Cultural Competence and Health Care: Japanese, Korean, and Indian Patients in the United States

Article excerpt

Abstract: Cultural competence requires sensitivity to the diverse ethnic, religious, and cultural expectations of patients in our health care system. In the increasingly multicultural world of the city hospital, patients will benefit from increased cultural competency on the part of health care providers. This study interviews Japanese, Korean, and Indian immigrants to the United States, showing that these individuals hold vastly different expectations concerning: 1) when to seek medical assistance; 2) the role of the doctor in the community; 3) the role of the patient and the patient's family in conversations with the medical specialist; 4) the roles of doctors versus nurses; 5) issues of privacy and disclosure to patient and family; 6) organ donation; and 7) end-of-life care. The paper concludes with immigrants' views on what would make their medical experience in the United States more comfortable, and, hence, potentially more beneficial to their mental and physical health. Key Words: Cultural Competence, Japanese, Indian, Korean, Patient Care

As the population of the United States grows more diverse, the need for culturally sensitive care also grows. As one article attests (Flores, 2000), presently 31 million patients speak different primary languages than their health care providers. Numerous studies already have explored the attendant need for culturally sensitive care theoretically (Harwood, 1981; Kleinman, 1978a; Salimbene, 1999) and curricularly (Caudell, 1996; Flores, 2000; Palmer, 1997; Zweifler & Gonzalez, 1998). While some authors argue that health care providers must become adept interviewers of their patients, so that they may gauge each patient's needs appropriately (Elwyn, 1997; Jones, Bond, & Cason, 1998; Pachter, 1994), others emphasize the importance of general education about, and awareness of, cultural differences (Bartol & Richardson, 1998; Salimbene, 1999; Sullivan, 1989). Although some studies explored the attitudes of specific populations toward issues of health, illness and medical care (Beine, Fullerton, Palinkas, & Anders, 1995; Kleinman, 1978b; Salimbene, 2001), these remain the exception rather than the rule. Far more common are theoretical studies that end with a call for substantive education and qualitative research (Navon, 1999).

This article seeks to answer that call through a careful examination of the cultural attitudes of patients from Japan, Korea, and India, all of whom utilize the health care system in the United States. As immigrants, these three patient populations share certain characteristics in common, such as feelings of uncertainty and trepidation when encountering an unfamiliar medical system; feelings of frustration when they are unable to communicate their symptoms effectively in English; and feelings of anger when they believe they are being viewed with suspicion and distrust by predominantly Anglo hospital staffs. Nevertheless, because Japanese, Korean, and Indian societies each articulate different cultural meta-narratives regarding illness and healing, individuals from these countries hold divergent patient expectations. Further, conversations with immigrants from these three Asian countries highlight the extent to which medical care in the United States, especially at the end-of-life, has become divorced from the kinds of spiritual rituals and narratives that traditionally have framed life cycle transitions such as birth and death. The challenge of providing sensitive health care to persons coming from cultures steeped in spirituality offers doctors, nurses, and hospital staffs in the U.S. the opportunity to learn more about diverse cultural worldviews as they seek to ease suffering and promote healing among their patients.

Methodology

This study utilized in-depth ethnographic interviews. In-depth interviews involving both patients themselves (Beine et al., 1995; Coulter, 2001; Mackinnon, Gien, & Durst, 1996) and health care providers (Blendon, 2001; Kirkham, 1998) have been used by several other studies that seek to understand the attitudes of specific populations to particular issues associated with health, illness and medical care. Moreover, Kleinman (1978b; 1988; 1995) and others (Elwyn & Gwyn, 1999; Loustaunau & Sobo, 1997) have defended the idea that such attitudes are appropriately uncovered via ethnographic and narrative methods.

I conducted interviews structured around the following questions:

1. In what situations do patients seek out doctors in Japan (Korea, India)? For minor complaints, or only when seriously ill? Do patients first go to their "family" doctor before they go to the hospital? Or in what cases will a patient go directly to the hospital before consulting their "family" doctor?

2. What type of authority is accorded to the doctor in Japan (Korea, India)? Are specialists/surgeons held in higher regard?

3. Do doctors strive to provide their patients with a warm and supporting, personal interaction, or do they deliver information about the medical condition more "objectively" and dryly, without becoming personally involved? Is this a topic of reflection/revision in the Japanese (Korean, Indian) medical system?

4. What is the role of the nurse in the Japanese (Korean, Indian) medical system? What is their "bedside manner" with their patients? Close and personally-involved, or more objective?

5. How does religion relate to a person's desire to seek medical assistance? Are members of certain religions in Japanese (Korean, Indian) less willing to seek medical care than members of other religions?

6. How do Japanese (Korean, Indian) people of different religions or worldviews view organ donation? How do they view keeping a patient on life support systems?

7. What kind of questions would be considered "rude" or "inappropriate" in an interaction between doctor and patient? How can American doctors avoid insulting their Japanese (Korean, Indian) patients?

8. Do family members come into the doctor's office with one another, or is the patient alone with the doctor? How much information is given to the spouse of a patient? How much information is given to the adult children of an elderly patient? How much control does the patient have in this process?

9. How is medical research conducted? Do you have the notion of "informed consent" in Japan (Korea, India)?

10. Do religious "chapital" or "clergy" from any of the different religions work as part of the hospital staffs, or do they have arrangements with the hospitals to visit with patients while they are there? What is the nature of the interaction of these individuals with the patient? Do they give spiritual advice? Do they perform rituals? What rituals are performed before a patient dies?

The Practice of Medicine in Japan, and Japanese Patients in the United States

In Japan, patients often visit specialists in large hospitals directly without any referral from what we would call a "family doctor," or in more contemporary phraseology, a PCP. There are two reasons for this. First, in Japan, the family doctor, or PCP system, has not really been established to the extent that it has been in the U. S. Indeed, many Japanese intellectuals argue that, in order to provide medical care more efficiently in Japan, rather than building larger hospitals, more attention should go into establishing a more reliable family doctor system.

