Background

It has long been said that America is a nation of immigrants. With 28.4 million foreign-born residents in this country (according to a 2000 US Census report),¹ this is as true today as ever. But clinicians often care for patients – sometimes for years – without knowing much about where they came from, why they came, and how they have been affected by the change to life in this country. While some people are able to make a fluid transition to the new way of life, others have greater difficulty. On a very practical level, patients may have difficulty negotiating the unfamiliar new customs and environment, particularly those of the American medical system. At times, patients may seem ‘difficult’ when they are accustomed to a very different healthcare system.

In Long Island City, New York, just over the 59th Street Bridge connecting Manhattan to the borough of Queens, there is a community health center that provides primary care to immigrants from over 40 countries who speak more than 25 different languages. This center also provides care to their sons and daughters and grandchildren, many born in this country, among other patients whose American, Italian, Greek, Jewish, and African ancestry dates back decades or centuries. The physicians, nurses, and other clinical staff are keenly aware that practicing medicine in this setting is unique in many ways. Some thrive on the challenges this incredible diversity poses and learn ways to deal with the unique situations that arise. Others are easily frustrated – even angered. They wish their patients would be ‘easier’ to deal with, rather than learning how to adapt their own paradigms and expectations to meet their patients’ needs.

While this community health center presents a striking example of diversity in healthcare, many community health centers, public hospitals, and even private medical practices today provide care for a growing and incredibly diverse immigrant population. But what exactly can we do to address the challenges that providing healthcare to new immigrants poses? Isn’t it enough to just be thoughtful, kind, and caring? These questions have led us to develop a curriculum for health professionals entitled The Patient-based Approach to Cross-cultural Care. Our goal was to identify the key issues that practicing physicians and other healthcare professionals face when caring for patients of diverse sociocultural backgrounds and to come up with some practical advice on how to manage these issues when they present themselves. This chapter provides a summary of how these principles of cross-cultural care apply to immigrant medicine. First, we will cover the basic concepts of crosscultural care; next, we will present our framework which consists of first assessing core cross-cultural issues; second, exploring the meaning of the illness; third, determining the social context; and fourth, engaging in negotiation.

Context

Cultural competence is the ability to provide high-quality healthcare to patients from diverse sociocultural backgrounds. Concern about cultural competence in healthcare has increased in recent years as providers and policy makers aim to close the quality of care gap between people of different racial, ethnic, and sociocultural backgrounds.² The greater attention given to the issue of racial/ethnic disparities in healthcare, and the potential role cultural competence can play in their elimination, has further raised the expectations for this field. It is undeniable that healthcare providers today face the challenge of caring for patients from diverse cultural backgrounds who may have limited English proficiency, different levels of acculturation, limited socioeconomic means, and unique ways of understanding illness and healthcare. The 2000 US Census reported that there are 28.4 million foreign-born residents living in the United States, and about 47 million residents (18% of the total population) who speak a language other than English at home.³ In some states, such as California, the figure is as high as 40% of the population who speak a language other than English at home. Nearly half of these individuals have difficulty speaking and understanding English. Patient satisfaction and adherence to medical recommendations are closely related to the effectiveness of communication and the doctor–patient relationship.⁴ However, immigrants face additional challenges to communication that are not just related to their potential limited English proficiency. Sociocultural differences between doctor and patient can include those related to health and treatment be-liefs, values, styles of communication and decision-making, im-migration experiences and related fears, and trust, which among others can lead to major communication and relationship barriers that extend beyond language. Health professionals are now challenged to learn a new set of skills and a knowledge base necessary to overcome these barriers.

This chapter is designed to provide practical guidelines and suggestions on how to manage cross-cultural issues in the delivery of healthcare to immigrants.

The Categorical Approach to Cross-Cultural Healthcare

Culture is a learned system of beliefs, values, rules, and customs that is shared by a group and used to interpret experiences and to direct patterns of behavior.^5,⁶ While it is increasingly common that multiple social and cultural influences blur the distinguishing lines between cultural or ethnic groups, many immigrants to the United States may identify strongly with a nationality or ethnic group – Hmong, Afghani, or Haitian for example. It would then make sense to understand some of the characteristics that help to define these groups in order to better understand them. Many Hmong, for instance, have strong spiritual beliefs about health and healing and may have a certain degree of mistrust towards Western medicine. The problem is, there are hundreds of distinct ethnicities, nationalities, and cultural groups in the US, each with its own complex set of beliefs, values, and health behaviors. It would be nearly impossible to learn meaningful and clinically relevant information about all of these groups, and equally difficult to fit it into one book chapter.

