Most things that don’t make sense from the outside DO make sense if understood from the inside…

Have you ever had this experience – you are talking with a patient about some care option and you just cannot come to an agreement?  It seems so obvious to you what needs to be done; how come he/she can’t see it?  It just doesn’t make sense….  Yet, perhaps it does.  People, especially those from different cultural backgrounds, often have very different ways of understanding illness, its consequences, and how best to treat it – a different explanatory model. 

Anthropologist Arthur Kleinman suggested that by exploring the explanatory model of illness we can better understand our patients and families; in effect making sense out of nonsense.  To understand others, ask What, Why, How, and Who questions:

What do you call the problem, What do you think the illness does, What do you think the natural course of the illness is, What do you fear? 

Why do you think this illness or problem has occurred?

How do you think the sickness should be treated, How do want us to help you?

Who do you turn to for help, Who should be involved in decision making?  

Inquiring about a patient’s or family’s explanatory model works best in the context of a meaningful relationship.  The inquiry is best initiated with a statement of respect such as, “I know different people have very different ways of understanding illness…Please help me understand how you see things.” 

The explanatory model can also be useful in interpreting the culture of Western medicine to others who find our explanatory model peculiar.  The Western medical model is mechanistic in nature; the body is a machine, prone to malfunctions, requiring tune-ups or occasional part replacement.  The patient’s obligation is to present this ‘machine’ to the ‘mechanic’ (physician) who will make repairs.  This explanatory model differs greatly from other models that view illness more as an imbalance of forces (e.g. Chinese – yin/yang; Hispanic – hot/cold) or as being influenced by unseen forces such as spirits, demons or curses.   

Gaining a better understanding of another’s explanatory model will not in and of itself resolve conflicts in end-of-life care.  However, a foundation can be established for negotiating a course of care that is acceptable within both the Western medical model and the model of the patient and family.  Negotiation and compromise are critical; trying to convince the other that your explanatory model is correct, and theirs is wrong, will not work and will only worsen your relationship.

See also Fast Fact #216 about asking about culture beliefs.  Fast Facts #204 and #275 describe communication considerations specific to certain cultures.

REFERENCES

1. Hallenbeck J, Goldstein MK, Mebane EW.  Cultural considerations of death and dying in the United States. Clinics in Geriatrics. 1996; 12(2):393-406. 
2. Kleinman A.  Culture, illness and cure: Clinical lesions from anthropologic and cross-cultural research.  Annals Int Med. 1978; 88:251-258.
3. Hallenbeck J. Cross-cultural issues. In: Berger A, Portenoy RK, Weissman DE, eds. Principles and Practice of Palliative Care and Supportive Oncology. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: pp661-672.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published August 2005; 3rd Edition May 2015. Current version re-copy-edited May 2015.