Modules

Cross-cultural communication

Part 1

Introduction

This case is about the Kostopoulos family and the physicians who looked after them. Panos, Sophia and their three children came to Canada from Greece 12 years ago. Panos and Sophia have a busy restaurant in the Greek neighbourhood of Toronto. Kostas is in the navy and away most of the time; Niki is married with two children; and Maria is a secretary, sometimes helps in the restaurant, and lives with Panos and Sophia. Panos speaks some English but Sophia speaks only Greek. They are very proud of their success in Canada.

Panos has been complaining about pain in his back for the past four months. He initially attributed this to lifting heavy barrels of cooking oil and other food supplies, but the pain has not gone away. He has been noticeably uncomfortable lately. On the day our story begins, Panos was getting supplies off a shelf, suddenly cried out and fell to the floor where Sophia found him, unable to get up. One of the customers called 911 and Panos was taken to the emergency room.

Here are the physicians who become involved with Panos during his illness:

  • Dr. Bolden, an emergency room physician
  • Dr. Tyson, a family medicine resident doing an internal medicine rotation
  • Dr. Cunningham, an oncologist
  • Dr. Harrell, a senior resident in internal medicine
  • Hi, I’m Kimiku Tyson, and I am a family medicine PGY1, doing a rotation in internal medicine.

    I recently had an experience that was very difficult. I had this family that came in through emergency because the father had fallen and he was suffering from severe back pain. Well, we discovered that he had advanced prostate cancer that was affecting his spine. I had a lot of trouble communicating with him because he’s Greek, and both he and his wife, they didn’t speak very much English. So I had to communicate with him through his daughters because we didn’t have a professional Greek translator available.

    The family had some expectations about his care that I had learned about, but I’d never encountered before.

  • Panos: (moans and calls out in Greek; he is obviously in a lot of pain)

    Dr. Bolden: Okay, do you speak English?

    Panos: No! (continues to speak in Greek)

    Dr. Bolden: Did anybody come with you who speaks English?
    (transition to Panos and family with Dr. Tyson)

    Dr. Tyson: I’m Dr. Tyson.

    Maria: Well, it’s about time …

    Dr. Tyson: You’re his daughter?

    Maria: Yes, I am.

    Dr. Tyson: Do you speak English?

    Maria: Yes, of course I do.

    Dr. Tyson: So, you speak English … ah, well, did you see what happened?

    Maria: No, I wasn’t there, my mom was there … he just fell down at the restaurant and he’s just in a lot of pain … I don’t understand …

    Dr. Tyson: Okay, well, it’s indicating that he has some problem with his back, obviously, he can’t move his legs very well. Um, it seems that on the x-ray it shows there’s an abnormality on his spine …

    Maria: An abnormality?

    Dr. Tyson: Yes, and so we hope that we can have him in for a few of days, run some more tests, and, uh, I’d like …

    Maria: A few days?

    Dr. Tyson: Yes …

    Maria: Tests? What are you talking about?

    Dr. Tyson: Well, he’s definitely in a lot of pain.

    Maria: I can see that, obviously. (interrupting Dr. Tyson)

    Dr. Tyson: And we need to make sure that there’s, you know, there’s no serious damage …

    Maria: Well, can’t you just give him something for pain? It couldn’t be that serious …

    Dr. Tyson: We will be giving him something for pain, but you have to understand … he can’t walk … so, if you can just explain to him that we’re going to run some more tests, we’ll be admitting him with Dr. Mayer’s service up on the eighth floor …
    (Panos groans in pain)

    Maria: I don’t think it’s gonna go well, but I’ll tell him, and if you’re telling me, I guess I’ll tell him …  (speaks in Greek to her father)

    (Panos moans, speaks in Greek to Maria)

    Maria: He doesn’t want to stay. Can’t you just give him some pain medication? I mean, really, we wasted so many hours here already. Just give me some pain medication, I’ll take him home …

    Dr. Tyson: We’re definitely going to do something to deal with his pain. We want to make him comfortable, but we need to make sure we run all the tests that are necessary to find out …

    Maria: You know, it’s not good enough. He wants to go home, he wants to go back to his business …

The immigrant and the health care system

Commentary on part 1
First impressions are important. Based on the part of the encounter between the Kostopoulos family and the physicians in the emergency room you saw, how do you think the interaction influences the impression the physicians and the patient and his family have of each other? What constitutes patient-centred behaviour in an emergency room? Is it possible? Review your own experience.

