We live in an increasingly diverse society in the United States, one that continues to grow because of an influx of immigrants from all over the world. For example, according to estimates from the United States Census Bureau, the U.S. Hispanic population grew 13 percent from 2000 to 2003, a rate almost four times greater than that of the general population, while the U.S. Asian population grew 12.5 percent.1 These demographic facts call for us to improve our understanding of cultural differences that can separate us from our patients, their families and their communities.
Improving cultural competency can appear extraordinarily difficult. Examine texts on medical anthropology and become lost in the intricacies of political economy, discourse analysis and ethnophysiology. Read popular works such as Anne Fadiman's The Spirit Catches You and You Fall Down and feel surrounded by a minefield of intercultural conflicts. And just try to digest the various tomes that specify the many behaviors of a seemingly unending list of ethnic groups.
Nevertheless, we contend that the basics of working across cultures are easily learned, not by an exhaustive review of attitudes and behaviors, but by reflection – both on one's self and on patients' lives, beliefs and actions. We offer below an alphabet of themes we hope will stimulate this thoughtful process.
This alphabet provides ingredients for the work, or “soup,” of cross-cultural medical practice:
A is for all. All clinical encounters are cross-cultural to some extent. Our patients bring perspectives to these encounters that are different from our own as physicians.
B is for biomedicine. As physicians, of whatever ilk, we share a distinct language, underlying beliefs and rules of conduct that bind us to the culture of biomedicine.
C is for culture. Culture is the fund of knowledge individuals need in order to behave appropriately in a given society.
D is for disease. Disease is the patient's problem from the biomedical point of view. It is something that we, as physicians, diagnose with science and treat with drugs and surgery. (For our patients' perspectives, see “I.”)
E is for environment. Physicians and patients exist in the same environment (e.g., medical offices or hospitals) for only brief moments, like the intersection of circles in a Venn diagram. Even the best of plans made there often face confounding forces in other contexts.
F is for fear. This is the central concern from which many problems in cross-cultural interactions stem. From the clinician's perspective, fear can isolate (“Why doesn't this patient act normally?”) or provoke anger (“What a difficult patient this is!”). It can trigger the same emotions in patients but for different reasons, and can forestall any efforts toward treatment planning.
G is for goals. “One step at a time” is an appropriate adage to follow in setting behavioral goals with many patients, especially those who acknowledge change only over generations, as is the case with some cultures.
H is for healing. Healing can be defined as a return to wellness or balance. It does not necessarily mean eradication of the disease process.
I is for illness. This is the patient's perspective and experience of his or her disease (see “D”). These views are influenced as much by hopes and fears as they are by folk traditions, family structure and common sense.
J is for justice. Different cultures imagine justice in different ways, for example, money, power, color, education or kindness. How do you spell justice?
K is for kinship. The family is one of the many influences on patients' cultural views and practices. While we like to define family as “a group of intimates with a history and a future,”2 others may see it more or less inclusively.
L is for language. One of the principle ways of conveying cultural attitudes is language. Manners, clothes and possessions also serve to communicate roles and rules.
M is for mensch. Patients want to be treated not as organs or diseases but as persons of “integrity and honor,” as the Yiddish word “mensch” signifies.
N is for negotiation. This is one of the many patient-centered skills that physicians can learn to use with their patients of any culture. Others include attentive listening, empathy and touch.
O is for opportunity. In a profession wedded to the appearance of perfection, practicing across cultures provides a wonderful opportunity for making mistakes. If we learn from these mistakes with grace and humility, our patients will come to appreciate us despite the gaffes we commit.
P is for personalities. Even within ethnic groups, individuals have distinct personalities that influence their outlooks on life and their behaviors. While generalizations about culturally specific behaviors can be helpful initially in connecting with patients, it is important to be sensitive to the patient as an individual.
Q is for quiet. An important skill in relating to patients of any culture is knowing when to be quiet and simply listen and observe.
R is for respect. This is the first of two pillars that support success in cross-cultural medical practice. Show consideration for patients. Hold them in esteem.
S is for scratching our heads. This skill is a useful complement to the spoken words: “I am not sure I understand. Can you tell me more about that?” This can be used either to clarify confusing responses or elicit information from otherwise reticent patients.
T is for trust. Trust is the other pillar of effective communication across cultural borders. Trust is a two-way street. To be trusted, we need to exhibit humility and kindness. We also need to demonstrate confidence in patients and their capacity to make medically related decisions. Without trust, there is no relationship and little chance for healing.
U is for understanding. In the hierarchy of understanding, physicians tend to place medical knowledge at the top. But what other people believe also matters, even if it contradicts our understanding.
V is for values. These are the core beliefs (e.g., family, honesty and respect) that form the foundation of any culture.
W is for wisdom. In the United States, medical knowledge is a highly valued commodity. But wisdom – the ability to distinguish when and how to apply one's knowledge – is generally the more honored currency across cultures.
X is for experience. This, combined with an openness to learn, is the secret to wisdom and knowing how to relate to others.
Z is for zest. When we seek enjoyment in the challenges of working with people who may think, look and behave differently than we do, we will often find satisfaction and renewed zeal for our work.
Why no Y?
It doesn't make much sense to have an alphabet without a Y. But not all interactions between doctors and patients make sense, at least at first blush. Rules are broken. Perspectives altered. Alphabets rearranged.
We hope our alphabet stimulates physicians to consider what other words might be added to the pot. For a flavor of stridency, simply replace “healing” with “hierarchy” or “respect” with “racism.” Add a dash of “freedom” to appreciate that ours is a pluralistic nation built on the opportunity to be different. Or mix in “awareness” to look at your personal involvement in clinical encounters and examine your own cultural biases.
Brokering medical services across cultural divides is an exciting and immensely satisfying venture. Ignore the attitudes, knowledge and skills reflected in this alphabet, and become both isolated and frustrated. Develop them, and savor the richness of the cross-cultural alphabet soup that results.