Key takeaways
- In a Los Angeles survey published in 1995, 87% of older European Americans but only 47% of older Korean Americans said a patient should be told that cancer had spread.
- A 1999 study found “hot” and “cold” explanations for the common cold in all five groups it studied, including middle-income Americans in Tampa.
- Economists estimate that after the Tuskegee study was exposed in 1972, life expectancy at 45 for Black men fell by up to 1.5 years as mistrust rose and doctor visits fell.
- In a randomized trial in Oakland, Black men assigned to a Black doctor were 49% more likely to get diabetes screening and 71% more likely to get cholesterol screening.
- Filling out an “explanatory model” worksheet before your next visit can help a clinician understand how you see your own illness.
Should a doctor tell a patient that cancer has spread through the body? In a study published in 1995, researchers put that question to 800 adults age 65 and older at 31 senior centers in Los Angeles County6.
Among European Americans, 87% said yes. Among Korean Americans, 47% did6. More than half of the Korean Americans said the family, not the patient, should decide about life support6.
Neither answer is simply wrong. Each reflects values about the self, the family and hope. Those values shape what happens in an exam room: what gets said, who decides and whether you trust the person in the white coat at all.
Medicine has been slow to ask about this, but it is learning. Here is what the research shows, why distrust in some communities grew from real events, and how you can use these ideas to get better care, whatever your background.
Every family has a theory of illness
In 1978, Arthur Kleinman, Leon Eisenberg and Byron Good published a paper in the Annals of Internal Medicine about culture and care1. Kleinman, a Harvard scholar, had been writing about the gap between how patients experience illness and how doctors focus on disease2.
The core idea is the “explanatory model.” It is your working theory of what is wrong, why it happened and what will help. Patients have one. So do doctors. When the two theories clash and nobody says so, care suffers.
To bring the patient’s theory into the open, the paper offered eight questions1. They ask what you call the problem, what you think caused it and why it started when it did. They also ask how you think the sickness works, how serious it is, what treatment you expect, what trouble it has caused and what you fear most1.
The questions became widely taught as a model of culturally informed care2. But in a 2013 essay in the New England Journal of Medicine, Kleinman voiced regrets. In practice, he wrote, the questions often became a “conversation stopper,” a box to tick, with beliefs recorded like a lab value2.
He made a second point that natural-health readers may appreciate. Too often, he argued, culture was treated as something only patients have2. Doctors’ beliefs are shaped by culture as well, including medicine’s own habits and assumptions2.
Hot and cold: an old idea that turns up almost everywhere
Many healing traditions sort illnesses, foods and remedies into “hot” and “cold.” A “cold” illness calls for “hot” treatment to restore balance, and the reverse45.
Where did the idea come from? Many scholars assumed that Latin American hot-cold beliefs came from Spain after the Conquest, as part of Europe’s old humoral medicine5.
In 1983, researchers Audrey Butt Colson and Cesáreo de Armellada challenged that view5. They documented hot-cold thinking among Carib-speaking peoples of the Guiana Highlands and argued that it was largely Indigenous5. Our article on humors, doshas and qi covers the European side of the story.
The idea isn’t limited to any one group. In 1999, a team of researchers compared beliefs about the common cold in five populations3. They included Guatemalans, Mexicans in Guadalajara, Mexican Americans in Texas and Puerto Ricans in Connecticut3. The fifth group was middle-income Americans in Tampa, Florida3.
All five largely agreed on the cold’s causes, symptoms and treatments3. And all five used hot-cold reasoning to explain it3. If you were ever told to bundle up so you wouldn’t “catch a chill,” you have met this idea, too.
Usually, hot-cold beliefs sit comfortably beside medical care. Trouble starts only when a belief keeps someone from a medicine they need.
A 2017 letter in a respiratory medicine journal raised one such case4. Some people see asthma as a “cold” illness that needs “hot” treatment4. The authors wondered whether a blue inhaler, blue being a “cold” color, might seem like the wrong medicine4.
