EDUCATION AND TRAINING

The ETHNIC(S) Mnemonic: A Clinical Tool for

Ethnogeriatric Education
Fred A. Kobylarz, MD, MPH, John M. Heath, MD, AGSF, and Robert C. Like, MD, MS

Geriatrics healthcare providers need to be aware of the effect that culture has on establishing treatment priorities,
influencing adherence, and addressing end-of-life care issues for older patients and their caregivers. The mnemonic
ETHNIC(S) (Explanation, Treatment, Healers, Negotiate,
Intervention, Collaborate, Spirituality/Seniors) presented
in this article provides a framework that practitioners can
use in providing culturally appropriate geriatric care.
ETHNIC(S) can serve as a clinically applicable tool for
eliciting and negotiating cultural issues during healthcare
encounters and as a new instructional strategy to be incorporated into ethnogeriatric curricula for all healthcare disciplines. J Am Geriatr Soc 50:15821589, 2002.
Key words: clinical tool; ethnogeriatric education; cultural
competency

ealthcare organizations, providers, and policy makers are becoming increasingly interested in the delivery of more culturally responsive services to our nations
diverse population groups. Reasons cited by the Georgetown University National Center for Cultural Competence
include: (1) responding to current and projected demographic changes in the United States; (2) eliminating longstanding disparities in the health status of people of diverse
racial, ethnic, and cultural backgrounds; (3) improving the
quality of services and outcomes; (4) meeting legislative,
regulatory, and accreditation mandates; (5) gaining a competitive edge in the marketplace; and (6) decreasing the likelihood of liability/malpractice claims.1
It is projected that, by 2030, older people from populations classified as racial and ethnic minorities (African

From the Department of Family Medicine, UMDNJ-Robert Wood Johnson

Medical School, New Brunswick, New Jersey.
Dr. Kobylarzs work has been supported by the Bureau of Health Professions Geriatric Academic Career Award 5 K01 HP 00003. The opinions expressed herein are those of the authors and do not necessarily reflect those
of the funding agency or the institutions they are affiliated with.
Address correspondence to Fred A. Kobylarz MD, MPH, Department of
Family Medicine, UMDNJ-Robert Wood Johnson Medical School, One
Robert Wood Johnson Place, P.O. Box 19, New Brunswick, NJ 08903.
E-mail: kobylafr@umdnj.edu

JAGS 50:15821589, 2002

2002 by the American Geriatrics Society

American, American Indian/Alaska Native, Asian/Pacific

Island American, and Hispanic American) will constitute
one-fourth of all older Americans.2 Currently, minority
older people constitute more than 16.1% of all older
Americans (65).3 Between 1999 and 2030, the older minority population is projected to increase by 217%, compared with 81% for the older white population. For example, the number of older African Americans will increase
by 128%, older American Indians/Alaskan Natives by
193%, older Asian/Pacific Island Americans by 301%,
and older Hispanic Americans by 322%.3
These broad classifications encompass many different
cultures of origin, and diversity is often greater within
than between groups in terms of health beliefs, attitudes,
and perspectives on the delivery of health care. Health
professionals who care for older minority patients need to
recognize this heterogeneity, avoid stereotyping and cookbook approaches, and employ therapeutic strategies that
result in more culturally appropriate care.
The goals of Healthy People 2010 focus on the elimination of health disparities while improving the overall
health of the American people.4 Many of the health-promotion and disease-prevention objectives apply directly to
the care of older people from diverse backgrounds. Older
people from different racial and ethnic minority groups
continue to experience troubling health disparities in access to care, service utilization, quality, and health outcomes.5,6 The literature reveals a consistent gap in deaths
from heart disease, cancer, and stroke, the three leading
causes of death in older people.7
Healthcare policy makers and other advocates have
proposed cultural competency as a strategy for reducing
racial and ethnic health disparities.8 Healthcare providers
need to understand the effect of factors such as socioeconomic status, education, race/racism, ethnicity, culture,
sex, disability, and sexual orientation on the health and
functioning of the older population. The American Medical Association (AMA) has defined cultural competency in
clinical care as the knowledge and interpersonal skills
that allow providers to understand, appreciate, and work
with individuals from cultures other than their own. Cultural competence involves an awareness and acceptance of
cultural differences; self-awareness; knowledge of the patients culture; and adaptation of skills.9
Healthcare providers in geriatrics become more culturally competent only with the support of the healthcare

