Cultural Issues

Confidence

Healthcare providers can serve several distinct decision-making roles vis-à-vis their clients. First, they can be agents, making decisions on the patient's behalf, as when the patient says (explicitly or merely implicitly), “I realize that the decision is mine legally, but would you please decide for me? After all, you're the expert, and besides, I'm just too upset by this horrible news to make the decision [Page 248]myself.” Second, they can be co-deciders, in the spirit of the shared decision-making paradigm. That is, the provider and patient work toward mutual agreement about, say, a workable hypertension management regimen for the patient to follow. Third, providers can be consultants, such that the patient reserves the right to decide personally but seeks the provider's opinion as input to the decision process, for instance, in the form of a prostate cancer prognosis or a recommendation for radiation therapy versus radical prostatectomy. Finally, providers can be (and invariably are) decision managers, deliberately or inadvertently exerting influence over how the patient chooses by, say, providing literature that favors radiation rather than surgical treatment for the patient's condition. Whether and how the patient allows the provider to assume these roles depends directly on the client's confidence in the provider's competence or expertise. And that confidence can easily be affected by cultural differences.

Impressions of expertise generally, and of decision-making expertise in particular, rest on several considerations. One consideration is acclamation, consensus among people one already respects. Such consensus in turn depends on factors such as the person's visibility and regard by one's peers. In the health arena, credentials and accomplishments in contemporary science-based medicine undoubtedly carry great weight even with people who normally have little to do with modern societies. Yet, all else being the same, a provider from a culture different from the patient's own almost necessarily is less well known in that patient's social circles than a provider who shares the patient's own culture and therefore suffers a perceived competence liability. Another consideration is style of speaking. People recognized as experts tend to speak with precision and confidence. A provider from a culture different from the patient's is unlikely to be fluent in the patient's native language and thus is incapable of exhibiting the linguistic trappings of expertise. Yet another consideration is factual knowledge. People expect true experts to be able to recite extensive facts about the domain in question. And they certainly expect experts to know virtually all the facts they know themselves, and more. As discussed below, cultures often differ in terms of disease prevalence rates as well as common treatments, including folk remedies. A provider from a different culture might well be ignorant of these facts that the patient knows personally, thereby suffering damage to his or her credibility in the patient's eyes.

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