Practicing cultural sensitivity in the office


Conversation depends on two people talking to each other and, hopefully, being heard and understood. But there are a host of unspoken cues that are conveyed which have nothing to do with words-but have everything to do with interpretation and meaning.

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

Conversation depends on two people talking to each other and, hopefully, being heard and understood. But there are a host of unspoken cues that are conveyed which have nothing to do with words-but have everything to do with interpretation and meaning.                                      

Did you know that putting your hand out with palm facing the other party (we might understand the motion as “stop”) can mean, “I want to rub your face in something disgusting,” or patting someone on the head to show concern can be deemed wildly offensive and a threat to the person’s soul?

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Unspoken communication

Welcome to the world of verbal and nonverbal communication, otherwise known as haptics and proxemics. Haptics are the things you can see, including age of the patient, sex, and manner of dress, and have been referred to as “the tip of an iceberg above water.” Proxemics refer to all the other things below the surface, including culture, attitudes, thoughts, and perceptions.

One must be aware of the “unspoken cues” of conversation. I learned this lesson the hard way when I performed an eye exam on a patient with several of her family members in the room.

Typically, I will finish an exam by asking the patient and family members if they had any questions. In this situation, seeing there were none, I gave what I thought was an innocent “thumbs-up” hand gesture to conclude the exam and indicate all was well with the patient. Unfortunately, that gesture was not received innocently, and significant drama occurred.

I was made to realize that my “thumbs-up” was not a friendly gesture in all cultures. In the end, I apologized to the patient and her family because they were guests of my practice. In reality, it was my responsibility to know better and make things right.

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Talking to patients

I know this seems obvious, but talking to patients is what we clinicians do, so we’d all better be good at it. We talk to patients to provide them with our professional understanding of their condition. It matters what is said. The details matter, the context matters. Gender, age and cultural awareness all matter. The diagnosis matters.

What if the information relayed might be only half of the conversation? What if things like body language, tone, choice of words, and personal deference all mattered and were important components to include in the conversation? In fact, if you don’t start the conversation off properly, the conversation might be over before it begins. Indeed, the “recipe” for combining all these ingredients may vary from patient to patient.


Patient understanding of what we say is more important than what we actually say. Consider: If patients don’t remember what we relayed to them, have we done an effective job? I used to think that it was my job to educate, and it’s the patient’s job to listen. Then I realized that some of my patients simply didn’t understand my explanations on lid hygiene, glaucoma, specialty contact lenses and all of the other items I had to convey.

Conveying information to patients and having them remember what occurred is the signature moment that lets people know they had an eye exam. Everything prior to that instant, while important, is almost minor. The patient must be able to remember what was conveyed in a manner that makes sense.

Related: Be present with your patients

Not the only way

A quick and important disclaimer. Park your attitudes and what you think you know at the door. It is impossible to be an expert in cultural relativism, but it is always possible to get smarter. Americans can and do commit actions which could be considered wildly offensive in other cultures. Don’t assume that what you know is the only way to do things. Being open minded goes a very long way to broadening the brain and learning new insights.

Interestingly, it can be as simple as culture. Americans can be considered by other cultures as very independent and ingrained with a “take-charge” attitude. We like to get to the root of the problem quickly and don’t believe in wasting time with idle chatter. But other cultures and countries favor relationships and devalue independence.1 Indeed, there might not be any growth in a business relationship until a well-worn path of comfort has grown between you and your business contact. This might mean no discussion of your business for days or weeks.

A simple and sincere greeting and a few moments to ask your patient about her family might be all that is needed to prime the conversation. Being aware of a patient’s manner of dress and realizing it might not be appropriate to shake a woman’s hand can go a long way to showing awareness and consideration.

Related: 5 ways to start the lens care conversation with patients

Know your audience

Sometimes what we don’t know causes our words or actions can lead to cultural miscommunication.

For example, in some cultures looking a patient in the eyes and addressing him is considered a type of intimidation. Patting someone on the head is considered potentially offensive, or handing something with someone’s left hand can show disrespect. Or using a “thumbs-up” gesture to convey no ocular pathology to the patient after the dilated fundus exam is offensive.

Even though you meant no harm by your gesture, you may not get a second chance to have a conversation with the patient. In his book Cross-cultural Business Behavior: A Guide for Global Management, Gesteland discusses a number of specific instances and provides the reader opportunities to understand how a communication approach in one country can be wildly successful, but wildly offensive in another.2 Awareness of the audience does matter.


Galanti, author of Caring for Patients from Different Cultures, calls it cultural competence. The skill of simply being empathetic affords the enlightened reader potential insight into the reasons why the other party might behave the way he does.3

Consider questions such as:

 • Why won’t this patient look me in the eye?

• Why did they not extend a hand when I went in for a handshake?

• Why did she look uncomfortable when I asked her why she was here today?

Think of cultural competence as a decoder ring which allows you to see and hear behavior in a manner that explains. This gives you an opportunity to alter your communication style and improve your chances of being heard the first time.

Related: Ensuring patient success with contact lenses

Cultural sensitivity is not a new “politically correct” device in the patient care spectrum. Indeed, the military recognized its important some time ago and spends an enormous amount of time and money for deploying soldiers to receive thoughtful training on the theater in which they are to be deployed, including basic phrases for communication, references to hand gestures, and knowledge about the cultural, gender, age, and socioeconomic structures of a particular location.4

There’s good reason to do this. Being in a foreign land, it would be important to know that a “thumbs-up” might be a cause for conflict.

Some might say, “A foreign patient is here in the United States, and he should get with the program to adopt our cultural quirks.” Personally, I think this is a short-sighted approach and does nothing for improving one’s ability to show respect and cultural awareness. Being insensitive to age, socioeconomic status, race, or culture can decrease your chances of making a difference in your patient’s life and can incredibly damage your reputation in a pool of patients.5

Unseen, nonverbal communication cues can rapidly bridge a divide and provide a course for effective communication. The culturally sensitive person is showing respect and politeness and is making a sincere effort to extend the hand of compassion. It will go a long way.

Being just a little more aware is a good thing. While it might seem that you are profiling your patients, you are simply trying to improve your chances of talking effectively with them. That’s a good thing, too. Keep doing it, and you’ll continue to improve. It will make the world a smaller place and you a better doctor.

Related: Two-way communication is essential to patient care


1. Berger JT. Culture and ethnicity in clinical are. Arch Intern Med. 1998 Oct 26;158(19):2085-90.

2. Gesteland RR. Cross-Cultural Business Behavior: A Guide for Global Management. Oslo: Copenhagen Business School Press DK. 2012. Print.

3. Galanti GA. Caring for Patients from Different Cultures. Philadelphia: University of Pennsylvania Press. 2013. Print.

4. McFate M. The Military Utility of Understanding Adversary Culture. Office of Naval Research, Arlington, VA. 2005. Print.

5. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.

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