Reflective exercise 2

The “Reflective exercises” focus on the ethical, communication and cultural MCC role objectives. There are no absolutely right or wrong answers but some options are better than others. Read the options and any questions arising from them and watch the videos (videos are available for only three of the four options). Use the questions associated with each option to guide your decision-making. After completing the exercise, you can read the commentary on each choice and consult resources.

If you were the physician in this situation and were asked “not to tell,” how would you respond?

Dr. Tyson: I’m sure you think that’s best for your father, but believe me, patients know. They know when something’s wrong, they figure it out by what they hear from the nurses and the techs, what they’re talking about, and then, they start playing these games with the staff and the family and everyone avoids talking to the patient and the patient gets isolated and … It’s just not good for anyone.

Niki: Playing games? What kind of place is this? Don’t your staff know what’s appropriate to say to patients? What do they do, spend the whole day in the corridors gossiping about patients? I thought that only happened on TV. I’m sure … I’m sure if you explain the situation to your staff, it’ll be okay.

Dr. Tyson: No, I’m afraid it’s not quite that simple. We simply … with all that is going on here, can’t control what a patient sees and hears.

Dr. Tyson: Well I’m sure you think that’s best for your father, but in fact, most people want to know about their condition. Have you thought about how he might feel if we … if we lie to him?

Niki: Oh no no no. I’m not asking you to lie, just don’t tell him anything … you know, just don’t mention anything about cancer, or about dying. He just won’t cope. It’s not a good thing.

Dr. Tyson: Well actually, most people find it better. They don’t have to play this game with their family of not knowing. They find it comforting that they can talk about it. And, he will have to, you know, take care of his affairs. He has a business, and he will have to take some decisions with that, won’t he?

Niki: Wait a second, you sound as if, you know, he’s going to die tomorrow morning or something.

Dr. Tyson: No, I’m sorry, not tomorrow, but sometime in the near future. And he’ll have to have some treatments, and what if he asks about those?

Niki: Well, the treatments aren’t an issue. He’ll do those, that’s no problem. And you know, you can talk to us, and we’ll be able to facilitate that. His English is not that great. He just can’t find out about, you know, he can’t find about having cancer, he won’t be able to manage.

Dr. Tyson: He just has to hear that one word: cancer, and understand it, and he’ll know. And we’ll have to get consent forms signed … What if he asks what those are for? I mean, I can’t lie to him. That would be deceptive to the patient.

Niki: Look …

Dr. Tyson: That … I wouldn’t do that, he wouldn’t trust me.

Niki: You’re not getting it. That’s not the way we do things. He can’t find out.

Dr. Tyson: Well, what if he asks what’s going on? What am I supposed to say?

Dr. Tyson: I’m sure you think that’s best for your father, but could you help me understand why? Because when families ask us to do this sometimes, it doesn’t work out very well.

Niki: Well, you know he’s just going to get really upset if he finds out, and turn his face to the wall, and basically give up.

Dr. Tyson: Well, actually, more often, we think that that’s how they are going to feel, but that’s not necessarily how the patient feels. Why don’t you tell me a little bit about your father, and help me understand why you think he’ll react that way.

Niki: Well, we’re Greek. I mean, he’s from Greece, and the way we do it in our culture is the patient never finds out anything about their condition. It’s, you know, they don’t want to disturb the patient with those kinds of details. It’s the family that takes care of everything and, you know, it’ll be better that way for both my parents. My mom just wouldn’t know how to cope if my dad knew.

Dr. Tyson: Ok. Well, there’s, you know, obviously a lot of people disagree whether the patient should be told their diagnosis and what’s going to happen and, I don’t want to make this harder for your family. So, I won’t say anything specific to him now, unless he asks, but you have to understand that I will answer his questions truthfully, if he asks me, okay? Now, I know this has been a shock for you, so maybe we need to take some time and think … and just … tell me how your mother’s been coping.

