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Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

Chapter 13

Intercultural Communication and Health Care

Study Objectives

After studying the material in this chapter, students should be able to accomplish the following

objectives.

1. Understand the importance of communication in health care delivery. Describe some of the

ways that communication can be overlooked and how this might impact the delivery of

medical services.

2. Explain some of the intercultural barriers to effective health care. Explain the ways that

some cultural groups have been or continue to be treated in the health care system.

Describe how prejudicial attitudes can influence health care delivery.

3. Explain how religious or spiritual beliefs may be important in effective health care

delivery. Describe some of the ways that health care professionals can deal with religious

and spiritual beliefs. Discuss the ethical implications of some of the ways that health care

professionals deal with religious or spiritual beliefs.

4. Explain how power differences can influence health communication.

5. Identify the four frameworks that physicians might use in communicating about a patient’s

health.

6. Describe the role of ethics committees. Describe some of the complex issues to be dealt

with in making ethical health care decisions.

Key Terms

• AIDS

• Benevolent deception

• Complementary and integrative medicine

• Contractual honesty

• Ethics committees

• Euthanasia

• Fat acceptance movement

• Health care professionals

• HIPAA

• HIV

• Medical jargon

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

• Medical miscommunication

• Medical terminology

• Prejudicial ideologies

• Religious freedom

• Religious history

• Strict paternalism

• Tuskegee Syphilis Project

• Unmitigated honesty

Detailed Chapter Outline

I. The Importance of Communication in Health Care

• Intercultural communication is increasingly relevant in the health communication context

for a number of reasons.

o First, as the population becomes increasingly diverse, complexities arise in

communicating about health issues.

▪ Not only are health care professionals communicating with people from

differing cultural backgrounds, but these same patients are communicating with

nurses, doctors, and other health care professionals from differing cultural

backgrounds.

o Second, health care professionals and patients may not realize the importance of

communication.

▪ This oversight may seem incidental to medical training and treatment, but the

reality is, much medical practice, particularly diagnosis, relies heavily on

patient communication.

▪ In many ways, this shortcoming in health care reflects a Western cultural

phenomenon, “due partly to the belief that the biomedical model of health

care—the predominant model in Western societies—is based on a range of

predominantly physical procedures (physical examination, physical

manipulation, injections, etc.) rather than communication between two parties.”

▪ However, good communication is crucial to quality health care. Health care

providers ask questions to diagnose problems, to help patients understand the

treatment, and so on. And patients come to health professionals to seek

treatment and ask questions.

▪ But even native English speakers complain about the use of medical jargon—

potentially confusing or difficult-to-understand medical terminology—by

physicians.

▪ For those patients who are communicating in a second language, medical

Chapter 13: Intercultural Communication and Health Care

terminology—scientific language used by doctors to describe specific medical

conditions—can be particularly confusing.

▪ And when cultural misunderstandings arise, it can lead to inadequate treatment.

This misunderstanding is sometimes called medical miscommunication. This

type of miscommunication can result in medical mistakes, problems with

patient use of medication and other problems.

o Third, and probably the most obvious barrier to health services, are language

barriers. Some health care providers ask their bilingual employees to serve as

interpreters to patients who do not speak English.

o Fourth, health care providers and patients alike may operate out of an ethnocentric

framework without realizing it, and assumptions about health care often have cultural

roots.

o Fifth, treating patients is not always a matter of communication between the

physician and the patient.

▪ While one-to-one communication generally works well in Western cultures,

which are more oriented to individualism, other cultures may focus more on the

family’s role in health care.

▪ Unfortunately, most health communication research has limited itself to the

physician–patient relationship.

• In the United States, disclosure of health information is guided by a federal law known as

the Health Insurance Portability and Accountability Act (HIPAA).

o HIPAA includes a strict privacy rule that restricts communicating health information

to anyone other than the patient and those who may need to know, for example, other

physicians, nurses, and health insurance companies for billing purposes.

o Cultural bias in thinking about the role of the family in health care can lead to

problems.

o Health care professionals must be sensitive to cultural differences and must adapt

their communication accordingly.

o Finally, some work has begun to show the importance of community involvement in

health care.

o In their work on community-based health communication, communication scholars

Leigh Arden Ford and Gust Yep found that a community oriented approach often

works much better than a focus on individuals.

▪ Part of this effectiveness emerges when community health workers “become

catalysts for change. Through their public health and communication network

role enactments, they promote community organizing efforts and enable

individual empowerment.

▪ Significantly, community health workers empower themselves as they become

a means to empowerment for individuals, families, neighborhoods, and

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Martin, Experiencing Intercultural Communication, 6e

communities.

o A focus on community as a foundation for health care is quite different from a more

traditional focus on the individual, but it seems to work.

