As healthcare providers in one of the world's great melting pots, physicians at the Hospital for Special Surgery face special challenges. The diverse values and belief systems of our multicultural population can have a significant impact on the progression of disease, treatment outcome and the patient-physician relationship.
Experts in the field of culturally sensitive care are working to address these challenges and to help patients, physicians and other health care professionals communicate more easily and effectively. Laura Robbins, DSW, Vice President, Education & Academic Affairs at HSS, and Associate Scientist, Research Division, conducts qualitative research on culturally determined health beliefs and behaviors and their impact on use of services such as health education and social support programs. Dr. Robbins brings insights from her research to students in her classes in the Masters program in Clinical Epidemiology and Health Services Research at Weill Medical College.
"Patient perceptions and attitudes about the origin of disease, the appropriateness of treatment, and health care providers vary considerably," Dr. Robbins says. "Not only is it helpful for the treating physician to take these attitudes into account, but also to ask 'What are my values?', 'What are my beliefs?' and 'How might they influence my relations with culturally diverse individuals?'" When the physician looks at both parts of this picture, he or she has a better chance of developing a mutual understanding with the patient and achieving better treatment outcomes.
Traditionally, social scientists and researchers who studied these issues tended to describe cultures in terms of specific ethnic or religious groups, for example, Latinos, Asian-Americans, or African Americans. "However," Dr. Robbins says, "we're moving away from that model. Instead, we are looking at what are called 'cultural universals' - beliefs, values and behaviors that are relevant to all of us, but that get expressed in varying ways. We can then approach a patient and explore how he or she expresses that commonly held value and how it fits in to his or her social system."
Gathering Information and Building Trust
While working to avoid stereotypes, Dr. Robbins finds it helpful to consider certain beliefs that are common to one or more cultures. For example, in groups where the physician is regarded as an authority figure, a patient may agree to follow a treatment regimen even though he or she does not intend to do so because it is at odds with a culturally-held belief. Conversely, he or she may be following methods of self-treatment, but may be unwilling to reveal this practice to the physician.
Patients who subscribe to the hot-and-cold theory of disease, for example, would treat gastrointestinal diseases characterized by cramps or diarrhea as a "hot" disease requiring remedies that are cold in temperature. Similarly, people with a "hot" arthritic joint may treat the affected area with cold-contrary to what is usually recommended by American physicians. "If the patient believes that eating certain foods is going to help their disease, it's fine if it does them no harm," says Dr. Robbins. "But what if it is making their disease worse? What if they don't take their prescribed medicine? These are the kinds of patient-specific behaviors that physicians need to know."
However, developing mutual trust across cultures can be difficult, she notes. "Partly it's a matter of time, something that develops over the course of a series of patient visits, but it's also very important that the patient feels that the physician does not pass judgement about his or her beliefs and values." Moreover, when language is a barrier, the physician should be aware that although a translator can provide the content of what the patient is saying, there may be nuances in meaning that literal translation doesn't provide. Translators who are not only bilingual but also bicultural may be most effective in such situations.
Being aware of cultural differences in the expression of pain can also be helpful. Recalling her own experience working directly with Asian-American women with cancer, Dr. Robbins, came to realize that expression of even intense pain was not considered appropriate. Only when these patients were given verbal permission by someone in their community or family group to express their distress did they do so.
Physicians may also find it useful to determine whether other family members should be included in the discussion of disease or treatment. Through her research with Latino families, Dr. Robbins found that often a male family member-whether or not he was the traditional head of the household (i.e. the father or husband)-needed to be consulted before certain healthcare decisions would be made for a female patient. She cautions that all patients should be treated individually and that the physician can open up a discussion by asking, "Is this something you and I should discuss alone?" or "Should we bring in a family member whose opinion you value?"
Some additional questions that physicians can ask their patients in order to gain a better understanding of their cultural beliefs include:
Bear in mind also that health beliefs and practices may vary within cultural groups according to the length of time the patient has lived in the United States.
Looking to the future of this field of inquiry, Dr. Robbins is optimistic about its impact on healthcare. "The young doctors and doctors-in-training that I am teaching now are interested in their own cultures and those of their patients They want to know what they can do to be more attuned and effective.
Not long ago, an Iranian student of Dr. Robbins brought up a cultural taboo against touching the female patient-a prohibition that applies to both male and female physicians in his native country. The class discussed the need to refrain from beginning a physical examination before asking relevant questions: Do you feel comfortable? Do you want someone else in the room? "Those simple things can go very, very far in establishing trust." says Dr. Robbins.
Summary prepared by Nancy Novick