One way that some have dealt with this issue is by lumping many smaller groups together into larger categories such as Asian and Hispanic/Latino, but this raises different problems. Latinos may have some commonalities (the Spanish language, for example) but they represent many different countries, ethnicities, and cultures, each with very different characteristics. There are Mexicans of Mayan descent, Argentineans with Italian roots, and Cubans of African ancestry, for example. Even within these subgroups there is a tremendous diversity based on social status, acculturation, age, local environment, and individuality, among other factors. The complex cultural and personal characteristics that make human beings as diverse as they are also makes any standardized guide to dealing with them cumbersome, stereotypic, and fairly useless. As such, we will not provide a ‘manual’ of how to care for patients from different racial, ethnic, or cultural groups. Instead, we will teach a practical framework to allow one to ascertain from the individual patient what social and cultural factors influence the patient’s health values, beliefs, and behaviors, and thus their interaction with the health professional.

The Patient-Based Approach

The patient-based approach to cross-cultural healthcare ⁷ involves principles of both patient-centered care and cultural competence. Rather than learning about individual cultures and their characteristics – which is impractical, impossible, and can lead to stereotyping and assumptions – this approach focuses on the issues that arise most commonly due to cultural differences, and how they may impact interaction with any patient.

Referring back to the Hmong patient example, we mentioned the issue of mistrust of Western medicine and the use of traditional or spiritual forms of healing. This is not specific to Hmong patients. This may also be an issue with Afghanis and Haitians, and is in fact common in cross-cultural encounters with many different groups. Rather than learn all about characteristics of the Hmong people, we can learn how to explore traditional healing practices with any patient whose culture is different than our own, along with ways to approach this issue. We can also learn how to identify mistrust, think about its causes, and learn trust-building strategies that are effective with all patients. Integrating these skills into routine medical practice can lead to more effective care, and can even save time by avoiding miscommunication and getting to the root of challenging interpersonal issues. Cross-cultural questions can be used selectively, similar to a review of systems.

Of course, it is still very helpful to explore the beliefs, values, and customs, as well as the demographic and historical experiences of the cultural groups that one sees most frequently following the principles of community-oriented care. This may be especially true with new immigrant groups, who may reside in the same neighborhood, share the immigration experience (which can be positive or negative), and have common beliefs about disease and illness, as well as specific expectations about healthcare. Working with a specific population or community for years imparts a level of cultural competence with that particular group that is hard to come by any other way. Those who gain this level of understanding often do so by taking the time to learn from their patients directly, and do not follow any manual but instead balance the knowledge they have with a patient-centered approach that prevents them from falling prey to stereotypes. Balancing learning about the individual while learning about groups is one of the key tightropes of cross-cultural healthcare, and one that must be understood clearly. Ultimately, it is important to realize that the patient before one is absolutely the best source of information regarding how social and cultural factors impact their health beliefs and behaviors.

Culture in the Clinical Encounter

When seeing a patient, it is important to understand that it isn’t just the patient’s culture that is at play, but one’s own culture, as well as the culture of medicine. All three of these cultures interact in ways we need to be sensitive to and aware of, as they influence the outcome of the encounter. To understand patients who are culturally different from ourselves, it is first necessary to recognize our own cultural beliefs, values, and behaviors as well as how our life experiences influence the way we think about healthcare, and how it shapes the way we make clinical decisions. Reflecting on what our parents did for us when we were sick, did we go to the doctor right away? Did we wait it out? Were doctors respected and trusted? Throughout this chapter, as culturally based issues are discussed, we must think about our own perspectives and anticipate how they impact our clinical behavior.

There is also a very powerful culture of medicine, which has its own particular beliefs, values, and customs – for example, the idea of patient autonomy and the value placed on scientific evidence. Looking at these cultural norms and how patients may differ, we can predict some of the cross-cultural conflicts and difficulties that may arise. For instance, patients may have a different view of the cause of illness based not on science but on folk beliefs, religious ideas, or their own common-sense explanations. They may appear skeptical about the efficacy of pharmaceutical medication or feel that surgery is too invasive. They may make decisions as a family unit rather than individually, and the hurried manner of health professionals may make them seem mistrustful. Their style of communicating may not be directly in line with the standard patient history format, and sometimes they may just not seem to ‘get it.’ They may be mistrustful of the organization we represent. The culture of medicine, as well as our own culture, must always be considered in our cross-cultural encounters.

