experiences. The subsequent section provides general strategies for addressing these problem areas.
Common areas of conflict or misunderstanding in the clinical encounter
There are several areas in which misunderstandings commonly occur during a clinical visit (Table 8.6). Each of these is described here, along with suggestions for improvement.
Prior experiences
Both the provider and the older adult bring certain expectations to the clinical encounter based on prior experience. Both may be unaware that their own ethnic or professional culture influences the interaction. Problems often arise due to the knowledge and power differential between the older adult and the health care provider.
Older adults may distrust their providers based on their own or others’ previous encounters with biomedicine, such as the American experience with the Tuskegee Syphilis Study. This research study exemplifies several factors that have influenced African Americans’ attitudes toward the biomedical community in the United States,47 although more recent research indicates that these attitudes may have ameliorated over the past two decades.48 This may be due to acculturation by the younger generation, rather than forgiveness on the part of those who were directly affected.
Providers may view the patients’ ethnic cultures as an obstacle. For example, because Afghani Muslim women do not seek health care from male practitioners,34 the woman receives care by proxy. Her husband describes her symptoms to the male practitioner, who then instructs the husband in the recommended treatment plan. Not all practitioners are comfortable practising medicine in this manner.
Identifying the patient
In general, Western biomedical culture focuses on the adult individual as the patient. As such, information is gathered from the patient and the patient alone (this is different from practising Western paediatrics, where the mother and child are often considered to be the ‘patient’). In many cultures, however, the family, or even the entire community, plays a major part in managing illness. In cases such as this, it is often best to include the entire family in decision‐making,49 including spouses and/or adult children.
Table 8.6 Common areas of cultural conflict.
| Mistrust garnered during prior contactsCultural differences in defining who the patient isVerbal and non‐verbal communicationPrior misconceptions about cultural normsAgeism by both patient and provider |
Communication
Communication may be verbal or non‐verbal, and both are important. When communication is hindered by a lack of a common language, health suffers. Patients not proficient in the local language are unable to take advantage of health promotion programmes.50,51 The clinician’s misunderstanding of the patient’s language can lead to inappropriate treatment,52 ranging from misdiagnosis to ineffective pain control.31
Although professional translators may be employed, providers must remember that misinterpretations may occur even when the same language is spoken. Providers tend to mix medical jargon and everyday language when they speak to patients, but a word may mean something different than intended to the patient. For example, a patient may refer to a stomach ache, which is duly interpreted to be a pain in the stomach. The patient may actually mean a pain in the abdominal area. The clinician should be careful when interpreting the symptoms as they are reported. This is particularly true when the interpreter is a child who may not have insight into how important it is to have an accurate description of the symptoms, even if the patient is uncomfortable sharing that information with either the clinician or the child.
A surprising amount of information can be communicated through non‐verbal cues. This has led to the successful development of pain assessment tools for demented patients.53 Research on such tools provides information about which non‐verbal assessment tools are most representative of the current state of the science, most clinically relevant, and practically applicable to integrate into everyday practice and support adherence to regulatory guidelines. Communication in the clinic is less well studied, but it is important to note certain areas of potential differences. For example, patients with different cultural backgrounds may have different ways of expressing distress. Some value stoicism, whereas others value the open expression of pain. The presence of non‐verbal behaviours such as reductions in activity, social withdrawal, self‐protective manoeuvres, increased alterations in facial expressions or body postures, and observable displays of distress in a stoic patient, who reports no such problems, would assist a provider in diagnosing unreported problems. The lack of these non‐verbal behaviours in a patient reporting that their symptoms are severe might identify a patient from a more expressive culture.54
Other potentially problematic areas of non‐verbal communication between people with different cultural backgrounds include the pace of conversation, whether interruptions are encouraged, the degree of physical proximity of the provider to the patient during history taking, and whether eye contact is appropriate or disrespectful. One unintended consequence of the introduction of the electronic record is the perception on the part of some patients that it is disrespectful of the clinician to interact with the computer screen more than with the patient.55 It is important to remember that the etiquette of touch, hand gestures, and finger‐pointing varies across cultures. Another area with wide cultural variability is attitudes toward the direct discussion of death and dying among clinicians and patients and their families.56,57
Stereotyping
Sometimes a little knowledge is a dangerous thing and can lead to stereotyping. Instead of trying to memorise what is appropriate for every culture, a brief conversation with the patient or interpreter can clarify what is acceptable and what is not and can clarify major points of potential conflict. Such a conversation would ideally take place during the initial visit with the older adult. A special place in the patient record could be the repository of such information, along with a reminder to refer to that note before the patient is seen. Because culture is fluid and changes with social interactions, brief follow‐up conversations about changes in health or to confirm previous conclusions would be appropriate at each office visit. It is important to understand that there is variation within cultural groups. There is no substitute for asking the older adult what their treatment goals are.58
Age
Very few health care providers are as old as their geriatric patients. Therefore, those providers bring limited personal experience with or insight into the nature of ageing and the consequences of chronic disease to the provider–patient relationship. There is a risk of the nature of ageing being stereotyped by younger health care providers. They may exaggerate the meaning/impact of functional differences, the consequences of chronic illnesses, and the degree to which disabilities that increase with age affect older adults’ quality of life. As a result, there is a risk that providers might fail to recommend lifestyle changes involving smoking cessation, good nutrition, and exercise that might help older adults continue to live independently for many more years. Alternatively, older adults may disregard the expert advice of health professionals who are significantly younger than they are (reverse stereotyping) because they feel that the provider does not understand ageing due to a lack of personal experience.
Increasing cultural sensitivity in the clinical encounter
Increase self‐awareness
Everyone has a culture. The provider brings an ethnic and/or national culture to a clinical encounter, in addition to the biomedical culture. Approaching the older adult as a