The purpose of our research was to explore how African American, Chinese, and Latino patients view effective communication in their medical encounters that included a CRC-screening recommendation, and how culture influenced their definitions of effective communication. We found that interpersonal relationship themes such as power distance, trust, directness/indirectness, and an ability to listen, as well as personal health beliefs, emerged as important factors affecting patient definitions of effective communication. In addition, we found that physicians did not solicit or directly address cultural barriers to CRC screening, and patients did not volunteer culture-related concerns they might have regarding CRC screening. Below we discuss our findings in more detail.
Our inability to find explicit references to cultural differences in physicians’ CRC-screening recommendations or in patients’ responses can be attributed to several explanations. One plausible explanation is that CRC-screening talk is often scripted. When physicians engage in scripted communication, they often operate on “automatic pilot,” thus reducing the potential to tailor messages culturally or individually (assuming the physician is aware of how to do so, or why it is important to do so). Tailoring is the adaptation of the intervention, and/or a total redesign to best fit the needs and characteristics of a target audience (Pasick, D’Onofrio, & Otero-Sabogal, 1996
). Cultural tailoring is the development of interventions, strategies, messages, and materials to conform to specific cultural characteristics (Pasick et al., 1996
). In our analyses of direct observations, we found little variation in CRC-screening talk given by one physician across several patients. Another explanation might be that, in discordant physician–patient encounters (when each is from a different ethnic group), physicians might not be aware of the need to culturally tailor; if they are aware of the need, they might not know how. Physicians’ self-awareness of the dangers of stereotyping might also account for the lack of cultural tailoring.
With regard to the finding that patients tended not to disclose culturally based concerns that they might have concerning CRC screening, one possible reason is that in scripted communication, there is little room for free exchanges of information. The structure of such interaction thus limits self-disclosure of personal concerns. As shown in direct observations, physicians often presented an uninterrupted narrative, and only at the end of the narrative were patients asked if they had any questions. Scripted communication is not conducive to manifestations and revelation of significant and relevant behaviors, as shown in Blackman’s (2002)
study. Another reason could be attributed to the power distance between providers and patients. Patients might feel that such information ought to be solicited, not volunteered, as evident in postvisit interviews. We can also posit that, in discordant encounters, patients might either feel inhibited or uncomfortable disclosing such information because they think physicians of a different cultural background might not understand their concerns. Consequently, this type of disclosure might be more likely to transpire in concordant encounters in which providers and patients share similar cultural assumptions and expectations.
Power distance was found to be a key cultural theme in our research. We found pronounced differences in expectations of low power distance and high power distance, as well as differences in conceptions, perceptions, and expectations of physician–patient relationships, in different cultural groups. That is, whether a visit to the doctor constitutes a personal encounter and engagement, or an impersonal and business-like transaction, differs among patients of varying backgrounds. Effective physician–patient interaction might require that physicians know how patients define and expect power distance by administering patient assessment (e.g., My doctor is someone who gives expert advice; My doctor is someone to whom I can talk about my medical problems). It is also important for physicians to understand that a relationship might take a long time to develop in some cultures, as shown in patient interviews. A lack of self-disclosure of relevant information on the part of the patient could be a barrier in providing quality care, as found in Ngo-Metzger and colleagues’ (2003)
study. Asian immigrant patients demonstrated reluctance in disclosing their use of traditional medicine to their physicians because they feared possible negative reactions, or a lack of understanding on the part of the clinician. It is worth noting that engaging in personal talk, telling jokes, sharing personal experiences, and shaking hands are examples of communicative acts that patients found to be meaningful in their relationship with their physician.
