Hilda Gomez, a monolingual Spanish-speaking patient, came in to the clinic three days in a row to complain of abdominal pain. The first two times, the staff used her young, bilingual daughter to translate. They then treated Mrs. Gomez for the “stomach ache” she described. The staff didn’t understand why she kept returning with the same problem. Finally, on her third visit, the nurse located a Spanish-speaking interpreter. It turned out that Mrs. Gomez needed treatment for a sexually transmitted disease, but was too embarrassed to talk about her sexual activity with her daughter as interpreter. It taught the staff an important lesson.

Helena became very frustrated while caring for Gwon Chin, a seventy-nine-year-old Korean man who had recently suffered a stroke. Her frustration and impatience were aimed at Mr. Gwon’s wife and daughter. Since Mr. Gwon spoke only Korean, she had asked his bilingual daughter to tell her father not to get out of bed because his gait was unsteady. Helena was afraid he would fall and hurt himself. Throughout the day, however, Mr. Gwon continued to attempt to get out of bed. He became very agitated and his wife and daughter seemed almost afraid of him. When Helena questioned the daughter about it, she would only say that her father was “confused.” Eventually Helena called on a Korean nurse to help her. When the nurse told Mr. Gwon not to get out of bed because he might fall, he asked in a surprised tone, “Why would I fall?” When the nurse explained that he was unsteady from the stroke, the patient was shocked. “I had a stroke?!” Helena was in disbelief. He had been on the unit for two days; how could he not know he had had a stroke? When she questioned Mr. Gwon’s daughter about this, she explained that her brother has been out of town. He would be back today and tell him. When Helena, stunned by this, asked the daughter why she didn’t tell her father, she replied, “I could never tell my father what is wrong with him and what he can or can’t do. It would be disrespectful for me to do that when he has always told me what to do and what was wrong.”

Although Helena was angry that Mr. Gwon’s daughter preferred having her father possibly fall and hurt himself than tell him why he was in the hospital and that he must stay in bed, Helena remained silent. She asked the Korean nurse to explain to the patient how the numbness on his left side would make walking difficult so he should remain in bed. She also added that his son would be in later that day and would explain everything to him. After that, the patient remained calm and stayed in bed.  [For more discussion, see Chapter 2 of Caring for Patients From Different Cultures.]

Juanita Avelar was a forty-nine-year-old Mexican woman with kidney failure and diabetes. She relied on her niece and nephew to drive her to the clinic and was often late. In Mexican culture, the needs of the family typically take precedence over those of an individual. The nurses learned to take this into account when scheduling her appointments, and they allowed plenty of time for the family to discuss Mrs. Avelar’s condition as a family. When certain tests and medications required specific timing for accuracy and effectiveness, they stressed the importance of clock time.

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.

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. [For more discussion, see Chapter 5 of Caring for Patients From Different Cultures.]

Pepe Acab, a Filipino patient, was being discharged on Coumadin, a blood thinner, to prevent clotting. Vitamin K reverses the effect of the drug and must be avoided. Normally, Libby, his nurse, would tell such patients to avoid foods like liver, broccoli, brussels sprouts, spinach, Swiss chard, coriander, collards, cabbage, and any green, leafy vegetables. She suddenly realized, however, that there might be other foods he should avoid. She spoke with Mr. Acab and his wife, and got a list of foods he commonly ate. She then did some research and discovered that two foods on the list—soybeans and fish liver oils—are very high in Vitamin K. She was then able to educate him properly on what to avoid.

Susi Givens, a thirty-seven-year-old woman with two children, was horseback riding one day when a snake startled her horse. She was thrown off and landed on a stump, resulting in massive internal injuries. She was rushed to the hospital, where the surgical team discovered that there was a large amount of blood in her abdomen and that she needed to have a kidney removed.

Mrs. Givens had a medical alert card identifying her as a Jehovah’s Witness and stating that under no circumstances was she to receive blood. Her physician knew this but felt impelled by his oath to save lives to give her a blood transfusion. The hospital was unable to locate her husband, so the physician decided to transfuse her.

His actions saved her life; however, she was not grateful. She sued her doctor for assault and battery and won a $20,000 settlement. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures.]

