A common concern is that using cultural information will lead to stereotyping. While this is an admirable concern, it is important to recognize that we are using generalizations, not stereotypes. The difference between a stereotype and a generalization lies not in the content, but in the usage of the information. An example is the assumption that Hispanic/Latinos have large families. If I meet Rosa, a Hispanic woman, and I say to myself, “Rosa is Hispanic; she must have a large family,” I am stereotyping her. But if I think, “Hispanic/Latinos often have large families,” and then ask Rosa how many people are in her family, I am making a generalization. A generalization is a beginning point. It indicates common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual. Generalizations can help us understand and anticipate behavior. Rather than becoming annoyed because a Hispanic patient is moaning and groaning in the absence of any serious problems, one might note, “Ah, Hispanic culture encourages emotional expressiveness.” Or, knowing that Asians value stoicism might help one remember to pay more attention to an Asian patient’s pain needs rather than draw (incorrect) conclusions based on the fact that the patient isn’t moaning or requesting pain medication. A stereotype is an ending point. No attempt is made to learn whether the individual in question fits the statement. Given the tremendous variation within each culture, stereotypes are often incorrect and can have negative results.

Time orientation, one’s focus regarding time, varies in different cultures. No individual or culture will look exclusively to the past, present, or future, but most will tend to emphasize one over the others. Chinese, British, and Austrian cultures have a past orientation. They are traditional and believe in doing things the way they have always been done. Interestingly, in many cases countries that emphasize the past are ones that were once more powerful than they are now. This may be their way of recognizing and valuing that time in their history. Time orientation can have an important impact on health related behavior. People from past-oriented cultures, for example, usually prefer traditional approaches to healing rather than accepting each new procedure or medication that comes out.

People with a predominantly present time orientation may be less likely to utilize preventive health measures. They reason that there is no point in taking a pill for hypertension when they feel fine, especially if the pill is expensive and causes unpleasant side effects. They do not look ahead in hope of preventing a stroke or heart attack, or they may feel they will deal with it when it happens. Poverty often forces people into a present time orientation. They are not likely to make plans for the future when they are concerned with surviving today. A sudden unpredictable change in life circumstances, such as a car accident that leaves one paraplegic, can also lead one to be present-oriented. A present time orientation, while generally negative from a preventive health care perspective, can also be positive. For example, the ability to focus on the present, rather than the future, can be beneficial for someone living with a cancer diagnosis.

Middle-class Anglo American culture, along with health care culture tends to be future-oriented. That is reflected in the medical system’s stress on preventive medicine and enthusiasm for each new medical technique or drug. In contrast to past-oriented cultures, progress and change are highly valued. China is also shifting to a future orientation, as evidenced, for example, by the long-term plan to reduce the country’s population by limiting family size. Patients with a future time-orientation are often more amenable to preventive medicine. They may also be eager for the newest drugs on the market, assuming “newer” is “better.”

Hispanics and African Americans tend to have a present time orientation. This does not mean that they do not recognize the past or the future, but that living in the present is more important to them. Their concept of the future may also be different from the Anglo concept. For example, African Americans are more likely to say “I’ll see you” than “I’ll see you tomorrow.” The former implies the future but is not specific. The future arrives in its own time. From this point of view, one cannot be late. Conflict may occur, however, in interactions with white middle-class people, for whom time is very specific.

As the last statement implies, time orientation can also refer to degree of adherence to “clock time” versus “activity time”. From the perspective of one oriented to the clock, someone who arrives at 3:15 for a 2:30 appointment is late. For someone who does not focus on clock time, both represent midafternoon. The time to arrive at the afternoon appointment is after the morning activities are completed.