Second, the Japanese national medical insurance, which covers all Japanese citizens, essentially allows any Japanese patient to be eligible to receive medical treatment at any medical facility, large or small, at any time. Under the Japanese national medical insurance system, then, all Japanese citizens are equally entitled to receive medical treatment at any of the well-known hospitals throughout Japan. In most cases, the patient him- or herself decides whether he or she will go to small clinics or to large public or private hospitals. This, however, does not necessarily mean that patients select small clinics for minor complaints and that they go to large hospitals for more serious illnesses. Because the Japanese national health insurance system allows patients to visit any medical institution regardless of the severity of their medical condition, some people prefer to visit large hospitals whenever they feel slightly ill or have even the most minor symptoms of a cold. On the other hand, certain patients, who are not comfortable going to doctors in general, sometimes will prefer to visit small medical clinics, even though they may have a very serious condition or their illness may be in an advanced stage.

From the perspective of the medical care providers, this unpredictability of patients' choice of medical facilities in Japan sometimes creates very serious logistical problems. For example, patients who are very ill and need immediate medical attention may have to wait for a very long time if the outpatient care unit of a large hospital is flooded with patients who actually have opted to go to the large hospital for complaints as minor as a slight headache or stomach upset.

In general throughout Japan, large hospitals in big cities tend to receive more patients than they can handle. Some people warn that, without establishing a family doctor, or PCP system in Japan, the medical care system eventually will collapse. More and more people are choosing to go to the larger hospitals for all medical needs, and they are selecting bigger hospitals, such as those established by University Medical schools, which receive more media publicity for their advanced research facilities for serious kinds diseases such as AIDS, myocardial infarction, etc. People often simply believe that the large research hospitals have more experience treating serious diseases and, therefore, that they can treat you better and more effectively, even if the complaint is minor.

In order to cope with overcrowding at major Japanese hospitals, the Japanese Medical Doctors' Association has issued its own guidelines in which medical care facilities are classified into three categories and people are encouraged to seek medical care according to the seriousness of their illness. Although this is merely a guideline and not a legal requirement, Japanese doctors are trying to ensure that patients receive medical treatment promptly according to their degree of illness. According to these guidelines, the first category of medical care facility is small clinics run by family doctors or smaller city hospitals that primarily provide care for elderly people and children. Japanese family doctors are usually internal medical doctors who have small, private offices in or near their residences or work in small clinics. These doctors usually only provide primary care, and if the find or suspect a serious illness, they make referrals to specialists in larger hospitals.

General hospitals or emergency hospitals established privately or by municipal governments comprise the second category of medical facility in Japan. And the third category consists of Japanese hospitals established for patients with very serious illnesses who need hi hly specialized medical treatments, for example, the National Cancer Center and the National Cardiovascular Treatment Center. The Japanese Medical Doctors' Association recommends that patients receive treatment first at the smaller facilities classified in the first category, and only afterwards at larger hospitals classified in the second or third categories. Additionally, in order to receive medical treatment at third-category medical facilities, patients should be referred by doctors at second-category facilities. But the system breaks down inasmuch as it is sometimes difficult to distinguish treatment facilities according to category. (See Norbeck (1987), and Sharts-Hopko (1996), for further details concerning the Japanese medical system.)

In general throughout Japan, doctors usually are referred to by the title sensei, which means "master," "teacher," or "doctor." In Japanese, the title sensei also is shared by such people as politicians, lawyers, professors, and teachers, all of whom are considered to be morally and socially responsible public figures. Although all medical doctors receive considerable respect in Japanese society, regardless of whether they are generalists, specialists or surgeons, doctors with particular areas of expertise, such as brain surgeons or heart surgeons, often are accorded higher regard because they are seen as saving the lives of patients who would otherwise not be saved. Among medical practitioners, surgeons often receive special treatment from their patients, since Japanese patients and their families customarily express special gratitude to surgeons before and after surgery.

With regard to selecting the appropriate method of treatment, Japanese patients traditionally have tended to accept the authority of the doctor in charge of the case or the team of doctors and/or researchers working with the patient. More recently, however, the notion of informed consent has become increasingly important in Japan, especially, when doctors are conducting medical examinations. In invasive medical examinations, without exception, doctors now are required to receive informed consent in either verbal or written form. This informed-consent requirement is beginning to change the system, because doctors need to describe for their patients available methods of examination and operations and then let the patients themselves decide the mode of treatment. (Consult Akabayashi (1999) and Elwyn (1998) for more on informed consent in the Japanese context.)

In the past, Japanese doctors were trained to treat as many patients as possible in a very short amount of time. People often criticized this approach, calling it the "three-minute medical treatment." Japanese medical treatment traditionally places heavy emphasis on examinations, medications, and surgery, and communication skills traditionally have not been a significant component of medical practice. Doctors' attitudes toward patients slowly are improving, however, resulting particularly from recent reforms in the national medical insurance system allowing Japanese doctors therefore have become more conscious of the need to communicate more so that they can remove patients/ anxieties about their illnesses. However, Japanese doctors usually do not like to be contacted privately, especially outside of hospitals.

Depending upon the intellectual level or personality of the patient, Japanese doctors are more and more willing to discuss the nature of the illness and treatment options with the patient in order to inform patients of their medical condition as clearly as possible. Japanese patients often bring their families with them when they visit the doctor's office, clinic or outpatient unit. Although doctors usually share all available information with both the patient and the accompaning family members, exceptions sometimes are made if doctors perceive some complicated human dynamic within the patient's family. In the case of elderly patients, doctors may provide more detailed explanations to the patients' adult children rather than directly to the patients themselves. The reasons given for this is that the patients might not be able to understand the information, and also that it is important for the adult children of the patient to understand the information clearly, since they are responsible for the parent's care. In Japan, once this type of medical information is disseminated to the family, it is not easily controlled by the patient. Rather, patients' spouses or families, as guardians, often have more control over medical information than do patients themselves. Although technically in the Japanese medical system, there is no discrimination between a husband and a wife, medical doctors sometimes regard the patient's first son as more important than the patient's wife, especially when the son is an adult and the patient's wife also is sick. And so, in some cases, medical information will be given to the son instead of to the wife of a sick patient. In addition, if doctors believe some information to be particularly serious, however, such as a cancer diagnosis, they sometimes fear the patient may be harmed psychologically by the news and they therefore usually attempt to consult or obtain permission from the patient's family members or friends before deciding whether, or how, to provide the information to the patient.

