Given the limited space provided for this column, an intensive exposition of cross-cultural communication would be impossible. Instead, an overview will be presented in an effort to render the practicing chiropractic physician sensitive to some of the nuances characterizing an intercultural transaction.
Multicultural chiropractic practices are on the increase, particularly in our larger cities. While the popular notion that "people are people" has some validity, closer examination reveals a more complicated picture when it comes to communicating with patients who are culturally different.
Research in speech communication does not equate contact with communication. This means that simply talking with a patient will not automatically insure the successful transfer of meaning and feeling. Moreover, studies indicate that the basic commonalities of such things as birth, hunger, family, sickness, and death are perceived differently by people of different cultural origins. Actually, human perceptions are often distorted, or exaggerated, if perceptual frameworks are complicated by such intercultural variables as attitudes, values, and beliefs.
Although a distinction should be made between patients who have recently arrived in this country and those who are first and second generation Americans, cultural differences in both cases warrant attention. For instance, it has been suggested that it takes a long time of non-insulated living in a new culture before a foreigner can comfortably relax into new ways of thinking and feeling about everyday events, new ways of perceiving life.
Culture represents a critical aspect of chiropractic care if effective communication is going to take place. If doctors have a poor understanding of their own culture, let alone the culture of their patients, their intervention can be noticeably affected. A case in point would be the American doctor who is offended by a patient who tried to stand too close to him. Conversely, in an Arab culture, such close proximity would be expected.
Smile
In America, we think nothing of smiling at a stranger. In Japan, it would be considered an act of impoliteness. The Japanese do not associate smiling with good humor or a friendly attitude, but rather, with genuine tragedy and sorrow, or with repressed anger. A smile by one of your Japanese patients should not automatically, be assigned the same meaning it ordinarily conveys in our culture. Of course, such discretion would probably not apply to a Japanese who has been acculturated. Also note that similar attitudes toward smiling are shared by the Koreans and Vietnamese. Both take time to get friendly with people and refrain from smiling at strangers.
Smiling is but one of many intercultural pitfalls in health care communication. Breakdowns in doctor-patient communication can be traced to such things as vocabulary, syntax, idioms, slang, and dialect. Each in a therapeutic context could result in a communication breakdown.
Trust
This human dimension should also be taken to be a cardinal element associated with culture and health care. The establishment of a trusting relationship between doctor and patient is essential if healing is to follow. One of the most effective ways to create this trust is for the doctor to learn some basic phrases in the patient's native language. The procedure is simple. First, determine which foreign cultures are represented in your practice. Then, from one of those foreign language series books, copy down some relevant phrases onto separate cue cards: "How are you today?"; "What seems to be the problem?"; and "Where does it hurt you?"
Jewaharlal Nehru succinctly captured the importance of being sensitive to another person's language when he wrote: "... if we wish to convince them, we have to use their own language as far as we can, not language in the narrow sense of the word, but the language of the mind."
Because the practice of chiropractic involves the laying on of hands in a very special and personal way, patient trust is an absolute must. Just telling a patient to relax is not enough. The doctor must make every effort to flesh out cultural similarities, not differences, between himself and his patient. Similarities instill trust, differences invite mistrust.
Semantics
As I have indicated in previous columns, words mean different things to different people. This distinction is particularly evident when one crosses cultural lines. This point was clearly illustrated by a humorous story told by an Indian hospital administrator: It seems there was a researcher who spent 13 years compiling a dictionary of one of Papua New Guinea's 700 tribal languages. To assemble a list of verbs, she had to act them out for the informant. For the word "jump" she jumped up and down in front of the village elder and recorded what he said. Six months later she found out that what he had said didn't mean "jump" at all. It meant, "Why are you acting so stupid?"
Consider how the Japanese use the word "No." According to professor Chie Nakane of Tokyo University, "Expression of no is virtually never used outside of completely reciprocal relationships, and from superior to inferior. You rarely receive a no from a Japanese, even when he means no, he would use yes in the verbal form." The doctor who is aware of such a linguistic distinction would find himself in a better position to interpret what Japanese patients might really mean when they say yes or no.
