Communication Skills Mentoring Program

Patient Encounter Tips


Culturally Competent Tips

Communication Across Cultures: Tips For The Orthopedic Interview With American Indians And Alaska Native Patients

  • Background

    In the 2000 Census 2.5 million Americans described themselves as American Indian or Alaskan Natives and an additional 1.6 million described themselves as AI/AN in addition to another ethnic group. This comprises 1.5% of the American population. Although they represent many different tribal entities and various degrees of transition into mainstream culture, they share a unique heritage and many traditions that are often similar enough to employ some common communication techniques. Unlike many other ethnic groups however, AI/AN may not necessarily be easily identifiable as AI/AN. Patients may have traditional surnames, or surnames that are Anglo, Scandinavian, Latino, Russian or, other. Yet their dominant cultural influences may be AI/AN.

    There are two unique, significant dimensions that distinguish the cultural identity of AI/AN from the cultural differences of other ethnic groups: their history of traditional culture and the historical interface between traditional culture and global culture. Identification of the patient's heritage and insight into these unique cultural differences is essential to effective communication during the medical interview. Aspects of these defining differences will be presented and some communication techniques described.

  • Traditional Cultures vs Urban/Post-Literate Mainstream Culture

    Intercultural communication with most other ethnic groups addresses primarily differences of language and custom. This is true when the parties are as different as English/Asian, Spanish/German, Arabic/Chinese. Both parties, however, derive from a 2000+ year old history of urban, literate culture. While on the surface the differences may seem significant, the underlying values and traditions share more in common. While not necessarily easy, communication has a large basis of understanding.

    AI/AN represent part of the rapidly vanishing world of traditional cultures. Traditional cultures derive from a largely non-urban, pre-literate history. Their nomadic, semi-nomadic or small village existence depends on subsistence hunting and fishing and perhaps limited agriculture. Knowledge is passed on through oral tradition. Society has a much simpler social structure. Individuals are less specialized in their roles within their culture and more fully competent in the majority of activities of their society. The values and perspective of traditional peoples are thus significantly different from that of mainstream global culture. Effective communication requires appreciation as well as understanding of these values and this different perspective.

    Time and space do not allow full comparison and contrast of these two cultures. Hopefully the parallel columns will allow insight into some of these differences.

    Traditional CultureItemGlobal Culture
    Intuitive and integrated<Knowledge>Objective, fragmented, data driven
    Avoids conflict or confrontation<Communication>Directness in communication
    Looks to past, focus seasonal, circular<Time Orientation>Looks to future, focus on the minute, linear
    Reverence, no ownership, respect for nature<Relationship to Land>Exploitative, private ownership
    Multi-competent, non-specialized, humility<Individual Role in Society>Highly specialized, achievement oriented
    Become archetypal human being
    • Who you are
    • Where you fit
    • How you relate
    • Repeat archetypal roles
    <Individual Objectives>Become useful citizen
    • Obtain marketable skills
    • Maximize leisure
    • Minimize labor
    • Reject past, innovative, individual
    Simple class distinctions<Societal Structure>Complex hierarchical distinctions
    Spiritual<Spiritual Orientation>
    (Until arrival of missionaries)

    A little reflection on these few, basic contrasts show how different the two cultures can be. Also remember that although he may be wearing a three-piece suit and she may have a Harvard MBA, his/her values may be much more traditional than global.

  • History of Traditional Cultures in USA

    The history of conflict between the global, urban culture and traditional cultures is long, sad and ongoing. Traditional cultures have always been looked upon as inferior by the global culture and thus ripe for persecution and exploitation. As history is recorded by the dominant, literate culture, our understanding of traditional cultures both ancient and contemporary is frequently poor and distorted. What was true for the Romans and the "barbaric" Celts has also been true for the United States and the AI/AN. The difference is that many AI/AN are within a handful of generations of the events. Many living elders tell their grandchildren of their experiences while the grandchildren experience their own. Our own unfortunate history includes some of the following official government policies regarding AI/AN: attempted extermination, forced relocation from ancestral lands, isolation on reservations, segregation, and forced cultural assimilation with complete loss of oral language and traditions. As our own history is part of our identity, so too is theirs. Further study from the reading list can be both humbling and informative.

