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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
A Cross-Cultural Phenomenon
Cultural Humility and Mutual Influence
Yes
We have much to learn about non-western communication styles.
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Melissa Quiros, Atlanta, GA USA Medical Student
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I appreciate the effort made by Lucy M. Candib, MD in her editorial “Si, Doctora” to address the importance of clear communication between a physician and a Hispanic patient. However, I feel that her article attributes a behavior to Spanish speaking patients that is not specific to Latin American culture. Many times in my own experience when I have attempted to educate my patients about their conditions or treatment plans, I have encountered a patient who would seem to accept my treatment plan and would later disregard my advice. I have noticed this phenomenon across cultures and education levels. Patients who feel informed about their condition and treatment choices and who have input into the medical decision process are more likely to follow through a treatment plan.(1) Patients prefer involvement in the decision process even in cultures where the physician-patient relationship is more paternalistic.(2) If physicians make the effort to elicit their patients’ preferences and beliefs and give their patients options in their treatment plan, the meaning of their patients’ response should not be so ambiguous. Although I realize working with other cultures may be a challenge at times, I would like to emphasize that although particular behaviors may seem to be inherent to a particular ethnic or cultural group, generalizations that attempt to describe all patients within an ethnicity may lead to lead to stereotyping. Not all Spanish speaking patients share a common background or system of beliefs, even among those who share a country of origin.(3) Not all Spanish speaking patients exhibit the tendency to meekly acquiesce to the doctor’s advice, whether or not they decide to follow through with the treatment plan. Dr. Candib has brought to light a valuable observation about the frustrations of miscommunication between physicians and their patients. I only encourage the reader to resist the temptation to associate the behavior she describes with a specific ethnic group or to make generalizations about an ethnic group based on one’s own experiences. 1 Say RE, Thomson R. The importance of patient preferences in treatment decisions—challenges for doctors. BMJ. 2003;327:542-545. 2 Sekimoto M, Asai A, Ohnishi M, et al. Patients’ preferences for involvement in treatment decision making in Japan. BMC Fam Pract. 2005;5:1. 3 Kleinman A, Benson P. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLoS Med. 2006;3:1673- 1676. Competing interests: None declared |
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Kim Marvel, Fort Collins, CO, US Educational Asso Director, Fort Collins Family Medicine Residency Program, Fort Collins, CO
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“Si, Doctora”, by Lucy Candib, is a wonderful example of cultural humility. In the telling of her story, the author demonstrates the benefits of being a reflective provider. The willingness to be a reflective provider is based, in part, on the value of humility. It means entering relationships with the belief that I can learn something new - not only to better understand my patients, but also to learn about myself. If I am willing to be influenced by my patients, I can grow both intellectually and emotionally as a provider and human being. The willingness to be influenced by one’s patients is a step beyond the more traditional approach to doctor-patient communication. Students and residents are often encouraged to listen carefully; to more fully understand the patient’s perspective and emotions. Clearly, this is an important communication skill with measurable benefits. In this article, Dr. Candib shows that the master clinician is also willing to use patient interactions as a mirror to reflect on one’s own belief system along with those of the patient. Detecting subtle incongruities between verbal and non-verbal behavior or attending to one’s visceral reactions can be clues to a better understanding of our selves as well as the patient. It requires a sense of humility to examine openly the assumptions and emotions we bring into patient relationships and to willingly modify our behavior. The result is more authentic and effective communication with patients. The mutual influence of patient and provider is a core tenet of the relationship-centered approach [ref]. Dr. Candib has given us a nice example of this mutual influence in her article. And her sense of humility allowed it to happen. 1. Beach MC, Inui T, and the Relationship-Centered Care Research Network. Relationship-centered care: a constructive reframing. J Gen Intern Med 2006; 21:X3-8. Competing interests: None declared |
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Iona Heath, London, UK general practitioner
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As Lucy Candib so perceptively illustrates, words are slippery and dangerous. She reports struggling with the misleading use of words across the linguistic gulf between English and Spanish but this seems likely to be a much more pervasive problem. I know many patients who are native speakers of London English who say ‘yes’ when they mean ‘no’ and ‘yes’ when they mean ‘maybe’ and ‘yes’ when they mean ‘I don’t understand what this is all about but I want to go home now’. The impossible but endlessly fascinating challenge is to discover which ‘yes’ is which. And if this happens with a word designed as a simple affirmative, the problems posed by a word such as ‘pain’ become daunting indeed. Experience, feelings and thoughts are necessarily lonely and only when expressed in language can they be shared. Precisely because they are shared, words represent what is universal in human experience, but therein lies their danger. The Norwegian writer Tarjei Vesaas expresses the ambiguity inherent in the nature of words: Words can cause trouble like large rocks in one's path. Wrong: Words can clear the largest rocks out of the way. Wrong again: Words can turn into dark chasms unbridgeable for a whole lifetime. We know very little about the power and the destructiveness of words. Mikhail Bakhtin described the way in which words become distorted - changed and refracted by each usage - continually subject to both centripetal and centrifugal forces. As each one of us appropriates words for our own purposes, we add our own particular shade of meaning producing a centrifugal force which continually develops and fragments language; yet at the same time, all language is social and built on the attempt to achieve shared and centripetal understanding. As Lucy Candib makes clear, hearing and recognizing a word are only the beginning of the process of understanding. Within the consultation that process involves listening and imagining and checking back in a continuous iteration that teaches us more every day about the dimensions and capaciousness of words and their capacity not only to mislead but also, quite suddenly, to open up a tunnel of light through the darkness. Competing interests: None declared |
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Sylvie Lo Fo Wong, Netherlands family physician-researcher Radboud University Medical Center Dept.Family Medicine/Women's Studies
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I have read and enjoyed Lucy Candib’s article. We doctors in the western world have much to learn about non-western communication styles. Much is known however not integrated in our medical curriculum. At least not in the Netherlands, although we have a colonial history with overseas countries. The growing knowledge on communication styles, mutual understanding between migrants and western family doctors and the way it influences patient’s compliance is important.[ref] An example from Dutch history: The 5 ways ‘yes’ could be interpreted when a Dutch plantation owner commissioned a native worker in Indonesia (former colony of the Netherlands) to a job: Yes, I am listening;Yes, I have heard; Yes, I understand; Yes, I agree and accept; Yes, I will do so. These ways still apply in business contacts. We have much to learn. Harmsen JA, Bernsen RM, Meeuwesen L, Pinto D, Bruijnzeels MA. Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting. Patient Educ Couns. 2005;59(2):171 -81. Epub 2004 Dec 21. Competing interests: None declared |
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