In the process of developing culturally responsive care, it is important to consider the ways in which patients’ health beliefs and behaviors are likely to differ from their provider’s if the two come from different cultural backgrounds. In this cross-cultural communications article we will take a look at one area that is commonly problematic – patients’ expectations of physicians. In particular, we will look at how trust is vested in medical professionals in different cultures, how social power distance affects the consultation approach promoted in patient-centered care, and how a patient’s cultural background will influence the way he or she goes about seeking a second opinion.
Credentials vs. Relationship
In western medicine as it is practiced in the United States, trust is vested in physicians based largely on credentials and education. In private practices, we expect to see a doctor’s educational and professional credentials displayed where we can view them. In choosing a primary care physician at an HMO, we want to read about the credentials of physicians on the organization’s website before we choose our primary doctor. We may even respond with greater confidence if we deem a physician’s alma mater to be an esteemed medical institution. This way of finding a doctor and establishing an initial degree of trust is comparatively easy. If we have the benefit of a recommendation from someone we know, all the better, but often that isn’t available. The initial consultation with a doctor provides the first opportunity we have to find out for ourselves how comfortable and confident we feel with the person’s expertise and bedside manner. Many of us have come to expect doctors to be hurried and over-busy. We want an expert’s opinion more than a connection, so we accept a bedside manner that may be less warm but is highly professional. For some people, the crowded schedules of esteemed specialists is actually reassuring – proof of sorts that we are lucky to be the patient of such a highly sought doctor.
In many traditional cultures of the world, trust is vested in health care professionals based on referrals from very well-trusted sources – usually close friends or family members. People in more collectivist cultures expect to establish a longer-term relationship with a doctor, especially their personal physician. At one time, this was more common in this country too; small town family doctors cared for several generations of families in their practices. A doctor nurtured relationships of great trust by investing in the welfare of “his families.” The relatively impersonal way we now seek out primary care providers and specialists is very difficult for people unaccustomed to our health care system in the U.S. The likelihood of establishing warm personal rapport is far less certain with a complete stranger who is often short on time. In Spanish, the word personalismo captures an ideal balance of professionalism and warmth many people seek. In any health care interaction where personalismo is clearly missing, compliance and health outcomes may be adversely affected; open communication between patient and provider will be difficult to establish.
Though time is definitely a finite resource in American medical culture, even the busiest health care professionals can do the following:
- Slow down just a little bit, and offer a few words of friendly conversation before getting to the medical issue at hand.
- Ask about the family’s well-being, which is a question of great significance in collectivist cultures.
- Offer a handshake that lingers a moment and is less business-like than an American professional handshake.
Doctors as Authority Figures
The cultural values of any group of people must bridge the many contradictions presented by practical circumstances of everyday life. Keep this in mind if the above section seems at odds with what follows.
Although patients from more traditional cultures may hold expectations for establishing a friendly warm rapport with American providers, they may also react with confusion and even consternation at the collaborative approach of patient-centered care. Best practices in western medicine in the U.S. today focus largely on establishing a dialogue between physicians and patients where the input from the patient is crucial. The physician acts more as an expert offering guidance than an authority figure (except in the case of emergency). Many Americans bristle at doctors telling them what to do if it feels like being given orders, unless of course the patient has asked for a medical directive. Doctors who don’t ask for patient input about their health concerns may be considered disconnected and unresponsive. The dimension of culture that we call “individualism vs. collectivism” applies here. In a highly individualistic culture, like American culture, it is common for people to believe the locus of control in their lives rests securely with themselves. They are not comfortable unless they feel a sense of control, and nothing signals this more than having a voice and being heard.
In collectivist cultures, and in societies where a high power distance is the norm, patients are more likely to view providers as authority figures who conduct themselves with utter certainty. A warm and paternalistic rapport is established between patients and physicians, but at the same time, patients may expect to be told what to do. High power distance in a society means people adhere to their proscribed place on the social ladder. Being asked, “What do you believe has caused your illness?” suggests to a patient perhaps that their opinion is equal to the doctor’s, and culturally speaking, this is impossible. In many countries, people visit a doctor or traditional healer expecting to be cured on the spot or to be given a medicine that will cure them after they leave. There is no experience with waiting for test results, no understanding of chronic disease, preventive medicine, or self-care. Being told that the diagnosis in inconclusive may be met with suspicion, mistrust, and frustration. So the question becomes, do we offer patient-centered care only to those who expect it and understand how to be actively engaged in the process? In other words, do we try to act in accordance with the cultural expectations of the patient/family by avoiding the collaborative approach in cross-cultural interactions? The answer certainly lies in the context of the cross-cultural situation; during a health care visit in this country, the culture of medicine as it is practiced takes precedence. We train physicians to LEARN – listen, explain, ask, repeat, and negotiate – in cross-cultural encounters especially. It is deemed the most responsive approach. However, it is also very important to be prepared for an apparent contradiction in values and expectations from some families who will want a provider to take time to get to know them and demonstrate warmth, yet also be directive. How to balance an expert’s authoritative stance with being receptive to things like traditional remedies isn’t always abundantly clear.
Seeking Second Opinions
Finally, it is important to mention the expectations people from different cultures may have about seeking second opinions. This issue is also related to the dimension of culture called power distance. Again, the degree to which a patient views a provider as an authority figure is influenced by culturally-based expectations. In the U. S., it is very common for patients to seek a second opinion, though there is often awkwardness between patient and doctor during this conversation, and some doctors do get defensive. However, with the growing focus on medical errors, the desire for second opinions is more and more common, especially for invasive procedures. Patients/families from cultures that respect physicians as authority figures, and who tend to be high context communicators focused on preserving harmony, will be far less likely to admit wanting a second opinion. They may experience such discomfort over discussing this with their physician that they avoid the conversation entirely. If they do seek a second opinion, thorough discussion of both the initial and second opinions will also be difficult for them. The culturally responsive physician anticipates this scenario and is proactive. She explains that seeking a second opinion in the U. S. is very common and that insurers may require second consultations for certain procedures, though they refuse to pay for them in many other cases.
Summary
Cultural responsiveness in health care describes the capacity to respond to the health care issues of diverse communities. Effective cross-cultural communication begins with understanding values-based health beliefs and behaviors – including the expectations different cultures have for physicians. Trust is not vested in medical professionals the same in all cultures. Social power distance affects success with the patient-provider collaboration approach promoted in patient-centered care as well as behaviors around seeking second opinions. It is helpful to be prepared for what may appear to be a contradiction of values and expectations operating in some cross-cultural interactions. Though at times challenging and more time-consuming, a culturally-responsive approach to patient care results in clearer expectations, better compliance, reduced medical errors and improved patient satisfaction.