Sol and Deborah Meyers, an Orthodox Jewish couple, came to the hospital late Friday night when Deborah was in active labor. When she gave birth at midnight, the nurses suggested that Sol accompany her to the postpartum unit and then return home to rest. He thanked them, then explained that he could not drive home because it was the Sabbath. The nurses suggested that he call a friend or relative to pick him up. Sol replied that he could not use the phone on the Sabbath, and even if he made a call, no one would answer because all his friends and relatives were also Sabbath-observant. The nurses understood and arranged for him to stay in his wife’s room, but were left wondering why Sol could drive to the hospital but not drive back home.

In the morning, a nurse noticed that Deborah had not received breakfast and was instead eating snacks from the bag she had brought from home. The nurse asked if she needed help ordering food, and Deborah explained that the hospital-provided meals did not adhere to kosher dietary laws. The nurse, trying to be helpful, suggested that Sol purchase kosher food from the gift shop on the first floor, but was told that due to the laws of the Sabbath, Sol was forbidden to ride in an elevator or handle money. The nurse left the room, confused but glad the couple had brought some food of their own. 

Later that afternoon, the nurse returned to check on Deborah, and made friendly conversation by asking how the baby’s nursery was decorated at home. She was surprised to learn that in Orthodox tradition, minimal preparations are made before a baby’s birth, and the baby’s room was not set up at all. Intrigued, she asked Sol to explain some of the laws of Sabbath observance. She learned that the couple had been able to drive to the hospital because, according to halacha (Jewish law), childbirth is considered an emergency requiring the breaking of the Sabbath, but that once the birth was over, they were not allowed to drive home due to the absence of an emergency.

Raj Singh, a seventy-two-year-old Sikh from India, had been admitted to the hospital after a heart attack. He was scheduled for a heart catheterization to determine the extent of the blockage in his coronary arteries. The procedure involved running a catheter up the femoral artery, located in the groin, and then passing it into his heart, where special x-rays could be taken. His son was a cardiologist on staff and had explained the procedure to him in detail.

Susan, his nurse, entered Mr. Singh’s room and explained that she had to shave his groin to prevent infection from the catheterization. As she pulled the razor from her pocket, she was suddenly confronted with the sight of shining metal flashing in front of her. Mr. Singh had a short sword in his hand and was waving it at her as he spoke excitedly in his native tongue. Susan got the message. She would not shave his groin.

She put away her “weapon,” and he did the same. Susan, thinking the problem was that she was a woman, said she would get a male orderly to shave him. Mr. Singh’s eyes lit up again as he angrily yelled, “No shaving of hair by anyone!”

Susan managed to calm him down by agreeing. She then called her supervisor and the attending physician to report the incident. The physician said he would do the procedure on an unshaved groin. At that moment, Mr. Singh’s son stopped by. When he heard what had happened, he apologized profusely for not explaining his father’s Orthodox Sikh customs. [For more discussion, see Chapter 4 of Caring for Patients From Different Cultures.]

Ricky, a five-year-old African American male with asthma, was supposed to take a controller medication (asthma inhaler #1, Steroid) twice a day as a preventative measure. When he was wheezing and/or having breathing problems, he was supposed to take asthma inhaler #2 (Albuterol) as an emergency medication. Dr. Arabel felt that she had given very clear instructions on how to use the two inhalers, but Ricky’s mother kept bring him back to the clinic with a lot of wheezing; his asthma was obviously not being well controlled. As it turned out, Ricky had not been using the inhalers as directed. His mother, who was enrolled in school, was overwhelmed and did not understand the significance of his asthma and the need to use the two inhalers properly. On one of the visits, Dr. Arabel learned that Ricky’s grandmother had accompanied them to the clinic. She brought the grandmother into the exam room, and explained everything to her. Once the grandmother became involved, everything changed. There were no more emergency room/urgent clinic visits and Ricky’s asthma was much better controlled. He only rarely needed the “emergency” Albuterol compared to earlier. Involving the grandmother had made a tremendous difference.  [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures.]

Julia was treating Mrs. Torres, an elderly Hispanic patient who was intubated. When she needed information, she would direct her questions to the eldest son. She assumed he would be the family spokesperson. However, he rarely had an answer for her. While in many cases the eldest son would be the decision-maker, in this case he was not. The youngest daughter held the durable power of attorney for medical decisions. It was several days before anyone even thought to ask the family who held power of attorney. The staff had made the mistake of stereotyping. Once Julia learned that the youngest daughter was responsible for making medical decisions for her mother, such decisions were reached more quickly and without unnecessary strain on the rest of the family. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures.]

