attempt to keep her Chinese grandmother unaware of her life-threatening illness.

Ted Talk “Challenges and Rewards of a Culturally Informed Approach to Mental Health”  These same approaches apply to the evaluation and care of physical symptoms as well as mental health issues.

Optional resources

To learn more about decision making and family dynamics listen to podcast This American Life: In defense of Ignorance .  Her family made this decision based on their culture and shared values, but it conflicted with Ms. Wang’s beliefs.  As you listen, consider: If you were a clinician caring for her grandmother in the US, how would these beliefs and values impact your care?  What challenges might you face?  How might you address them?