0002-8614/02/$15.00

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system. Cultural competency must also be institutionalized; techniques that have been proposed include, but are
not limited to, cultural competency training, medical interpreter services, recruitment and retention of a diverse
health professions workforce, coordination with traditional healers, collaborating with community health workers, culturally competent health promotion, involvement
of family and community members in decision making,
and administrative and organizational accommodations. 10
Healthcare delivery systems have multiple, often-competing responsibilities to comply with legislative, regulatory, and accreditation mandates in the delivery of culturally and linguistically competent healthcare services to all
patients served. Recent federal requirements seek to ensure
that all people entering the healthcare system receive equitable and effective treatment in a culturally and linguistically appropriate manner.1113 Although some improvements have been made in addressing cultural and language
barriers through the availability of bilingual staff, face-toface medical interpreter services, contracted community
language banks, and telephonic interpreter services in hospital settings, the real-time availability of these language
services, specifically in ambulatory office settings where
older patients receive most of their health care, remains
problematic.
ETHNOGERIATRIC EDUCATION FOR
HEALTHCARE PROFESSIONALS
Improving the quality of services provided through integrating cultural competency training into health professions
schools is an area of growing interest.14 Movement towards
this effort in medical education at the undergraduate15,16
and graduate17,18 level include the Liaison Committee on
Medical Educations 19 and Association of American Medical Colleges (AAMC)20 recently approved cultural diversity
accreditation requirement and the American Council for
Graduate Medical Educations 21 incorporation of attitudes,
knowledge, and skills in humanism, professionalism, and
cultural sensitivity into training for medical students and
physicians. Professional societies such as The Society for
Teachers of Family Medicine,22 The American Academy of
Pediatrics,23 and The American College of Obstetricians
and Gynecologists24 have published relevant recommended
guidelines. Family medicine,25 internal medicine,26 pediatrics,23 and psychiatry27,28 have also developed educational
programs in this area.
As related specifically to geriatric healthcare training,
the term ethnogerontology first appeared in the 1970s
in literature describing cross-cultural aging.29 In 1987,
core faculty members of the Stanford Geriatric Education
Center adapted the term ethnogeriatrics specifically for
health care for older people from different cultures. The
members of the national collaborative on ethnogeriatric
education have recently revised a core curriculum in ethnogeriatrics to provide a comprehensive and detailed curriculum for all types of healthcare providers to increase
their cultural competency in the care of older people.30 To
improve the access and use of services and ultimately the
quality of care older people from diverse backgrounds receive, a core ethnogeriatric curriculum has been proposed
at every level of healthcare professional training.31 A critical next step is the operationalization and integration of

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this curriculum into geriatrics educational programs and

demonstration of its effect on clinical practice.
THE ETHNIC(S) MNEMONIC
Once cross-cultural areas of differences are recognized as
being important in health care, a means of addressing
them is needed, based on a more thorough understanding
of these differences and their implications. The concept of
the illness explanatory model (EM), developed by Kleinman et al.,32 has been used to develop specific teaching
techniques for understanding patients perceptions of their
illnesses and effective methods of negotiating acceptable
treatment. EMs are not intended to replace the standard
medical history-taking process but rather are proposed to
serve as a framework within which to facilitate communication during clinical encounters. Existing EM frameworks
include Listen, Explain, Acknowledge, Recommend, Negotiate (LEARN),33 Background, Affect, Trouble, Handling, Empathy (BATHE),34 and Explanatory model, Social and
environmental factors, Fears and concerns, Therapeutic
contracting (ESFT).35
In applying the EM concept to cross-cultural clinical
encounters, Levin et al. developed the mnemonic, ETHNIC, as a practical interviewing tool and framework for
clinicians to use in addressing cross-cultural healthcare issues with their patients.36 The ETHNIC mnemonic was
designed to be integrated into the routine 15-minute visit
between physicians and their patients in the ambulatory
office setting, the hospital, and other ambulatory settings
but is also applicable in other healthcare settings. It focuses on the acute and chronic sick visit but can also be
applied to preventive care measures. The present authors
have broadened the mnemonic to ETHNIC(S), by including the letter S for Spirituality and to remind the practitioner to elicit the health and illness beliefs and practices
of seniors and their caregivers. Each letter refers to an aspect or domain of the cultural aspects of health and illness
that are important for the healthcare provider to explore
explicitly. Table 1 presents the mnemonic with suggested
probes to elicit additional information.
Description of ETHNIC(S) Mnemonic
Explanation (E)
Within the context of geriatric healthcare interactions, the
lack of questioning or explanations offered by an older patient may reflect a passive role that sometimes can impede
cross-cultural understanding. Some older people may be
reluctant to provide a response initially, whereas others
may avoid this issue with a reply like, Thats your job
doc. Gentle prodding and the use of normalizing phrases
from the provider, such as, I often learn important things
from hearing peoples ideas about why they are ill and
what they think should be done about it may be effective
in eliciting this information.
If patients do not offer explanations, ask what concerns them about their problems. Included in the explanation is also the inquiry of how older patients perceive that
others view their condition. This is important to elicit because the opinions of other caregivers, whether present in
the clinical setting, at home, or living miles away, may be
as important to patients as their own explanations.