Juan Martinez, a thirty-six-year-old Mexican man with second-degree burns on his hands and arms, posed a problem. The skin grafts had healed, and there was now danger that the area would stiffen and the tissue shorten. The only way to maintain maximum mobility was through regular stretching and exercise. The nurses explained to Mr. Martinez’s wife that feeding himself was an essential therapeutic exercise. The act of grasping the utensils and lifting the food to the mouth stretches the necessary areas. Mrs. Martinez seemed to understand the nurses’ explanation, yet she continued to cut her husband’s food and put it in his mouth.

When Linda, one of his nurses, observed this, she took the fork out of Mrs. Martinez’s hand and told Mr. Martinez to feed himself because he needed to exercise his arms and hands. Linda again explained to Mr. Martinez’s wife how important it was for him to do it himself. Mrs. Martinez appeared skeptical but did not argue. Mr. Martinez looked at Linda peevishly and made a feeble attempt at eating. His wife watched with pity. Linda knew from seeing Mr. Martinez when his wife was not around that he was perfectly capable of feeding himself. Linda left the room. When she looked in five minutes later, she saw Mrs. Martinez once again cutting her husband’s food and putting it in his mouth. [For more discussion, see Chapter 6 of Caring for Patients From Different Cultures.]

Before taking my course in cultural diversity, Jennifer, like all the nurses on her unit, tried to avoid taking care of Naser Assharj, a middle-aged Iranian Muslim patient, because the entire staff found his family to be very “uptight and demanding.” The nurses rotated care for this patient, because no one was willing to care for him more than one day at a time. When Jennifer learned a bit about Muslim culture, however, she understood why his family kept demanding a private room and made such a fuss over his meals. It was their way of showing love and care for their family member. He needed a private room so that, as devout Muslims, the family could pray together five times a day as commanded by Allah. It was also important that his food be halal, or follow the Muslim laws of what is permissible (see Chapter 5). Once Jennifer realized this, she contacted her supervisor and arranged to have the patient moved to a private room and spoke to the dietician regarding his food. The family members were very grateful for her efforts, and became much easier to deal with.

Amira Faroud was a three-year-old Middle Eastern patient, newly diagnosed with type 1 diabetes. Understanding the importance of involving the entire family in the patient’s care, Lisa tried to get the patient’s father, Mr. Faroud, to participate. She had seen other fathers reluctant to learn in the past, but eventually, they all were persuaded. But not Mr. Faroud. He would not even consider it. Eventually, Lisa changed the teaching plan to include Amira’s grandmother rather than her father, and all went well. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures.]

A female resident could not get a Hispanic mother to sign consent for a procedure for her child; she, too, insisted on waiting for her husband. In this case, however, it was urgent that the procedure be done as soon as possible. The resident asked an older male physician to speak to the mother. Apparently, the combination of his age and gender were enough to convince her to sign consent without speaking first to her husband.

Amiya Nidhi was a young woman in her twenties who had recently immigrated to the United States from India. She was in the hospital to give birth. Her support person was her sister, Marala. Marala kept telling her to get an epidural, but Amiya said that even though she would like one, she could not get one; her husband would not allow it. Cindy, her nurse, overheard the conversation. Having learned that husbands are the authority figure in the traditional Indian household, she went to speak with Mr. Nidhi. She explained why an epidural would be advisable. She said that he seemed pleased that she came to him about it. He said he would think about it, and let her know. About thirty minutes later, he came to Cindy and told her that he would like his wife to have an epidural. Everyone was pleased. By using cultural competence, Cindy helped her patient get the care she wanted, while still respecting the authority structure within the family. [For more discussion, see Chapter 7 of Caring for Patients From Different Cultures.]

An Iranian mother and father admitted their thirteen-month-old child, Ali, to the pediatrics unit. After three days of rigorous testing and examination, it was discovered that Ali had Wilms’ tumor, a type of childhood cancer. Fortunately, the survival rate is 70 to 80 percent with proper treatment.

Before meeting with the pediatric oncologist to discuss Ali’s treatment, Mr. and Mrs. Mohar were concerned and frightened, yet cooperative. Afterward, however, they became completely uncooperative. They refused permission for even the most routine procedures. Mr. Mohar would not even talk with the physician or the nurses. Instead, he called other specialists to discuss Ali’s case.

After several frustrating days, the oncologist decided to turn the case over to a colleague. He met with the Mohars and found them extremely cooperative. What caused their sudden reversal in behavior? The fact that the original oncologist was a woman.

