Cultural aspects of everyday life are often difficult for people of dominant cultures to discern because their practices, traditions, values, and understandings are taken for granted as the norm. For them, there’s no apparent need to examine cultural difference, and thus, no inclination to do so. In the US, middle-class European Americans are typically so unaware of their own culture they believe that American culture is a melting pot of other cultures. This misperception is further complicated by confusion over terms such as Caucasian, the dominant majority, mainstream, middle class, western, and so on. For our purposes here specifically, where we use the terms “American and American culture” we refer to “cultural ways of the group that in recent decades has held a mainstream position in North America. These are people who are primarily of Western European descent, with a social position that is often characterized as middle class on the basis of having participated in high levels of formal schooling and associated occupations.” (Rogoff 2003)

Now that we’ve established what the term American points to in this article, let’s begin to look at some specific dimensions of American culture. A dimension of culture is a recognizable point of comparison used to explain how different cultures prefer to approach and solve a universal problem. There are more cultural dimensions than we can possibly address here, so we will focus on a few that seem especially relevant to patient/provider interactions.

Time and Its Control

For Americans, time is a critical factor that is battled on a daily basis. We’re in an adversarial relationship to time. We talk about saving or wasting time, managing time and beating the clock. Americans invented day-timers and added the term multi-tasking to the English language. We invented fast food and made it even faster by adding the drive-thru.  Now even our pharmacies offer drive-thru pick-up.

Many of the other cultures in the world have a more relaxed view of time. In a health care setting, busy practitioners may not realize that patients from different cultures often experience the rushed pace of an office visit as disturbingly impersonal. It is important to slow down enough to exchange a few words of personal conversation with patients. Ask how their family is doing. This gesture only takes a few moments.  It puts patients more at ease so they can respond more openly to medical questions. If the doctor is in a big hurry, patients won’t ask for clarification about treatment and medications. Establishing a conversational style also helps providers introduce conversation about cultural beliefs around illness which can be very important in diagnosing and achieving patient compliance. Physicians will succeed best with patients from different cultures when the care and the cure are experienced as inseparable.

Task vs. Relationship

Very closely related to time control is the American tendency to focus on getting things accomplished, so much so that building rapport with people gets overlooked. In more traditional cultures people focus on establishing rapport first and ensuring harmony in interactions with others. In health care settings, building trust between patient and doctor often depends on developing formal but warm interactions. In Spanish the word personalismo speaks to this balance of professionalism and friendliness. Taking a moment to ask about the family, a handshake that lingers just a bit longer than a business handshake – simple gestures such as these go a long way.

Comfort with Change

Americans are fundamentally optimistic and place faith in the future. As a young culture with few traditions tying us to ways of the past, our identity and inspiration are projected forward in time. Americans link change to progress, development, and growth. We like things that are “New and Improved!” Older traditional cultures consider change to be disruptive and unpredictable. In other words – negative. When a new medical procedure or miracle drug becomes available, Americans are likely to respond with optimism while patients from risk-adverse cultures will show pessimism.  Doctors who demonstrate balance in this area will gain the most patient confidence. Clearly risk-avoidance varies from person to person within a culture, and plenty of Americans prefer what’s safe and predictable too. But as a generalization, we in the US do tend to take chances and embrace change.

Personal Control Over Destiny

Americans tend to believe that every individual has primary control over his or her destiny. There isn’t typically a strong belief in the power of fate or karma. In many cultures there is a belief that things, including illnesses, happen for a reason and may be beyond our control. People may show a tendency to resign themselves to bad things in a way that Americans never would. “It s God’s will.”   This doesn’t mean patients/families won’t put faith in an American doctor’s medicine, but there may be surprising belief systems operating around what has caused illness or how much control they can exert on the outcome. A Hispanic mother may believe that her child has Mal d’ojo, or has been cursed with the “evil eye.” Members of the traditional Hmong culture believe a baby’s soul can be detained by a malevolent spirit called a dab causing a number of serious illnesses including epilepsy.

Self-Sufficiency

Closely related to the American emphasis on individual control over destiny is the value of being self-sufficient. To succeed without depending on others shows supreme self-determination, self-reliance, and self-confidence. The concept of being self-sufficient, however, doesn’t translate into all languages and the trait is not valued in many other cultures. People from Hispanic and Asian cultures, who have strong attachment to families and communities, emphasize a skillful use of the bonds between families and friends when making decisions and getting things done. Interdependency is a more helpful cultural adaptation in many cultures around the world. The US health care system presents all of us with a unique set of challenges, but those who are from different cultures will really struggle to demonstrate the kind of self-sufficiency we respect in America.  The very nature of working together to find solutions means everyone – provider, staffs, patients, and their extended families – relinquishes self-sufficiency to some degree.

