15: Cross-cultural Communication

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.

Communication involves the exchange, processing, and interpretation of messages—both verbal and nonverbal. In this complex process, there are myriad opportunities for miscommunication: messages can be incomplete, confusing, and contradictory; language barriers as well as emotional and physical distractions can interfere with the receipt and relaying of information; and unspoken assumptions can influence the meaning one person attributes to another’s statements or actions. Much of this takes place outside of conscious awareness. With this in mind, this section reviews three fundamental aspects of communication to which the clinician should direct particular attention: (1) attempting to understand the illness from the patient’s perspective; (2) ensuring that the patient understands, as much as possible and at an appropriate level, biomedical explanations of the illness and its treatment; and (3) guiding patients through the ritualized clinical encounter and the health care bureaucracy in ways that increase their familiarity and comfort with it.

The Patient

Barriers to health care affecting both immigrants and disadvantaged minority groups—such as lack of insurance and other financial resources, physical distance, and low literacy—often make biomedical treatment an option of last resort. Clinical consultations for such patients will frequently be more time consuming and require increased patience by the clinician. Extra effort may sometimes be needed to teach such patients to be assertive, ask questions, and raise concerns. Clinicians who treat large numbers of such patients will benefit the most from reading about and becoming personally familiar with them outside of medical settings.

Explanatory Models

Explanatory models refer to theories of disease causation, prognosis, typical symptoms, and appropriate treatment. Eliciting patients’ explanatory models of disease offers unparalleled insight into their sense of self and relationships with significant others while yielding clues about how they are likely to interpret, resist, or accept biomedical explanations and treatments. Knowledge of the patient’s perspective also facilitates the ability to ease patient fear and anxiety. Understanding the patient’s explanatory model of illness is especially important when treating potentially debilitating chronic conditions, where nonadherence is a common concern and where the psychosocial dimensions of illness loom large.

Typically, the most important component of a patient’s explanatory model is the idea of illness causation (see Table 15-2). To elicit this belief the clinician can ask, “What do you think caused your problem?” and then listen carefully to the answer as it is likely to reveal crucial feelings related to moral failings, discord with significant others, financial and practical challenges in daily life, and whether there is a sense of hope for the future. The clinician should not expect patients to answer questions about causation with simple and mechanistic explanations. Additional probing may also be required. For example, the clinician could follow up with questions, such as “What do you think you have? What is the name you give to this condition?” “Why do some people get this illness and not others?” “Who or what is responsible (or to blame) for this problem?” and “Do you ever think that you did (or didn’t do) something to bring this on yourself, or that someone else did (or didn’t do) something?” Additional questions can allow patients to elaborate on their explanatory model: “What do you think should be done to treat you?” “Do you think a complete cure is possible?” “How long will the problem last?” “What do you think needs to be done to relieve this problem?” The advantage of such questions is that they are open ended, are applicable to every patient, and can help to correct or refine initial clinical assumptions or preconceptions. They are also powerful in their ability to provide clues about what the patient may find difficult to understand or accept when it comes to explaining the illness in biomedical terms.

Some patients, especially recent immigrants, may be reticent about sharing their explanatory models of illness out of concern that their beliefs will be viewed as ignorant or superstitious. Alternatively, such patients may feel that they have come to hear the doctor’s expert opinion, and that their own perspective is of little consequence. It is sometimes prudent to allow patients’ explanatory models to emerge slowly, through gentle probing, over the course of several visits. Inference combined with direct questioning (e.g., “other patients believe X, what do you think about this?”) and background knowledge of the patient’s social location will often be necessary to form a coherent picture.

Shared Decision Making

Patient centeredness and involving patients in complex decisions about their health care are important goals in medical care; however, it is still the case that most medical decisions are made by physicians with little input from patients or families. In shared decision making, a patient and clinician work together to evaluate trade-offs based on the patient’s values and preferences in light of the risks and benefits of various treatment options. Shared decision making is most important for preference-sensitive conditions in which there are at least two legitimate treatment options available but each has different levels of risk or types of side effects.