In Japanese Buddhist families, end-of-life decisions are usually done by the consensus of the family council (see Konishi (1998), and Nakasone (2000)). The family, however usually looks to the eldest member for advice. Individuals and families also may seek advice from the deceased by approaching the family altar and the memorial tablet of an honored elder. Some Chinese Buddhists, and, to a lesser extent, some Japanese Buddhists, believe that the spirit of the individual resides in the memorial tablet, a practice that reflects the continuing relation of the living with the dead.

In Japan, nurses assist in medical care, and they also assist patients in their everyday life activities, advising and preparing patients for future independent living. At the bedside, it is considered very important for Japanese nurses to respect patients personalities. More concretely, nurses often are expected to stay and listen to their patients' complaints with an open and compassionate heart. High expectations are placed on Japanese nurses to be able to understand each patient as an individual person. It is also important for them to understand patients' family environments, lifestyles, or their interests, apart from their illnesses. Furthermore, Japanese nurses help orient patients to the hospital or clinic environment and assist each patient by responding to their individual problems, protecting privacy, and securing the proper living space in the hospitaL The issue of privacy is particularly significant, because Japanese hospitals do not have many private rooms. In such an environment, nurses' attitudes to patients become very important, especially within the patient community in the hospital. For example, when a patient dies, nurses must not cry in front of other patients because it is believed that their tears may have a negative effect upon other patients. Instead, nurses are expected to be pleasant towards their patients, since it is believed that a smile may be as effective as medicine for particular patients. Generally speaking, then, Japanese nurses are much more capable of interacting with patients in a more personal style than are Japanese doctors. While nurses occasionally counsel their patients to ease their anxieties about illnesses or economic problems, however, they almost never interact with their patients concerning religion or spirituality.

The medical care system in public hospitals, such as city or national hospitals, does not contain an explicit religious dimension. Religious clergy only are allowed to visit patients if the patients request such visitations. The role of ministers in hospitals also is limited to listening to patients to ease their anxiety concerning suffering and death. And any kind of evangelical initiative on the part of a religious clergy visiting the hospital, religious propagation, or forced conversions are explicitly prohibited, since Japan has been plagued in the past by newly-established religious groups that have forced patients to make donations to their religious organizations and that have recommended to patients that they refuse medical care.

A short digression into the classification of the types of Japanese religious practices will help to clarify the role of religion in the Japanese medical establishment. Regardless of religious affiliation, Japanese religious practices roughly can be classified into three types. First, some religious practices, undertaken to fulfill one's wishes, emphasize the power of prayer. In the case of illness, one usually appeals to the power of God, of gods, or other supernatural powers, requesting a cure by offering prayers. Practitioners seeking the fulfillment of their wishes also rely on the power of prayer by religious clergy, whom they believe embody the miraculous healing powers of God or of other supernatural beings. Because such practitioners tend to put more emphasis on religious and magical prayers than on medical treatments, in some cases leading to the refusal of treatment, Japanese doctors usually do not allow this type of spiritual healing practice to be performed in the hospital.

The second type of religious practice common in Japan emphasizes self-control. Such practitioners seek to live their lives in accordance with the will of God, gods, or other higher spiritual principles. They accept their illnesses as given to them, and they seek to manage their lives within the constraints of their illness. This religious view can tend towards determinism, with patients believing that no one can alter the will of the absolutely powerful being. Practitioners in this category often cultivate patience to accept the realities of life, and individuals with this view understand illness as an unavoidable fate determined by God, by gods, or by higher universal principles. Although doctors do not believe that this kind of mindset contributes positively to the treatment protocol, they consider these religious practices less threatening to effective medicine than those of the first, wish-fulfilling type.

A third type of Japanese religious practice involves the cultivation of mind through what is understood to be universal truth. Instead of reconciling themselves to sickness as their unavoidable fate, followers of this worldview seek spiritual release from suffering by recognizing the true nature of illness as a part of the truth of human life. Buddhism, for example, teaches that nothing is permanent and that everything, including all living beings are interdependent. On the basis of such teachings, Buddhism teaches patients to recognize the state of their own illness objectively as a part of natural reality and to seek new paths to fulfill their lives by transcending states of suffering caused by sickness, aging, and dying.

Historically, pharmaceutical research and the production of traditional Japanese medicines developed in areas in which the practice of Buddhism, especially Jodo Shinshu Buddhism, was strong. Jodo Shinshu Buddhist followers did not believe that prayer cures sickness, nor did they give themselves up easily to illness as their unavoidable fate. Instead, such Buddhists understood illness to result from causes and conditions, and they directly sought its eradication through the development of medications and treatments. Because of their religious conviction, then, Jodo Shinshu Buddhists traditionally are more willing to seek medical care than followers of other religions in Japan.

Compared to other countries, Japanese people traditional are resistant to the concept of organ donation, a situation that reflects the Japanese understanding of life and death and the Japanese view of the human body. For example, in Shintoism, the human body must be treated with respect because it is given by kami (deities), or in accordance with the principle of nature. Shintoism also teaches that the body is still necessary after one's death in this life in order to be reborn in the next life. Therefore, Shinto followers naturally respond negatively to the idea of an organ transplant from another body, because it harms people even though they have already died.

In contrast to Shinto followers, Japanese Buddhists exemplify three perspectives on organ donation, "permissive, "restrictive," and "moderate." Those individuals who adopt a permissive stance think that organ transplantation and organ donation should be encourage because they believe that it is in accordance with the Buddhist idea of a non-ego transcending all attachments, or in accordance with the intention of the bodhisattva, who wishes happiness for others.