Several weeks later, it became necessary to insert a permanent line into Ali to administer his medication. The nurse attempted to show Mrs. Mohar how to care for the intravenous line, but Mr. Mohar stopped her. “It is my responsibility only. You should never expect my wife to care for it.” Throughout each encounter with the hospital staff, Mrs. Mohar remained silent and deferred to her husband. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures.]

A twenty-eight-year-old Arab man named Abdul Nazih refused to let a male lab technician enter his wife’s room to draw blood. She had just given birth. When the nurse finally convinced Abdul of the need, he reluctantly allowed the technician in the room. He took the precaution, however, of making sure Sheida was completely covered. Only her arm stuck out from beneath the blankets. Abdul watched the technician intently throughout the procedure. [For more discussion & explanation, see Chapter 7 of Caring for Patients From Different Cultures.]

Fatima, an eighteen-year-old Bedouin girl from a remote, conservative village, was brought into an American air force hospital in Saudi Arabia after she received a gunshot wound to her pelvis. Her cousin Hamid had shot her. Her family had arranged for her to marry him, as was local custom, but she wanted nothing to do with him. She was in love with someone else. An argument ensued, and Hamid left. He returned several hours later, drunk, and shot Fatima, leaving her paralyzed from the waist down.

Fatima’s parents cared for her for several weeks after the incident but finally brought her to the hospital, looking for a “magic” cure. The physician took a series of x-rays to determine the extent of Fatima’s injuries. To his surprise, they revealed that she was pregnant. Sarah, the American nurse on duty, was asked to give her a pelvic exam. She confirmed the report on the x-rays. Fatima, however, had no idea that she was carrying a child. Bedouin girls are not given any sex education.

Three physicians were involved in the case: an American neurosurgeon who had worked in the region for two years; a European obstetrics and gynecology specialist who had lived in the Middle East for ten years; and a young American internist who had recently arrived. No Muslims were involved. The x-ray technician was sworn to secrecy. They all realized they had a potentially explosive situation on their hands. Tribal law punished out-of-wedlock pregnancies with death.

The obstetrician arranged to have Fatima flown to London for a secret abortion. He told the family that the bullet wound was complicated and required the technical skill available in a British hospital.

The only opposition came from the American internist. He felt the family should be told about the girl’s condition. The other two physicians explained the seriousness of the situation to him. Girls in Fatima’s condition were commonly stoned to death. An out-of-wedlock pregnancy is seen as a direct slur upon the males of the family, particularly the father and brothers, who are charged with protecting her honor. Her misconduct implies that the males did not do their duty. The only way for the family to regain honor was to punish the girl by death.

Finally, the internist acquiesced and agreed to say nothing. At the last minute, however, he decided he could not live with his conscience. As Fatima was being wheeled to the waiting airplane, he told her father about her pregnancy.

The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatima’s brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, “She died.” Family honor had been restored. The ethnocentric internist had a nervous breakdown and had to be sent back to the United States.

Sofia Toledo, a sixty-five-year-old upper-class Mexican woman, refused to be dialyzed when she learned that her usual dialysis station was unavailable. She said she would wait until her next treatment, when she could have her customary place. Unfortunately, this was not a viable alternative. Missing a treatment could result in serious complications or even death. When Julia, the nurse, asked her why the new station was unacceptable, Mrs. Toledo was very vague.

Julia finally called Mrs. Toledo’s daughter, and together they solved the problem. Mrs. Toledo’s usual station was unusual in that neither the nurses nor the patients at the other dialysis stations could see it very well. The rest of the stations were very open, designed for high visibility by the nurses. To be dialyzed, the patient had to remove her pants and don a patient gown. Her underwear was exposed during the process. Mrs. Toledo’s sense of modesty, a quality very strong in Hispanic women, made the more open station intolerable.

Julia said that at the time she found Mrs. Toledo’s behavior annoying. She and the other nurses saw it as a delay that would prevent them from leaving on time. They did not want to have the extra work of moving machinery or remixing the dialysate. She did not understand the importance of modesty in Hispanic culture, but she did realize that it was important to Mrs. Toledo, a normally “compliant” patient. In this case, a screen or curtain might have alleviated the problem.