This type of time orientation appears to be related to subsistence economy. In countries with economies based on agriculture, people tend to be more relaxed about time; as I like to say, “The crops don’t care what time they get picked.” Many people in traditional agricultural villages do not own clocks; the pace is slower and more attuned to nature’s rhythms. They tend to focus more on activities, rather than on the clock. In contrast, industrialized nations must pay attention to clock time. There are large numbers of people to organize, and each must complete his or her task according to schedule in order for the next person to begin. Without clocks, chaos would reign.

Just as cultures differ in time orientation, they also vary in social structure. American culture is organized according to an egalitarian model. Theoretically, everyone is equal. Status and power are dependent on an individual’s personal qualities rather than age, sex, family, occupation, or any other characteristic. In reality, things may operate differently, but we hold equality as our ideal. Some cultures, including many found in Asia, are based on a hierarchical model. Everyone is not equal. Status is based on such characteristics as age, sex, and occupation. Status differences are seen as important, and people of higher status command respect. Social structure, then, can have an important influence on the way people interact.

Values are the things we hold as important. Just as each individual holds certain values, each culture promotes different ones. American culture (this term is used loosely because there are literally hundreds of subcultures within the United States) currently values such things as money, freedom, independence, privacy, health and fitness, and physical appearance.

One way to assess a culture’s values is to observe how it punishes people. In the United States wrongdoers are punished by being fined (taking away their money) or incarcerated (taking away their freedom). The Mbuti pygmies of Africa value social support, and they punish people by ignoring them. The kind of health care provided by the American medical system is often influenced by financial considerations, whereas concern for family, low on the list of “American” values, influences much patient behavior. Hence conflict may develop between health care providers and patients.

In the United States, independence is manifested by the desire to move away from home as soon as one is financially able. In many cultures that value family more than independence, adult children rarely move out before marriage and often not thereafter. The health care culture also supports the values of independence and autonomy in its efforts to teach self-care and in often giving information only to the patient, excluding other family members.

Privacy is also very important to most Americans, who build fences to separate their houses from each other. The U.S. health care culture tries to provide privacy for patients by limiting visiting hours and offering no sleeping accommodations for visitors. Many non-Anglo patients, however, prefer just the opposite.

Health and fitness are popular movements, particularly on the West Coast. There are hundreds of food products labeled “low fat” and “low cholesterol.” People can be seen jogging on most city streets, and attendance at gyms is high. This obsession with health leads the medical profession to expect patients to comply with suggestions regarding changes in diet and exercise, assuming that health and fitness is a value shared by all. It is not. Furthermore, what is considered “healthy” varies cross-culturally.

Concern for physical appearance is manifested at every magazine stand. There are few women’s magazines that do not have articles on the latest diet, makeup, hairdo, and clothing. The incidence of cosmetic surgery for both men and women is at a record high. Surgical techniques are developed to minimize scarring and maintain beauty. What is considered “beautiful,” however, is not the same for every culture.

Understanding people’s values is the key to understanding their behavior, for our behavior generally reflects our values. A dramatic example occurred in the early 1980s, when a Japanese ship captain was bringing a boatload of cars to the United States. There was a disaster at sea, and the cargo was ruined. The captain had done nothing to cause the disaster, and he could not have prevented it. If an American ship captain had had a similar experience, the first thing he probably would have done when he reached land was call his insurance agent to see who would pay for the damages. The Japanese captain killed himself. There is obviously a big difference between calling one’s insurance agent and killing oneself. The different reactions are dictated by different values. The hypothetical American captain would probably value money; his concern would be for the financial loss. The Japanese captain was concerned with his honor. As the captain of the ship, he considered himself responsible for the accident. The loss of the cargo meant the loss of his honor. Without honor, he felt he could not live. Committing ritual suicide was the only way for him to regain his honor.

Values influence our everyday behavior as well. Nearly everything we do reflects our values on some level.

How much does the patient want? Some patients want a lot of information; it gives them a sense of control and reduces anxiety. Others may want very little. For example, in rural Vietnamese culture, it may be believed that verbalizing something negative will make it more likely to occur. This will increase their anxiety. Patients should be asked how much information they want about their condition.