On the other hand, those Buddhists who adopt a restrictive stance voice strong opposition to organ transplantation, claiming that medical practice should concentrate on how we can live our lives naturally. They also claim that artificially prolonging a human life through organ transplanatation merely reflects human attachment to life, which goes against Buddhist principles. Additionally, they cite the Buddhist teacing that body and mind are inseparable, and they view organ transplantation as a violation of this teaching. They also argue that promoting organ transplants implies that some people may subconsciously hope that others will become brain dead, which violates the Buddhist precept against killing, which should even be observed mentally. Finally, some Buddhists object to the brain death criterion of death, because Buddhists traditionally have associated life with sentience, which, in its broadest sense, includes animals and plants. Because sentience also implies feeling, many Buddhists are reluctant to endorse organ transplantation, especially heart transplant.

Moderate Buddhists believe that organ transplantation should be permissible only for recipients who can respond with gratitude to the organ donor, and for those who would regard the organ transplant as their birth into a "second" life. This refers to embarking upon a new relationship, in which the donor and the recipient live together in one body. After receiving an organ transplantation from a person who had suffered brain death, one Japanese Buddhist stated:

I can't express my gratitude for the donor. If the donor didn't give his organ to me, I would have died soon. The donor's organ, that is, his life, is living now in my body. After receiving this organ, I am not my previous self, because the life of the donor's organ exists now in my recipient's body. I can accept my new life by organ transplant as my second birth.

A spiritual interaction is believed to occur between donor and recipient, in which the recipient never will forget the donor's aspiration for wishing the recipient's spiritual and physical well-being. In such a spiritual interaction of two lives, the dignity of the lives of both donor and recipient is preserved, which is in accordance with the Buddhist tradition of respecting both life and death.

To summarize, then, permissive Buddhists believe that organ donation is a compassionate act that will help the donor's stance. Restrictive Buddhists, on the other hand, believe that receiving an organ reflects human attachment to the notion of eternal life, and they therefore criticize the recipient's stance. And using more of a relational model, moderate Buddhists believe that seriously ill and dying people will produce a compassionate relationship between donor and recipient, which they believe reflects the Buddhist notion of compassion as arising from the realization of the oneness of all life.

As for Japanese Christians, both Catholics and mainline Protestants generally react very positively to the notion of organ transplantations, probably because they believe that donating their organs after their deaths to save the lives of others is in accordance with the Christian spirit of "love thy neighbor." While Japanese people traditionally are hesitant to accept organ transplantation as a standard medical procedure, more recently, even the moderate stance among Buddhists has become more popular.

Regarding life support, many elderly Japanese patients who request doctors to stop life support because they prefer to die naturally. This reflects the Japanese view of the naturalness of both life and death. In Japan, doctors respect patients' choices regarding death with dignity, which is legally permitted. However, active euthanasia by doctors is not allowed. On the other end of the spectrum, Japanese views toward artificial means of facilitating reproduction have yet to be discussed openly in public, but there is some quiet consensus that Japanese people generally hold negative views concerning artificial intervention into the processes of both death and life.

Although very few religious chaplains or clergy work as staff in Japanese public medical care facilities, clergy do work as staff at facilities established for terminal cancer patients, such as in public palliative care facilities, Christian hospices, or Buddhist vihara hospitals (the Buddhist version of hospice). Hospices and vihara hospitals contain chapels, and patients can attend religious services and listen to sermons at the chapel or while they are in bed. At this important end-of-life juncture, pastoral care focuses on the "care of the heart," without denying patients' individual religious views and views regarding life.

The word "vihara" refers to "a temple (shoja) or a monastery (coin)," "peace of body and mind," or "a place of practicing asceticism and resting, a hospital." In early and later Pure Land Buddhism in Jam pan, movements have arisen to provide care compassionately to the sick. Through caring for the sick, caregivers are considered to cultivate self-reflection and contemplation as they walk together with the sick along the path of the Buddha Dharma.

Initiated by Masashi Tamiya in 1984, the modern vihara movement in Japan involved the teamwork of specialists in Buddhism, medical care, and social welfare. Learning from the spirit of hospice care, which was developed with in the context of Christianity, the vihara movement was developed to create a network of caregivers and facilities to provide humane and whole-hearted support for patients so that they are not left alone while they are undergoing medical treatment.

Vihara care in Japan begins by communicating with patients and their families with love and respect and sincerely listening to their voices. It is a movement that aims to link bereaved people and loved ones through precious memories that continue after death. The vihara movement accepts a person's death as a unique individual death, and people are said to learn many things from their loved one after they are separated from them. Also, in the midst of their grief, the vihara movement provides support for family members and also helps the surviving family use their memories of the deceased as a form of guidance in their current lives. Participants in the vihara listen to patients and their families to understand their thoughts on the meaning of death and dying, love and care of others, and the meaning of their own lives. They aspire to give hope to patients and their families through acceptance of the reality of dying, and by teaching them that those who die live on in the memories of the people who are left behind. Although Japanese Buddhists enacted deathbed rituals for dying people during the medieval period, contemporary Japanese Buddhists do not actively engage in such rituals. Buddhism in modern Japan tends to emphasize that people can be saved through the cultivation of heart and mind while they are alive, not by rites occurring at the time of death.

Having reflected upon the medical system in place in Japan, how can doctors and nurses here in the U.S. best respond to their Japanese patients? Recognizing that the following comments generalize, and therefore need to be considered in context, let us begin by noting that Japanese patients tend to assume a humble attitude towards doctors. And in keeping with cultural conventions in Japan, conversations involving direct eye contact may best be avoided. Japanese patients often do not want to hear the name of their illness directly from their doctors, but they instead wish to be informed indirectly before their interaction with the doctor, so they can be prepared before their doctor comes talk to them about the illness. It generally is considered a virtue in Japan to suppress feelings of anger and sadness in front of others, so Japanese patients do not want their doctors to know that they are mentally upset by hearing bad news about their illness. Offering effusive comfort to a Japanese patient who had broken down with grief, for example, could prove very embarrassing for the patient.