Kayla was a staff nurse on a medical-surgical floor when she first met Dr. Ling, an Asian physician. They got along well until Kayla transferred to the diabetes clinic. Clinic protocols allow nurses to order new medications, adjust medications, and order lab work as needed, as long as they get a physician to sign the order. When Kayla asked Dr. Ling for his signature, he would rudely question why she felt the medication was necessary, and on a few occasions refused to sign, stating that he disagreed with the medication she had ordered. After learning more about Asian culture in a cultural competence course, she realized he probably perceived her approach as showing a lack of respect, despite the fact that she was following clinic protocols. She then changed her approach. Rather than just asking him to sign the medication order, she would go to him, explain the situation with the patient, tell him what she was considering, and ask him what he would like done. Kayla reported that Dr. Ling was much more receptive to this approach, probably because it allowed him to feel respected and in control. Taking the extra time to do this repaired the lines of communication between them. Although it could be argued that Dr. Ling is the one who should have changed his behavior, that is probably less realistic than having Kayla apply her cultural knowledge to achieve the results that she wanted.

Josepha, a Filipina nurse, did not get along well with her coworkers. The nursing staff on her unit was composed of two Anglo Americans, two Nigerians, and Josepha. She felt her coworkers were taking advantage of her, because they would ask for assistance whenever they saw her. Josepha was angry over what she perceived as obvious discrimination. She cheered herself by reminding herself that she was a better nurse than the others; she could do her work without their help. In addition, she was not lazy like they were. She took care of her patients; the other nurses insisted that their patients take care of themselves.

One day, Rena, one of the Anglo nurses, was unusually friendly, so Josepha opened up to her. As they got to know each other better, Josepha shared her feelings of being taken advantage of. Rena explained that it was common procedure for the nurses to help each other with their work. Rena confided that the others thought Josepha was being snobbish and proud because she never asked for help. They saw what Josepha had interpreted as laziness on the part of the others as being team players. Rena also explained that American health care providers believe that independence is important and encourage self-care among their patients.

Josepha was stunned by Rena’s revelations. Rena offered to help bridge the communication gap between Josepha and her coworkers. She explained to the others that Josepha was trying to save face by never asking for help; she didn’t want them to think she couldn’t do her job. Josepha began to teach her patients self-care and to ask her coworkers for assistance. Over time, the cross-cultural misunderstandings were resolved, and Josepha’s coworkers became her best friends.

Leslie reported that her hospital had recently hired five new Korean nurses. Unfortunately, they did not get along well with the rest of the nursing staff. They rarely said “please” or “thank you” and were generally perceived as rude. Leslie was reading an earlier edition of this book and suddenly realized that the Korean nurses were older than the other nurses on the unit and probably felt that “please” and “thank you” were implicit. Leslie then showed the other staff nurses the section on “Please” and “Thank You.” She reported that morale on the unit is much improved. Sometimes, all it takes is a little understanding.

An American physician and professor, consulting in Japan, was about to address a group of university physicians; it was fully understood by all that he would give his talk in English. He nevertheless prepared a brief introduction in Japanese, concluding with the statement, “My Japanese is limited, so with your permission, I will continue in English.” When he asked his Japanese secretary if his statement was grammatically correct, she seemed uncomfortable. On further questioning she reluctantly admitted that, grammar aside, it was not appropriate for someone of his stature to ask the audience for permission, and that this would diminish the audience’s ability to respect anything else he said. Instead, she suggested, he should merely announce that he would continue in English. In this context “asking permission” was entirely pro forma in American culture; it would be seen as a polite gesture. In Japan, however, it was considered inappropriate from someone in a position of authority, and would likely result in a loss of respect for the person doing the asking. [For further discussion, see Chapter 8 of Caring for Patients From Different Cultures.]

A labor and delivery nurse reported that the most difficult patient she ever attended was Robabeh Farag, an Iranian woman, who yelled and screamed for the entire duration of her labor. After she delivered their child, her husband presented her with a three-karat diamond ring. When her nurse commented on the expensive gift, she responded dramatically, “Of course. He made me suffer so much!” Iranian custom is to compensate a woman for her suffering during childbirth by giving her gifts. The greater the suffering, the more expensive the gifts she will receive, especially if she delivers a boy. Her cries indicate how much she is suffering. A young Iranian doctor recently told me that when his wife has a baby, he will present her with a diamond ring or a watch. [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures.]

Naomi Freedman, an Orthodox Jewish woman, was in labor with her third child. She had severe pains, which were alleviated only by back rubs between contractions. Her husband asked Marge, a nurse, to remain in the room to rub his wife’s back. Because she had two other patients to care for, Marge began to instruct him on how to massage his wife. To Marge’s surprise, he interrupted her, explaining that he could not touch his wife because she was unclean. Marge, assuming he meant she was sweaty from labor, suggested that he massage her through the sheets. In an annoyed tone, he explained that he could not touch his wife because she was bleeding. Marge was further surprised when, while Naomi began pushing, her husband left the room and did not return until after their baby was born.

