Pudor, honor, and autoridad: the evolving patient-physician relationship in Spain

The expression of emotion and the sharing of information are determined by cultural factors, consultation time, and the structure of the health care s ystem. Two emblematic situations in Spain - the expression of aggression in the patient-physician encounter, and the withholding of diagnostic informa tion from the patient - have not been well-described in their sociocultural context. To explore these, the authors observed and participated in clinic al practice and teaching in several settings throughout Spain and analyzed field notes using qualitative methods. In this paper, we explore three cent ral constructs - modesty (pudor), dignity (honor), and authority (autoridad ) - and their expressions in patient-physician encounters. We define two ty pes of emotions in clinical settings - public, extroverted expressions of a nger and exuberance, and private, deeply held feelings of fear and grief th at tend to be expressed through the arts and religion. Premature reassuranc e and withholding of information are interpreted as attempts to reconstruct the honor and pudor of the patient. Physician authority and perceived loya lty to the government-run health care system generate conflict and aggressi on in the patient-physician relationship. These clinical behaviors are cont extualized within cultural definitions of effective communication, an ideal patient-physician relationship, the role of the family, and ethical behavi or. Despite agreement on the goals of medicine, the behavioral manifestatio ns of empathy and caring in Spain contrast substantially with northern Euro pean and North American cultures. (C) 2001 Elsevier Science Ireland Ltd. Al l rights reserved.