II. Intercultural Barriers to Effective Health Care

A. Historical Treatments of Cultural Groups

• Historically, widespread ideologies about different cultures have fostered differential

treatment for some groups, especially racial and ethnic minorities, by medical

professionals.

• In the past, medical conclusions about alleged racial difference have justified a number

of deplorable social practices, from slavery, to colonization, to immigration restrictions.

• Differential treatment has caused some cultural groups to be justifiably suspicious of

contemporary health care.

o For example, the infamous Tuskegee Syphilis Project, conducted by the U.S.

Public Health Service on unsuspecting African Americans in Tuskegee, Alabama,

over a 40-year period, spurred some of these concerns.

▪ In this study, Black patients who sought out medical care for syphilis were

instead given placebos (sugar pills), but were not told that they were part of

a study, simply to establish an experimental control group.

▪ The purpose of the study was to explore how syphilis spreads in a patient’s

body and how it spreads in a population.

▪ The Tuskegee Syphilis Project, among other studies and projects, has

reinforced suspicion about the medical community from many marginalized

communities.

• The rise of AIDS (acquired immune deficiency syndrome) and HIV (human

immunodeficiency virus) in the late twentieth century provoked new fears among gays

and minorities that the medical community would again provide differential treatment.

• The slow response to the AIDS epidemic by the federal government has been widely

discussed and critiqued.

B. Prejudicial Ideologies

• Prejudicial ideologies—sets of ideas based on stereotypes—about various cultural

groups affect both health care professionals and patients. These attitudes can present

significant barriers to intercultural communication.

• Given the concern with the kinds of health care received by members of nonmainstream

cultural groups, these comments take on even more significance than simply being

Martin, Experiencing Intercultural Communication, 6e

prejudicial.

o Such attitudes may influence the quality of health care that patients receive. And

health care professionals are hardly immune to prejudice. Attending nursing

school or medical school does not purge feelings of homophobia, racism, sexism,

and other kinds of prejudice.

• Patients, too, often enter the health care system with prejudicial attitudes toward health

care providers.

o Because of this mistrust, many people prefer to obtain a significant amount of

their medical information from their own communities.

III. Religion and Health Care

• Even when they are not facing serious illness or death, many people turn to religion or

spirituality to help them try to understand the complexities of life.

o When they are ill, however, some people are driven to seek answers to questions that

science cannot always answer.

• Sometimes, spirituality and/or religion can be helpful in the healing process; other times, it

may be helpful in facing death.

• The role of religion and spirituality in health care is still a controversial topic, but today

“more than half of the med schools in the country” offer courses in religion and

spirituality, “up from just three a decade ago.”

o Yet the role of religion and spirituality in health care raises a number of issues about

ethical ways to approach the topic of incorporating health practices into existing

beliefs and helping patients avoid any pressure they may feel about their beliefs.

• It is also important for health care professionals to avoid imposing their beliefs on patients.

o Dr. Susan Strangl, a family-medicine doctor at UCLA, [had] a Muslim patient who

needed medication but was observing Ramadan and couldn’t drink or eat during the

day. After taking a religious history—routine for all hospitalized patients at

UCLA—Strangl chose a once-a-day medication that could be taken after sundown.

• While religious and spiritual beliefs vary widely, Drs. Koenig, McCullough, and Larson

attempted to survey the studies available in this area and compiled the Handbook of

Religion and Health Care.

• The understanding of the role of religion and spirituality in health leaves behind many

unanswered questions, but they do recommend the following seven specific strategies for

physicians and other health care professionals in dealing with patients:

o Take a religious history.

o Support or encourage religious beliefs.

o Ensure access to religious resources.

o Respect visits by clergy.

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

o View chaplains as part of the health care team.

o Be ready to step in when clergy are unavailable.

o Use advanced spiritual interventions cautiously.

• Some physicians, however, argue against some of the previously suggested guidelines.

o For example, Dr. Richard P. Sloan of the Columbia-Presbyterian Medical Center

cautions against praying with patients: “It confuses the relationship. It may

encourage patients to think a prayer is going to somehow improve their well-being. It

certainly will improve their spiritual well-being but there’s no evidence it’s going to

improve their health.”

o Sloan’s biggest concern about health care professionals engaging in religious issues

is “Manipulation of religious freedom. Restriction of religious freedom. Invasion of

privacy. And causing harm. It’s bad enough to be sick, it’s worse still to be gravely

ill, but to add to that the burden of remorse and guilt for some supposed failure of

religious devotion is unconscionable.”

