Cultural Assumptions in Healthcare: How They Cause Errors and How to Spot Them

Some years ago my husband and I were given a tour of a small remote hospital in western Uganda by the American doctor who had founded it. While we were there, he treated a woman with a badly infected leg. He cut into the wound to drain it, cleaned it out, and packed it. There was no local anaesthetic and no pain relief, most likely because there was so little of anything to spare.

I was so caught up in watching the procedure that I missed the thing that mattered most. It was only afterwards that it struck me. Through the whole of it, the draining, the cleaning, the packing, the woman had not made a sound. She had not flinched. She had not spoken.

At the time I thought nothing of it. I have thought about it a great deal since.

Because if I had met that woman on a ward instead, with a pain chart in my hand and a corridor full of other patients waiting, what would her stillness have told me? Comfortable. Coping. Low priority. And I would have been wrong.

That is what this article is about. Cultural assumptions are the unexamined defaults we carry into every patient encounter, and in Australian healthcare they quietly cause real clinical errors. Not because anyone is careless or unkind, but because we read each other through our own cultural lens and call what we see the truth.

Let me be clear about the frame, because it changes everything. This is not a values problem. It is a patient-safety problem.

What we mean by cultural assumptions

A cultural assumption is the default you reach for without checking it: how pain is expressed, who makes the decision, what a nod means, what silence means, whether a question is welcome. We all carry them. They are not a character flaw. They are how human beings move through a busy day without re-deciding everything from scratch.

The trouble starts when we treat the assumption as a fact about the patient rather than a habit of our own. Anthropologist Arthur Kleinman warned years ago that culture is not a list of do’s and don’ts you can memorise by ethnicity, “Chinese believe this, Japanese believe that,” as if a whole people could be reduced to a tip sheet.¹ His alternative was simple. Ask. What do you call this problem? What do you think is causing it? How serious do you think it is?

The assumption is the thing you didn’t think to ask.

The four places cultural assumptions cause clinical errors

Pain assessment

We under-treat pain when a patient expresses it differently from how we expect to see it. Pain is filtered through culture before it ever reaches us, and a clinician who expects loud distress can read a quiet patient as comfortable.² In Australia this lands hard with Aboriginal patients. As one Australian nurse-researcher put it, labelling an Indigenous person “stoic” because they don’t vocalise pain “may turn out to be a culturally unsafe act,” and when assessment misses the way a person actually shows pain, the result is ineffective treatment and unnecessary suffering.³

I understand now what that woman endured, because I recently had an abscess of my own drained. Mine was so painful that the lightest touch made me jump. The local anaesthetic stung going in, but once it took hold I felt nothing, and the wound was drained without pain. I could not have lain still for that procedure without it. She had no anaesthetic at all, and she stayed silent. Her stillness was never the absence of pain. It was a different way of carrying it, and reading it as comfort would have been a clinical mistake.

The danger runs both ways. One direction is the patient whose pain we miss because they do not show it the way we expect. The other is what we believe before a patient shows us anything at all. In a study of American medical students and residents, half endorsed false ideas about biological differences between black and white patients, and those who did rated black patients’ pain lower and made less accurate treatment recommendations.⁴ Same patient, same presentation. A different assumption produced a worse clinical decision. That is the whole argument of this article in a single finding.

Informed consent

Consent obtained on a polite nod is not consent. Patients recall or comprehend as little as half of what a clinician tells them in a single visit, and yet we routinely take agreement as understanding.⁵ Real consent is more than handing over information. It means the patient can weigh the options and tell you what matters to them, which they cannot do if they never understood the choice in the first place.⁶

The assumption hides in a language gap most of all. In Australia, valid consent for a procedure legally requires a professional interpreter when there is a language barrier, not a bilingual family member doing their best.⁷ If you have ever watched a patient agree to something while their eyes asked a question, you already know the difference between a signature and a decision.

Handover

Handover is where assumed shared context fails, and the safety data here is sobering. Inadequate handover is one of the major contributing factors to adverse events, including wrong-site surgery, delayed treatment, falls and medication errors.⁸ When we hand over, we assume the next clinician knows what we know. Often they do not.

The risk grows when the team itself is cross-cultural. Australia depends on internationally trained clinicians, and the evidence shows their communication difficulties with patients, families and colleagues are frequently put down to culture rather than competence.⁹ A doctor trained in a steep medical hierarchy may give a junior nurse’s concern less weight than it deserves, or may not flag uncertainty because, where they trained, you simply didn’t. The clinical facts get handed over. The unspoken context does not.

Discharge

We assume that because we explained it, the patient understood it. The same comprehension gap that undermines consent walks the patient out the door. In one study, doctors stopped to check that the patient had actually understood in only one visit in five.¹⁰ The instruction was given. Whether it landed was left to chance.