Maria: Well, you know, she’s very upset, but she won’t tell papa, and you know what, Niki? Maybe … maybe papa would want us to do it this way, but, you know, he should know and it’s the old way … maybe we should tell him. You know, he’s not stupid, he’s going to know.

Niki: I know he’s not stupid, but you know, really for you and me, this way would be the best way, but for mom and dad, I don’t think so. They just wouldn’t be able to know. They just won’t know how to handle things.

Option 4

You decide that Niki’s request is unrealistic and that you must talk to Panos about his condition and ask him how much he wants to know. You decide to call in a professional interpreter. Should you seek the family’s permission first? Would doing so without seeking permission be deceptive? What might be the repercussions of such an action?

  • Well, as you can see, I didn’t know how to respond to Niki’s request that I don’t tell Panos about his condition. She seemed to be speaking for the whole family. Now, I didn’t want to make a judgment on their cultural traditions, but my understanding of optimum patient care is in conflict with their wishes. We are taught that we should respect other cultures, so in that case the best course of action would be to try and understand what their request is even if it goes against what I think is best. There really wasn’t a correct response.

Commentaries

Commentary on option 1
Many problems and errors in the complex field of health care are not caused by any one individual’s actions but by a “systems error”: an important lab report gets lost in a pile of paper; the nurses in the hallway are not talking about Panos but they are right outside his door so he thinks they are.

In this response to Niki’s request, the physician may very well be right. It is difficult to keep information, or misinformation, from hospitalized patients. Dr. Tyson may not be able to control every interaction between her patient and numerous health care workers but she can control what she does and says. Does invoking a “systems problem” — blaming others — absolve the physician from responding to Niki’s request? How should she respond to Niki’s complaint about gossip?

Most hospitals have policies or codes of conduct about confidentiality and similar issues. Dr. Tyson is a resident, which means she may spend a variable period of time in any one institution. She should be aware of the policies of any institution in which she works, but practically, she may not be.

Which, if any, of the four possible responses to Niki’s concern would you use, assuming that Dr. Tyson agrees to Niki’s request not to tell Panos about his cancer?

  1. “The people who work here are all professionals. They won’t say anything inappropriate to any patient.”
  2. “I will speak to the ward manager and ask her to tell everybody not to speak to your father about his condition.”
  3. “This hospital has a confidentiality policy. I will get a brochure on it for you to read.”
  4. “I will give you the contact information of the hospital’s patient advocate whom you can call to discuss your concerns.”

Commentary on option 2
In this option, Dr. Tyson gives the standard “truth-telling” response she learned in ethics classes. There is considerable literature supporting this position. There are many studies showing that patients want to know about their condition and that “not telling” results in isolation, poorer response to treatment and poorer quality of life. Sometimes families get it wrong and think that their family member would not want to know, when in fact they do. Sometimes the patient goes along with the deception in order to spare his or her loved ones the distress of talking about an impending death.

However, most of those studies were conducted in western patient populations, usually American. Studies involving patients from non-western cultures sometimes tell a different story. This depends, however, upon the patient’s acculturation to the local culture (see option 3).

Some ethicists feel that there is no difference between lying and not revealing the whole truth because the intent is the same, that is, to deceive the patient. Both instances have the same result: the patient cannot be a fully informed decision-maker. Others feel that lying is a worse decision in that, if found out, trust in the physician would be destroyed, whereas with failure to provide relevant information, the resulting decisions made by the patient would be their responsibility. It may also have something to do with the fact that for most of us, we have been taught from childhood that lying is wrong. We should at least realize that failure to reveal, even if done with beneficent intention, is not necessarily benign.