    An additional aspect of this history relates to the provision of health care. The U.S. Government agreed in treaties signed in the 19th century to provide health care to AI/AN. The level and quality of care has and does range from excellent and state of the art to unavailable and poor. An individual AI/AN patient may present with a history of negative experiences with the health care system that may represent a challenge for the orthopedist to overcome. Hopefully with some basic understanding of their unique cultural differences and their history and with sound communication techniques we can meet this challenge.

  • The Greeting

    A smile and a patient, positive attitude will make up for almost any intercultural faux pas you may make. A sullen, unhappy demeanor is easily construed as prejudice.

    If the patient's cultural heritage is uncertain but you assume they are AI/AN, treat them with the respect we owe all patients. They may share their identity or not. Remember the differences in communication styles from the cultural comparison section above. Unless you are certain and are fluent in their language, an attempt at greeting in their tongue will look silly and perhaps demeaning. Addressing as Mr., Mrs., or Miss shows respect and is always safe. Apologetically asking for help with pronunciation of a surname is also appreciated. It is important to greet everyone in the room and establish relationships. Extended family relationships with cousins, aunts and uncles are often as close as immediate family and their role in the patient encounter should be treated accordingly.

  • The Interpreter

    Elders will frequently be accompanied by a family member in the role as interpreter although this is felt to be less than ideal in other cultural settings, it is not necessarily so with AI/AN particularly with elders. The principles of speaking to the patient directly and not relating to but through the interpreter are important. Eye contact with the patient and gently nodding while the interpreter speaks conveys understanding of what is said.

  • Tips and Pitfalls
  • Some traditional AI/ANs are often reserved and non-confrontational. Direct, but open-ended questions, may be necessary to accomplish your goals. "What did you hope we could do for you today?" The response may be abbreviated but the words well chosen. Be patient and make a point of listening and pausing before your response. Some AI/AN believe words have great power and should be respected. Slowness of speech does not indicate slowness of mind but respect for speech. Rapid-fire questions and pressure to respond are particularly offensive.
  • Time will be expressed in vague terms. If you need to be more specific, ask about the season. "Do you think it started in the spring?"
  • Punctuality can cause problems with a schedule. Lateness is not meant as disrespect but is the result of a different sense of time. You may have to be a little more flexible.
  • Humor is appropriate only after significant rapport is established. Gentle, self-deprecating humor helps to connect on a personal level. There should never be reference to either party's ethnicity.
  • Remember that hunting and fishing, herding and gardening are communal, cultural rituals with spiritual implications tied to the earth and sea. Inability to participate in these subsistence activities can represent grave loss as an individual and a sense of isolation from the community. Many urban AI/AN return to their village or reservation for at least part of these important seasons. To be able to return to these activities is extremely important.
  • In many AI/AN cultures "western medicine" is an adjunct to traditional medicine. Some Native Healers use ritual, herbals and some invasive techniques. Health or "wholeness" may not be achieved without the shaman or healer. Respectful questions about a specific technique may reveal certain risks i.e., poultice dressing on a post op wound or needling a joint. Careful explanation of the potential consequences usually achieves cooperation.
  • Most AI/ANs welcome reviewing imaging studies and frequently have excellent understanding of anatomy because of hunting and herding experiences. Cartilage, bone and tendon are things they have touched and seen. Printed pamphlets and drawings are useful and the time spent discussing increases trust.
  • Conclusion

    I have tried to present a few perspectives and tips to help you develop some insight into the culture of the AI/AN. In conjunction with the general principles of the Institute's Patient-Physician Communication Program this should help in your providing culturally competent care to your AI/AN patients.

  • Acknowledgements

    Much of the material is derived from Father Michael Oleksa's series: Communication Across Cultures, KTOO, Juneau, Alaska, 1994. I use this program for staff orientation at the Department of Orthopedic Surgery, Alaska Native Medical Center, Anchorage, Alaska. It is available from KTOO Juneau (907) 586-1670.

    Also recommended is Speaking for the Generations, Simon J.Ortiz, Editor, University of Arizona Press, Tucson, Arizona. Bury My Heart at Wounded Knee, Dee A. Brown, author, Henry Holt & Co. New York, NY.

    I would also like to thank Vivian A. Ecchavarria, MPH, CHES, Orenzo Snyder MD, Carrie Nelson, RN, and Shay McEwen for viewpoints from Athabascan, Navajo, Ojibwa and Athabascan perspectives.

    R. David Beck, MD
    Department of Orthopedic Surgery
    Alaska Native Medical Center
    4315 Diplomacy Drive


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