Also, inquiring about personal information unrelated directly to patients illnesses are considered very rude and inappropriate. Japanese patients also have difficulty openly discussing what are considered embarrassing or stigmatized problems, such as mental illness, unless they have established a firm bond of personal trust. Interestingly, however, many Japanese people consider American in-patient treatment of mental illness to be much better than that found in Japanese hospitals.

In general, Japanese patients are more comfortable in U.S. medical environments when doctors respect their personal modesty and sense of shame, and when they also respect patients' overall human dignity. Japanese patients feel that the most practical way to avoid unnecessary bad feelings is to provide Japanese language assistance to Japanese patients. In part because they fear misdiagnosis, Japanese patients in the U.S. find it exceeding frustrating when they are not able to explain their symptoms well in English. This often occurs, even for Japanese immigrants with a very good command of English as a second language, especially when they experience an emergencies. Translation assistance, especially in an emergency setting when patients are often upset and flustered, is of paramount importance and much appreciated.

Medicine and Patient Care for Korean Immigrants

Most people do not have "family doctors" in Korea, nor do they possess a clear concept of what a "family doctor" is. My informants told me that the idea that a family, or members of a family, would routinely go to the same general physician was, by and large, unheard of - if it occurred at all, it would only apply to those Koreans of a high class and high socioeconomic status. Nevertheless, if a doctor exists within the circle of relations or close friends, Koreans usually will consult him or her first in cases of illness.

Many Koreans will not go to see a doctor at all unless they are seriously ill. Instead, they will visit the neighborhood pharmacy, since pharmacists in Korea have the right to prescribe medications. In the case of serious illnesses, Korean patients usually go directly to the hospital. Larger hospitals, including university hospitals, are seen to have more credibility and reliability than do individual doctors. Furthermore, Korean medical insurance is considered to be very inexpensive (somewhere around $30 a month for the whole family) and, hence, it is affordable for the population at large. (See Association NER (1994), Miki (1995), and Son (1999) for more information about the Korean health care system.)

Except when they are interns and residents, Korean doctors are accorded absolute authority and are considered to be masters of sorts. For example, one informant responded that his sister, a doctor, was not accorded high authority until she became a fourthyear resident, a so-called chief. Furthermore, if one holds a specialist license and a Ph.D., one will be regarded as one of the best doctors in Korea. Specialists and surgeons in Korea are'-held in higher regard and are more respected then are general practitioners, and, indeed, guardians of a patient sometimes are known only to consult specialists in cases when a patient's health is declining.

In Korea, if a specialist has a nationwide reputation in a specific area, or was trained in a famous international hospital, or is a graduate of one of top medical schools, for example Seoul National University Medical School, she or he will be swamped by patients. As in the United States and in Japan, doctors in Korea are overloaded. While some Korean doctors strive to have a good level of personal interaction with their patients, many do not have enough time or energy to support their patients, and they are seen to deliver medical information very "objectively" and "dryly." One informant stated that doctor-patient relationships are not warm in Korea. He added that patients complain about what they perceive as doctors' "cold-blooded attitudes," and patients sometimes comment that they simply must endure doctors' lack of personal attention when they interact with them. Of course, there are exceptions to this type of characterization - one of my informant's sisters, referred to earlier, is known to pray for her patients and to ask her family also to pray for them. Still, this issue of the doctor-patient relationship is being discussed openly and seriously among doctors in Korea, especially young doctors, and improving it is seen as a big challenge for the Korean medical system.

Because of the tremendous time pressure on doctors and specialists in Korea, it is not surprising that nurses are relatively closer and more personally involved with their patients. They visit patients more frequently, and they usually have a greater degree of personal contact with their patients than are Korean doctors. Still, like some Korean doctors, nurses, too, are seen as taking a neutral or "objective" attitude towards their patients. In addition, nurses' roles in the Korean medical system are not perceived as being very significant. Nurses generally are accorded less authority and credibility than doctors, and they tend to be seen merely as "assistants" in the eyes of both doctors and patients.

Normally, when illnesses are relatively minor, Korean patients go to the doctor alone unless they are not yet adults. But in cases of more severe illness or emergency, Koreans usually will take family members with them to the hospital. Family members often want to come into the doctor's office, but usually a nurse asks the patient to come in alone. As in Japan, in cases of severe illness such as cancer or another critical condition, medical information would be given first to family members including the spouse or adult children of the patient, since the medical staffs are worried about the patient experiencing shock (see Kim (1991) for more on the involvement of family in the medical decision-making process in Korea). As one informant put it, "Usually, a doctor lets his/her family (any one else but the patient him/ herself) know the result of the examination or the situation in a serious situation such as cancer." In a critical condition such as cancer or a heart attack, even though the patient may assume full control of the situation, other family members' involvement would be increased. In general, however, elderly persons in Korea are highly respected and hold much control in determining the mode of their health care. Korean patients generally trust their doctors concerning the choice of treatment, so they are still somewhat vague when it comes to the notion of informed consent (though informed consent is routine before surgery). Nevertheless, Koreans in the U.S. are becoming acclimatized to the notion of informed consent, and one sees increasing use of informed consent in Korea.

Religion plays a significant role in determining patients' attitudes towards medical intervention in Korea. Various forms of Christianity, especially Protestantism, have done remarkably well in Korea - Korean Protestantism is varied, with three major denominations and more than one hundred minor denominations. Korean Protestantism emphasizes the healing power of the Holy Spirit, and most religious leaders and ministers encourage sick parishioners to seek medical attention. They also support sick members of their congregations by visiting them, praying for them, and conducting worship services. However, some conservative Korean Protestant denominations ask members of their congregations to rely only on the healing power of a GoT"who is listening to his people's crying" rather than to seek medical treatment.