Beliefs about medicines predict whether people use them, they noted, and they suggested ideas such as pairing the inhaler with hot tea4. It was a commentary, not a study, but it shows how small details matter.
Me or we: who hears the news and who decides
The Los Angeles survey, published in JAMA in 1995, went further than cancer news6. Asked whether the patient should make decisions about life support, 65% of European Americans and 60% of African Americans said yes6. Only 41% of Mexican Americans and 28% of Korean Americans agreed6.
Instead, 57% of Korean Americans and 45% of Mexican Americans said the family should decide6. The authors called this a family-centered model. In it, the family shares in hearing bad news and making the hardest choices, which the authors linked to a high value on family harmony6.
To people raised on individual rights, that can sound like a loss of control. To others, it is relief from a burden no sick person should carry alone6. The researchers also cited reports that some families fear blunt news can take away a patient’s hope6.
Two details keep this from becoming a stereotype. First, at least 90% of every group wanted the family told the diagnosis and outlook, too6.
Second, culture moves. Mexican Americans who were more acculturated, or more at home in mainstream U.S. culture, favored telling the patient about cancer 83% of the time, compared with 60% of those who were less so6.
The practical lesson is simple. Don’t assume, in either direction. Tell your clinician early how you want news delivered and who should be in the room.
Tuskegee: distrust that was earned
Some distrust of medicine is cultural. Some is learned the hard way.
In 1932, the U.S. Public Health Service, working with the Tuskegee Institute in Alabama, began a study of 600 Black men, 399 with syphilis and 201 without7. The men were told they were being treated for “bad blood,” a local term covering several ailments7.
They got free exams, free meals and burial insurance7. No one collected their informed consent7.
By 1943, penicillin was the treatment of choice for syphilis7. The men were not offered it7. The study ran until a 1972 Associated Press story exposed it, and an advisory panel then called it “ethically unjustified”7. A class-action suit led to a $10 million settlement in 1974, and President Bill Clinton formally apologized on May 16, 19977.
Economists Marcella Alsan and Marianne Wanamaker asked what the revelation did to trust. Their study, published in the Quarterly Journal of Economics in 2018, compared older Black men with other groups before and after 1972, and by how close they lived to the men in the study8.
After the news broke, the authors found, mistrust of medicine rose among older Black men, and their visits to doctors fell8. Their death rates rose8. The effects were strongest near Tuskegee and faded with distance9.
The authors estimate that life expectancy at 45 for Black men fell by up to 1.5 years8. That could account for about 35% of the 1980 life-expectancy gap between Black and white men8.
For anyone who has felt brushed off by doctors, this research carries a message. Distrust is not always irrational. Sometimes it is a memory.
Trust can also be rebuilt
If broken trust keeps people away, can trust bring them back? Alsan and two colleagues tested that in Oakland, California, in a randomized trial published in the American Economic Review in 201910.
They recruited more than 1,300 Black men at barbershops and flea markets with coupons for a free health screening10. About half came to the clinic, where each man was assigned by chance to a Black or non-Black doctor10.
Seeing a Black doctor raised a man’s chance of accepting preventive services by 18 percentage points10. They were 49% more likely to get diabetes screening and 71% more likely to get cholesterol screening10. They were also 29% more likely to bring up other health problems10.
Doctors of every race got positive reviews from their patients, and the researchers found no sign that doctors held back services10. The authors traced the difference to communication: more information flowed between patient and doctor10. That is something every clinician can work on.
From cultural “competence” to cultural humility
For years, medical training leaned on “cultural competence,” often taught as facts about groups211. In 1998, Melanie Tervalon, who had directed a multicultural training program at Children’s Hospital Oakland, and Jann Murray-García argued that this was the wrong goal11.
Competence sounds like an endpoint you can reach after a course. They warned that it can create false confidence and stereotyping11. Their example: a nurse dismissed a Latina patient’s moaning after surgery because a class had taught her that Hispanic patients overstate pain11. A Latino doctor had noticed the woman was in real pain11.