Case Study: A 35-year-old Ashkenazi Jewish woman went in for a baseline mammogram. A lump was discovered. When discussing it with the radiologist, the woman questioned him about all the possible treatments if it turned out to be cancerous, as well as all the side effects of the treatment, and the possibility of testing for the BRCA gene. The radiologist had little patience for her questions; he repeatedly told her they should wait until after they get the results of the biopsy before they start discussing the side effects of chemotherapy and radiation. The woman, however, felt that she had to know everything possible about the potential negative outcome; only through knowledge could she feel a degree of control. The lump turned out to be benign, but she went into the biopsy procedure much more relaxed than she would have had she not known every possible eventuality.

Ask: How much information would you like me to give you at this time?

The current is emphasis on shared decision-making, where physicians and patients are partners in the decision-making process. This makes sense in an egalitarian social structure like our own, but not in one that is hierarchical (as in many Asian cultures). Patients who come from hierarchical cultures, in which the physician has a great deal of authority and may expect—and prefer—to be told what to do. They may interpret a lack of directiveness as a sign that a treatment or procedure is not important. Or see it as a lack of accountability on the part of the physician.

Case Study: A 27-year-old pregnant Mexican woman who had been living in the US for two years went to see a genetic counselor at the urging of a friend. XFAP tests indicated the possibility of Down syndrome in her unborn child. She declined the offer of amniocentisis, however, based upon the manner of the genetic counselor, who told her not to be afraid and to do whatever she wanted. The patient later said she interpreted the lack of directiveness as an indication that the positive screening was “no big deal” and that if there were any real danger, the counselor would have insisted on the test.

Ask:

• How would you like to go about making a decision?
• Would you like me to discuss all the issues with you and then we can come to a decision together?
• Or would you prefer some other way?

Since American culture values independence and individualism, there is an expectation that individuals will make their own decisions regarding their own health care. It is understood that patients may want to consult with other family members, but the individual is seen as the one who will ultimately make the decision. This is not always the case, however. In cultures which value interdependence, it is the family, rather than the individual who is expected to make decisions.

In cultures where men are dominant (for example, many Hispanic, Asian, and Middle Eastern cultures), traditionally oriented women may defer decision-making to their husbands, whether it be for themselves or their children.

Case Study: A middle-aged Mexican female patient suffering from acute liver cirrhosis with abdominal ascites, began to experience extreme shortness of breath. The physician, a liver specialist, asked her to sign consent for an abdominal tap. The patient refused, saying, “I am going to wait until my husband arrives.” The physician was not happy with her response as he felt it was necessary to do the procedure as soon as possible. Fortunately, the patient’s husband arrived within an hour, the paracentesis was done, and her shortness of breath was minimized.

Ask:

• How would you like to go about making a decision?
• Do you want to consult with family members before making a decision?

Medical culture is future-oriented and expects patients to make sacrifices now (diet, exercise, medication) for a future reward (better health). Middle and upper middle class individuals from industrialized countries (such as the US) tend to be future-oriented and can usually understand the rationale. However, poverty often forces people to live in the present. Convincing such patients to practice preventive medicine will be much more challenging for the physician.  It may require more patient (in both senses of the word) teaching.

Case Study: An African American man in his 40s, suffering from diabetes and hypertension presented to his physician, complaining of “feeling poorly.”  When questioned, he admitted that he was not taking his insulin regularly; only when he felt that his sugar was high.

Explain:

• Why it is important to take medication for chronic conditions on a regular and consistent basis, rather than only when they experience symptoms.

• Why it is necessary to complete a course of antibiotics, even when symptoms have ceased.

• Why follow-up visits are necessary.

It can also help to tie adherence to something they value, such as seeing their daughter get married, or holding their grandchild.