Trust is another important cultural theme in the effectiveness of CRC-screening recommendations. Our findings showed how patients related to trust, how they made sense of trust in the context of their relationships with their physicians, and how they differed with regard to sources of trust. Arguably, in discordant interactions, trust might compensate for or mitigate the effect of the absence of culture-tailored communication. Thus, developing a trusting relationship is central to increasing the quality of physician– patient communication. Through analysis of physician strategies and patient perceptions of these strategies, Burke and colleagues (2005)
drew the same conclusion. Although physicians did not perceive their behaviors and strategies as culturally informed (as evidenced in their review of videotaped CRC discussions), patients interpreted them as culturally resonant, thus leading to a deepening of relationship and trust with their physicians. Our analysis extends this finding to note that patients who trusted their physician saw their physician as competent, or as their advocate. This finding is consistent with prior work that identified trust or continuity as a promoter to CRC screening (O’Malley, Beaton, Yabroff, Abramson, & Mandelblatt, 2004
In contrast, the feeling of distrust went beyond the office visit. Patients talked about their fear of being victimized by the system, fear of negative racial prejudice, and past negative experiences with health care. Prior work has shown similar suspicion of the motives of the health care system and of the advocate role of physicians (Greiner, Born, Nollen, & Ahluwalia, 2005
), as well as perceptions of unfair treatment because of race or low income (Blanchard & Lurie, 2004
; Corbie-Smith, Thomas, Williams, & Moody-Ayers, 1999
; Freimuth et al., 2001
; Gamble, 1997
; Gregg & Curry, 1994
; O’Malley et al., 2004
). This finding suggests that building trust is extremely important, especially among cultural groups in which trust has been questioned and in which differences exist in terms of the source of trust (role-directed vs. relationship-directed), and how individuals build trust.
In addition to all of the above issues, patients’ health beliefs influenced how they receive CRC-screening recommendation and the perception of its effectiveness. Patients who were supportive of preventive care and early detection were more receptive to screening tests and were more motivated. This finding is consistent with prior work in a study of urban African Americans, in which hope was associated with CRC and other cancer screening tests, and anticipation of positive outcomes was seen as a source of hope (Greiner et al., 2005
). Passive acceptance of cancer and misconceptions about how cancer spreads, however, have also been shown to contribute to resistance to screening (Gregg & Curry, 1994
; Greiner et al., 2005
; O’Malley et al., 2004
). In addition, fear of learning they had cancer was an important barrier for Hispanic women to overcome in Pap screening (Vanslyke et al., 2008
A physician’s communication style constitutes another influential aspect. Patients across different cultural/ethnic groups preferred that their physicians communicate with them in a direct and an explicit way, as demonstrated in patient interviews. Patients also perceived direct and explicit communication as indicators of honesty and trustworthiness. This finding indicates that, despite differences of cultural backgrounds, patients favored a low-context communication style that is direct and explicit, and they attached positive meanings to directness. An ability to listen is another theme that influenced physician–patient interaction. Patients felt that they could relate, talk, and disclose to their physicians if physicians showed an interest in listening. Effective physician–patient communication requires that physicians engage in active listening. Active listening has been identified as a key component of patient-centered health care (e.g., Bensing, 2000
; Charon, 2001
; Lang et al., 2000
), and physicians’ capacity for active listening was perceived as a valued quality by patients (Oliffe & Thorne, 2007
This study has several limitations that are worth noting, and might affect the generalizability of our results. First, our sample size was relatively small because of the intensive nature of our research. Second, a large number of the patients who were observed and interviewed had established relationships with their physicians, particularly in the integrated health care system. Third, the study was limited in scope because our design focused on discordant communication. It would be useful in future studies to observe and compare both discordant and concordant encounters. Fourth, we did not follow patients to ascertain whether or not they followed through with colorectal screening. However, as a developmental study exploring the role of culture in communication, this was beyond the scope of our study. Despite these limitations, this study is significant because the findings show that health communication research on such topics as CRC-screening recommendations should be examined in a broad cultural context. That is, we need not only to investigate specific CRC-screening recommendations and strategies, but to consider other cultural aspects that mediate the effects of such efforts and are central to patients’ overall experience with their physician. Such necessity was evident in prior work (Zapka et al., 2004
). In addition, our findings were based on a rare combination of direct observations and postvisit interviews, thus providing an in-depth examination of cultural issues that were specific to each individual’s circumstances. Our findings, though limited in sample size, provided thick descriptions of how patients made sense of their physicians’ CRC-screening recommendations, and what was meaningful to them (Geertz, 1973