They proposed cultural humility instead11. It asks clinicians to commit to lifelong self-reflection, to correct the power imbalance between doctor and patient, and to build equal partnerships with communities11. Kleinman’s later warnings point the same way2.
The federal government has its own guide. In 2000, the HHS Office of Minority Health issued the National Standards for Culturally and Linguistically Appropriate Services, called CLAS, and updated them to 15 standards in 201312. The main standard calls for care that is respectful and understandable, and that responds to people’s cultural health beliefs, preferred languages and health literacy12.
The standards are voluntary. As of a 2017 analysis, the office had urged but not required adoption, partly because research hasn’t shown that any single standard reduces disparities13. By December 2024, its free training site had drawn more than 1.1 million registrants since 200414.
What the evidence shows
| Claim | Rating | What research found |
|---|---|---|
| Hot-cold ideas about illness are found only in immigrant communities | Middle-income Americans in Tampa used hot-cold reasoning about colds, as did four Latino groups3 | |
| Seeing a doctor who shares your background raises use of preventive care | One randomized trial among Black men in Oakland found large gains in screening10 | |
| A public betrayal of trust can measurably harm a community’s health | One rigorous economic study tied the 1972 Tuskegee disclosure to more mistrust, fewer doctor visits and shorter lives8 | |
| Asking explanatory-model questions improves health outcomes | Widely taught since 1978, but its lead author warns it can turn into rote box-checking12 | |
| Adopting the National CLAS Standards reduces health disparities | HHS urges but does not require them, partly because no single standard has been shown to cut disparities13 |
Your explanatory model worksheet
Use this before an appointment, especially for a new or confusing problem. Jot short answers on paper or your phone, and hand them over or read them aloud. It is our adaptation of Kleinman’s approach, written from the patient’s side, with two extra prompts on family and trust.
- My name for it: What do I call this problem? Is there a word for it in my family’s language or tradition?
- Where it came from: What do I think started it? Why do I think it began now and not earlier?
- How it works: What do I believe is going on inside my body? Is it about balance, hot or cold, something I was exposed to, stress, or something else?
- How serious: Do I think this will pass on its own, last a long time or get worse?
- What I’ve tried: What remedies, foods, teas, herbs, prayers or medicines have I already used, and did they help?
- What it’s cost me: What has this changed at work, at home or in how I feel about myself?
- What I fear: What worries me most about the illness? What worries me about the treatment?
- Who decides: Who should hear news about my health, and who helps me make choices?
- What makes trust hard: Has anything in my life or my family’s history made it hard to trust clinics like this one?
Then try a script like this: “Before we start, I’d like to share how I understand what’s going on, so we’re on the same page. Afterward, could you tell me what you think is happening and how sure you are?”
Two cautions. If a belief makes you want to stop a prescribed medicine, say so out loud instead of quietly stopping. And list every herb and supplement you use, because some interact with medicines. For sudden chest pain, trouble breathing or signs of a stroke, call 911 first and talk later.
Questions readers ask
Will a doctor think less of me if I share my beliefs?
A good one won’t. The federal CLAS standards call for care that responds to people’s cultural health beliefs12. If a clinician brushes you off, our article on what to say when a doctor isn’t taking you seriously offers specific words to use.
What if my family wants to keep a diagnosis from a relative?
Families in many cultures do this out of love and a wish to protect hope6. A clinician can ask the patient privately how much they want to know and who should be involved. That respects both the person and the family.
Can I ask for a doctor who shares my background?
You can ask, though availability varies. The Oakland trial suggests a shared background can make preventive care more likely for some patients10. In that trial, patients rated doctors of every race well, so a clinician who listens can earn trust across lines10.
Did the Tuskegee researchers infect the men with syphilis?
