Understanding Cultural Diversity in Healthcare Understanding Cultural Diversity in Healthcare Understanding Cultural Diversity in Healthcare Understanding Cultural Diversity in Healthcare Understanding Cultural Diversity in Healthcare

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The 4C’s of Culture is a mnemonic developed by Drs. Stuart Slavin, Alice Kuo and Geri-Ann Galanti to help clinicians remember what questions to ask their patients in order to get the patient’s point of view. They should be used with all patients.

Download the 4C’s

How can you as a healthcare professional increase understanding and patient adherence?Watch this video for useful tips creating a more compassionate approach to helping patients heal.

Get to your patient’s point of view with The 4C’s…

1.  What do you CALL your problem?

Remember to ask, “What do you think is wrong?” as a way of getting at the patients perception of the problem. Don’t literally ask, “What do you call your problem?”

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The same symptoms may have very different meanings in different cultures and may result in barriers to adherence. For example, among the Hmong, epilepsy is referred to as “the spirit catches you, and you fall down.”  Seeing epilepsy as spirit possession (which has some positive connotations for the possessed) is very different from seeing it as a disruption of the electrical signals in the brain.  This should lead to a very different doctor-patient conversation and might help explain why such a patient may be less anxious than the physician to stop the seizures.  For an excellent example of what can happen when caring, competent physicians do not understand the patient’s perspective, see Anne Fadiman’s 1997 book, The Spirit Catches You and You Fall Down.  Understanding the patient’s point of view can help the healthcare provider deal with potential barriers to adherence.

Case Study: 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.


2.  What do you think  CAUSED your problem?

This gets at the patient’s beliefs regarding the source of the problem.

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Not everyone believes that disease is caused by germs.  In some cultures, it is thought to be caused by upset in body balance, breach of taboo (similar to what is seen in the US as diseases due to “sin” and punished by God), or spirit possession.  Treatment must be appropriate to the cause, or people will not perceive themselves as cured. Doctors thus need to find out what the patient believes caused the problem, and treat that as well.  For example, it may sometimes be appropriate to bring in clergy to pray with them if they believe God is punishing them for some transgression.

Case Study: 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.

3.  How do you COPE with your condition?

This reminds the practitioner to ask, “What have you done to try to make it better? Whom else have you been to for treatment?” Also, “How have you been coping with your illness?” “What effect has it had on your life/daily routine?”

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This will provide the healthcare provider with important information on the use of alternative healers and treatments.  Most people will try home remedies before coming in to the physician; however, few will share such information due to fear of ridicule or chastisement.  It’s important that healthcare providers learn to ask – in a non-judgmental way, since the occasional traditional remedy may be dangerous, or could lead to a drug interaction with prescribed medications. This question can also help you discover if they’ve been unable to cope with whatever it is that’s going on.

Case Study: 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.

4.  What CONCERNS do you have regarding your condition?

This should address questions such as “How serious do you think this is?” “What potential complications do you fear?” “How does it interfere with your life, or your ability to function?” It is important to understand the patient’s perception of the course of the illness and the fears they may have about it so you can address their concerns and correct any misconceptions.

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It is important to understand their perception of the course of the illness and the fears they may have about it so you can address their concerns and correct any misconceptions.  You also want to know what aspects of the condition pose a problem for the patient; this may help you uncover something very different from what you might have expected. It is also important to know their concerns about any treatment you may prescribe.  This can help avoid problems of non-adherence, since some patients may have misplaced concerns based upon the experience of others.  For example, some patients may not be taking insulin because they believe insulin causes blindness.  They’ve seen friends and family members go blind after going on insulin, and they incorrectly perceive that as the cause; it’s a logical assumption based on observed cause and effect.  Unless a healthcare provider asks, however, such beliefs may not be elicited from the patient, who will simply not take their insulin.  By asking, the healthcare provider can correct any misconceptions that can interfere with treatment.

Case Study: 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.