Dimensions of Culture

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As I reflect on what I’ve learned from the trainings I completed in over thirty private pediatric practices so far, I’d like to address one question that has been asked consistently by training participants: How can I deal with patients from other cultures who are insistent and hard to please?

It seems every practice has at least one story about a family that is especially challenging to deal with during office visits. In some cases, no matter how accommodating the provider and staff try to be, they can’t achieve a satisfying interaction with a particularly difficult parent or family. The parent(s) never seem satisfied with the medical advice, attention, and treatments recommended. They don’t accept an answer if it isn’t what they want to hear. They push to get the answer they want. In short, there’s always tension.

In answering this pressing question, we start by recognizing that people from all cultures can be challenging in healthcare settings. We must avoid stereotyping.  Not all Asians are soft spoken and compliant. Not all Hispanics have low English proficiency and a relaxed attitude towards time. So if we are experiencing a patient/family as being insistent and hard to please, we need to avoid seeing that behavior as entirely cultural. In some cases, it may be much more a part of an individual’s personality than his or her culture. Think of people in your own family and social groups. Surely you can think of one or two who can be “difficult.” I had an uncle who was polite and courteous in most situations, but in restaurants he was impossible to please and impatient with waiters. I avoided dining out with him. That had nothing to do with his being American. It was his personality.
Once we’ve adjusted our mindset to avoid stereotyping, we can look for some helpful clues via cultural generalizations to understand patients who tend to be a challenge during office visits.  While it is impossible to make precise characterizations of a culture and people with any degree of accuracy, there are commonalities and unique characteristics in every culture. Remember that the definition of culture includes the following:  Culture influences what people perceive and guides people’s interactions with each other.

Two cultures mentioned as sometimes being challenging to deal with are Indian and Russian. Let’s take a quick look at these two cultures as generalized examples of how behavioral norms don’t always translate easily cross-culturally.

Based on research in the field of intercultural communications (see reference at end of article), people from India may be highly perseverant. In other words, they believe that if they don’t give up and accept a situation as it is, they will get what they want. In an over-crowded country such as India, people have to persevere to survive. Scarcity is a fact of life for many. If you know these things about the culture of India, it makes sense that during an office visit people from India may be very determined and persistent by American standards. The squeaky wheel gets the grease, and taking NO for an answer is culturally unacceptable especially when the stakes are high− often the case in healthcare situations. To get the answer or outcome one needs or desires, it proves effective to try and try again.  This is acceptable and even normal behavior in many countries of the world.

When looking at Russian culture, we can see some similarities in approach. Russian culture traditionally emphasized status difference and an unequal distribution of wealth. When the communist regime took over, the system seemed to favor equality among people, and yet, there were always privileges to be had. One got what one needed through connections to people who could make things happen. People learned to rely on a system of favors. If it took three days standing in line to get a drivers license, it made sense to find someone who had the right connections who could speed up the process. If it took half a day standing in line to get a loaf of bread, people naturally learned to be very assertive in those bread lines. Only by pushing and working the system could one survive.  Taking NO for an answer could truly be unacceptable from a survival standpoint. A Russian immigrant relatively new to the US is not going to be able to shift gears immediately and operate as an American naturally would. Even those immigrants who have been living in the US a while will fall back on old behavioral patterns when things don’t go smoothly and obstacles need to be overcome. The average American has the same obstacles to overcome in dealing with the US healthcare system. 

We push too; we just do it in ways that are culturally normal for us. For example, in American culture it is perfectly acceptable to ask to speak to a manager when there’s a problem. We take the issue to another level of seriousness by doing so. This approach is unfamiliar to people from many other countries. Culture-specific assertiveness – it would actually make an interesting cross-cultural topic to study at greater length.
For our purposes in this newsletter article, we need to focus on the practical aspects of dealing more effectively with the “difficult” patients in cross-cultural interactions? First, keep in mind that there are culture-specific ways of interpreting dialogue, so understand that “no” doesn’t mean ABSOLUTELY NO in many cultures. In cultures where bartering and haggling are common, the first “no” is never really a final answer. It some cases, it can be seen as the first step in a back and forth process where both people end up meeting in the middle. As a healthcare provider or staff member, if you really do mean “no” when answering a patient, try to cushion your response with words of understanding. But make the final answer clear. “I understand what you are asking, and I would like to be able to help you, but my answer is no. It is out of my hands. There is nothing more I can do.”

It is critical to remember that “difficult” patient behavior is often born out of intense emotions such as anxiety, fear, anger and even sadness. Simply recognizing and validating your patients' frustrations and concerns may improve the therapeutic relationship. If you find yourself in a situation that is escalating out of control, take a time out if possible. Tell the patient, "I understand this is very upsetting to you, and I empathize with what you are feeling." Then leave the room to give the patient time to absorb what is happening. Give them five minutes or so. If your job is handling patients at the front desk, it will be hard to take a time out. Perhaps you can ask a co-worker to step in. Sometimes a new face in the conversation will de-escalate the situation. However, be sure that there is a unified voice among the providers and staff.  If one person says no and the next person says yes, then the patient learns to keep asking until she finds the person who will tell her what she wants to hear.

Finally, don’t take the American idea of customer service to an extreme. We are just about the only country in the world where “the customer is always right.” Try taking that attitude to India or Russia. Try taking it to France if you really want a cross-cultural shake-up. Unfortunately, some new immigrants to the US do get carried away with this perceived advantage. Like a magic trick, they need to keep convincing themselves it really works. As a private pediatric practice, you are running a business. You determine what’s acceptable in interactions with your customers, not the other way around. You set the tone. You are in a position of authority and should not be afraid to act accordingly. Being courteous in a professional way will actually gain the respect of patients.

One practice I visited had a very good philosophy about dealing with difficult patients. One of the nurses told me, "Our philosophy is that we're not going to let it get to us," she says. "We try to identify the patient's real problem. Maybe they're afraid we won't take them seriously, are anxious about money or were treated poorly elsewhere. We do the best we can and then move on. The next time we see that patient, we treat it like a new opportunity to have a good interaction. We start fresh.” Now that’s what I’d call a highly effective cross-cultural mindset.

(Referenced for this article: Culture’s Consequences by Geert Hofstede, second edition.)