Imparting accurate information about the nature and course of the disease, framing numerical risks, and eliciting a patient’s outcome preferences are all important for shared decision making. Successfully sharing decisions, however, also requires a consideration of cultural influences. For example, certain patients (e.g., some older patients or patients who grew up in authoritarian societies) may not wish to participate in making a final treatment decision but instead wish to be involved only in articulating preferences and in selecting the most desirable outcome. Thus, the process of promoting patient centeredness should involve directly asking patients how involved they would like to be in decision making.

In emphasizing the importance of rational decision making, traditional shared decision making approaches implicitly stress how patients “should” behave while often overlooking how they, in fact, do behave. To address these challenges, clinicians should strive to meet patients closer to where they actually begin the decision-making process. Eliciting patient explanatory models may allow patients and clinicians to consciously recognize and correct misconceptions. Sources of patient fear can be elucidated and, where possible, reassurance can be offered. Patients can also be asked to recount stories about other people who faced similar illnesses so that their attitudes and perceptions can be clarified and they can be helped to understand key differences between these stories and their own circumstances.

Sometimes there is medical uncertainty about the value of a medical test or intervention (e.g., prostate-specific antigen [PSA] screening), or there may be more than one treatment option, none of which is clearly superior in terms of prevention, cure, or control of symptoms, but each of which differs significantly in terms of cost or in the likelihood of various adverse effects on quality of life. In these instances, before taking action the clinician should attempt to gauge both the patient’s desire for information as well as preferences for decision making. Studies have shown that most patients wish to be “maximally” informed about their diseases as well as medical treatments and evaluations, but there is variability in their desire to assume or share responsibility for making actual treatment decisions. Only through probing is it possible to determine how much information patients want and how much they want to share in the decision-making process. Providing too much information or attempting to make the patient accept responsibility for a medical decision can be counterproductive, but so can an approach that is overly paternalistic. One strategy is for the provider to state that there is a choice and perhaps some medical controversy or uncertainty; briefly mention the pros and cons of each option; elicit patient outcome preferences; and then wait for the patient to ask for more details, voice concerns, or express a preference.

Fatalism

Members of some groups, including many immigrants, may seem to be fatalistic in their attitudes toward illness. They may be passive about seeking treatment, persist in unhealthful behaviors, or accept misfortune because they believe it is preordained. It is important not to assume that this style of explaining and dealing with illness is indelibly rooted in the culture or religion of the patient’s racial or ethnic group. In fact, fatalism is widespread and is common among people who have little control over the circumstances of their lives. It also emerges out of a kind of valid logic that observes that serious illness can befall even those who have no bad habits and live a “clean” or “virtuous” life. Fatalism does not usually imply a lack of interest in preventing or treating disease. Rather, it can be viewed as an idiom for describing a person’s perceived powerlessness in the world, lack of hope, and even distrust. The doctor can approach this problem by acknowledging the real challenges the patient faces, and by clearly articulating the practical steps the patient can take to resolve or manage the illness.

The Passive Patient

Some immigrants and older patients may be exceptionally reserved or deferential in clinical interactions, often preferring to avoid direct eye contact. The clinician should not assume that such patients are shy, uninterested, unintelligent, or uneducated simply because they avoid eye contact, agree with everything the doctor says, express a great deal of uncertainty about instructions, or are not forthcoming with information. In these circumstances, the clinician should speak clearly without reverting to an overly simplistic, commanding, frustrated, or patronizing tone of voice. Further clinic visits and gentle elicitation of questions and concerns may be necessary before the patient begins to interact more openly. The patient’s behavior may reflect not only cultural norms toward those in authority, but uncertainty, fear, the expression of trust through passivity, or a desire to attain a better impression of the clinician before revealing intimate details.