Marge later learned from Mrs. Freedman that in halacha (Jewish law), the blood of both menstruation and birth render a woman spiritually unclean and therefore physical contact between husband and wife was prohibited. Mrs. Freedman also explained that in some Orthodox communities, husbands are prohibited from being present at birth in non-emergency situations.

[For further discussion, see Chapter 9 of Caring for Patients From Different Cultures.]

Maria Salazar was a thirty-two-year-old recent immigrant from Mexico with an infected incision from a caesarean section. She asked Tonya, her nurse, for some water. When Tonya grabbed the bedside pitcher to refill it, she discovered it was full. When Tonya pointed this out to her, she answered in Spanish, “Yes, but I have a fever and a cough. If I drink that cold water I will get even more sick.” Tonya, who spoke some Spanish, was taking a course in cultural diversity at the time and was elated to see hot/cold beliefs in action. She then emptied the ice water and refilled it with warm water. Curious, Tonya asked her if there were any changes she would like to see in her treatment. Mrs. Salazar nodded her head. She said she didn’t understand why the nurses kept insisting she do things that would make her ill—things like taking a shower. Didn’t they understand she had a fever and had just delivered a baby? And why did they want her to spend so much time walking, when she knew she should stay in bed and rest as much as possible? [For further discussion, see Chapter 9 of Caring for Patients From Different Cultures.]

Raul Santiago was a Hispanic male in his seventies who had been in the hospital for seven months. He had been admitted for abdominal pain, but it soon became apparent that he had advanced stage pancreatic cancer. Mr. Santiago had 12 children, who all conspired to avoid using the word “cancer” in front of their father or to even acknowledge his fatal prognosis. Instead, they referred to his condition as “abdominal pain.” During the time he was in the hospital, Mr. Santiago became close to the nursing staff. One day while Tiffany was administering his pain medication, he looked directly at her and said with resignation, “I’m going to die, aren’t I?” Without waiting for her to respond, he continued. He explained to Tiffany that he didn’t want his children to suffer because of his illness, and he knew that if they knew that he knew he had cancer, it would cause them great distress. He told her that he was ready to be with his wife who had died two years earlier. He was content to pretend to be ignorant of his disease if it eased his family’s suffering. Whether or not it would have caused his children to suffer if they knew he knew, or if it would have been a relief is unknown. But the nurses honored his decision.

A fifty-two-year-old African American man named William Jefferson was admitted to the critical care unit with a diagnosis of pneumonia. On admission, he was offered an Advance Directive, which he refused, saying that God would help him with his illness. His lung cancer had gone into remission after radiation treatment; he believed that God had helped him through that illness, and would help him through the current one. He thought that signing a Do Not Resuscitate form or Advance Directive would be a sign of giving up or losing faith in God. Unfortunately, he died ten days later, after enduring a great deal of suffering. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures.]

Ngoc Ly, a twenty-five-year-old Vietnamese man, was hit by a car while riding his bicycle to work. Paramedics were able to resuscitate him, but the physician at the local trauma center determined that Mr. Ly was clinically brain dead. He placed him on life support until the family could be notified.

An interpreter explained Mr. Ly’s condition to his wife and parents. They nodded in understanding and quietly left the hospital. Normally, the staff neurosurgeon would then have pronounced Mr. Ly dead and removed him from the ventilator, but he was suddenly called to surgery.

Later that afternoon, Mr. Ly’s family met with Dr. Isaacs, the physician they had spoken to earlier. Dr. Isaacs intended to tell them of the plan to pronounce Mr. Ly dead and discontinue the ventilator, but the Lys had other plans. They informed him that they had consulted a specialist who said this was not the right time for him to die. Dr. Isaacs was confused. What kind of specialist would make such a recommendation? An astrologer who had read Ngoc Ly’s lunar chart advised that his death be postponed until a more auspicious date.

The physician had never encountered a situation like the one now facing him. Fearing legal repercussions if he did not abide by the family’s request, he agreed to keep Mr. Ly on life support until further notice. A little less than a week later, the Lys called to tell him that Ngoc could now die. [For further discussion, see Chapter 10 of Caring for Patients From Different Cultures.]

