are most representative of the current state of the science, most clinically relevant, and practically applicable to integrate into everyday practice and support adherence to regulatory guidelines. Communication in the clinic is less well studied, but it is important to note certain areas of potential differences. For example, patients with different cultural backgrounds may have different ways of expressing distress. Some value stoicism, whereas others value the open expression of pain. The presence of non‐verbal behaviours such as reductions in activity, social withdrawal, self‐protective manoeuvres, increased alterations in facial expressions or body postures, and observable displays of distress in a stoic patient, who reports no such problems, would assist a provider in diagnosing unreported problems. The lack of these non‐verbal behaviours in a patient reporting that their symptoms are severe might identify a patient from a more expressive culture.54
Other potentially problematic areas of non‐verbal communication between people with different cultural backgrounds include the pace of conversation, whether interruptions are encouraged, the degree of physical proximity of the provider to the patient during history taking, and whether eye contact is appropriate or disrespectful. One unintended consequence of the introduction of the electronic record is the perception on the part of some patients that it is disrespectful of the clinician to interact with the computer screen more than with the patient.55 It is important to remember that the etiquette of touch, hand gestures, and finger‐pointing varies across cultures. Another area with wide cultural variability is attitudes toward the direct discussion of death and dying among clinicians and patients and their families.56,57
Stereotyping
Sometimes a little knowledge is a dangerous thing and can lead to stereotyping. Instead of trying to memorise what is appropriate for every culture, a brief conversation with the patient or interpreter can clarify what is acceptable and what is not and can clarify major points of potential conflict. Such a conversation would ideally take place during the initial visit with the older adult. A special place in the patient record could be the repository of such information, along with a reminder to refer to that note before the patient is seen. Because culture is fluid and changes with social interactions, brief follow‐up conversations about changes in health or to confirm previous conclusions would be appropriate at each office visit. It is important to understand that there is variation within cultural groups. There is no substitute for asking the older adult what their treatment goals are.58
Age
Very few health care providers are as old as their geriatric patients. Therefore, those providers bring limited personal experience with or insight into the nature of ageing and the consequences of chronic disease to the provider–patient relationship. There is a risk of the nature of ageing being stereotyped by younger health care providers. They may exaggerate the meaning/impact of functional differences, the consequences of chronic illnesses, and the degree to which disabilities that increase with age affect older adults’ quality of life. As a result, there is a risk that providers might fail to recommend lifestyle changes involving smoking cessation, good nutrition, and exercise that might help older adults continue to live independently for many more years. Alternatively, older adults may disregard the expert advice of health professionals who are significantly younger than they are (reverse stereotyping) because they feel that the provider does not understand ageing due to a lack of personal experience.
Increasing cultural sensitivity in the clinical encounter
Increase self‐awareness
Everyone has a culture. The provider brings an ethnic and/or national culture to a clinical encounter, in addition to the biomedical culture. Approaching the older adult as a cultural equal will reduce conflict between cultures. A sense of humour about small misunderstandings is crucial. Asking for explanations about the patient’s culture and offering explanations to the patient about the biomedical culture shows goodwill and a desire to communicate. None of the cultures involved are problems to be overcome. Rather, they are opportunities for sharing.
Table 8.7 ETHNIC(S) mnemonic for improving communication.
| Explanation Treatment Healers Negotiate Intervention Collaborate Spirituality/seniors |
Be prepared to address potential cultural differences when they arise. Not all patients identify strongly with their ethnic culture. Educational level, dominant language, religion, gender, year of immigration, and even personality may have more of an effect on interactions with health care providers than cultural identity.59 The best way to find out what influences the patients’ cultures have on their health is to ask them directly and listen carefully to what they have to say.
Improve communication
The simple mnemonic ETHNIC(S) (Table 8.7) provides an easily remembered framework for providers to use in providing culturally appropriate geriatric care.60 ETHNIC(S) can serve as a clinically applicable tool for eliciting and negotiating cultural issues during health care encounters. Geriatrics health care providers need to be aware of the effect that culture has on establishing treatment priorities, influencing adherence, and addressing end‐of‐life care issues for older patients and their caregivers.
Explanation
It is the practitioner’s job to elicit explanations from the older adult as to why they are seeking care. This may be achieved by asking direct questions about what they think the symptoms indicate and/or what they think family members or other sources may have suggested. It is a rare patient who is unaffected by television or the Internet. This is a good time to evaluate how well the older adult understands the symptoms and what they are worried about.
Treatment
Ask what the patient has already tried to alleviate symptoms, and specifically mention some commonly used complementary and alternative medicine treatments. All older adults have home remedies that are used when a symptom first presents. Sometimes those remedies are helpful, and sometimes they are harmful.
Healers
This is an opportunity for providers to indicate to the older adult that they understand that they may not be the sole health care provider for the older adult. Knowing who the other healers are goes a long way toward knowing who needs to be included in the treatment plan when applying more complicated remedies.
Negotiate
Recovery from an illness requires teamwork, especially with the older adult. Informal caregivers may need to be engaged in the healing process. The provider needs to know how much of a partner the older adult intends to be in their own recovery.
Intervention
The degree to which the older adult is willing to participate in proposed medical interventions must be determined. If compromises must be made based on cultural conditions, or if misunderstandings can be resolved, then the planned interventions can be implemented or modified in a timely manner.
Collaborate
Not only do the older adult and provider need to work together, but informal caregivers and family members, other healers, other
