The 4 C’s of Culture

A mnemonic for health care professionals developed by Stuart Slavin, MD, Geri-Ann Galanti, PhD, and Alice Kup, MD

1. What do you call your problem?

Get the patient’s perception of the problem. Remember to ask, “What do you think is wrong?” Do not literally ask, “What do you call your problem?” The same symptoms may have very different meanings in different cultures and may result in barriers to adherence. For example, among the Hmong, epilepsy is referred to as “the spirit catches you, and you fall down.” Seeing epilepsy as spirit possession (which has some positive connotations for the possessed) is very different from seeing it as a disruption of the electrical signals in the brain. This should lead to a very different doctor-patient conversation and might help explain why such a patient may be less anxious than the physician to stop the seizures. For an excellent example of what can happen when caring, competent physicians do not understand the patient’s perspective, see Anne Fadiman’s 1997 book, The Spirit Catches You and You Fall Down. Understanding the patient’s point of view can help the health care provider deal with potential barriers to adherence. 

2. What do you think caused your problem?

Get to the patient’s beliefs regarding the source of the problem. Not everyone believes that disease is caused by germs. In some cultures, it is thought to be caused by upset in body balance, breach of taboo (similar to what is seen in the U.S. as diseases due to “sin” and punished by God), or spirit possession. Treatment must be appropriate to the cause, or people will not perceive themselves as cured. Doctors this need to find out what the patient believes caused the problem, and treat that as well. For example, it may sometimes be appropriate to bring in clergy to pray with them if they believe God is punishing them for some transgression.

3. How do you cope with your condition?

Find out what the patient has done to improve his condition. Remember to ask, “What have you done to try to make it better? Who else have you been to for treatment?” Ask, “How have you been coping?” “What effect gas it had on your life/daily routine?” This will provide the health care provider with important information on the use of alternative healers and treatments. Most people will try home remedies before coming in to the physician; however, few will share such information due to fear of ridicule or chastisement. It’s important that health care providers learn to ask – in a non-judgmental way, since the occasional traditional remedy may be dangerous, or could lead to a drug interaction with prescribed medications. This question can also help you discover if they’ve been unable to cope with whatever it is that’s going on.

4. What are your concerns about the condition/treatment?

Find out the main concerns regarding their condition and treatment. Address questions such as, “How serious do you think this is?” “What potential complications do you fear?” “How does it interfere with your life, or your ability to function?” “Do you know anyone else who has tried the treatment I’ve recommended? What was their experience with it?” You want to understand their perception of the course of the illness and the fears they may have about it so you can address their concerns and correct any misconceptions. You also want to know what aspects of the condition pose a problem for the patient; this may help you uncover something very different from what you might have expected. It is also important to know their concerns about any treatment you may prescribe. This can help avoid problems of non-adherence, since some patients may have misplaced concerns based upon past experience. For example, some patients may not be taking insulin because they believe insulin causes blindness. They’ve seen friends and family members go blind after going on insulin, and they incorrectly perceive that as the cause; it’s a logical assumption based on observed cause and effect. Unless a health care provider acts, however, s/he may not elicit such beliefs from the patient, who will simply not take their insulin. By asking, the health care provider can correct any misconceptions that can interfere with treatment.