Canh Cao was a thirty-four-year-old Vietnamese woman who was treated by a medical student at a public health clinic. She had made several visits for various physical complaints—abdominal pain, backache, headaches. She was diagnosed with somatoform pain disorder—preoccupation with pain in absence of physical findings.

Several months later, Cao attempted suicide. She was sent for evaluation to a psychiatrist, who at that point diagnosed her with depression. She had been depressed all along, but the medical student was both inexperienced and unaware of cultural issues, so he missed it. [For further discussion, see Chapter 11 of Caring for Patients From Different Cultures.]

Amelia avoided a potential child abuse report with a Cambodian family, the Chhets. The child had suspicious burn marks on her body. Instead of assuming child abuse, she first interviewed both parents separately. Both explained that they had treated their child using cupping and coining to make her feel better and help her recover more quickly. Amelia then explained to her supervisor what she had learned from the parents, and they decided it was not a child abuse situation. The Chhets practiced the traditional form of cupping. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

Mexican American mother refused to use cooling measures in caring for her febrile infant, despite medical instructions to do so. Mrs. Lopez had called the hospital because her infant’s temperature was very high. She was told to give the baby a mild analgesic and a cool bath and then to bring her in. Mrs. Lopez ignored both cooling instructions and, to the consternation of the medical staff, brought the child wrapped in several layers of blankets, outer garments, undershirt, and several pairs of socks. When asked why she did not follow the instructions given her, she replied, “He must sweat the fever out. Besides, he could get pneumonia from the night air and die.” [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

Fariba was asked to interpret for Fereydoon Jalili, an Iranian man who had come to the hospital with gastrointestinal bleeding. Mr. Jalili spoke some English, and when the physician had asked him what medications he was taking, he told him he didn’t take any. When Fariba was brought in to interpret, she began talking to him about his health. During their conversation, he admitted that he took vitamins to stay healthy and he was very proud of the fact that he had never been sick. He also mentioned that he took two aspirins a day for his heart after seeing a commercial on television which said it prevented heart attacks. When Fariba asked him why he didn’t tell the doctor about the vitamins and aspirin, he said that he didn’t consider anything he bought over-the-counter to be a “real” medication. Once the physician learned what he had been taking, he educated Mr. Jalili on appropriate aspirin consumption, since that was the likely cause of his GI bleed. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

Jen, a second-year medical student, was on a pediatrics visit learning how to perform a newborn exam. As she followed the attending into the patient’s room, she noticed that the baby’s mother was sitting on the side of the crib talking in Spanish to her husband. The attending started to explain to Jen what is important to notice about a baby and what to look for on the physical exam, and proceeded to ask her questions about the causes of pneumonia and meningitis in the newborn period. As they were talking, the infant’s mother came over to the crib. In an attempt to welcome her into their conversation, Jen said “hello,” and proceeded to compliment her on her beautiful child. As soon as she finished the sentence, the mother said “thank you,” but frowned, and her demeanor changed slightly—she stopped smiling, and looked nervous.

Jen wondered what she had done wrong, and suddenly realized that the family was Mexican, and her complimentary words, intended as a tool to gain the mother’s trust, resulted in causing her distress. Remembering what she had learned about Mexican culture and mal de ojo (evil eye), she touched the baby’s hand, and looked back at the mother. The change was remarkable—the mother smiled back at her, and nodded her head. She did not say anything, but her smile and nod tacitly communicated her gratitude for preventing mal de ojo. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

An eighty-three-year-old Cherokee woman named Mary Cloud was brought into the hospital emergency room by her grandson, Joe, after she had passed out at home. Lab tests and x-rays indicated that she had a bowel obstruction. After consulting with Joe, the attending physician called in a surgeon to remove it. Joe was willing to sign consent for the surgery, but it would not be legal; the patient had to sign for herself. Mrs. Cloud, however, refused; she wanted to see the medicine man on the reservation. Unfortunately, the drive took an hour and a half each way, and she was too ill to be moved. Finally, the social worker suggested that the medicine man be brought to the hospital.

Joe left and drove to the reservation. He returned three hours later, accompanied by a man in full traditional dress complete with feather headdress, rattles, and bells. The medicine man entered Mrs. Cloud’s room and for forty-five minutes conducted a healing ceremony. Outside the closed door, the stunned and amused staff could hear bells, rattles, chanting, and singing. At the conclusion of the ceremony, the medicine man informed the doctor that Mrs. Cloud would now sign the consent form. She did so and was immediately taken to surgery. Her recovery was uneventful and without complications. . [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

Emma Chapman was a sixty-two-year-old African American woman admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.”