The Triad of Empathy, Curiosity, and Respect

At the heart of any meaningful and successful medical encounter (especially one across cultures) are three core values: empathy, curiosity, and respect. As the old metaphor goes, they are like three legs of a stool. When one is missing, the stool collapses. The stool represents our connectedness with our patients, and our ability to understand who they are, and what makes them unique. This is more than just fluff. Patients who feel their doctors listen to them, understand them, and care about them are less likely to file malpractice suits, and this type of connection can lead to better health outcomes.⁸ And yet, we tend not to connect with people that are different from us. The death of thousands in an earthquake in Turkey affects most of us much less than the death of a member of our own community, even if we don’t know that person. It is normal for us to care more about people who are like us, and we tend to like people who are similar to us. But imagine being a patient and feeling that your doctor doesn’t connect with you or care about you so much because you are somehow different. As physicians and healthcare providers, we are morally obligated to try to overcome these tendencies, and to care about all of our patients as equally as possible. We need to develop our ability to empathize with, be curious about, and respectful of all people, both for the sake of our patients and for our own personal growth.

Empathy is perhaps the most crucial of the three values to put into practice. It can be defined as an active process of learning about an individual, and perceiving and responding to his or her thoughts and feelings. The central techniques for this are actually quite straightforward. They involve: (1) identifying a thought or emotion that a patient is experiencing, (2) identifying the source of the thought or emotion, and (3) responding in a way that shows you have made the connection between the first two steps.^9,¹⁰ Maintaining an attitude of curiosity towards our patients is of particular importance when dealing with people who are more likely to think and act in ways that are unfamiliar. People are fascinating when you make a small effort to learn about them. We have an entire world of cultural influences and perspectives right in our own hospital beds and waiting rooms. And as healthcare providers we have a privileged window into the lives of people with whom we may have otherwise had only the most superficial contact, if any. Respect in crosscultural interactions means that regardless of differences, people should be treated with dignity and their perspectives should be taken into account. We are used to reserving our respect for people whom we feel deserve it. We tend to have less respect for those who do not fit our expectations of how people ‘should be,’ and those expectations differ according to cultural norms. We have to be careful as providers of healthcare to apply a basic level of respect to all individuals regardless of differences in values and behavior.

The triad of empathy, curiosity, and respect represents core values that are fundamental to the practice of medicine in a diverse society. They may have a tendency to wane under the burden of long hours, heavy caseloads, time pressures, and less-than-perfect role models. By holding on to them and integrating them into your daily practice our patients will benefit – as will we. Nowhere is this triad more important than in the care of immigrants, with whom we may have little baseline connection due to cultural and linguistic barriers and lack of personal experience.

The Framework for Cross-Cultural Care

Assess core cross-cultural issues

Interactions between immigrant patients and healthcare professionals often lead to misunderstandings that reflect inherent differences in cultural values and expectations. These misunderstandings can originate from healthcare providers being inattentive to ‘hot-button’ issues which can lead to outcomes ranging from mild discomfort, to noncooperation, to a major lack of trust that disintegrates the therapeutic relationship. As previously discussed, the vast number of cultural and ethnic groups in the US and their heterogeneity makes it impractical if not impossible to learn specific aspects of each that could influence the medical encounter. Fortunately, certain core cross-cultural issues tend to recur across cultures. For example, one study found a lower level of patient autonomy, and an emphasis on the role of the family in medical decision-making among both Korean and Hispanic patients compared to African-Americans and European-Americans.¹¹

Rather than attempt to learn an encyclopedia of culture-specific issues, a more practical approach is to explore the various types of problems that are likely to occur in cross-cultural medical encounters, and to learn to identify and manage these as they arise. Box 8.1 lists five core cross-cultural issues that should be taken into account with immigrant patients in order to avoid cross-cultural misunderstanding. Once a potential core issue is recognized, it can be explored further by inquiring about the patient’s own belief or preference, which may be quite different from the ‘cultural norm.’ Box 8.2 describes three case vignettes which we will refer to in this chapter to highlight some of these core cross-cultural issues.

Box 8.1 Core cross-cultural issues

Styles of communication

Mistrust and prejudice

Decision-making and family dynamics

Traditions, customs, and spirituality

Sexual and gender issues

Box 8.2 Three case vignettes

An 8-year-old boy whose family emigrated from Vietnam several years ago is brought into an urgent care center with an asthma exacerbation. While talking to the family, the physician pats the boy on the head and notices that this seems to make his parents very uncomfortable. During the examination, the physician notices several red streaks on the boy’s chest, which appear to be caused by trauma. Worried about the possibility of abuse, he discusses the case with a colleague who is familiar with the custom of coining. She states that among some Southeast Asians, to treat certain maladies, a coin is rubbed briskly over the skin in several places, raising linear, red lesions, a technique known as coining.

