Recognizing the power of diversity.

Diversity, at its most basic level, is simply all the ways in which people are different. The most powerful differences are age, race, ethnicity, gender, sexual orientation and physical ability. But diversity is not limited to these dimensions. According to Loden and Rosener,(2) there are secondary dimensions of diversity that also affect how people behave, how they see the world, and what values drive them. For physician executives, all of these dimensions of diversity influence how people approach health-related issues. Among the secondary dimensions that affect medicine are educational background, income, geographic location, and religious beliefs. While these diversities can and do fundamentally shape patient views toward health care, they are considered secondary because they are mutable, whereas age, race, gender and even sexual orientation, according to Loden and Rosener, are not.

Culture: How It Shapes Behavior

Beyond understanding the broad definition of diversity, it is critical to understand how culture shapes behavior. The easiest way to see culture's pervasive influence is through the use of a computer metaphor, where human beings are likened to the hardware. Culture, on the other hand, is the software that "programs" people, telling them how to behave and delineating the rules of conduct. Culture involves everything you do, from what you eat for breakfast and how you introduce people to the rules of hygiene and physical proximity. More specifically for health care, views of pain and suffering, life and death, individual responsibility, and predestination are influenced by culture. People are generally unaware of culture until they bump up against someone whose cultural programming is different. That is when problems arise. Different norms are generally seen as not the "right" way to be.

Equally important, sometimes different cultural norms annoy or irritate us and become a source of conflict between staff members. The physician who stands too close is seen as pushy and intimidating, the patient who does not make eye contact is considered passive and unassertive, the nurse who didn't tell you she didn't understand is suspected of lying. Many other cross-cultural norms that affect interactions between physicians and staff members or between all hospital personnel and patients can be seen in the "Characteristics of Culture," adapted from Harris and Moran.(3) While all the dimensions have relevance to health care, the significance of culture can be seen in three primary areas.

* Issues around Relationships. Mainstream American cultural norms are shared with approximately 30 percent of the world. Our culture gets high marks for task accomplishment but lower marks for tending to relationships, a reality that has signfficant consequences in health care, particularly in patient-physician relationships. One way to illustrate the differences between these norms and the other 70 percent of the world is to recall the movie "The Doctor," with William Hurt in the title role.

Hurt, as the quintessential technically excellent surgeon in prototypical Western fashion, treated the disease but was not particularly cognizant of the human being suffering from it. Relationships were not his strong suit. Investing time in the socioemotional aspects of patient care was not of value. But in Hollywood all things are possible, and there is usually some crisis that precipitates learning. In this case, Hurt develops cancer, sees patient care from a different perspective, and forever changes the way he practices medicine. The postcancer physician comes to realize that a Hispanic patient who wanted closeness and rapport with his doctor needed that contact as much as he needed a good surgeon. Hurt also comes to realize what many physicians who practice medicine cross-culturally already know: The human element is probably the critical factor in determining patient satisfaction. Bedside manner may be universally important, but it is seen as more central in other parts of the world.

While "The Doctor" was only a movie that makes a point about the necessity of tending to relationships, we saw the issue of cross-cultural values conflict between task and relationship in real life played out at a local children's hospital. A physician who specializes in treating a rare disease demonstrated great care and kindness with his patients, so much so that he saw fewer patients than his colleagues. His contract was not renewed. While his chief of medicine understood how much his patients and families loved this doctor, the institutional view was that his approach was a luxury the hospital could not afford. It is not for us to comment on the wisdom of either keeping this doctor or letting him go. What we are saying is that in a culture that measures most things in the "bottom line," there needs to be a way to acknowledge the importance of patient-doctor relationships in the healing process. With the realization that illnesses can be psychosomatic comes acknowledgment that the physician can make a critical difference in patient attitude, level of confidence, and results. This faith is even more central in intuitive, less analytical non-Western cultures.

* Issues around Communication Communication is often difficult between people with the same language, similar experiences, and familiar environments. It is even more so when all these factors are not shared. How physicians talk to patients and families about illness and death, or deal with nurses from cultures where saying yes may mean no, or show patience with an elderly patient who has memory problems is tricky at best. It requires a delicate and tactful manner. American culture believes the shortest distance between two points is a straight line. We are notoriously direct. Sayings such as, "Don't beat around the bush," "Get to the point," "Put your cards on the table," and "Tell it like it is" all are idioms that reinforce the same message. This directness is not the language of soft|ness and is the antithesis to preferred communication in most cultures, where American clarity and assertiveness are considered harsh and offensive. Physician executives trying to help their own staffs deal with changing populations and communication norms need to teach them that diplomacy and tact, while helpful and important in any environment, will be especially prized in a diverse patient base.

There are other issues around communication, not the least of which involves language differences. Speaking languages other than English in the workplace usually stirs up feelings of inadequacy in employees, as well as fears of being talked about. Language issues are often very volatile, but these problems can be solved with sensitivity and even be converted into a competitive advantage. One hospital in Southern California was smart enough to realize the high cost of language barriers as well as a hidden opportunity. Realizing it was located near many Japanese businesses, all of which take good care of top executives and their families, it decided to capitalize on a vacuum in.the market. Rather than complain about the language problems, this hospital offered Japanese patients 24-hour-a-day translation services and nurses in OB/GYN who speak Japanese. They are now the hospital of choice for Japanese firms' executive physicals as well as for other family care. The bottom line? Better service for patients and increased profitability for the hospital.

