Within each large culture, such as here in America, are many subcultures (Box 2-1). For instance, North versus South, white collar versus blue collar, young versus old, and so forth, and each defines the behaviors expected of its members.

Box 2-1 Subcultures

We tend to think of geographical or national areas as having just one culture within the borders. When we consider the many different nationalities and ethnic groups in our own nation, we realize others have just as many intermingled cultural groups as we do. All of these groups practice traditions that may be important to consider in health care.

Subcultures you may see in your medical practice include the following:

• Anglo-American: this designation includes western European countries such as England, France, and Germany.

• African-American: ancestry from any of the countries within the African subcontinent.

• Latino: includes Puerto Rico, Cuba, Mexico, and South and Central America. The term Chicano generally refers to Mexican descent and Hispanic to other Spanish-speaking ancestry.

• Asian-American: countries of origin or ancestry include China, Japan, Korea, The Philippines, Thailand, Vietnam.

• Native American: includes all tribes of American Indians, including Eskimos and Aleuts.

• Eastern European: Russian, Polish, Serbian.

• Middle Eastern: includes Arabic, Pakistani, Iranian, Iraqi, and Israeli.

The subcultures listed in Box 2-1 are almost as broad as the major cultures. Within any of these subcultures are also further divisions, such as provinces of China, Native American tribes, and African-American ancestries spread through many regions. All of these factors affect health care based on physical characteristics, dietary habits, genetic heritage, and religious practices. To relate to the groups present in your community, learn as much as you can about the cultures, beliefs, practices, and customary diet. Rather than trying to change these beliefs and customs, try to work within the cultural traditions. If the physician feels that the patient’s cultural practices are affecting his health, it is the physician’s responsibility to discuss this with the patient.

Suggestions for interacting with cultures different from our own usually involve common sense, good manners, and a high tolerance for differences, such as the following:

• Learn as much as possible about the cultures represented in your area. See these differences as an opportunity to grow in cultural understanding.

• Stress the things that most cultures have in common and accept the differences.

• Always assume that patients prefer that you use the family name unless you are given expressed permission to use a given name. This is true of all patients, but is especially important in other cultures.

• Encourage patients to talk about their illnesses and look for areas of misunderstanding between cultural beliefs and the current diagnosis.

• Look for confusion and fear; watch for cues and respond with compassion. Do not ignore culture-based anxiety. Talk to your patients and explain why and how the health care directives help recovery.

• Evaluate nonverbal communication by observing proxemics, kinesics, and other cues (see Chapter 1, “Introduction to Communication”). They may be very different from yours.

• Treat all patients with respect, concern, and compassion. Try to learn what it is about this illness that this patient sees as most important. It may be different from your reaction to the same illness.

• Determine what is important in this culture. What are the religious doctrines and food rituals? How do persons in this culture respond to pain? What is the general level of hygiene?

• Find out who makes the decisions. In matriarchal societies, the oldest female makes all decisions; in patriarchal societies, it is the oldest male relative. This patient may not consent to treatment without consulting the authority figure in the group.

• Be aware that the dominant authority figure in this patient’s group may accompany the patient and may be the one to whom you direct questions and give instructions. The patient may not be allowed to respond or make decisions without this person’s permission.

• Recognize that other societies are not as time-sensitive as Americans. A 10:00 a.m. appointment may mean any time in the morning, or even tomorrow. Your exasperation will not change this behavior, but your understanding will change your exasperation.

• Understand that certain cultures avoid eye contact as a matter of respect. Many Asian populations, Native Americans, Arabs, and certain Hispanic groups consider it rude and disrespectful to meet your eyes. For example, Latino women are taught that downcast eyes are a proper response to authority. This is not avoidance; this is tradition.

• Recognize that many cultures are less likely than most Americans to “get to the point.” They may see a brief, exact response as abrupt or rude. Rather than “yes/no” or other brief answers, they may give elaborate responses to avoid appearing rude.

• Be aware that not expressing pain or illness may be a cultural response. Look for incongruent messages. If the patient appears ill or in pain but denies it, he may feel he cannot acknowledge what he sees as weakness. The outward appearance of strength may be his cultural tradition.

• Acknowledge that many cultures are intensely involved with the supernatural and may believe that spirits, hexes, and the like cause illness. In these cultures, the supernatural must be appeased (soothed or satisfied) before healing can begin (Box 2-2).