A 33-year-old Haitian woman presented for routine care to a family medicine practice along with her 2-year-old son. She was employed but had a low enough income to qualify for the Women, Infants, and Children program, a federally sponsored program designed to provide enhanced nutrition for low-income mothers and their young children. The physician strongly encouraged her to sign up for the program and provided paperwork and a brief explanation. When she returned the next time, she had not enrolled, so the physician referred her to a social worker. The woman became upset, refusing to fill out any forms against her will.

A 45-year-old, healthy Egyptian woman presents as a new visit to a male physician, accompanied by her husband. Her husband is somewhat overbearing, answering all of the medical history questions himself. When the conversation is shifted back to the patient, he states that she does not speak English very well. During the physical examination, the husband is respectfully asked to leave the room, and it becomes clear that the patient is quite proficient in English. A history of menstrual irregularity is elicited which had been denied or minimized previously. While the patient remains comfortable during the examination, she becomes very anxious and refuses a breast examination.

Styles of communication

Differences in styles of communication between patient and provider can lead to discomfort and potential miscommunication. This includes culturally based customs around both verbal communication and nonverbal communication such as eye contact, touch, and personal space. The first case vignette illustrates how some cultures may be offended by what is perceived to be inappropriate physical contact, in this case touching a patient’s head. Direct eye contact may also be avoided in some cultures while in others it is a sign of respect. Providers should be aware of their own behaviors and be sensitive to the preferences of their patients. Other aspects of communication include level of assertiveness, which may range from very deferent to very aggressive (often influenced substantially by culture). It is helpful not to assume that a patient agrees with the plan outlined by the provider (a mistake made in the second vignette). A deferent patient may simply be hesitant to voice a conflicting view, making it crucial to ask for the patient’s input and encourage verbalization of any disagreement.

More complex communication issues include preferences regarding relating ‘bad news’ to a patient. Providers often assume that patients should be told just as they themselves would want to hear it. Yet personal and/or cultural preferences for a direct or indirect approach may vary, and should be elicited from patients, ideally before ordering an important test. This technique is often used in HIV pretest counseling, and an abbreviated version can be adapted prior to a colonoscopy or CT scan, for example.

Adapting to different communication styles and customs

• Get a sense for the patient’s general communication style and adapt your style of communicating to fit best with it.

• Try to draw out indirect or reserved patients by making them feel comfortable, asking open-ended questions, and making it acceptable to voice their opinion. Do not assume that lack of resistance means agreement with your plan or recommendations.

• Determine how the patient prefers to receive bad news (e.g. test results), for example:

‘I am going to check the report of your sonogram tomorrow and would like to let you know the results. Some of my patients want to be told directly, no matter what the test shows, even over the phone. While I don’t suspect that there will be anything serious, I would like to know how you prefer to hear the results.’

• Get a sense for whether the patient is more stoic or expressive of pain and symptoms. Avoid judging patients based on one’s own cultural perspective.

• Pay attention to cultural differences in personal space, eye contact, body language. Try to be flexible without being misled by differences in meaning.

Mistrust and trust-building

Trust is a crucial element in the therapeutic alliance between patient and healthcare provider. It facilitates open communication and is directly related to patient satisfaction and adherence to provider recommendations.¹² Yet research highlights that public trust in healthcare has dropped to an all-time low from 1966 to 2002.¹³ While trust in one’s own personal physician has stayed somewhat higher in general, many minority patients have less inherent trust in the healthcare system due to historical mistreatment and fear of discrimination.¹⁴ While much of the literature in this area focuses on African-American patients, a recent survey by the Kaiser Family Foundation showed that Latinos and Asians also are much more likely than whites to worry that they will be treated unfairly by the healthcare system due to their race/ethnicity.¹³ Previous bad experiences, poor communication, disrespectful treatment, and the general loss of control that patients experience when ill can compromise trust by patients across all cultural, ethnic, racial, and socioeconomic backgrounds, but may be a particularly sensitive issue for immigrants.

In the second case vignette, the origins of the patient’s anger and mistrust were multifactorial. She felt that the physician was being condescending to her by assuming that she wasn’t able to provide for herself and her son. Also, she was afraid that filling out government forms could lead to her deportation. It is wise for providers not to blindly assume that patients will trust them fully. Being aware of cues that may be signs of some degree of mistrust is particularly helpful. Patients may express concerns about whether a particular test is necessary, or they may mention some bad experience in the past, for example. These should be taken seriously and should lead to direct efforts at reassurance and trustbuilding. This includes developing good rapport, communicating effectively, allowing patients a decision-making role in their own care, and respecting patients’ needs, fears, and concerns. Here is a list of helpful suggestions for building trust with patients, especially across cultures.