Another issue around communication involves the incorrect assumptions human beings tend to make. They are more difficult to correct in the face of language differences. At a hospital recently, a physician took blood tests every four hours for a young Vietnamese infant who was ill. The parents spoke limited English but barriers, both cultural and language, got in their way. They didn't understand the reasons for the frequency of the tests and felt that the taking of blood was weakening their child, so they assumed the worst and feared for their son. The doctor was upset because he felt his competence and judgment were being questioned. The hospital got a Vietnamese physician to intercede and become a cultural interpreter. When differences in culture are ignored as a source of conflict in the communication process, misperceptions and problems arise.

* Issues around Specific but Different Cultural Norms Cultural norms have a powerful influence on perceptions and values regarding health, wellness, pain, suffering and death. The following are just a few of the ways culture can affect health care delivery to Southeast Asians:

* There are three possible causes of illness: physical, metaphysical (the yin/yang principle), and spiritual. Physicians treating Southeast Asians need to at least know about their belief in balancing hot and cold temperatures of liquids as a way to balance the state of the body and maintain its harmony.

* The head is the seat of life essence. It is highly personal and untouchable. Touching it will be disturbing and will cause soul loss.

* Blood is the life energy force and losing it is irreversible. Its use as a diagnostic measure is not well understood.

* Diet norms are different and affect health. For example, tea consumption in many Asian cultures, especially among the elderly, takes place throughout the day. The tannins in tea inhibit iron absorption, so anemia is widespread in many tea-drinking countries.

* Surgery is seen as a potential cause of soul loss.

In other cultures, there is a strong belief in predestination, which affects attitudes toward illness and death. There is an acceptance of God's will and, therefore, often less intervention on one's own behalf. There is also a more hierarchical view of relationships, with deference paid to people with titles. The physician-patient relationship is less a partnership, and there is less questioning of the physician's treatment. Depending on the population served, one thing a physician executive can do is structure learning experiences about the norms, customs, and beliefs of the patient population as they relate to spirituality, pain, values, and core beliefs. Doing so will give physicians and other hospital employees some of the information they need to effectively deal with today's pluralistic patient base.

Concepts about Culture

Beyond having interpreters to help a staff learn about the ways to best serve a particular population, an important step in handling workplace diversity is to create an environment where tolerance of differences prevails. The following model, called "Concepts about Culture, explains three steps in creating an inclusive climate where differences can be bridged.

* Cultural Sensitivity and Acculturation 

Cultural sensitivity and acculturation implies that cross-cultural adaptation is a two-way street. Physicians and their staffs, if dealing with a primarily Hispanic population, for example, may need to become more culturally sensitive and realize that, while school--age children may interpret for parents, respect and eye contact must still be given to the adult. In addition, large extended families may accompany the patient to the doctor's office. Patients may be less willing to volunteer relevant information regarding health histories, and negative feedback regarding existing treatment may be withheld for fear that it could be disrespectful to the doctor. On the other hand, the doctor can help the patient acculturate by carefully explaining the purpose for certain medication and the consequences of not taking it. Telling the patient and family why information is needed, that it helps the doctor do a better job, is another way to help the patient help him- or herself more.

* Ethnocentrism to Synergy The second step is moving from ethnocentrism to a more synergistic approach. Ethnocentrism involves the very human and predictable, but often problematic, tendency to see the world through our own experiences. We determine that the way we see the world and behave is the "right way." A physician treating patients who come from cultures that do not have such a rigid and linear time consciousness may be irritated at what he or she considers rude, inconsiderate behavior and a lackadaisical attitude. However, if the physician sees the behavior as a different cultural norm, one that may be less stressproducing than the American reliance on schedules, he or she may find it is more productive to see patients on a first-come, first-served basis rather than by set appointment.

* Diversity Conflict or Creativity

Diversity can lead to both creativity and conflict. A case in point is the often-cited hospital frustration with patients who have large groups of extended family visiting. One hospital, rather than have this issue be a source of conflict, found a creative and lucrative solution. Empty patient rooms resulting from low census were converted to hotel-like accommodations for family members who wished to remain overnight. Not only did the hospital generate income from previously unused rooms, but it also gained a marketing advantage over competitors in the community.

Another often-cited conflict is that of gender differences. A woman physician may find obstacles in treating patients from cultures where women are not generally seen in the workplace, for example. Gender can also produce obstacles to collegial relationships. While it is common for women to be physicians, gender continues to be an impediment to the success of females in medicine, with women being more readily accepted in pediatrics and OB/GYN than in neurosurgery. However, many practice groups are finding that having female partners is a boon to business, as one of the most frequent requests to physician referral services is for a woman doctor.

Diversity is clearly an issue whose time has come in most of the major urban centers of this country. By accepting it in all its richness, by making it a competitive edge, and by helping physicians adapt and respond to the different patient and employee populations serve or worked with, an organization can set itself apart from the pack and make the future its friend.

References

1. Glasgow, A. Teacher's Inspirations. Lombard, Ill.: Great Quotations, 1990.

2. Loden, M., and Roseher, J. Work force America! Homewood, Ill,:Business One Irwin, 1991.

3. Harris, P., and Moran, R. Managing Cultural Differences. Houston, Tex.: Gulf Publishing, 1987.

Lee Gardenswartz, PhD, and Anita Rowe, PhD, are principals of Gardenswartz and Rowe, a management consulting firm in Los Angeles, Calif. Dr. Gardenswartz is a member of the ACPA Faculty. Drs. Gardenswartz and Rowe coauthored Managing Diversity: A Complete DESK Reference and Planning Guide. Homewood, Ill.: Business One Irwin, 1993.