Cultural and Communication Problems
A factor that inhibits the American Indian use of White-dominated health ser- vices is a deep, cultural problem: American Indians suffer disease when they come into contact with White health care providers. American Indians feel uneasy because for too many years they have been the victim of haphazard care and disrespectful treatment. All too often, conflict arises between what the American Indians perceive their illness to be and what the physicians diagnose.
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American Indians, like most people, do not enjoy long waits in clinics; separa- tion from their families; the unfamiliar, regimented environment of the hospi- tal; or the unfamiliar behavior of the nurses and physicians, who often display demeaning and demanding attitudes. Their response to this treatment var- ies. Sometimes, they remain silent; other times, they leave and do not return. Many American Indians request that, if the ailment is not an emergency, they be allowed to see the medicine man or woman first and then receive treatment from a physician. Often, when a sick person is afraid of receiving the care of a physician, the medicine man or woman encourages the person to go to the hospital.
Health care providers must be aware of several factors when they com- municate with American Indians. One is recognition of the importance of non- verbal communication. Often, American Indians observe providers and say very little. A patient may expect a provider to deduce the problem through instinct rather than by the extensive use of questions during history taking. In part, this derives from the belief that direct quoting is intrusive on individual privacy. When examining an American Indian with an obvious cough, a provider might be well advised to use a declarative statement—“You have a cough that keeps you awake at night”—and then allow time for the patient to respond to the statement.
It is American Indian practice to converse in a very low tone of voice. It is expected that the listener will pay attention and listen carefully in order to hear what is being said. It is considered impolite to say, “Huh?” or “I beg your pardon” or to give any indication that the communication was not heard. Therefore, an effort should be made to speak with patients in a quiet setting, where they will be heard more easily.
Note taking is taboo. Indian history has been passed through generations by means of verbal storytelling. American Indians are sensitive about note tak- ing while they are speaking. When one is taking a history or interviewing, it may be preferable to use memory skills rather than to record notes. This more conversational approach may encourage greater openness between the patient and the provider.
Another factor to be considered is differing perceptions of time between the American Indian patient and the provider. Life on the reservation is not governed by the clock but by the dictates of need. When an American Indian moves from the reservation to an urban area, this cultural conflict concerning time often exhibits itself as lateness for appointments. One solution is the use of walk-in clinics.