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Table 1. ETHNIC(S): A Framework for Culturally Appropriate Geriatric Care

EXPLANATION
Direct question to be asked: Why do you think you have
this . . . (use the patients phrase for their) symptom/
illness/condition?

TREATMENT
Direct question to be asked: What have you tried for this . . .
(use the patients phrase for their) symptom/illness/
condition?

HEALERS
Direct question to be asked: Who else have you sought
help from for this . . . (use the patients phrase for their)
symptom/illness/condition?
NEGOTIATE
Direct question to be asked: How best do you think I can
help you?
INTERVENTION
Direct statement: This is what I think needs to be done
now.

COLLABORATE
Direct question to be asked: How can we work together on
this and with whom else?
SPIRITUALITY SENIORS
Direct question to be asked: What role does faith/religion/
spirituality play in helping you with this . . . (use the
patients phrase for their) symptom/illness/condition?

Probe questions to be asked: What do friends, family, and

others say about these symptoms? Do you know anyone
else who has had or who has this kind of problem? Have
you heard about/read/seen it on television/radio/newspaper/
Internet? (If the patient cannot offer an explanation, ask
what concerns them about their problems).
Probe questions to be asked: What kind of medicines, home
remedies, or other treatments have you tried for this illness?
Is there anything you eat, drink, or do (or avoid) on a regular
basis to stay healthy? Tell me about it. What kind of
treatments are you seeking from me?
Probe question to be asked: Have you sought help from
alternative or folk healers, friends, or other people who are
not doctors for help with your problems?
Try to find options that will be mutually acceptable to you and
your patient and that incorporate your patients beliefs
rather than contradicting them.
Determine an intervention (e.g., diagnostic, pharmacological,
psychosocial, educational) with your patient that may also
incorporate alternative treatments, spirituality, healers, and
other cultural practices (e.g., foods eaten or avoided in
general and when sick).
Collaborate with the patient, family members, healers, and
community resources.

Tell me about your spiritual life. How can your spiritual beliefs
help you with this?

Finally, the role that the media may play in this aspect
should also be noted, if the patient offers. This may facilitate subsequent communication with the patient using a
common point of reference. Many older people receive
health information from a diversity of sources of variable
reliability. Healthcare providers from one cultural background may have limited awareness of the media sources
used by patients from different cultural backgrounds.

ing alternative medicine in 1999, with the two most common modalities being chiropractic and herbal.37,38 To encourage patients and their caregivers to talk about CAM,
providers should ask open-ended questions such as Are
you doing anything else for this symptom/illness/condition? or Are you taking any over-the-counter remedies
such as vitamins or herbs?

Treatment (T)
In inquiring about treatments or interventions that patients have employed before the current encounter, the
healthcare provider needs to be explicit in asking about
any and all treatments that a patient is willing to share at
the time of the encounter and not just the ones that a patient perceives would be acceptable to the provider. The
strong desire of many older patients to seek the approval
of the physician may lead them to present just that information that they feel the physician will agree with and
avoid other information that might provoke disagreement
or disapproval. Older patients from varying cultures traditionally use complementary and alternative medicine (CAM)
treatments; these should be explored explicitly. Foster et al.
reported that 30% of Americans aged 65 and older were us-