A. Cultural Influences on Approaches to Medicine

• Different cultures bring different perspectives on health—how people stay healthy, as

well as how they fall ill.

• There are also many cultural differences about what might be considered something that

needs medical attention.

• Cultural attitudes about weight have changed over the years in the United States, as well

as in cultures around the world. Once seen as a sign of wealth, today obesity is seen as a

sign of medical disorder in need of medical treatment.

o The debates over weight and what should be acceptable have been at the forefront

of the Fat Acceptance Movement, a social movement that works to end

discrimination against overweight people and the assumption that they are

necessarily unhealthy or in need of medical treatment.

• In the United States and many other westernized nations, the dominant model of

medicine is based on biomedical science. All other approaches fall under the term,

complementary and integrative medicine.

• There are too many other approaches to medicine that would fall under complementary

medicine than one can list here, but they are also seen as equally valid approaches to

health care.

IV. Power in Communication about Health Care

A. Imbalances of Power in Health Communication

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

• Communication between physician and patient is often marked by an imbalance in

power with regard to medical knowledge and access to treatment.

• Physicians in health maintenance organizations (HMOs), which are increasingly

common in the United States, can elect to refer or not refer patients to specialists.

Physicians have power over patients in other ways as well.

o For example, they can recommend certain treatments (and not others), order

medical tests, and otherwise determine what kind of treatment the patient receives.

• This power imbalance is built into the health care structure in the United States, but

physician-patient communication also reflects these power differences.

• Because patients may encounter many health care workers in a single day, cultural

differences in communication may be exacerbated.

o Some physicians would be amused, but others would be irritated by the perceived

effort to challenge the power imbalance.

B. Health Care as a Business

• It is important to remember that the health care industry in the United States is a huge

business.

• Rising health care costs have had a huge impact on how people think about medical

resources and their distribution.

o Medical debt is increasing as a factor in decisions to declare personal bankruptcy.

o Medical debt is often referred to collection agencies far faster than other types of

debt.

• In response to growing costs and concerns about the U.S. health care system, President

Obama signed the Patient Protection and Affordable Care Act into law on March 23,

2010.

o Although sometimes derided as “Obamacare,” this act marks a major change in

health coverage.

▪ It aims to reduce the number of uninsured (or under-insured) Americans and

decreasing the rapid rise of health care costs overall.

▪ Many of these changes will take place over a number of years, and the U.S.

Department of Health and Human Services has set up a website to explain

all of the changes: www.healthcare.gov.

• Patients from countries where health care is provided by the government may be

confused by the private health care system in the United States. U.S. Americans, too,

can become lost in the maze of rules and regulations governing the access to specialists

and special treatments.

C. Intercultural Ethics and Health Issues

Chapter 13: Intercultural Communication and Health Care

• With regard to communication ethics in health care, physicians can give information

about the patient’s health within the following four general frameworks.

o Strict paternalism: It reflects a physician’s decision to provide misinformation to

the patient when the physician believes it is in the best interests of the patient.

o Benevolent deception: It occurs when the physician chooses to communicate

only a part of a patient’s diagnosis.

o Contractual honesty: It refers to the practice of telling the patient only what she

or he wants to hear or to know.

o Unmitigated honesty: It refers to when a physician chooses to communicate the

entire diagnosis to a patient.

• The fear of malpractice suits guides many decisions related to ethics.

o Sometimes health care organizations use ethics committees—often staffed by

health care professionals, religious leaders, and social workers—to help make

decisions about ethics.

• In some cultures, the family is intimately involved in the health care and medical

treatment of its members. In other cultures, medical information is confidential and is

given only to the patient, unless he or she is incapacitated or incapable of understanding.

• Knowing the appropriate way to communicate with patient and family is not easy.

o In some religious systems, euthanasia, which involves ending the life of a

terminally ill patient, is seen as suicide and therefore is unacceptable. In other

religions, euthanasia is acceptable for terminally ill patients.

Discussion Questions

1. Why might people in the United States seek out alternative forms of health care such as

acupuncture?

2. How might misunderstandings due to intercultural communication arise between patients,

their families, and health care professionals? Provide an example for each.

3. What medical jargon have you encountered in your interactions with health care

professionals? Did it affect your communication with these individuals? If so, how?

4. In your opinion, why was the Tuskegee Syphilis Project allowed to continue for 40 years?

5. How do families differ with regard to the health care expectations of each member?

6. How might prejudicial ideologies (on the part of the health care professional and/or the

patient) present barriers to intercultural communication?

7. Why do you think most insurance companies refuse to pay for alternative treatments such

as acupuncture or chiropractic care?

8. What religious beliefs might impact the health care routine of a Muslim woman?

9. How can religion and spirituality enhance the healing process of an individual?

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

10. Give some examples of power imbalances in the health care interactions between

individuals?

