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Communication may be verbal or non‐verbal, and both are important. When communication is hindered by a lack of a common language, health suffers. Patients not proficient in the local language are unable to take advantage of health promotion programmes.^50,51 The clinician’s misunderstanding of the patient’s language can lead to inappropriate treatment,⁵² ranging from misdiagnosis to ineffective pain control.³¹

Although professional translators may be employed, providers must remember that misinterpretations may occur even when the same language is spoken. Providers tend to mix medical jargon and everyday language when they speak to patients, but a word may mean something different than intended to the patient. For example, a patient may refer to a stomach ache, which is duly interpreted to be a pain in the stomach. The patient may actually mean a pain in the abdominal area. The clinician should be careful when interpreting the symptoms as they are reported. This is particularly true when the interpreter is a child who may not have insight into how important it is to have an accurate description of the symptoms, even if the patient is uncomfortable sharing that information with either the clinician or the child.

A surprising amount of information can be communicated through non‐verbal cues. This has led to the successful development of pain assessment tools for demented patients.⁵³ Research on such tools provides information about which non‐verbal assessment tools are most representative of the current state of the science, most clinically relevant, and practically applicable to integrate into everyday practice and support adherence to regulatory guidelines. Communication in the clinic is less well studied, but it is important to note certain areas of potential differences. For example, patients with different cultural backgrounds may have different ways of expressing distress. Some value stoicism, whereas others value the open expression of pain. The presence of non‐verbal behaviours such as reductions in activity, social withdrawal, self‐protective manoeuvres, increased alterations in facial expressions or body postures, and observable displays of distress in a stoic patient, who reports no such problems, would assist a provider in diagnosing unreported problems. The lack of these non‐verbal behaviours in a patient reporting that their symptoms are severe might identify a patient from a more expressive culture.⁵⁴

Other potentially problematic areas of non‐verbal communication between people with different cultural backgrounds include the pace of conversation, whether interruptions are encouraged, the degree of physical proximity of the provider to the patient during history taking, and whether eye contact is appropriate or disrespectful. One unintended consequence of the introduction of the electronic record is the perception on the part of some patients that it is disrespectful of the clinician to interact with the computer screen more than with the patient.⁵⁵ It is important to remember that the etiquette of touch, hand gestures, and finger‐pointing varies across cultures. Another area with wide cultural variability is attitudes toward the direct discussion of death and dying among clinicians and patients and their families.^56,57