The fix is not more information delivered faster. It is teach-back: asking the patient to say back, in their own words, what they are going to do. It works, it is endorsed by the Australian Commission on Safety and Quality in Health Care, and it is still used far too little.¹¹

Why this is a clinical-risk issue, not a values issue

Here is the shift I want every manager and clinician to make. Every example above is a defect you can measure, not a question of who has the kindest heart.

Look at the evidence as a whole. Assumptions change the clinical decision itself, as the pain research showed earlier. More than sixty per cent of medication errors trace back to mistakes in interpersonal communication, and the same study found that even when staff held serious concerns, fewer than one in ten fully raised them, with one in five doctors reporting they had seen a patient harmed as a result.¹² Hierarchy and fear keep people from escalating, and both are shaped by culture.¹³

So the question to stop asking is “what is different about this patient.” The better question, and the one the research points to, is “what did I assume, and did I check it.”¹⁴ Cultural awareness here is not a soft skill bolted onto good medicine. It is a clinical skill.

How to spot your own cultural assumptions

You cannot examine an assumption you don’t know you’re making, so the work is learning to catch yourself in the act. A few honest prompts.

Notice the polite nod. If a patient is agreeing with everything and asking nothing, treat that as a question, not a green light. Notice when you skip a question because “they probably won’t understand anyway,” because that thought is the assumption talking. Notice impatience and the clock, because teach-back is the first thing to slip when we feel rushed, which is exactly when comprehension is most likely to fail. And when something feels off, ask the kind of open questions Kleinman urged rather than filling the silence with your own guess.

None of this is about doubting your competence. It is about doubting your defaults.

What teams can do

This cannot rest on individual goodwill, because goodwill is the very thing that fails quietly. The fix belongs to the system. Use a structured handover tool so shared context is stated out loud rather than assumed. Make teach-back the normal way information is closed off, and back it from the top so it survives a busy shift. Build a team where a junior nurse or a newly arrived doctor can raise a concern without paying for it. And bring this into supervision and case review, not just the annual training day, because a one-off session does not change what happens at three in the morning.

This is also why a single DEI training day rarely shifts anything on its own. The assumptions live in daily practice, so that is where the work has to live too.

The assumption you never noticed

Communication doesn’t only break down when people don’t care. It breaks down when careful, competent people read each other wrongly and never stop to check.

The most dangerous cultural assumption a clinician makes is the one they never noticed they were making.

If you lead a team working across cultures, this is worth taking seriously as a safety issue, not a values one. Our Communication for Safety course is built to make these assumptions visible and workable, and if you’d like to talk through what that could look like for your team, book an introductory consultation.

References

1. Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. Read the study. ↩

2. Narayan, M. C. (2010). Culture’s effects on pain assessment and management. American Journal of Nursing, 110(4), 38-47. Read the study. ↩

3. Fenwick, C. (2006). Assessing pain across the cultural gap: Central Australian Indigenous peoples’ pain assessment. Contemporary Nurse, 22(2), 218-227. Read the study. ↩

4. Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301. Read the study. ↩

5. Schillinger, D., Piette, J., Grumbach, K., et al. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. Read the study. ↩

6. Elwyn, G., Frosch, D., Thomson, R., et al. (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361-1367. Read the study. ↩

7. NSW Health. (2017). Interpreters: Standard Procedures for Working with Health Care Interpreters (PD2017_044). NSW Ministry of Health. Read the policy. ↩

8. The Joint Commission. (2017). Sentinel Event Alert 58: Inadequate hand-off communication. Read the alert. ↩

9. Michalski, K., Farhan, N., Motschall, E., Vach, W., & Boeker, M. (2017). Dealing with foreign cultural paradigms: A systematic review on intercultural challenges of international medical graduates. PLoS ONE, 12(7), e0181330. Read the study. ↩

10. Schillinger, D., Piette, J., Grumbach, K., et al. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. Read the study. ↩

11. Talevski, J., Wong Shee, A., Rasmussen, B., Kemp, G., & Beauchamp, A. (2020). Teach-back: A systematic review of implementation and impacts. PLoS ONE, 15(4), e0231350. Read the study. ↩

12. Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence Kills: The Seven Crucial Conversations for Healthcare. VitalSmarts/AACN. Read the report. ↩

13. O’Neill, S. M., Clyne, B., Bell, M., et al. (2021). Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. BMC Emergency Medicine, 21, 15. Read the study. ↩

14. Burgess, D. J. (2011). Addressing racial healthcare disparities: How can we shift the focus from patients to providers? Journal of General Internal Medicine, 26(8), 828-830. Read the article. ↩