Status

In American culture we value the idea of equality. The quotation “All men are created equal…” is arguably the best-known phrase in any of America’s political documents. (Thomas Jefferson first used the phrase in the Declaration of Independence as a rebuttal to the going political theory of the day: the Divine Right of Kings.) Perhaps in reality some of us are clearly more equal than others, yet egalitarianism is a defining aspect of American culture and one in which we differ from other cultures that actually embrace a set social hierarchy. Americans’ insistence on collapsing social hierarchy leads to our preference for informality in social interactions, demonstrated in a well-known tendency to use first names when we address others, even with strangers. This degree of informality can make people from some other cultures uncomfortable, especially when there is a perceived status difference between people, as in patient/family/doctor interactions. It is best to rely on formal terms of address, using Mr. and Mrs. instead of first names. This will likely make people in many cultures more comfortable.

Language

Language use as a cultural dimension deserves a whole separate article, but the basics can be touched on here.

Americans are low context communicators, so the words we speak are expected to deliver everything that’s important during verbal interaction. We pay far less attention to factors such as body language and the context of what is being said. In high context cultures, gesture, body language, eye contact, pitch, intonation, word stress, and the use of silence are as important as the actual words being spoken in conversation. High context cultures tend to communicate in a less direct fashion. Americans, being low context, are comfortable with very direct speech and sometimes seem abrupt to people from high context cultures. We miss the nuances of conversation. Americans appreciate communication that gets straight to the point and tend to interrupt when conversation isn’t moving along.  People from many other cultures do not feel they have had a chance to adequately explain their concerns until they have told “the whole story.”  This is important to keep in mind when communicating with people from different cultures, especially those who are relatively new to the US. Interactions with Americans who are highly verbal and direct can be challenging for someone who is accustomed to telling a story as a way of answering a question. Americans aren’t the only direct/high context communicators in the world, but we certainly rank among them.

Individualism

Cross-cultural research shows US Americans score higher on this cultural value than any other culture in the world. All the values we’ve addressed up to this point are closely related to this one aspect of American culture. Individualism is the belief that each individual’s interests should take precedence over those of the social group. Collectivist cultures, by comparison, assign value based on the role a person plays within a group. If people were stars in the sky, being one of the seven brightest stars forming the Big Dipper would be more important to someone from a collectivist culture than being the single brightest star. In American culture, where the individual is paramount, everyone wants to be the North Star.

Individualism versus collectivism is an important dimension of culture because it affects the way people live together – for example in nuclear families or extended families – and it has many implications for values and behavior. Child rearing as a whole is handled differently in collectivist cultures. The child in a collectivist culture is seldom alone, either during the day or night. Children are reared by an extended kin group that may or may not include family like ties with persons who are not biological relatives.  Important health decisions are not made solely by an individual – parent or otherwise. In many collectivist cultures, the term “family” doctor points to a medical relationship that is indeed more like family. Several generations visit the same physician, establish rapport and hold certain expectations for interaction with their doctor. Compare this to searching for doctors on the Internet in the United States, or having to choose from an approved list of physicians in a managed care network. Feeling like an isolated stranger visiting a doctor’s office can cause great anxiety for a recent immigrant. There’s much uncertainty about how the medical system works, about insurance, about how an American doctor will relate to cultural and language barriers. All of these worries are an added burden to the actual illness that requires medical attention in the first place. So, a mother from a collectivist culture will likely bring a grandmother, aunt, or family friend for support when she visits a pediatrician. Big decisions about procedures, such as surgery, may take hours as wives ask husbands, husbands consult elder brothers, elder brothers consult the father or perhaps even a community healer. This can create confusion and frustration for western doctors, but collectivism is a deeply rooted value. The classic American individualist who stays aware of how collectivist cultures operate will be much more skillful in cross-cultural interactions.  Being group-oriented isn’t better or worse than being more individualistic. Both ways of approaching life have advantages. As with all the dimensions of cultures, awareness of difference without judgment is the path leading to happier healthier patients and successful providers.

Summary

This article has introduced six dimensions of American culture. Learning about our own cultural patterns provides us with a baseline for comparing cultures that are different. As we develop self-awareness around cultural experience, we are able to observe without leaping to judgment. We realize there’s a difference between what we actually observe and how we label our observations based on our own cultural programming. In the process of becoming more aware of interactions with culturally diverse patients, providers hone communications skills that benefit all patients. Increased patient satisfaction and health outcomes lead to happier providers and more successful practices. Certainly within the medical culture, that’s seen as a win-win situation of great value.

‘Eight Dimensions of American Culture’ by Marcia Carteret. Copyright © 2011. All rights reserved.