11. Consider a situation where a patient calls his/her doctor by the first name. How does this

have an impact on the physician–patient power imbalance?

12. If you were suffering from a disease, which ethical framework (strict paternalism,

benevolent deception, contractual honesty, or unmitigated honesty) would you want your

health care professionals to apply when they are communicating with you and your family?

Why?

13. What are some of the key issues in the ethical debate regarding euthanasia?

14. In Western society, we believe that germs cause illness. What other cultural or religious

explanations exist for people falling ill? How might these affect treatment?

Classroom Exercises and Chapter Activities

1. Communication about Health Care Interview Assignment: This assignment focuses on

exploring the intercultural communication challenges faced by health care professionals.

Instruct students to interview a health care professional about his or her experiences with

cultural differences in communication. Advise them to follow the suggestions and

guidelines given below and then answer the following questions. The suggestions detailed

for interview assignments in previous chapters may also be helpful to your students.

• Who did you interview, and what is his or her job as a health care professional?

• Which cultural/ethnic group members does he or she interact with on the job?

• What challenges has he or she encountered in the communication process?

• How did he or she deal with such challenges?

• What advice does he or she offer regarding communicating interculturally with

patients to persons wishing to become health care professionals in the future?

• What does the future hold for health care professionals with regard to the change in

patient demographics?

2. Intercultural Communication Training Program for Health Care Providers Assignment:

This group project is designed to help students explore how health care providers can

improve their intercultural communication skills. Students will prepare a short, mock

training program for health care providers on the topic “What Health Care Providers Need

to Know about Serving a Diverse Patient Population.” Assign students to groups and tell

them that they will be expected to present a seven- to ten-minute program to the entire

class. Students should start by discussing their experiences with health care professionals

among the members of the group. Based on this discussion, they can decide on at least

three suggestions for improving intercultural communication between patients and

professionals. Next, students should take the group members’ suggestions and determine

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

the manner in which they want to communicate this information to the class. Students

should pretend that the class is filled with doctors, nurses, or other health care

professionals. In general, the audience can be thought of as health care providers who are

eager to learn more about intercultural communication and the ways to serve a diverse

patient population. Encourage students to have fun and be creative while doing this

assignment. They should use all the resources available, such as video equipment,

PowerPoint, and role play. Students will probably need about two weeks to prepare their

presentation, and, depending on the size and duration of the class, you should allot one or

two class sessions for each of their presentations.

3. Popular Culture Assignment: This assignment is designed to utilize popular medical TV

programs to highlight intercultural communication conflicts between health care

professionals and patients. Instruct students to watch a popular medical TV show such as

Grey’s Anatomy or Private Practice. They should pay attention to the conflicts that result

from poor communication between a health care professional and a patient (or the patient’s

family). Students should write a two- to three-page paper or journal entry covering the

following aspects of the TV show:

a. The name of the show.

b. A description of an incident based on poor communication between a health care

professional and a patient or his or her family. Students should be sure to provide

details concerning the participants, what happened, and the resulting outcome.

c. The issues that led to the conflict. Conflicts can arise due to religious, cultural,

gender, or ethnic differences.

d. Suggestions for dealing with the clash. Could it have been avoided? If yes, then how?

4. Guest Lecturer Activity: Invite one or more practitioners of alternative medicine (reiki,

acupuncture, traditional healing, etc.) to come to the class and discuss their perspectives on

healing. Prepare students with a primer about each method (Wikipedia is a comprehensive

source here, as are Internet searches).

5. Communication and Alternate Forms of Healing. Instruct students to present alternative

theories of disease and healing not common in the United States (e.g., evil eye,

acupuncture, coining, etc.). Instructors can read a scenario from a book called

Multicultural Manners to illustrate these kinds of practices. For each alternative therapy or

explanation, ask students to evaluate the usefulness of the approach. Issues concerning

prejudice, ethnocentrism, and stereotyping may arise in the course of the conversation.

6. The Spirit Catches You and You Fall Down, 1997. This book by Anne Fadiman details the

experience of Lia Lee, a Hmong child with epilepsy, and the cultural conflict which arose

Chapter 13: Intercultural Communication and Health Care

Martin, Experiencing Intercultural Communication, 6e

between her family and community and the doctors who treated her. Have students read

excerpts from the book or summarize the issues discussed in the book. Have them discuss

the different cultural perspectives of the people involved and the ethical issues faced by the

doctors who treated her. Have them debate over whether they think removing her from her

family to enforce treatment was the right thing to do. Assign sides randomly, or have

students take the side they disagree with and then argue for it.