Commentary on option 3
Here, Dr. Tyson is trying to obtain information about Panos’ beliefs and values. How should she interpret the information Niki gives her? Are we getting information about Panos or about Niki and how she thinks about things? By including Maria and Sophia in the discussion, Dr. Tyson is certainly trying to find common ground between her medical beliefs and those of the family. But which set of values and beliefs should take precedence? Should she follow the medical view that in almost all cases it is best for patients to be told of their conditions or should respect for others’ cultural values prevail? Should she accept Maria’s or Niki’s assessment of the intergenerational differences in approach to truth-telling? If Dr. Tyson tells Panos about his diagnosis in spite of the family’s objection, is she behaving with respect for patient autonomy or paternalistically in deciding herself what is best? For instance, if she agrees not to tell Panos, is she denying him the opportunity to decide what to do with his life? Perhaps he might not accept treatment, believing that his condition is not so serious. If he is told, what might be the consequences of angering his family? What additional questions should Dr. Tyson ask that might be helpful in determining Panos’ wishes?

None of these questions are easy to answer but thinking them through is necessary before taking action. Broadening the discussion to include other physicians or an ethicist might be helpful.

Commentary on option 4
Many would say that this is the best course of action. We have no evidence that Panos has ever discussed how he would like information to be handled if he became sick, and it would appear that Niki is making assumptions based on what she thinks he would want. Dr. Tyson’s responsibility is to the patient first, even if this might anger the family. A number of studies have shown that physicians are poor judges of patients’ desire for and need for information and that the best thing to do is to ask directly. However, as in this case, there may not be an available interpreter and, as we saw, using a family member might not provide the information required. Also, one must keep in mind that even if asked directly, a patient might defer to family out of concern for them, feeling the family could not cope with discussing such issues with their loved one. Finding out what a patient really wants to do in these situations requires tactful exploration of their values and relationships, and cannot be accomplished with a few brief questions.

For more information on working with interpreters, see the “Working with interpreters” section of this module and “Cross-cultural interviewing.”

Final comments on reflective exercise 2

Niki has made her request while she herself is under stress, having just heard of her father’s diagnosis. This may not be the best time to make such a request nor to agree to it. If there is time (e.g., no imminent danger of death), everyone should think through the issues and possible consequences. This should be viewed as an ongoing process and not a final decision. The family, the physician and the patient may all change their minds during the course of the illness. It is important that they all understand that and do not feel bound by a previous decision.

At what Bennett level is the physician in each option? What would have to occur for the physician to attain a higher level?

Other types of truth-telling
While breaking bad news about a diagnosis is perhaps the most often cited form of truth-telling dilemma, there are others. The informed consent process is closely related, as we saw in “Consent and confidentiality.” The distinction often is that a treatment or procedure may not be offered. Some physicians feel that they do not need to give patients potentially troubling information if nothing can be done, but in fact, evidence shows that patients want to have information regardless. Not to do so would deny the respect due to persons as autonomous beings.

Exceptions to truth-telling
There are few exceptions:

  • Clearly, in the case of the unconscious or incompetent patient, the substitute decision-maker would be told the truth.
  • If the patient really indicates a desire not to be told. The physician should be cautious about becoming the decision-maker in these instances. Some form of dialogue should occur with the patient or other family member. (See the articles on decision-making.)

Therapeutic privilege
Truth-telling is a process and the timing and degree of disclosure can be adjusted to circumstances, as in option 3. If the physician truly has good reason to believe that the patient might come to harm from being told something, then a temporary waiver of revealing the truth might be appropriate. Such instances are rare and legally the courts take a dim view of therapeutic privilege.

Cross-cultural interviewing: What do we need to know?

  • Dr. Tyson: Hi, Dr. Cunningham?

    Dr. Cunningham: Yes?

    Dr. Tyson: I just wanted to talk to you about the Kostopoulos family.

    Dr. Cunningham: Uh huh.

    Dr. Tyson: You’ll be seeing the father, Panos, to talk to him about his prostate cancer.

    Dr. Cunningham: Uh huh.

    Dr. Tyson: … well, his family doesn’t want him to know about his condition, and I don’t really see how we can keep it from him and properly inform him about what his treatment options are.

    Dr. Cunningham: So they don’t want him to know that he has cancer?

    Dr. Tyson: No.

    Dr. Cunningham: Well, it will be difficult but we’ve had cases like this before. You know, in many cultures the family believe that it’s better for the patient if they don’t know their condition. It makes it awkward for us sometimes, but you do understand that you are under no obligation to lie to him?