Many Koreans also place a tremendous amount of trust in religious leaders themselves, according them miraculous powers the way Koreans traditionally have accorded the shaman-ness such magical abilities. One informant stated:

As you know, we Koreans have diverse religious and cultural backgrounds. Among them, in the long history of Korea, shamanism has played important roles in peoples' everyday lives. When someone was sick, they went to a shaman-ness" (a woman priest - there are only female priests in Korean shamanism) for overcoming one's illness. People also asked the shamanness for a good harvest and the welfare of families. Even though many Koreans have converted their faith to Christianity, there exists the image of the shaman-ness in their mind. So, when people became devote Christians, they have tendencies to trust their pastors who have powerful abilities to help their family members to escape from being sick. Some pastors also mislead their lay people by overly emphasizing God's or Jesus' mysterious healing powers, which are recorded in the Bible.

When a conventional medical treatment proves ineffective, religious Koreans often depend on the power of prayer or of some other type of divine intervention. For example, one of my informants related that when his sister's daughter was born with Down's syndrome, the hospital treatment caused her so much pain that the family elected to discontinue medical treatment and to rely only on prayer; unfortunately, the young child died after eighteen months.

From time to time in Korea, the tension between respect for modern medicine and more fundamentalist tendencies to eschew medical treatment altogether becomes a nationwide issue, especially in cases in which a patient dies and both pastors and churches are believed to be guilty of misconduct. In some cases, family members of patients who have died have sued pastors and churches. While this phenomenon is not limited to particular denominations, one informant did single out three religious groups that have come under scrutiny for encouraging members to forsake medical treatment, the Full Gospel Church, which represents a kind of Pentecostalism; the Korean Baptist Church; and some of the more conservative Presbyterian churches.

Regardless of their religious backgrounds, many Koreans have negative views about organ donation, in part emanating from their Confucian heritage. For Koreans, harming one's own body conflicts with the teachings of great Confucian scholars. The issue of organ donation evokes ideals of filial piety and respect for ancestors. One of my informants observed that most Koreans dislike the idea of organ donation because they believe that their physical bodies come from their parents or ancestors. They therefore feel that donating organs for medical purposes directly disrespects their ancestors.

Furthermore, many East Asians believe the body is an integral part of nature, which also mitigates their willingness to donate organs. Koreans traditionally care for their bodies extremely carefully, and even into the early 1900s, this extended to the practice of not cutting hair for both men and women. Koreans also tend to eschew organ donation because they believe that people have their own destiny according to cosmic providence, whatever religion they have. Thus, when they face death, Koreans usually try to accept it. Some people view organ donation and other artificial means of sustaining life as reckless attempts to avoid death, which is a providence of our nature and Nature in general. Conservative Korean Christians also dislike organ donation, since adherents believe that it presents problems for their future resurrection. If one donates one's eyes, how will they be able to see when they live another life in the future?

Since the Korean modernization movement of the 1960s, however, Korean ideas have changed significantly, such that traditional ideas about Confucianism and Nature have less of a determining effect then previously. Using the phrase the "sharing of caring," some Christian groups in Korea also view organ donation favorably as a way to practice love. As a result, many pastors, priests, nuns, and religious leaders have signed agreements to donate their organs when they die. Additionally, several movements have sprung up in Korean trying to persuade people to participate in organ donation, regardless of their reli ious beliefs. (See Frank (1998) for more on end-oflife decision-making in Korea.)

In part because of the influence of Christianity in Korea, in contrast to Japan where it is not nearly as popular, most Korean hospitals have chaplains on their staffs, usually Protestants. Some larger hospitals and university hospitals have four or five chaplains, including Catholic priests and Buddhist monks. Interestingly, however, while the Protestant chaplains often work for the hospital on their staffs, Catholic Fathers and Buddhist monks usually are affiliated clergies and are not direct employees. In general, hospital clergy visit patients regularly, providing spiritual advice when the patient requests it, and helping patients feel peaceful They also perform rituals such as prayer meetings and regular worship services, for the patients, the family members, and also for the staffs in many Korean hospitals.

Regarding the treatment of Korean patients in the U.S., one of my informants shared an interesting personal anecdote. This Korean man related that his wife had recently delivered a baby boy at Brigham and Women's hospital in Boston. During the pregnancy, the young Korean couple "mostly was comfortable in interacting with doctors and nurses." But the informant added:

However, when my wife delivered a baby, one doctor and a nurse asked about personal information such as nationality, job, major field of stu and future plan. (Examples: "Where are you from." "What are you guys doing here?" "What are you studying?" "Will you go back to your country after finishing your studies? ) Some of the hospital staffs have not good manner and face expression when they could not understand because of our English accents.

When I asked my informant to clarify which questions in particular had offended the couple, he answered:

I think that asking personal questions are O.K., and that will be helpful when they are trying to do their best for taking care of their patients. When we were asked our nationality and the area of studies, those questions did not really other us. However, they asked two useless questions. ("What are you guys doing here?" and "Will you go back to your country after finishing your studies?") We felt that there were negative nuances and thought that these are very useless questions for taking care of patients.

One of the most interesting comments I heard from my Korean informants had to do with views on the efficacy of Western medicine in general in treating Korean patients. One informant, a graduate student in the U.S., made the following remarks:

I heard that the constitution of Koreans is radically different from any Western person. For example, when a woman gives birth to child, our treatment on her would be really different. If the doctor forces her in Western way of treatment, it would be very dangerous to her because her constitution basically is different. There is another example: when a person catches a cold, we drink hot tea and keep our body warm. This is the problem of constitution. I don't know what the constitution is exactly, but there are some differences and it is not just a cultural difference. ... Basically, most Korean people do not believe that Western way of medical treatment does work well at treating our diseases.

Any treatment of Koreans in the U.S., then, will need to take into account such views about constitutional uniqueness. Indeed, this remark explains to me why so many of my Korean graduate students remain wary about seeking medical attention in the West at all. (See Sung (1998) for further insights on regarding Korean immigrants' perceptions of the American medical system.)

