The no-shows were wreaking havoc with the appointment schedule at the suburban Bailey's Health Center in Falls Church, Va. Week after week, follow-up visits were missed when patient after patient failed to come, call or cancel.

Most were immigrants from Central America, and frustrated staff members started asking questions - and discovered the patients had known all along that they couldn't come back on the dates given to them. But to refuse an appointment, to say "no" to medical authority, would have been extremely impolite, if not unthinkable.

The scheduling snafus dramatize the challenges that a diverse population poses to doctors'offices, clinics and hospitals. Bridging that cultural gulf has become a top priority of the medical universe because much of the health care system remains ill-prepared. The result can be inadequate care and, in extreme cases, it can risk lives.

The diversity challenge

"This isn't singing 'Kumbaya,'"said Harold Ross, whose consulting firm, Cook Ross Inc., created an internet program offering background on ethnic and religious groups to medical providers. "If physicians truly embrace what this means, it will require a complete overhaul of not only how we practice medicine, but how we train for medicine."

Ross recalls his firm's early work at a Michigan hospital where Vietnamese women were becoming dehydrated after giving birth. The staff did not realize how some Asian cultures divide life into hot and cold periods and strive for balance between them. The days following birth are considered a cold time, and women are supposed to consume only warm fluids and food.

"And what does a good nurse bring to the bedside of a hospital patient? Ice chips and cold water,"Ross said. Consequently, the new mothers were drinking little to nothing. The solution was to ask them what temperature they wanted their water to be.

Ross remembers thinking, "Wow, how many other things are like this?"

Plenty, it became clear.

Cultural nuances are why a Hmong man would be insulted if a doctor looked directly at him during a lengthy conversation and why a Salvadoran woman who feared mal de ojo, or the evil eye, would seek a folk medicine healer, a curandero.

At Bailey's, where 10 percent of patients speak Arabic, Farsi or Urdu as their primary language, cultural norms were the reason a breast self-exam program for Muslim women several years ago took place before regular business hours and involved only female staff. The center agreed that no male employees would be on the premises.

"It all gets down to basic respect," said Christina Stevens, program director of the Fairfax County, Va., Community Health Care Network. "And it's better medicine."

Lubaba Mohammed, a young Ethiopian woman in Prince George's County, Md., was taken aback by the information she was asked during medical appointments. The doctors' manner seemed so forward, she said.

"You are surprised when they ask you questions, especially (about) a woman thing,"Mohammed recounted, her toddler daughter balanced on one hip. "You are afraid to speak, to explain. You never used to back home. You are shy."

But she has since become Americanized: "If I have a problem, I have to talk. If I don't talk, it gets worse. That's what I learned."

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