When Judy, her nurse, asked her what she thought had caused the problem, she said she had sinned and her illness was a punishment. According to her beliefs, illnesses from “natural causes” can be treated through nature (e.g., herbal remedies), but diseases caused by “sin” can be cured only through God’s intervention. Remember, treatment must be appropriate to the cause. In addition, Mrs. Chapman may have felt that to accept medical treatment would be perceived by God as a lack of faith.

Mrs. Chapman finally agreed to the surgery after speaking with her minister, whom Judy called to the hospital. [For further discussion, see Chapter 12 of Caring for Patients From Different Cultures.]

A fifty-year-old Mexican woman named Sandra Ramirez came to the ER with epigastric pain. She told the nurse that she had been experiencing the pain constantly for the past week, but denied any nausea, vomiting, diarrhea, or constipation. There had been no changes in her diet or bladder or bowel function. She revealed that when she had experienced similar pain in the past, she was treated with an unknown medication that helped her greatly. The nurse who was interviewing her had just been introduced in class to the concept of the 4 C’s, so she also asked the patient what she thought the problem was. The patient called her condition “stressful pain,” and elaborated that it wasn’t the pain that caused stress, but that stress caused the pain. It turned out that the medication that had helped her in the past was Xanax. She had stopped taking it eight days earlier; the pain began seven days ago. Had the nurse not gotten the patient’s perspective on her condition—that it was related to stress—they would have done just a standard abdominal workup and perhaps not discovered that it was due to anxiety.

Emma Chapman, a sixty-two-year-old African American woman, was admitted to the coronary care unit because she had continued episodes of acute chest pain after two heart attacks. Her physician recommended an angiogram with a possible cardiac bypass or angioplasty to follow. Mrs. Chapman refused, saying, “If my faith is strong enough and if it is meant to be, God will cure me.” When her nurse asked what she thought caused her heart problems, Mrs. Chapman said she had sinned and her illness was a punishment. Her nurse finally got her to agree to the surgery by suggesting she speak with her minister. If she hadn’t learned about Mrs. Chapman’s religious beliefs while asking what she that was the cause of her heart problems, she might not have thought to contact her clergyman.

Olga Salcedo was a seventy-three-year-old Mexican woman who had just had a femoral-popliteal bypass. Anabel, her nurse, observed that Mrs. Salcedo’s leg was extremely red and swollen. She often moaned in pain and was too uncomfortable to begin physical therapy. Yet during her shift report, her previous nurse told Anabel that Mrs. Salcedo denied needing pain medication. Later that day, Anabel spoke with the patient through an interpreter and asked what she had done for the pain in her leg prior to surgery. Mrs. Salcedo said that she had sipped herbal teas given to her by a curandero (a traditional healer; see Chapter 12); she didn’t want to take the medications prescribed by her physician. Anabel, using cultural competence, asked Mrs. Salcedo’s daughter to bring in the tea. Anabel paged the physician about the remedy and brought it to the pharmacist, who researched the ingredients. Because there was nothing contraindicated, the pharmacist contacted Mrs. Salcedo’s physician, who told her she could take the tea for her pain. The next day, Mrs. Salcedo was able to go to physical therapy and was much more motivated and positive in demeanor. Although it took some time to coordinate the effort, in the end, it resulted in a better patient outcome. Had Anabel not asked what she had been using to cope with her pain, it is likely Mrs. Salcedo would have delayed physical therapy and thus her recovery.

Jorge Valdez, a middle-aged Latino patient, presented with poorly managed diabetes. When Dr. Alegra, his physician, told him that he might have to start taking insulin, he became upset and kept repeating, “No insulin, no insulin.” Not until Dr. Alegra asked Mr. Valdez what concerns he had about insulin did he tell her that both his mother and uncle had gone blind after they started taking insulin. He made the logical—though incorrect—assumption that insulin caused blindness. In this case, the patient expressed his fears, and because the physician was competent enough to pick up on them and explore them, she was able to allay them. In many cases, however, unless the physician specifically asks about concerns, patients will say nothing and simply not adhere to treatment. By asking, the health care provider can correct any misconceptions that can interfere with treatment.

A 35-year-old 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.  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.

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.

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.

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.

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.

Bobbie, the 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, “Even 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 imbedded 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.

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.