Interpreters

Trained medical interpreters can greatly facilitate patient–clinician communication and improve quality of care. Unfortunately, perhaps because of economic constraints and clinicians’ beliefs in their own ability to simply “get by,” well-trained interpreters are underused in many medical settings, with negative consequences for patient care. For example, although clinicians with some ability in conversational Spanish may assume they understand a Puerto Rican patient’s use of the term “ataque de nervios” (literally a “nervous attack”), the patient is actually referring to a culturally specific syndrome with identifiable precipitants and clear symptoms that has little to do with a “nervous breakdown.” Although family members often act as de facto interpreters, this can also introduce problems. For example, a relative who “already knows” what is wrong with the patient may not wish to bother the physician with the full details of the patient’s complaints, thereby omitting important symptoms. Children and adolescents are inappropriate interpreters for many reasons, including an often incomplete mastery of English, insufficient knowledge of the subtleties of translation, and issues of relationship and status.

Trained medical interpreters can provide more than literal paraphrasing: they can serve as ‘cultural interpreters’ by explaining patient’s illness labels and idioms for the practitioner, and translating biomedical concepts and instructions into the patient’s vernacular. Interpreters should be treated as full members of the health care team. Prior to the interaction, the clinician may want to meet briefly with the interpreter to review the goals for that discussion (e.g., addressing the patient’s understanding of and compliance with a particular medication). In addition, the clinician should periodically stop the interview to seek clarification from the interpreter: “The patient has mentioned ‘nerves’ a few times. I was assuming that she felt nervous, but now I’m not so sure. Could you explain to me what she means?”

When using an interpreter, it is important to consider the physical arrangement of the participants. The clinician should always face and speak to the patient directly. The interpreter can sit next to the physician (though some patients may find this arrangement threatening), or the patient and interpreter can sit side by side. Some clinicians prefer the traditional triangular arrangement so that all parties have equal space and symbolic power, but the easy flow of conversation may be compromised as patient and provider often cannot resist the impulse to direct their attention toward the interpreter instead of toward each other.

The Clinician

Understanding illness from the patient’s perspective—traditionally regarded as the essence of cultural competence—must be balanced by the equally important task of knowing how to communicate biomedical explanations about the disease and its treatment to the patient (i.e., serving as interpreter of biomedical culture for patients). The desire for such information is usually one of the patient’s primary motivations for visiting a doctor. The clinician should offer explanations in terms the patient can understand and then gently test this understanding.

Naming and Explaining the Disease in Neutral Terms

Naming a disease helps to transform a patient’s inchoate fears into something that can be perceived and addressed directly. Speaking about disease in neutral and mechanistic ways can also dispel feelings of shame and ideas about etiology that are rooted in personal weakness and social failure. Patients will often seize upon, and benefit from, explanations that appropriately relieve them of personal responsibility for their misfortune. Giving a specific name to a disease and explaining it in neutral terms should be regarded as one of the primary goals of communication. Reaching this point, of course, may depend upon an initial period of testing and observation.

Medicalization

Although reductionistic disease labels and explanations are often helpful, they may contribute to the medicalization of conditions whose etiologies reside in adverse environmental (e.g., polluted air and water) or social circumstances (e.g., racism, intimate partner violence, sexual abuse, and work-related stress). In other words, defining illness entirely in terms of how it adversely affects the body can direct attention away from other, more fundamental causes. It is important to remain mindful of, and at times acknowledge, the broader context that gives rise to the illness. This is often very difficult for physicians to do, in part because they are not trained to recognize these links and are limited in their ability to resolve problems such as poverty, unemployment, poor housing, or lack of education and opportunity. For example, declaring that a patient’s asthma is made worse by living near a factory from which, for economic reasons, the patient cannot easily move away may imply that nothing can be done about the problem. Nonetheless, awareness of such constraints can help the clinician to better understand and sympathize with the patient and tailor therapies that are realistic and appropriate. In addition, it is extremely common for patients of all backgrounds to believe that illness is caused by breaches in the moral order, social discord, and the failure of one’s self or significant others to fulfill expected roles. Purely mechanistic biomedical explanations cannot simply replace these types of beliefs, which tend to be deeply rooted and resistant to change. Educating the patient about disease terms and pathophysiology should complement but not supersede the importance of understanding and acknowledging these other aspects of the patient’s explanatory model.

