Traditional Chinese medicine
Many East Asians derive their conception of illness from traditional Chinese medicine (TCM), a broad range of therapies including herbs, acupuncture, massage (tuina), and diet that has been used for millennia. Similarly, South Asians are influenced by the Ayurvedic or Unani traditions. TCM views the body as an energy system, rather than a machine, through which the life force, or chi, flows. Health is not just the absence of disease, but a proper balance of the antithetic forces, yin and yang, maintained by herbs, diet, and acupuncture.33 TCM is often preferred for treating chronic conditions and viral syndromes, or as a substitute for Western medications with adverse effects.34 It is most popular among newly arrived immigrants, those with low literacy, and those with limited access to conventional medical treatment.34 Most Western physicians know little about TCM, feel uncomfortable when their patients use it, and fail to recognize its popularity.34,35 Likewise, most Asian patients are reluctant to discuss their use of TCM unless questioned about it in a nonjudgmental manner.
Many East Asian cultures practice a distinct form of folk healing known as “coining,” in which a coin dipped in cold oil or Tiger Balm is rubbed against the skin, enabling “wind illness” to escape the body (FIGURE 1). Linear bands of painless petechiae develop. The more extensive the bruising, the more illness is thought to be released. Failure to expel “wind-cold” from the body is believed to account for many ailments. Other traditions are moxibustion and cupping. In moxibustion, a smoldering plug of dried artemisia herb (moxi) is either impaled upon an acupuncture needle or placed directly on the skin to create a burn (FIGURE 2). In cupping, a flame is quickly passed through a glass bowl which is then placed against the skin. The resulting suction creates a circular bruise and draws blood to the area (FIGURE 3). Many folk remedies have been mistaken for child abuse by individuals unfamiliar with such practices.36 Occasionally TCM may result in harm from burns, unsterilized acupuncture needles, or (most commonly) adulterated herbal formulations.37
Culture-bound syndromes
Asian folk illnesses usually go unrecognized by western practitioners, and many of these are somatic presentations of mental illness or stress (TABLE 3). A classic example is the Korean folk condition Hwa-byung, which may include the sensation of an abdominal mass. US practitioners might pursue a fruitless abdominal workup before suspecting a psychiatric condition, even though a careful history would likely elicit other anxiety symptoms and loss of sleep and appetite.26
Asian social conventions
Asian cultural conventions often create considerable confusion. In India, head waggling (shaking the head back and forth) is equivalent to nodding in conversation, indicating an acknowledgement of communication. To western eyes, it appears that the patient is resisting advice rather than welcoming it. In East Asians, smiling expresses a variety of emotions, including polite disagreement. Acute embarrassment may provoke giggling. Eye contact is usually for social equals; avoiding it, especially between the sexes, is the norm. Only the right hand should be used when giving patients a prescription; the left hand is considered unclean. A patient’s head should only be touched with advance permission, as it is viewed as the seat of the soul and is therefore sacred. Under no circumstances should a patient ever see the bottom of the practitioner’s feet or be touched by them.38 Demonstrating respect (especially for older Asians) and preserving modesty are essential when examining patients.
Naming conventions can also be confusing. In China and much of Southeast Asia, it is customary for the surname to precede the given name, often with the 2 run together, rather than the other way round. It is best to ask how a patient would prefer to be addressed, regardless of how the name appears on the medical chart.38
Cultivating knowledge of Asian culture provides a framework from which practitioners can better understand and treat their patients. By asking respectful, open ended questions and encouraging patients to take an active role in their own treatment, physicians become therapeutic allies actively engaged in the healing process. Asking patients to share their use of alternative remedies allows the option of rationally integrating those most meaningful for the patient.
The cross-cultural interview
It is helpful to have a specific approach in mind when interviewing patients from other cultures. A number of mnemonic techniques exist.39-41 Perhaps the most useful of these is the LEARN model, which stands for Listen, Explain, Acknowledge, Recommend, and Negotiate.39 The physician first listens carefully to the patient’s perception of his illness before explaining any medical (disease) issues. This exchange is followed by acknowledging differences and similarities between the 2 viewpoints. Finally, the physician recommends a treatment plan and negotiates patient agreement.39 Negotiation implies flexibility and willingness to compromise with reasonable cultural demands, without compromising patient care. Use of the LEARN model aids in the identification and resolution of any cultural conflicts that might arise during the course of the clinical interview.