No. According to CDC, the study enrolled 399 men who already had syphilis and 201 who did not7. The harm lay in what researchers withheld: honest information, consent and, once it became standard, penicillin7.
Are hot and cold remedies harmful?
Hot-cold ideas are common across many groups3, and most of the time they can sit beside medical care. The risk comes when a belief leads someone to skip a needed medicine, such as an asthma inhaler4. Tell your clinician, so you can find an approach that honors both.
The bottom line
Culture shapes how you name an illness, explain its cause, share bad news and decide whom to trust. Research shows those differences are real and sometimes run deep, from hot-cold reasoning about a cold to distrust earned through a historic betrayal.
The best response is curiosity in both directions. Know your own explanatory model, say it plainly and ask your clinician for theirs. Care works better when both theories are on the table.
Keep exploring: wellness community beliefs.
Related reading
About this article
This article was researched from peer-reviewed studies in medicine, anthropology and economics, CDC records and materials from the HHS Office of Minority Health, all listed below. It was reviewed in October 2026. It is general education and not medical, legal or financial advice.
Sources
- Kleinman A, Eisenberg L, Good B. “Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research.” Annals of Internal Medicine, vol. 88, no. 2, 1978, pp. 251–258 (questions as reproduced in a Tanenbaum Center teaching handout). tanenbaum.org
- Kleinman A. “From Illness as Culture to Caregiving as Moral Experience.” New England Journal of Medicine, vol. 368, 2013, pp. 1376–1377 (Harvard DASH repository copy). pubmed.ncbi.nlm.nih.gov
- Baer RD, Weller SC, Pachter L, Trotter R, et al. “Cross-cultural perspectives on the common cold: Data from five populations.” Human Organization, vol. 58, no. 3, 1999, pp. 251–260. researchexperts.utmb.edu
- Ahmed S, Salim H, Steed L, Pinnock H. “Blue inhalers: blowing hot and cold.” npj Primary Care Respiratory Medicine, 2017. pmc.ncbi.nlm.nih.gov
- Colson AB, de Armellada C. “An Amerindian derivation for Latin American creole illnesses and their treatment.” Social Science & Medicine, vol. 17, no. 17, 1983, pp. 1229–1248. ideas.repec.org
- Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. “Ethnicity and attitudes toward patient autonomy.” JAMA, vol. 274, 1995, pp. 820–825 (University of Southern California copy). annenberg.usc.edu
- Centers for Disease Control and Prevention. “The Untreated Syphilis Study at Tuskegee Timeline.” Last reviewed September 4, 2024. cdc.gov
- Alsan M, Wanamaker M. “Tuskegee and the Health of Black Men.” Quarterly Journal of Economics, vol. 133, no. 1, 2018, pp. 407–455 (NBER Working Paper 22323). nber.org
- Fitzgerald J (NBER Digest). “Why life expectancy for black men fell following the infamous Tuskegee experiment.” PBS NewsHour, August 8, 2016. pbs.org
- American Economic Association. “African American doctors and trust in Oakland” (Research Highlights on Alsan M, Garrick O, Graziani G, American Economic Review, vol. 109, no. 12, 2019). December 11, 2019. swlb1.aeaweb.org
- Tervalon M, Murray-García J. “Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education.” Journal of Health Care for the Poor and Underserved, vol. 9, no. 2, 1998, pp. 117–125. med.umn.edu
- U.S. Department of Health and Human Services, Office of Minority Health. “National CLAS Standards” fact sheet. Think Cultural Health. cccdpcr.thinkculturalhealth.hhs.gov
- Aggarwal NK, Cedeno K, John D, Lewis-Fernández R. “Adoption of the National CLAS Standards in State Mental Health Agencies: A Nationwide Policy Analysis.” Psychiatric Services, vol. 68, no. 8, 2017, pp. 856–858. pmc.ncbi.nlm.nih.gov
- U.S. Department of Health and Human Services, Office of Minority Health. Think Cultural Health newsletter, December 2024.