Indian Medicine and Experiences in the United States

People rely on the word-of-mouth recommendation of the people they know when selecting a doctor in India. When Indian immigrants, especially professional immigrants, reach the United States and are deciding upon which doctor to consult, they tend to rely on this same sort of networking, especially with Indian physicians who have taken up practices in the] United States. Both traditionally and today, doctors in India have a great deal of personal interaction with their patients. Doctors will know the whole family and will establish a strong personal relationship with all the members. This element of community contributes to patients' trust and confidence in their medical care providers.

Although Indians place much trust in their "family doctor," this notion tends to be associated with the wealthier members of Indian society in actual practice, since the poor hope to find medical assistance wherever they can. Wealthy members of Indian society go to doctors even for minor complaints, while the rest of the members of Indian society usually will try some home remedy and go to the doctor only if it fails to work. In the villages, Indians frequently consult what is called the local vaid, a Hindi term translating loosely as "the person who knows." In Muslim villages, one consults the hakim, a doctor well versed in Arabic healing and medicine frequently found in the northwest of India, in Uttar Pradesh, Hyberabad, and the Punjab. In direct contrast to the situation in Japan, even in the cases of extreme illness, individuals almost never go directly to the hospital before consulting their "family doctor," who sometimes will come to the patient's home. People do not consult specialists of their own accord in India, although in the larger cities, family doctors are beginning to send their patients to specialists. Still, this is very expensive, and specialist care is not prescribed easily. When Indian immigrants come to the United States, they tend to follow this custom. Indians in the U.S. are extremely reluctant to go to a hospital directly without first consulting their primary doctors, and an Indian patient would find it very strange to consult a specialist directly without going through the intermediary of a primary care physician.

Unlike Japan, where all citizens can rely on the national insurance system to pay for their medical needs, and unlike Korea, in which medical insurance is very affordable, many Indian patients must rely on their own resources to pay for medical care. Indian health insurance is less comprehensive than it is in the United States, so the poor and lower middleclass usually frequent charitable dispensaries where medical care is given at a relatively low cost. For example, the Ramakrishna Order of monks manages several hundred urban and rural dispensaries and a few hospitals, where poor patients are treated free of cost.

In the last ten years or so, India also has seen a resurgence of interest in traditional Ayurvedic medicine (also see Sengupta (1998)), and many wealthy people now seek Ayruvedic physicians and homeopaths (also see Lambert (1992; 1996)) instead of Western-style doctors. Many Indians place full faith in their homeopaths, especially when they have found a good one. Homeopaths are especially popular choices for chronic conditions such as allergies, backaches, pain, and respiratory ailments, especially in places such as Bombay. Although some shorter appointments are creeping into the protocols in the largest hospitals in places such as Bombay and Delhi, the idea of a 15-minute medical interview, as Indian patients experience the system here, is extremely foreign. Especially if an immigrant has come to the United States from a smaller town or village in India, they find it very difficult to acclimate to this aspect of our medical delivery system. (See Apte (1994), Baru (1998), and Jaggi (2000) for more on the Indian health care system.)

Both general care physicians and specialists are accorded high esteem and respect in India, though specialists and surgeons are accorded a higher degree of awe and admiration. Indian patients tend to trust their doctors, and they follow their advice, for example taking medications as prescribed. Unlike in the United States and Japan, where nurses have a prominent role, the role of Indian nurses is far in the background. Of course, this will vary from person to person, and also depending upon the nature of the institution. In government hospitals in India, the nurses generally do not become too personally involved in the care of their patients. In private nursing homes, where the nurses are better paid and the patients are elites, nurses are more closely involved with their patients. Since Indian doctors already take the time to establish personal relationships with their patients and their families, Indian nurses do not need to fill that gap, as do Japanese and Korean nurses. Still, because Indian patients generally experience high levels of trust, they do not tend to be wary of American nurses, who often are accorded more decision-making authority and who frequently explain and administer medications. Indian patients quickly learn that U.S. nurses are very well trained, and they tend to accept their authority without question.

My Indian informants felt it was important to make a distinction between waves of Indian immigrants who have come to the United States at different periods. For example, many professional Indians who immigrated to the Boston area between the 1950s and 1970s come from larger cities in India, where they already had been exposed to Westernstyle hospitals and medicine. Since the 1980s, however, the Indian immigrant population to the United States has shifted somewhat away from professionals and towards a relatively higher percentage of merchants, grocers, and shop owners. Whereas Indian professional immigrants tend to merge more with the general U.S. population, the merchant immigrants tend to create more insular communities in which they speak their native languages and do not generally mix with Americans. Many recent Indian immigrants arriving in the United States also speak less English than earlier waves of immigrants, making the presence of Hindi translators at American hospitals critical. Furthermore, because of the changing demographics of the Indian immigrant population, hospitals also would do well to employ Tamil translators (for immigrants from South India) and also for Gujarati translators (for immigrants from regions northwest of Bombay).

Hindus comprise the majority of Indian immigrants to the UpS., while Christians, Muslims, and secularists constitute the minority. But dissimilarly to the Korean case, religion does not figure prominently in the thinking of many Indian immigrants as they seek medical assistance in the United States. No Hindu teachings religious teachings explicitly reject the idea of organ donation or life support, and these decisions tend to be made on a case-by-case basis. Traditionally, the idea of reincarnation reduced the incentive for life support in India, but as the idea of reincarnation continues to lose its sway, more people seek life support in Indian hospitals. Economics play a role, however, since a poor family simply cannot afford to have the patient taken to a big hospital for a long stay, let alone to afford the costs associated with maintaining the patient on life support.

Regarding artificial means of facilitating reproduction, in vitro fertilization is available in some cities in India, e.g., Bombay. Hindus do not tend to find IVF problematic per se, though people hold more ambiguous views on the practice of freezing embryos. Still, one informant commented that techniques such as IVF will never be that popular in Indians tend to accept infertility as part of their lot. Even adoption is rare in India, for similar reasons. As one of my informants put it succinctly, "The artificial means of facilitating reproduction haven't yet become a big issue in India. Again, it is something only the rich are concerned with. Because of India's growing population, the problem there is not facilitating reproduction but arresting it!" And so the Indian government encourages the use of contraceptives and other methods of family planning, which are coming into limited use in Indian society.