“Blaming the Victim”

When it is possible to trace the etiology of disease to potentially destructive personal behaviors, such as “risky” sex, smoking, alcoholism, and drug abuse, or the worsening of disease to medical nonadherence, two pitfalls should be avoided. One is emphasizing personal culpability at the expense of helping the patient to understand the nature of the disease itself. Without adequate education, patients may have a difficult time perceiving the relationship between their behavior and the outcomes these generate, and will therefore see less reason to make changes. Although it is important to stress that certain habits are harmful and should be altered or discontinued, this should be done in a straightforward and nonjudgmental manner. The second pitfall is failing to acknowledge the personal situations and social contexts that contribute to or sustain these behaviors. Low self-esteem, depression, chronic pain, social isolation, lack of “legitimate” employment, and a strong desire to experience a sense of social belonging can contribute to many varieties of harmful and risky practices. To the extent possible, clinicians should attempt to determine the factors that perpetuate or encourage harmful behaviors and discuss these with their patients in an open and frank manner. Doing so will demonstrate empathy and concern, and help patients understand how their behavior (arising as it might for understandable reasons) should nonetheless be modified, and how this might be achieved.

Communicating Bad News

Naming the disease is a cornerstone of communication in the biomedical model. However, a more flexible approach to informing patients of their diagnosis is often appropriate, particularly when the diagnosis is cancer or a terminal illness. Knowledge of a patient’s social location and explanatory models of illness (including cancer), as well as in-depth questioning of the patient and family, will provide the best understanding of cultural differences and preferences. Chapter 3 offers a more complete discussion of this topic.

Evidence-Based Medicine and Minimizing the Overuse and Misuse of Clinical Services

Promoting clinician stewardship over limited health care resources and ensuring the delivery of cost-conscious, evidence-based care have become increasingly important as health care expenditures have risen to unsustainable levels in the United States. Influences that promote the overuse and misuse of clinical services include financial gain for clinicians as well as defensive medicine (ordering tests, procedures, or visits primarily in order to reduce perceived exposure to malpractice liability). Patient expectations—shaped by clinicians themselves, the popular media, direct-to-consumer advertising, and anecdotes of friends and family—are also important drivers of medical overuse. It can be a significant challenge convincing patients that more care, more expensive care, or even the latest technology do not necessarily mean better care, especially because unmet expectations for care can be associated with less patient satisfaction and reduced intentions to adhere to prescribed therapy. Nonetheless, evidence-based practice often depends on a clinician’s ability to elucidate patient expectations that are unrealistic or not medically valid, the beliefs and worries that underlie these, and then on an ability to engage patients in conversations that educate and, where possible, reassure. Helping patients to feel like they have been understood is a key way of earning their trust and realigning their expectations.

Psychiatric Diagnoses

For patients of many backgrounds, profound stigma is often attached to behavioral and psychiatric diagnoses. Labels such as “depression,” referrals to psychiatrists, or prescriptions for “mind-altering” medications may be strongly resisted, interpreted as insulting by some, and may severely compromise the practitioner–patient relationship. For such patients, somatization is often the most “legitimate” way of expressing distress. If there is any doubt regarding the patient’s perception of psychiatric labels and referrals, the clinician should carefully explore the meanings that patients and their families attribute to them.

Patient Interpretations of Acute Illness, Chronic Illness, and Preventive Medicine

Many patients do not clearly differentiate acute from chronic illness, nor do they make distinctions among curing, managing, and preventing disease. Commonly, they assume that symptoms or diseases are self-limiting or curable with a single course of therapy. This can frustrate the clinician’s ability to provide education and can contribute to poor adherence. If in doubt, the clinician should determine whether patients believe a cure is possible (not generally the case with chronic illness) or whether patients believe the absence of current symptoms implies the absence of future disease (suggesting poor understanding of preventive medicine). Gently correcting patients’ misconceptions should be viewed as an ongoing process that takes time and bears repetition.

Patients with Poor English Literacy

It is estimated that up to 21% of American adults are functionally illiterate and many more are only marginally literate, limiting their ability to understand medical information and engage in meaningful discussions with their providers. Feelings of embarrassment may lead patients to conceal this problem. Strategies for managing such patients include speaking slowly, using simple terms, targeting written materials to at most a fifth-grade reading level, and using clear pictures and diagrams whenever possible. Instruments such as the Test of Functional Health Literacy in Adults (TOFHLA) can provide rapid estimates of the ability to read and comprehend common medical and lay terms. Such tools can assist clinicians in tailoring both written and spoken information, and are probably more accurate at assessing the patient’s reading and numerical skills and ability to function effectively in health care settings than subjective clinician impression alone.

