Times of India
12 February, 2010
Nagesh Rao

Doctor–patient communication has a cultural dimension
In 1992, i was a graduate student in the US and noticed one day that the lymph nodes in my neck were enlarged. I went to the health centre on campus and the doctor gave me some pills and sent me on my way. Two weeks later, i noticed no change in my symptoms and went back to the same doctor. He gave me some new pills and asked me to return in two weeks, which i did. No change again. With a kind, but firm tone, the doctor told me, “There are four possible diagnoses.” He described three types of lymphoma (cancer) or that it could be benign. With some trepidation, i asked, “What next, doctor?” He said, “I will arrange for surgery of the lymph nodes and in 12 weeks, after a set of biopsies, we will know the results.”

For four of those 12 weeks, i did not tell my parents in India wishing to protect them. Once i told them, my wise mother asked a question that propelled my passion for exploring culture and health. She said, “Why did the doctor feel compelled to tell you about the options, and especially cancer, when he did not know what was going to happen in 12 weeks? Was he not concerned about your emotional health?”

Based on US laws, the doctor was legally bound to tell me. In an individualistic culture like the US, personal goals are more important than group goals. The doctor was giving me the power to decide. I would have preferred that he not tell me the options, but share his diagnosis with me after 12 weeks. Why did I feel this way? Are there cultural differences in the way we define “health”, and how we practise “good health”? If that is the case, aren’t there significant implications for how doctors and patients communicate with each other?

Answers to the question “what is good health?” are neither conclusive nor simple. The perception about health has changed over time and is influenced by multiple factors, with culture as a leading factor. Over 50 years ago, the World Health Organisation recognised health as multidimensional and defined it as a state of complete physical, mental and social well–being, not merely the absence of disease and infirmity.

As a health communication researcher, i have explored good health from different cultural perspectives. To understand doctors’ perspectives, 109 doctors in India, Argentina, Brazil and the US were interviewed about how they would tell a patient he has leukemia. American doctors, on an average, tend to tell patients directly and explicitly. In Argentina, Brazil and India, however, doctors tend to share the same news with a patient in small doses over time and/or tell a family member before telling the patient. A doctor in Brazil referred to this strategy as using “half–truths” strategies when communicating bad news to their patients.

As a doctor in India noted, “If i knew a patient had a terminal illness like leukemia, i would tell him that we have to do more tests before we can really be sure. If i tell him directly, he could die of shock. If i think he is stronger, i may tell him that there are several possibilities and one could be cancer. If he is not strong, i would see which family member he has come with and take him aside to tell him the news. We are very familyoriented.” This orientation is called “therapeutic privilege” where the doctor chooses the appropriate strategy of sharing challenging news with a patient.

We can see the relevance of culture shaping one’s health beliefs, values and behaviours. In individualistic cultures like the US, it is common to focus mostly on the physical dimensions of health. In more community–oriented cultures like India, the psychological, social and relational aspects of health play a key role in defining good health. In some ways, every encounter between a doctor and a patient is intercultural in that each party brings fundamentally different world views on health and how one gives or receives appropriate healthcare. As one scholar, Athena Du Pre, puts it, “While the doctor focuses on illness, the patient may be more interested in wellness.” In other words, the doctor may focus only on a person’s physical wellbeing while the patient may have physical, emotional and relational needs. In this context, it is particularly relevant for doctors to be better prepared to communicate more effectively with their patients.

Given India’s diversity and the increase in medical tourism, doctors are constantly interacting with patients from different cultural backgrounds (class, caste, gender, age, etc). In this global and diverse context, it is important for doctors to be culturally competent when doctor and patient communicate to optimally fulfil the goals of both parties. If i were a doctor and had to tell a patient that she has leukemia, how would i do it? It depends… on the patient.

The writer is an associate professor, department of communication and journalism, University of New Mexico.