One of my Indian informants mentioned that Indian society is much more lax about the notion of privacy of medical information than we are here in] the United States. If a woman from a small town or village does not understand her medical information, it would seem quite appropriate to Indian families for this information to be given directly to the woman's husband. As in Japan, medical information in India tends to be shared with the patient when he or she seeks medical attention. Indeed, doctors may tell husbands or children of the elderly about a situation first. If a patient in India is suffering from a terminal disease, the doctor usually gives the news to the next responsible person in the family, and he or she breaks the news gently to the family member. How much control the patient has over decisions regarding their care depends on various factors, such as the condition of the patient, the doctor treating the patient, and the patient's escorts.

Regarding care of Indian patients here in the United States, American doctors and nurses would do well to be especially sensitive is in respecting the life choices of Indian patients. One of my informants related the following anecdote about a friend of his, an Indian woman who lives in California:

XXX suffers very much from migraines. She's never "worked" i.e., had a paying job. She raised her children, stayed home, kept a house and a garden and was what one generally refers to as a housewife. Whenever she'd see a doctor about her migraines, they always presupposed that she was miserable and frustrated because she was "just" a housewife. They even said things quite plainly to her to that effect. They don't seem to realize that, at least in the Indian culture, being a good mother and a good wife is seen as a wonderful thing in and of itself. They don't have to "prove" themselves or "find" themselves through some external agency of wage earning. XXX would be so hurt, so irate by the nasty comments. Some blatant and some attempting to be subtle.

Another Indian informant stressed that American doctors and nurses need to communicate to the patient that they are trying to understand him or her and that they would like to learn something about Indian culture. As we will recall, however, the Korean couple mentioned earlier did not respond well to too much questioning about their personal lives. In contrast, Indian patients would like to experience a sense of "belonging" when they are treated in U.S. hospitals. Show an interest in the patient and the patient's culture, and make them feel at home, suggested my informant, perhaps by displaying a map of the world in the waiting room. A sentence here or there asking about the patient's natal country would go a long way towards making patients feel more connected. At the same time, because of the enormous diversity in Indian populations, one should not assume that because one has a general understanding of one patient from a particular region of India that this same information can be applied directly to other Indian patients. Some professional Indians will be more or less at home with Western culture, while other immigrants who have arrived only recently will not be well integrated with the general population in the United States.

As with Japanese patients, one of the major problems faced by India patients in the United States may be their shyness in front of doctors. Indian women are particularly shy in front of male doctors, especially if they have come to the United States from smaller towns in India. These patients may tend to want to bring their husband with them into examining room. Having a female nurse present during an examination also is considered extremely helpful. Indeed, many Indian women may prefer women doctors, especially gynecologists, since they are quite comfortable and familiar with women doctors in India. The notion of a female, American doctor with a male Indian patient, on the other hand, would seem very foreign to many Indian men, especially those from smaller towns and villages in India.

In India, religious professionals do visit hospitals, but they do so on their own, and it is not considered to be their duty. Hindus often pray, chant the names of God, sing hymns, or recite from holy texts such as the Gita while sitting hear an ailing patient. Even in the United States, some families may wish to bring a CD or audiotape of religious music to the hospital, or a person who will sing or chant. Other patients may want holy water from the Ganges be placed in their mouths. In the United States, the doctor or nurse in charge of an elderly or terminally-ill patient Hindu patient may want to approach the family very gently and ask whether or not they would wish to provide music or chanting for the patient. In contrast, Indian Catholics may prefer visitations from their ministers.

Conclusion

Japanese, Korea, and Indian experiences of the U.S. health care system differ markedly. Whereas Japanese patients may be more comfortable approaching the hospital directly, Korean patients may tend to rely on over-the-counter medicines from pharmacies, and Indian patients may seek a recommended primarycare physician from a relative or acquaintance. While Japanese and Korean patients may be somewhat reserved when asked about the personal lives and professional reasons for being in the United States, Indian patients may want to share relatively more about their country or region of origin. However, individual cases also will vary, so doctors and nurses must remain sensitive to each patient's uniqueness. Nevertheless, Japanese, Korean, and Indian immigrants also share many similarities. All may be shy in front of doctors, and all may find it awkward if sensitive medical information is given directly to the patient him- or herself. Finally, all may experience difficulty communicating the nature of their symptoms in English, especially when they are experiencing an emergency. Translation assistance offered by the hospital would benefit such patients greatly.

To close, it is worth noting that cultural competence in health care delivery will continue to become more and more complex as processes of globalization and patterns of immigrant continue to bring more of the world's diversity to the door of the city hospital. Doctors, nurses, and hospital staffs may view the charge of responding appropriately, and sensitively, as a welcome opportunity to learn more about alternative medical traditions and diverse cultural practices from other reaches of our world.

Acknowledgements

I wish to thank the Spiritual Task Force at Carney Hospital, Dorchester, Massachusetts for inviting me to deliver a plenary address at the "Healing & Spirituality: Ethics and Diversity Conference" in March 2000. My plenary address at that conference serves as the basis for this paper.

I also am indebted to a group of very generous conversation partners, Naoki Nabeshima, Ronald Nakasone, and Eisho Nasu discussing Japan, Il Joon Park, Jin Woo Chun, Jee Ho Kim, and Yohan Ka discussing Korea, and Swami Tya ananda and Ambalini Selvaraj discussing India. Finally, I wish to thank my Research Assistant at Boston University, Ms. Marylu Bunting, for her assistance with bibliographic research and contextualization of interview results relating to this study.

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[Author Affiliation]

JENSINE ANDRESEN, PHD

[Author Affiliation]

Jensine Andresen, Ph.D., is an Assistant Professor, Graduate Program in Science, Philosophy, and Religion, Boston University School of Theology.

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