Reviewing Medications

Failure to discuss medications is one of the most frequent lacunae in practitioner–patient communication. Misunderstandings and fears about medications are extremely common and are major contributors to nonadherence. Pharmaceuticals, however, are generally the most tangible and therapeutically important products that result from the clinical encounter. Special care should therefore be given to explaining their purpose, mechanism of action, and common side effects. Eliciting patient concerns and questions to uncover erroneous beliefs is also important. This is particularly likely to benefit patients who are reticent or unable to express these concerns on their own.

Sometimes it may be helpful for clinicians to personalize information by acknowledging common challenges they face in educating and treating patients.

This kind of approach may help some patients to understand and sympathize with the challenges faced by the clinician, promoting a sense that the two are allies in achieving a common objective.

Assessing Patient Understanding

To ensure that biomedical explanations are correctly understood, the clinician should ask patients close- and open-ended questions about their disease process and ask them to repeat instructions. For example, “Tell me what you understand about the cause of your diabetes and what you think will happen if we cannot adequately control your blood sugar. How often should you check your blood sugar? What should you do if you feel light-headed and sweaty?” Such checks will help to reinforce knowledge and understanding and identify areas that benefit from further counseling.

The Clinician as Cultural Broker and Institutional Guide

As described above, cross-cultural communication is enhanced by attention to patients’ social location because it allows provisional inferences to be made about how patients, as individuals, are likely to interpret and respond to their illness. Initial clinical impressions are then modified by eliciting patients’ explanatory models of illness. This information helps to tailor communication regarding the biomedical perspective. Finally, communication is further enhanced by understanding how patients perceive key features of the clinical process and by guiding them through its ritual and bureaucratic aspects.

Clinical Rituals

Repetitive and predictable patterns and rules circumscribe patient–clinician interactions. In the ambulatory setting, for example, the nurse measures the patient’s blood pressure and then brings the patient to see the physician, who directs the proceedings according to a predefined format of greeting the patient, asking questions in a certain order, examining the patient, and offering explanations and recommendations. The patient is given a specific place to sit and generally knows that the consultation will last a fixed amount of time. In the hospital, the medical team rounds in the morning and obtains a standard template of subjective and objective information. The basic format of these rituals is fairly simple and can be readily learned by patients and by the new initiates into the profession.

Such ritual aspects of medicine can both facilitate and impede effective communication. For example, consistency minimizes confusion about what is acceptable and unacceptable and about what will happen. Ritual offers a sense of security when patients are undressed or are sharing personal information. The ground rules and scripts of ritual are translatable from one setting to another and operate even if practitioner and patient have never met. They allow the involved actors to focus greater attention on the content of their exchanges and, in themselves, these rituals can be comforting and even therapeutic.

On the other hand, rituals can impair communication if patients and practitioners differ in their expectations about how they are supposed to work, or if rituals become inflexible, blind routines that leave little room for digression, variation, and opportunities for patients to express themselves freely and in fully emotional ways. This frequently happens when the clinician is pressed for time and wants the patient to provide the “facts” as tersely as possible, or when the patient yields all spontaneity of self-expression to the perceived all-knowingness and authority of the doctor. Ritual should not become so fixed that its participants become inflexible. Awareness of these pitfalls and the ability to make spontaneous adjustments to unspoken aspects of ritual can do much to enhance communication with the patient. Brief, unexpected, or even surprising disruptions to ritual—such as a joke, a doctor’s personal reflection, allowing the patient to shed a tear or relate a piece of medical history during the physical examination, or briefly and politely answering a patient’s personal question about the doctor or his family—can, when judiciously applied and without breaking the overall structure of the encounter, foster more effective communication and enhance the therapeutic relationship.