Salutations
How one greets a patient also deserves the doctor's attention. In Latin America, greeting a new acquaintance involves three names: a first, or "given" name, and a compound last name, comprising the father's name followed by the mother's name. Therefore, in meeting an Hispanic patient named Juan Gutierrez-Garcia, you would properly refer to him as Mr. Garcia. Conversely, if your patient is from Portugal or Brazil, the formula is reversed: the father's name, which comes last, should be used with a title.
Gestures
In America, we employ a gesture in which the forefinger and thumb touch and the other fingers are extended upward. This sign is made to represent "O.K.!" "Great!" or "Fine!" However, this same sign in Brazil is considered obscene; it is also impolite in Greece and the Soviet Union. In fact, in some cultures, it represents the female genitalia. If the gesture is done to a woman, it is taken to be a sexual proposal. If it is done to a man, it casts aspersions on his masculinity. Warning: If a patient said she felt terrific after your last adjustment, you would be committing a serious cultural faux pas if you displayed this form of nonverbal affirmation.
Time
Most chiropractic offices operate on an appointment basis. A patient calls in and is given a specific time to appear for treatment. Although our culture demands considerable clock watching, other societies treat time differently. The Arab views time as an endless process. The past is revered, while the future and the immediate past are of little concern. In consequence, don't be surprised if some of your Arab patients fail to honor their appointment time as faithfully as you would expect. The French sociologist, Georges Gurvitch, expressed it by saying, "Time in France is not the same as time in Norway nor with time in Brazil."
Voice Volume
The loudness or softness of voice also displays a cultural dimension. Anthropologist Edward Hall observes that in overall loudness, the American voice is below that of the Arab, the Spaniard, the South Asian Indian, and the Russian, and somewhat above that of the English upper class, the Southeast Asian, and the Japanese. Given these culture-specific differences, it behooves the doctor to take this lead from a foreign patient; i.e., listen to the patient's voice volume. If the new patient is soft spoken, and has never had chiropractic before, a loud speaking doctor will add to any existing apprehension.
Addressing the Foreign Patient
We all know of the tendency Americans have of speaking to foreigners as if they were deaf. The impression given is that if one speaks louder, they will be understood. Talking to those who do not speak English, or speak it poorly, as if they were children is a shameful breach of courtesy. Dennis Bloodworth skillfully illustrates this patronizing indiscretion with the following story: An elderly club member was attending a public dinner in London. He was disconcerted to find himself seated next to a silent Chinese. Wanting to be courteous, however, he leaned over and asked, tentatively, "Likee soupee?" The Chinese looked at him briefly, nodded, but said nothing, and conversation lapsed. However, it appears that the Chinese was a foreign guest of some note, for as coffee was served he was called upon to say a few words. He rose, bowed, and made a 15 minute speech in impeccable English about the sociological significance of the European Common Market. Amid polite applause, he then sat down, turned to his abashed English neighbor, and after the briefest of pauses, asked softly, "You likee speechee?"
Stereotyping, at best, is an unwise practice. This is especially true when it comes to health care. As I mentioned earlier, patients must trust their doctors. Addressing non English speaking patients in such a condescending manner will, most assuredly, erect walls, not bridges, between doctor and patient. Speak simply, slowly, and in a sympathetic tone of voice. Put yourself in their place; imagine yourself in a country where all you were armed with was a scanty knowledge of the language. You would certainly not appreciate being asked, "Likee soupee?"
In the words of Marshall McLuhan, we now live in a "global village." Cultures are being brought together at all levels of society. This is particularly evident in the field of health care. The presence of foreign doctors, nurses, and other hospital personnel is self-evident. This same presence is also manifested in the private practice sector on both sides of the examining table. And so, while not all of us may have a multicultural practice, those that do should pay closer attention to the felt need for improved intercultural communication.
Abne Eisenberg, PhD, DC
Croton-On-Hudson, New York
Editor's Note: As a professor of communication, Dr. Eisenberg is frequently asked to speak at conventions and regional meetings. For further information regarding speaking engagements, you may call (914) 271-4441 or write two Two Wells Avenue, Croton-On-Hudson, New York 10520.