Healers (H)
Similar to the above treatment issue, this item explicitly
seeks to explore all providers, both medical and alternative healers that older patients might be consulting in addition to their usual source of health care. Given the increasing prevalence of alternative healthcare utilization by many
older people, especially for chronic conditions such as arthritis and cognitive impairment, this item is important to
allow the patient to disclose any other sources of healthcare. This item also implicitly acknowledges the provider
as another healer but not necessarily the sole healer for the
patient.
Many practitioners find it challenging to work with
alternative providers and need to strike a balance between
respect and autonomy for their older patients choices and

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potential adverse interactions of treatments. Encouraging

discussion of alternative providers and their treatments establishes a certain level of trust that can help facilitate further communication.
Negotiate (N)
This item tries to establish whether the older patient is
willing to work with the current provider to seek outcomes that will be mutually acceptable to the provider and
the patient. This item builds on the previously identified
beliefs in a jointly acceptable manner. Negotiation implies
that both parties are actively seeking to work together.
When applied to the care of an older patient for whom a
caregiver is involved, that individual, whether a family
member or involved friend, needs to be explicitly acknowledged as well. In the particular areas of providing end-oflife care to culturally diverse older populations, this item
may focus on functional outcomes or symptomatic relief.
This item also explicitly allows for the identification of expectations from the patient or caregiver that the provider
would otherwise consider unrealistic.
Intervention (I)
With interventions, providers and older patients or their
caregivers discuss and mutually propose their courses of
action (e.g., clinical preventive services, diagnostic testing,
medication, psychosocial counseling, rehabilitation) in addressing the needs identified earlier. This item allows for
the blending of clinically appropriate healthcare services
within the context of the developing culturally competent
encounter. Careful attention to a patients responses as revealed through the prior steps can assist providers in constructing a more effective bridge between the scientific understanding of the symptom/illness/condition and a patients
comprehension of the situation. Those clinical interventions
that the provider may have been ready to propose before
proceeding through the earlier steps can now be modified
and individualized based upon the information received and
processed in the above steps. In chronic disease states being
managed during end-of-life care, there is great variability in
the potential interventions that the provider or the patient
individually might consider appropriate but now, at this
stage in the process, can be more likely agreed upon.
Collaborate (C)
Collaboration refers not only to the patient and provider
directly involved with the encounter, but may also involve
caregivers or family members, any other healers the patient may have identified earlier, professionals from other
disciplines, and community resources. The item does not
necessarily ask for the patient to agree with all that the
provider has proposed but rather to mutually discuss and
share information about how the therapeutic relationship
can best develop. The item is similar to therapeutic contracting, which has been proposed in other patient encounters in which the physician and other providers seek
to effect change, but emphasizes the interactive nature
rather than a provider-dictated course of action.26
Some older patients may choose not to make a meaningful agreement here, especially in the course of a brief

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first encounter. Instead, the initial focus of collaboration

would be on the development of a trusting interpersonal
relationship that may eventually become a therapeutic alliance. Further understanding of the patients responses and
relationships can help guide decisions about the need to
work with other individuals and organizations.
Spirituality (S)
Spirituality is often a neglected factor in the health care of
older patients.39 The concept of spirituality is found in all
cultures and is expressed in a patients search for ultimate
meaning through participation in religion or belief in God,
family, naturalism, rationalism, humanism, and the arts.
The AAMC Task Force Report on Spirituality, Cultural Issues, and End of Life Care40 has proposed outcome goals
for physicians to incorporate awareness of spirituality, and
cultural beliefs and practices, into patient care in a variety
of clinical contexts.
Although recognizing the value of spirituality in the
abstract, many healthcare providers feel uncomfortable
addressing the topic during the course of direct patient
care. In addition, many older patients and their accompanying caregivers may not expect to be asked about their
perceptions of the influence their spiritual beliefs have on
their health conditions. Nevertheless, healthcare providers
should be prepared to respond to spirituality issues that
their older patients coping with chronic illnesses, advance
directives, and end-of-life care might raise. The role of
prayer as an intervention for illness or disease and the spiritual meaning that the suffering can bring to illness experiences for some individuals are both examples of how spirituality has great relevance in the care of older people from
varied cultures. Having the provider acknowledge these issues in the presence of the patient can demonstrate cultural sensitivity to an issue often not addressed during
clinical encounters. In instances in which the older patient
is struggling with end-of-life issues, having the healthcare
provider raise the spiritual dimension of the patients experience may itself provide for hope and important meaning for the encounter. Once the issue is raised, some older
patients may then provide a spiritual history, which can be
recorded as part of the social history, but, sometimes, spiritual issues may arise earlier in the encounter and can help
develop rapport. The ETHNIC(S) mnemonic does not
have to be followed in a linear fashion. It can provide an
opportunity to explore spiritual issues at any time and allows for rapport to be developed to facilitate this degree of
sharing of cultural and spiritual perspectives. It also may
facilitate providers sharing their own spiritual beliefs and
values, when appropriate, with the patient. This can often
enhance the therapeutic relationship between provider and
patient in a unique and often mutually satisfying way.
Clinical Application of the ETHNIC(S) Mnemonic
The following case vignettes provide selected examples
from our experiences in caring for culturally diverse older
patients and illustrate the clinical application of the ETHNIC(S) mnemonic. The health- and illness-related attitudes, beliefs, and values discussed in each individual case
should not be used to stereotype or generalize about a particular ethnic group.

