CULTURAL ASPECTS OF PAIN MANAGEMENT

David E. Weissman, Deb Gordon, Shiva Bidar-Sielaff

Studies have shown that patients from ethnic minorities and cultures different from the health care professionals treating them, receive inadequate pain management. Each of us has the impression that people from distinct cultures are more or less likely to express their pain experience in a manner that is somewhere between quietly enduring (stoic) or very expressive. Just ask yourself this question—what populations do you regularly encounter that are more likely to be stoic, to be expressive? Now ask yourself a second question—do you treat such patients who are stoic differently from those who are expressive? Ideally, the answer would be no, we should treat everyone the same. However, in truth, we are likely to provide more attentive and compassionate care to the patient who is stoic compared to the expressive patient. This is because the culture of pain in Western Civilization tends to honor the stoic person (no pain = no gain; the football player who makes a touchdown despite a broken leg).

What is it about people that directs them to express their pain experience in different ways? Culture is the framework that directs human behavior in a given situation. The meaning and expression of pain are influenced by people’s cultural background. Pain is not just a physiologic response to tissue damage but also includes emotional and behavioral responses based on individuals’ past experiences and perceptions of pain (e.g. when you were a child was your expressive behavior tolerated or were you expected to be stoic). Note: Not everyone in every culture conforms to a set of expected behaviors or beliefs, so trying to categorize a person into a particular cultural stereotype (e.g. all North Dakota farmers are stoic) will lead to inaccuracies. On the other hand, knowledge of a patient’s culture may help you better understand their behavior.

Even more important than understanding the culture of others, is understanding how your own upbringing effects your attitude about pain. We are likely to believe that our reaction to pain is “normal” and that other reactions are “abnormal”. Thus a doctor or nurse from a stoic family may not know how to react to a patient who responds to pain by loud verbal complaints (or discount the pain because of the apparent mismatch between the injury and the verbal response). Even subtle cultural and individual differences, particularly in nonverbal, spoken, and written language, between health care providers and patients impact care.

To be Culturally Competent, you must:

· Be aware of your own cultural and family values

· Be aware of your personal biases and assumptions about people with different values than yours

· Be aware and accept cultural differences between yourself and individual patients

· Be capable of understanding the dynamics of the difference

· Be able to adapt to diversity

You must Listen with empathy to the patient’s perception of their pain; Explain your perception of the pain problem; Acknowledge the differences and similarities in perceptions; Recommend treatment; and Negotiate agreement. Questions that staff can use to help assess cultural differences include:

· What do you call your pain? Do you have a name for it?

· What do you think caused your [pain]?; Why do you think it started when it did?

· What does your [pain] do to you?; How does it work?

· How severe is your pain? Will it have a long or short course?

· What are the most important results you hope to receive from the treatment?

· What are the main problems your [pain] has caused you?

· What do you fear most about your [pain]?

References:

Bates M.S., Rankin-Hill, L., & Sanchez-Ayendez, M. (1997) The Effects of the Cultural Context of Health Care on Treatment of and Response to Chronic Pain and Illness. Social Science and Medicine, 45(9). 1433-1447.

Berlin EA Fowkes WC. A teaching framework for cross-cultural health care. WJMed 1983;139:934-938.

Kleinman AK, Eisenberg L, Good B. Culture illness and care. Clinical lessons from Anthropologic and cross-cultural research. Ann Int Med 1978;88:251-258.

Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. “We don’t carry that”-failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342:1023-1026.

Edward E. Rylander, M.D.

Diplomat American Board of Family Practice.

Diplomat American Board of Palliative Medicine.