For almost all patients, illness is not simply an individual malady, but a social disruption that both affects and requires the involvement of significant others. The paradigmatic private, dyadic nature of biomedicine’s doctor–patient relationship can also impair communication when working with patients for whom the involvement of family members is very important. When desired by the patient, and to the extent possible, allowances and arrangements should be made to incorporate the family into diagnostic and treatment plans (see Chapter 11).

Institutional Guide

Health care is often highly fragmented. The increasingly sharp separation between hospital and ambulatory medicine, a large variety of subspecialists, and the growing importance of health care “teams” means that patients often interact with a bewildering variety of individuals whom they have never previously met and whose roles are not always apparent. Carefully guiding patients—anticipating their possible confusion, explaining the function of different health care workers, and encouraging patients to ask questions at any point during their trajectory through an illness episode—can go a long way toward alleviating their fear, misunderstanding, and distrust. Providers should be especially sensitive to immigrants and other vulnerable patients who may have a particularly poor understanding of how the health care system works. Providing education about where to report for laboratory work and procedures, when results will be returned and what will be done with these, the roles of various office staff, the hours of operation, rules pertaining to the presence of children, and so on will increase efficiency, improve patient use of resources, and also increase patient trust and adherence by demystifying what seems to be a complex and threatening bureaucracy. Of note, some patients may not wish to fill out forms because of fears of deportation; it is important to be explicit about the purpose and confidentiality of medical information.

Despite its depth of knowledge and undeniable efficacy in many areas, biomedicine is for many patients simply one healing option among many others, some of which are employed simultaneously and without apparent contradiction. If the patient wishes to discuss or solicit the provider’s opinion about other healing modalities, the clinician—unless there are concrete reasons to the contrary—should be willing to acknowledge the beneficial role that nonbiomedical approaches may have for the patient. If there are potential adverse interactions or side effects of “alternative” therapies, or if there is concern that potentially beneficial biomedical therapies might be thwarted by other types of healers, the clinician should express these concerns but should always respect the fact that patients are the ultimate arbiters regarding the healing modalities for which they are best suited (see Chapter 33).

By virtue of their race or ethnicity, patients are sometimes said to be “at risk” for certain diseases. Examples include diabetes mellitus among Native Americans, breast cancer among Ashkenazi Jews, and prostate cancer among African Americans. Particular forms of treatment are also believed to be more (or less) effective among certain racial/ethnic groups compared with others. For example, among African Americans compared with whites, it is said that the combination of isosorbide dinitrate and hydralazine is more effective for treating heart failure, angiotensin-converting enzyme (ACE) inhibitors are less effective for essential hypertension, and a therapeutic response to selective serotonin reuptake inhibitor (SSRI) antidepressants takes place at lower doses. Each of these examples is highly controversial, reflecting long-standing, often heated disputes about whether race and ethnicity are primarily social constructs or, instead, meaningful and valid surrogates for biological difference. It is beyond the scope of this chapter to summarize the elements of this debate. We believe, however, that in communicating with patients it is important for clinicians to avoid oversimplifying the relationship between race/ethnicity and genetics. Although knowledge of race or ethnicity might prompt genetic testing or detailed family history taking in particular instances, the issues are simply too complex and the evidence too uncertain in a relatively small number of conditions for clinicians to make unqualified assertions to patients that they are “at risk” for a particular illness or unlikely to respond to therapies solely on the basis of their racial/ethnic background. In very real ways, believing that one is “at risk” can unnecessarily increase stress, fear, and feelings of stigma, uncertainty, and worthlessness. When discussing with patients the possible relevance of race and ethnicity, clinicians should openly acknowledge that experts do not always agree and they should quantify and convey individual risk through a consideration of as many relevant variables as possible.

Cross-cultural communication can be learned and enhanced through reflection and practice with a variety of patients from different cultures. Biomedicine has its own distinct culture and practices that may be difficult for many patients to comprehend and access. Cultural stereotypes are rarely useful in clinical encounters; instead, clinicians should attempt to understand the social location of their patients as reflected in their race and ethnicity, gender, age, immigration status, literacy level, occupation, sexual orientation, and other characteristics. As their skills develop, clinicians will find enormous gratification in caring for patients who are very different from them.