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Case 1. Meaning and Management of Chronic Illness

A 65-year-old Hispanic man presents to the physicians office with poorly controlled type II diabetes mellitus. Although his native language is Spanish, he speaks limited
English and says that he does not need an interpreter.
The nurses intake note says that he is here for a routine
check-up and has not been feeling well lately. The patient has been coming to the office for 1 year but is seeing
this physician for the first time. His medical record indicates that he often has expressed somatic complaints that
the doctors have not been able to match with any specific
diagnosis beyond his diabetes mellitus. Chart notes also
indicate that his prior office visits have often occurred
only when his home remedies have not been effective in
helping his vague symptoms. He has undergone diabetic
teaching and told a diabetes educator that he understands
diabetes mellitus as meaning high blood sugar, and he
must cut out eating sweets. He is supposed to be taking
two different oral diabetic medications every 12 hours, for
a total of four pills, although, based upon his most recent
blood work, it appears that he is not adhering to his medications.
At this particular visit, he complains of fatigue and, as
the physician asks more about each symptom, he raises additional complaints of dizziness and headaches. In response to the physician asking about what his own explanation is for all these problems, he says, The diabetes is
not what is making me sick. I feel symptoms all over my
body and think I may have been cursed. (E) He has gone
to a curandero several times over the past year (H and S)
who has performed certain ceremonies involving the application of oils to the body and burning incense to try to dispel the curse (mal). He believes that this healer is the only
one that can remove the curse. For his headaches, he
drinks bitter herbal teas that his family sends from his
county of origin that he must sweeten to make drinkable
but feels are helping. (T) The patient wants to keep going
to both this office and to his other healer (the curandero) because both can help me. He was afraid to mention the curandero to the previous physicians because
they wouldnt understand.
The physician responds by acknowledging his concerns that his symptoms could be a combination of his beliefs about the curse and his diabetes mellitus (E and N).
The physician comments that the blood work results suggest that the patient is probably not taking the medication
prescribed. The patient replies that the curandero told him
that he is probably taking too many pills and that is why
he has not yet been able to remove the curse (E). The physician then suggests a modification of his current prescription medication regimen so he takes fewer pills daily (I).
The patient agrees to give this a try (N). The physician also
asks him to bring in the herbal medications that he is taking so that the office staff can determine what he is actually taking and asks him to follow up the following
month.
Case Comment
In the above case, the use of the ETHNIC(S) tool allowed
the physician to develop a therapeutic alliance with the patient and explore the meaning and management of his

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chronic illness. The physician and patient established a

