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

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

What is the explanatory model? Anthropologist Arthur Kleinman suggested in 1978 that by exploring the patient’s culturally determined beliefs about their underlying illness (or their explanatory model of illness) we can better understand the personal and social meaning they attach to their disorder, their therapeutic goals, and their therapeutic expectations. To understand others explanatory model of illness, clinicians should ask What, Why, How, and Who questions:

• What do you call the illness? 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?  

Communication pearls when using the explanatory model: Research into the clinical implementation of the explanatory model remains immature.  There is no proven gold standard in how to employ explanatory model inquiries with patients nor which patient groups are the best to utilize it in.  Most of the clinical research was utilized in patients with medically unexplained symptoms or other mental health disorders; however, experts believe explanatory model inquiries also can be a culturally responsive way to understand the illness perspective of patients with terminal diseases too. Here are some communication tips based on anecdotal experience.

• Inquiring about a patient’s or family’s explanatory model works best in the context of a meaningful relationship. 
• If you opt to utilize it in a patient you do not know as well, initiate the inquiry 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 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.  Bidirectional understanding, trust, 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 Fact #204 and Fast Fact #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.
4. Dinos S, Ascoli M, Owiti JA, Bhui K.  Assessing explanatory models and health beliefs: an essential but overlooked competency for clincians.  BJPsych Advances 2017; 23(2):106-114.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2^nd Edition published August 2005; 3^rd Edition May 2015; 4^th Edition December 2023.

Conflicts of Interest: none to report