Partners in Care: knowledge in herbal and natural remedies. If the patient gets worse and has means, the next stop will be a local medical clinic or referral hospital.
The medical standards of care likely differ significantly based on the resources available and may be influenced by a limited insurance formulary – and limited skilled personnel – depending on the country. Parents may be forced to make impossible decisions like choosing between taking a child for treatment( leaving the rest of the family to starve, meanwhile) versus letting the sick child pass away at home, to try and keep the other children fed and healthy. 911 is a foreign concept.
Possibly the most significant difference is that in other cultures, there are different belief systems regarding the cause and treatment of diseases. The combination of all these previous experiences and beliefs means that many immigrant patients come with completely different expectations compared to the average American. It’ s imperative that we put aside our assumptions, that we approach with respect and curiosity, hoping truly to grasp their expectations, their understanding of disease and what they value most for health.
I like a useful framework, the“ Four C’ s of Culture,” 1 that can help us to come up with conversation starters as we consider treatment options and the risks and benefits specific to each patient. It would be impossible to know the best option for a particular patient without a deeper conversation to understand their values, their goals of care and how various types of treatment would be expected to impact their life.
- What does the patient CALL the problem?( what do you think is wrong?)
- What does the patient think CAUSED the problem?( root belief about the issue)
- How does the patient COPE with the problem?( attempted remedies)
- What CONCERNS the patient about the problem?( what bad outcomes do they want to avoid?)
There are many examples in health care of making patient-centered decisions that may not be the textbook medical option. Sometimes these decisions do not follow guidelines due to barriers: patient level, system level or even social determinant of health level. We strive to recommend the most appropriate and beneficial course for that patient at that moment in time. We might use metformin or single daily dose long-acting insulin due to inability to safely or effectively manage diabetes with any other protocol. We make follow-up appointments farther apart for chronic disease management. We simplify a medication regimen to aid adherence. We delay elective surgery to work around a patient’ s schedule. Considering cultural differences in medical decision-making may seem foreign to us initially, but it is vital for individualized care.
It is impossible to avoid bringing our own assumptions to the exam room with us, but if we pay close attention, we will learn to practice cultural humility. There is such significant variation in patients’ diverse cultural contexts that no one can assume that the norms of a particular country will apply to the next patient from the same country. It is for this reason that cultural humility is a lifelong process that is never finished. Some common assumption areas that need attention in medicine follow:
- Literacy level: the handouts or habits we provide could be useless. Can the patient read, and is the handout in his language?
- Education level: many refugees’ education was interrupted, or never happened, due to war.
- Math literacy: as it relates to understanding units of measurement and dosing sizes and schedules.
- Religion: and its effect on medical decision-making preferences( each person has a unique interpretation).
Each individual family’ s country of origin culture continuously hybridizes with their new American one. We should not withhold any treatment option for fear that it would be somehow offensive, nor should we push a particular treatment without exploring potential barriers. For example, if we recommend universal counseling on a topic like sexual and reproductive health, that conversation should look incredibly similar among patients, including a robust explanation of the“ why” of the screening and education being offered. Some providers may be surprised to find that many immigrant women from backgrounds where birth control was not allowed, are in fact interested in learning about and using the full assortment of contraceptive means, for varied reasons. The confidential delivery of such care requires delicacy and assurance of her safety and ability to continue that care. Curiosity, without being judgmental, is required to build the genuine rapport that underlies every good patient-physician relationship and risk / benefit analysis.
To illustrate, let me share some challenging cases where significant personal and cultural factors affected risk / benefit ratios and medical management decisions.
- Consider the 6-year-old immigrant boy, just in the U. S. for a month, with weakness and newly diagnosed muscular dystrophy. His mother did not believe that medical treatment or specialists could help the child. When asked about what she believed had caused this, the mother shared her painful recollection of having witnessed a family member burn alive in a car bomb outside their home, just after dinner. In her grief, she consoled her 6-month-old son with her breast. She believed the“ bad” milk had made him sick and weak ever since. The mother would need a solution to incorporate the spiritual issue alongside conventional medicine options. The father initially believed the boy had no significant health problem and later believed that the treatment was causing
( continued on page 12)
November 2025 11