    Dr. Tyson: Oh yes, I told them that and I think they understand, but how do we make sure that he understands enough that he can make a decision? He doesn’t speak English very well and we don’t have a hospital interpreter available who speaks Greek.

    Dr. Cunningham: Well, often when we don’t have a hospital translator the best solution is to ask the family. Do you know if any of them speak English well enough?

    Dr. Tyson: Yes, his daughters, but how do I know that they will tell him what he needs to know when they don’t even want him to know what his condition is?

    Dr. Cunningham: Do you have any reason to believe that they won’t cooperate, or won’t act in his best interest?

    Dr. Tyson: Well …

    Dr. Cunningham: Well, I mean, do they seem dysfunctional as a family?

    Dr. Tyson: No, his wife is there all the time, and the daughters do seem genuinely concerned so …

    Dr. Cunningham: So then I would say that if they understand the treatment options and what we need to do to help him, then you can ask them to translate for you. Listen, let me know what happens. If it doesn’t work out then maybe I can step in.

    Dr. Tyson: Okay, great … well, thanks for your help. I really wasn’t sure what the best way was to handle this, so I appreciate it.

    Dr. Cunningham: Oh, well you’re welcome.

    Dr. Tyson: Okay bye.

    Dr. Cunningham: Bye bye.

  • Dr. Tyson: Could you please tell him that we have come to talk about treatment, and that I’ve asked you to interpret.

    Niki: Sure.

    (Niki and Panos converse in Greek)

    Niki: He says he wants to go home.

    Dr. Tyson: Oh, of course, but we do have to get the urine and the back problem sorted out, so could you tell him that? And then ask him if he would like the information to come to him, or to you, or what.

    (Niki and Panos converse in Greek)

    Maria: Niki, you can’t say …

    Niki: Shhh, shut up, Maria … (turns to Dr. Tyson) Everything is, uh, okay, he said just go through us … whatever you need.

    Dr. Tyson: (doubtful) Okay, uh … well, I will call a surgeon and an oncologist to meet with you, but I would think it’s important that your father be at the meeting as well, okay?

    (afterwards, in the hallway)

    Sophia: Maria, Niki …

    Maria: Niki, you’ve got to tell him. I mean, who’s going to take care of the business?

    (Sophia and Niki converse in Greek)

    Niki: You’re just going to have to go to the restaurant.

    Maria: What! Are you crazy?

    Niki: Why? What’s your excuse?

    Maria: What! I can’t handle that on my own! You’re talking about a business …

  • Well, that didn’t go as well as I’d hoped, and I’m not sure that Panos really understands the treatments that we are suggesting … and then Maria, she got upset with something that Niki said, and there seems to be this family fight happening … I think I should have tried to get an interpreter after all. I guess this has been a really important learning experience for me. I need to learn more about how to work with an interpreter and how to communicate with families in conflict.

     

Reflective exercise 3

Reflective exercise 4

  • This exercise is not directly related to this module but can be used to reflect upon the issues of working in a cross-cultural medical environment, specifically when working with interpreters.

    Read the following scenarios, answer the questions and submit the answers in order to read the commentaries.

  • 1. A recent immigrant brings his wife to the clinic saying that she does not speak English and he will interpret for her. He says she is pregnant but healthy. She is dressed in traditional clothing and stares at the floor. The physician notes that the husband answers the questions put to her and does not address his wife. When asked about this behaviour, he states that they have discussed it all before coming.
  • 2. A Senegalese woman brings her 12 year old daughter to the community clinic. She speaks little English, but brings with her a note from the community worker who speaks her language. It says that the woman needs to have her daughter circumcised. It explains that this is very important in their culture and that the whole family would be ostracized and would suffer significantly if the procedure was not performed. It further requests that if no one at the clinic can perform such an operation, that the mother and daughter be referred to someone who can do it. The physician asks the child, who has been going to school in English, if she knows about this. The girl looks frightened and states her mother says she must have it.
  • 3. An Egyptian taxi driver is brought to the emergency room, having been stabbed by a drug-seeking passenger. In spite of efforts to save him, he dies. Shortly after, a police officer brings the taxi driver’s wife and three children to the hospital. The woman speaks little English. The oldest child is nine and is fluent.
  • 4. A Spanish-speaking patient is sent for psychiatric assessment. His wife says he has been hearing voices and accusing her of trying to poison him. She fears for her safety. A secretary from the records department is asked to translate and, during the interview, indicates that the patient is rational and denies any symptoms of psychosis.