rapport that allowed the patient to share his explanation
for his current symptoms that had previously not been revealed. Although the specific health and illness beliefs described here are clearly individual to this patient and not
generalizable to all patients of Hispanic descent, their detail and relevancy for the treating physician are important.
Some Hispanics may consider illness to be unnatural,
and curanderos or espiritistas may be sought to assist with
physiological, psychological, social, or spiritual maladjustments.41 The physician here neither validated nor repudiated the advice and care the curandero provided but simply acknowledged this individual as another healer who
had seen the patient.
Diabetes mellitus is a chronic condition that is often
challenging to treat because of the multiple interactions of
diet, medications, and lifestyle factors, which are greatly
influenced by culture. The patients recent use of complementary and alternative treatments should be evaluated
because of concerns such as toxicity and the potential for
dangerous medication interactions.
Case 2. Addressing End-of-Life Care Issues
An 87-year-old Chinese-American woman is admitted to
the hospital with vomiting and weight loss. She speaks a
dialect of Mandarin and requests that her two sons serve
as interpreters during the emergency room assessment and
subsequent admission. She has been seeing a neighborhood Chinese woman known for her skills in traditional
herbal medicine from local markets as her only healthcare
provider for years at home, where she lives with her extended family (T and H). Her sons and their families apparently managed months of progressive fatigue and associated functional decline at home until the vomiting could
not be relieved and the family insisted on bringing her to
the hospital.
Initial emergency room medical investigations revealed significant anemia, abnormal liver function tests
suggestive of possible metastatic disease, and a gastric outlet obstruction noted on radiological studies. Through the
family, the inpatient clinical team requests that the patient
be asked for her consent to undergo an upper endoscopy
procedure. Her son reports that his mother consents but
that the results of any biopsies are only to be reported to
the family (her two sons) and not to the patient herself.
As part of the admission process to the hospital, the
attending physician requests a Chinese-speaking interpreter through the hospital language bank, and a dietary
worker is identified who can adequately speak the patients own dialect. With the family members absent and
using this nonrelative interpreter, the patient states that
her vomiting made it impossible to stay with her sons anymore and that this is what is wrong with her (E). She confirms that she would agree to anything her sons wish her
to have done in the hospital and that she wishes them to
be informed of the results of all tests. She wishes only to
be directly told what I must do next. She signs the consent for the endoscopy that subsequently reveals an extensive gastric malignancy (N). The gastric outlet obstruction
is partially relieved through laser ablation done as a palliative procedure. The diagnosis of metastatic gastric cancer
with its poor prognosis is given to her family only, and,

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through her sons interpretation, the patient is told the endoscopy was able to open her stomach a little (I). The
family appears grateful to learn that the vomiting may be
relieved and, away from the patient, report knowing
that their mother was dying before bringing her to the hospital.
The patients nausea appears to be better controlled,
but she refuses to eat the soft diet hospital food presented
to her. She does, however, begin to eat the rice her family
brings from home, because they report that she has never
had food presented to her without rice (C). The family is
pleased that her vomiting is now improved and wishes to
take the patient home. They are made aware of the poor
prognosis, including the potential for hemorrhage and recurrent gastric obstruction and will consider hospice services. The patient and her family express much gratitude
that she is able to return to her sons home where, according to the family, she will be much more comfortable dying in accordance with her religious tradition (S).
Case Comment
In the above case, the use of the ETHNIC(S) tool allows
the hospital-based clinicians, patient, and family to explore and address culturally appropriate end-of-life issues.
Clinicians need to understand the diverse ways that people
experience and cope with death and dying and develop
greater awareness and sensitivity to preferences in end-oflife decision making.4248 The use of language interpreter
services illustrated in this case allowed the treating clinician a better perspective about the patients own wishes
and perception of her condition. In this particular instance, they were well represented by her children in this
close-knit Asian family but are reflective of only this particular case.
Clinicians must access appropriate interpreter services
for their patients. The Office for Civil Rights (OCR) August 30, 2000, Policy Guidance12 provides an important
discussion about acceptable language assistance options
that can be used when caring for patients with limited English proficiency (LEP). According to the OCR Policy
Guidance, keys to Title VI compliance in the LEP Context
include (1) Having policies and procedures in place for
identifying and assessing the language needs of the individual provider and its client population; (2) A range of oral
language assistance options, appropriate to each facilitys
circumstances; (3) Notice to LEP persons of the right to
free language assistance; (4) Staff training and program
monitoring; and (5) A plan for providing written materials
in languages other than English where a significant number or percentage of the affected population needs services
or information in a language other than English to communicate effectively. The problems that can occur when
family members or friends are used as interpreters are discussed, and the prohibition against the use of minor children is emphasized.
Case 3. Negotiating a Mutually Acceptable
Therapeutic Plan
A 78-year-old Italian woman who has been visiting her
son in the United States for the past month is brought to
the hospital clinic for recurrent knee pain. She is being
seen for her third appointment in 2 weeks and complains