Box 2-2 Cultural Healers

Many ethnic societies have long histories with folk or cultural healers. These include the Indian shaman, the Korean mansin, the Haitian mambo, the African sangona, the Chinese wu, and the Spanish curandera. To these societies, our medicine is considered alternative medicine.

Cultures that depend on these healers feel they have many advantages over traditional medicine, including those listed below:

• They speak the same language, live in the same environment, and understand the cultural traditions.

• The society may believe the healer is endowed with special powers to heal, perhaps by divine assignment.

• They are usually less expensive. Many trade in barter, or an exchange of goods, such as food or other items.

• While our medical profession relies on technology to determine the cause of illness, healers seem to know instinctively. Most are excellent at reading cues and may have the advantage of more personal knowledge of the patient’s history and current situation.

• They are more accessible and understand the patient’s needs in a personal and cultural perspective.

Do not try to change patients’ beliefs in traditional healers; this only adds to the stress of illness. If at all possible, the best course is to include as many cultural beliefs and traditions as is reasonable into the patient’s treatment plan.

• Incorporate the patient’s folk remedies into treatment if at all possible. In fact, you should ask if he or she has consulted a folk healer. If the answer is “yes,” try to determine what therapies the patient is using.

• Learn about the many current medicines and treatments that started as folk or herbal remedies. Talk with your physician about those the patient is using. It may be possible to incorporate them into standard treatment.

• Discuss the health care directives to determine whether these will separate the patient from the group’s rituals and traditions. If this happens, you cannot realistically expect compliance.

• Be aware of the preferred diet. New Food Guide Pyramids are adapted to many ethnic diets. These are covered in Chapter 5, “Communicating Wellness.”

• If you must impose on the patient’s culture by entering private space or by asking probing questions that make patients uncomfortable, apologize and explain why this is necessary.

Other Cultural Barriers

We are usually aware of national and ethnic cultural differences, but there are other cultures within our society, such as wealth versus poverty, male versus female, and youth versus age. Any of these individual differences can interfere with understanding and rapport.

Wealth versus poverty has far-reaching health care significance and is one of the most difficult barriers to overcome. Since most health care workers are middle class, the cultures at opposite ends of the socioeconomic spectrum are almost as alien as those from distant countries. For example, wealthier patients have better access to health care and generally consult health care providers much earlier than patients who have no permanent physician and who rely on emergency room physicians. The underprivileged are less likely to be well educated and may not understand what they hear in the medical setting. With less self-esteem and self-worth, they are less likely to ask for clarification about anything they do not understand. Wealthy people are usually very concerned with wellness and practice consistent preventive care. Poor people only “fix it” when it is too “broken” to tolerate, since needs other than wellness are far more important, such as a place to live and food to eat (see Chapter 4, “Educating Patients” for discussion of Maslow’s hierarchy). Wealthy people may be treated better by health care professionals than the underprivileged because of issues such as hygiene, presumed compliance, background knowledge of the presenting disorder, and, unfortunately, ability to pay for care. With so many stressors, disadvantaged patients are more likely than wealthy patients to use inappropriate coping mechanisms, such as substance abuse and domestic violence, although neither group is immune to these problems. Poor patients are more likely to see the health care worker as well educated; wealthy patients may see you as someone hired to serve them. If you can think of poverty and wealth as simply other cultures, each with its own language and customs, you will be better able to interact with both groups.

Male culture versus female culture also may be significant. Stereotypically, many men are taught to be strong about pain, to “tough it out,” and to see illness as weakness. Conversely, when they do admit to illness, some men regress and expect to be comforted. (Regression as a coping mechanism is covered in Chapter 5, “Communicating Wellness.”) Women, if they have the luxury to do so, may have been taught that illness and weakness are acceptable female reactions. For many generations, women were expected to “swoon” (faint) and actually had “fainting couches” to sink into at the first sight or mention of anything unpleasant. Of course, those who had the luxury of swooning were usually wealthy; there is no record that ladies’ maids were allowed to swoon. Since women as a group have been conditioned by society to be more vocal about their feelings, they frequently are seen as complainers.

Youth versus age as a communication challenge is covered later in this chapter. As we will discuss, life stages present barriers unique to each group.