Some families may want information withheld from the patient because it is thought to be insensitive or to create a sense of hopelessness and thus hasten their death. Sometimes that reflects the patient’s wishes; other times, they prefer to know the truth. You can only learn by asking…when the patient is alone.

Case Study
A Chinese woman in her 60s was diagnosed with cancer and scheduled to receive chemotherapy.  She was unaware of her diagnosis, due to her son’s insistence. The staff was uncomfortable with having to withhold this information from her, so they asked her whether she wanted to know her diagnosis and why she was receiving chemotherapy medication.  Her answer was no.  She said, “Tell my son; he will make all of the decisions.”  They resolved the matter by having hersign a Durable Power of Attorney, appointing her son as legal decision-maker.  They were thus able to remove the legal and ethical obstacles to her care.

Ask:

• How much information would you like me to give you?
• Do you want information about your condition to be given to you or to some other family member?
  

Some cultures teach its members that it’s important to be stoic when in pain; others allow for emotional expressiveness. It’s important not to assume that a patient is not experiencing pain if it’s not being expressed. At the same time, it’s essential not to ignore a patient’s moans and cries, just because they’re from a culture that allows emotional expressiveness.Case Study: Bobbie, a nurse, had two patients who had both had coronary artery bypass grafts. Mr. Valdez, a middle-aged Nicaraguan man, was the first to come up from the recovery room. He was already hooked up to a morphine PCA (patient-controlled analgesia) machine, which allowed him to administer pain medication as needed in controlled doses and at controlled intervals. For the next two hours, he summoned Bobbie every ten minutes to request more pain medication. Bobbie finally called the physician to have his dosage increased and to request additional pain injections every three hours as needed. Every three hours he requested an injection. He continually whimpered in painful agony. Mr. Wu, a Chinese patient, was transferred from the recovery room an hour later. In contrast to Mr. Valdez, he was quiet and passive. He, too, was in pain, because he used his PCA machine frequently, but he did not show it. When Bobbie offered supplemental pain pills, he refused them. Not once did he use the call light to summon her. Nurses usually report that “expressive” patients often come from Hispanic, Middle Eastern, and Mediterranean backgrounds, while “stoic” patients often come from Northern European and Asian backgrounds. As a young Chinese man told me, “Ever since I was little boy, my family watched dubbed Chinese movies, and by watching many of the male protagonists state, ‘I’d rather shed blood than my tears,’ it is embedded in my mind that crying or showing pain shows my weakness.” However, simply knowing a person’s ethnicity will not allow you to predict accurately how a patient will respond to pain; in fact, there are great dangers in stereotyping, as the next case demonstrates.Case Study: Mrs. Mendez, a sixty-two-year-old Mexican patient, had just had a femoral-popliteal bypass graft on her right leg. She was still under sedation when she entered the recovery room, but an hour later she awoke and began screaming, “Aye! Aye! Aye! Mucho dolor! [Much pain].” Robert, her nurse, immediately administered the dosage of morphine the doctor had prescribed. This did nothing to diminish Mrs. Mendez’s cries of pain. He then checked her vital signs and pulse; all were stable. Her dressing had minimal bloody drainage. To all appearances, Mrs. Mendez was in good condition. Robert soon became angry over her outbursts and stereotyped her as a “whining Mexican female who, as usual, was exaggerating her pain.”After another hour, Robert called the physician. The surgical team came on rounds and opened Mrs. Mendez’s dressing. Despite a slight swelling in her leg, there was minimal bleeding. However, when the physician inserted a large needle into the incision site, he removed a large amount of blood. The blood had put pressure on the nerves and tissues in the area and caused her excruciating pain.She was taken back to the operating room. This time, when she returned and awoke in recovery, she was calm and cooperative. She complained only of minimal pain. Had the physician not examined her again and discovered the blood in the incision site, Mrs. Mendez would have probably suffered severe complications.Ask: How much pain are you experiencing?Explain:  Pain can interfere with healing and it’s important to control it before it gets bad.