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of worsening left knee pain. As per the patients own

wishes, her son acted as her interpreter for the first two of
these appointments, but an Italian-speaking neighbor has
come with her for this visit. At the time of her first appointment, the diagnostic impression was osteoarthritis,
confirmed by x-ray, and a prescription for a nonsteroidal
antiinflammatory medication was written. Weight reduction and a knee brace were also advised, along with a referral for physical therapy. She returned a few days later
for the second appointment, having neither filled the prescription medication nor seen the physical therapist, and
reported that the knee was worse. Sample medications
were given to the patient, along with reinforcement about
needing to adhere to a routine walking program and see
the physical therapist. At todays return appointment, she
continues to say, My knee is no better after having taken
all the pills.
Working with the Italian-speaking neighbor, the physician asks the patient about what she thinks is causing her
knee pain. She initially responds by looking away, stating
that, I wouldnt presume to play doctor. With further
gentle questioning however, she reports feeling that her
knee pain must mean that something bad is going to happen, because her last episode of knee pain happened back
in Italy just before the death of her husband (E). That episode of arthritic flare-up had almost made it impossible
for her to walk behind his funeral procession until her
physician gave her a shot in the knee that helped immensely (T and H). She is currently visiting her son in the
United States because of his marriage ceremony, which is
coming up in 5 days, and fears not being able to walk
again. She wishes she could now receive a shot but reports
that her son had previously told her, Doctors in this
country dont do such things. She felt intimidated about
asking for such a shot during prior visits with her son
present, but now, with him absent, specifically asks if she
might receive a knee injection (N). She wants to be able to
walk up the aisle at her sons wedding without a cane. Afterwards, she plans to return to Italy, where she will use
the rather unsightly knee brace that she already has but
did not bring with her to this county. She is overjoyed to
learn of the possibility of receiving an intra-articular steroid injection and agrees to go to physical therapy only after learning that this was not a first step for a subsequent
joint replacement surgery but rather for local modality
treatments (I and C).
When, at the end of the encounter, the physician inquires about how the wedding plans are going, she admits
to being upset with her son for not having a church wedding. She reports not sleeping but instead spending most
evenings walking the floor and worrying. She thinks
that this has also worsened her knee pain. The name of an
Italian-speaking priest is provided, should the patient wish
to discuss her concerns about this matter (S).
Case Comment
In the above case, the use of the ETHNIC(S) tool allows
the physician to explore cultural and psychosocial issues
surrounding the patients symptoms. Together they negotiated a mutually acceptable therapeutic plan in the context
of an acute encounter. The patient initially chose to have a
family member (her son) serve as an interpreter. Although

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the therapeutic interventions proposed in the patients first

two clinical encounters were medically appropriate, the
patient did not initially accept them. This case also illustrates how older minority patients have differing ideas of
the meaning of their own illness from those of their healthcare providers. Clinicians who are able to effectively elicit
the meaning of illness from their patients can develop a
deeper relationship, which may foster improved therapeutic outcomes. ETHNIC(S) can be used with patients from
all racial, ethnic, and sociocultural backgrounds.
CONCLUSIONS
Cultural and linguistic competence is an essential component of providing health care to older patients. The mnemonic ETHNIC(S) provides a framework for cross-cultural interviewing that physicians and other healthcare
professionals can use and easily integrate into ethnogeriatric curricula. It is neither a scoring sheet nor a detection
scheme to uncover hidden cultural issues but rather a clinically applicable tool for eliciting and negotiating cultural
issues during healthcare encounters. These issues are relevant in the wide variety of ambulatory, home health, hospital, and long-term care settings where older patients receive services.
Although ETHNIC(S) can be helpful in facilitating
cross-cultural communication during clinical encounters,
it does not address important systemic, institutional, or interpersonal barriers to access and culturally competent care.
These include poverty, classism, ageism, racism, sexism, homophobia, other forms of bias, prejudice, and discrimination. Additional limitations include the need to address disability-related issues and communication impairments that
are common in older people, such as hearing, language, and
cognitive barriers. Future empirical research is also needed
to study the effectiveness of ETHNIC(S) and other techniques designed to enhance cultural competency in health
professions training programs and clinical care settings.
Developing cultural competence is an ongoing, lifelong journey for individuals, families, organizations, and
communities.49,50 The cultures of patients and their caregivers, healthcare providers, and healthcare systems may not
be in concurrence. It is important that differences in expectations, priorities, therapeutic goals, and roles be recognized.
Maintaining cultural humility, avoiding stereotyping, engaging in mutually respectful communication, and fostering
empowerment in relationships are critical.51 The challenge
for practitioners therefore is to develop and nurture cultural
competence in the care of their older patients.
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