Comments on Reflective exercise 4

“A” is of course the best answer in all of these situations. Practically, however, there is rarely a professional interpreter available at the time and for the language required. The question then is: What is the next best option? Sometimes the “culturally sensitive” and the “ethically correct” are in conflict.

Professional interpreters

Professional, or cultural, interpreters are more than translators. They have been trained not only to convey as precisely as possible what is said by interviewer and patient, but also to interpret non-verbal behaviour and to be a “culture broker” between them. They are aware of cultural taboos and usual practices, adjusting their language with the patient when necessary. They can inform the interviewer of a patient’s values and belief systems. They are also trained in medical terminology and the principles of ethical health care, including confidentiality. For these reasons, working with such an interpreter is preferable and is certainly culturally sensitive. It also seems ethically correct in that it affords the best chance to obtain accurate information from the patient and to accurately convey the diagnoses, treatment options and other information.

If professional interpreters are not available, can a health care institution be said to be providing adequate care? The answer is not clear cut. Hospitals and other health care systems must balance finite resources against the needs of the population served.

Volunteer (non-professional) interpreters (scenarios 2, 3, and 4)

Most health care institutions keep a list of all bilingual or multilingual employees. They may or may not have had training in being an interpreter. Their educational level and linguistic abilities are quite variable. If the ethnic community is small, they may know the patient. They may be thrust into very emotional situations, as in scenario 3.

Is it ethical to ask a young inexperienced kitchen worker to translate? Unfortunately, this question is rarely asked. In such cases, the translator may be emotionally traumatized and the patient and family may receive incorrect or poorly conveyed information.

In scenario 2 there is a community worker who is presumably a member of the patient’s ethnic group. Could this be a problem? While this person certainly seems to know the cultural values of the patient, could this lead to bias? Is there a limit to cultural sensitivity if the wishes of the patient conflict with best (western) medical practice? (For example, the policies of the College of Physicians and Surgeons of Ontario state that any physician performing a female circumcision or referring a patient to such a practitioner is subject to a charge of professional misconduct. It further states that any child in this situation must be referred to the Children’s Aid Society.

If you asked the community worker to translate, how would you know if your statements were being correctly conveyed? Finally, if a patient and translator are from the same small community, the patient may not wish to reveal embarrassing or sensitive information.

In scenario 4 we observe the problems that can arise if a non-professional attempts to interpret in a psychiatric interview. Psychiatric interviewing is perhaps the most culture-laden and language-dependent of all areas of communication. Use of language is critical in eliciting information, for instance, the translation of “depression” into some languages may not result in obtaining information about that diagnosis as the language might not have a word that means what it does in English. If psychotic symptoms are intermittent, a simple direct question like “Are you hearing voices” might miss the mark and the interpreter might say that the patient does not hear voices.

Family as interpreters

This is the most frequent interpreter issue we face as health-care workers. This issue often occurs in highly charged situations such as sudden death, end-of-life or delivering bad news. A family can be drawn together, or torn apart, depending upon how the issue is handled. Three common situations are portrayed in these scenarios and in the case involving Niki and Maria.

In scenario 1 the patient evidently has deferred to her husband to provide information and to make decisions on her behalf. This is customary in some cultures. However, some ethicists raise the question  that, given the choice, would the woman want this? Here again there is a potential conflict for the physician between being sensitive to the patient’s culture, and not only respecting the individual (in a western sense) but also respecting basic human rights. (Read Waiver of Informed Consent, Cultural Sensitivity, and the Problem of Unjust Families and Traditions, by Insoo Hyun.) In scenarios 2 and 3, a child is placed in the position of having to translate emotionally charged information. In both scenarios, this may traumatize the child. As well the child may be unable intellectually to convey the information correctly. In other situations, children provide valued services as family interpreters, of which they are justly proud. It all depends upon the context.


 

Next: Part 2

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