In healthcare, we talk a lot about listening, to symptoms, to families, to our patients’ stories. But when it comes to pain, what we hear is often filtered through our own assumptions. I’ve watched patients clench the rails, shiver, guard their incisions, and still tell me they’re “fine.” Others cry out loudly at the first discomfort, only to be labeled dramatic or noncompliant. Neither group is wrong. They’re just speaking different emotional languages, and most hospitals are only fluent in one.
Pain is biological, but pain expression is cultural. And when we treat everyone like they speak the same pain dialect, we fail them.
The Hidden Curriculum of Pain
Clinically, pain is defined as a sensory and emotional experience. But culturally, it’s coded. Who is allowed to show pain? How loudly? For how long? With whom? These aren’t personal quirks — they’re learned scripts, deeply shaped by gender, class, and culture.
Anthropologist Mark Zborowski saw this decades ago in how different ethnic groups reported illness and pain. Later studies confirm that what counts as “appropriate” varies widely. Mediterranean, Latin American, and Middle Eastern patients may express discomfort loudly and emotionally, not because they’re exaggerating, but because expression signals a need for care. Meanwhile, many East Asian and Northern European norms teach that quiet endurance is honorable.
This becomes a problem in fast-paced hospitals, where staff often rely on speed, directness, and checkboxes. A quiet patient might be in crisis. A vocal one might just be communicating the only way they’ve ever known how.
Pain Isn’t Just Physical — It’s Rhetorical
In a hospital, pain is a high-stakes message. And like any message, it’s shaped by who’s speaking, who’s listening, and the constraints in the room. That’s the rhetorical situation of pain.
A patient may downplay their pain due to gender expectations or fear of not being believed. They may exaggerate because they’ve learned that’s the only way to get help. There may be a language barrier, or they may not have the words to describe what they feel. Then there’s the institutional script: the infamous 1–10 scale, which assumes every patient can and will rank their pain like it’s a Yelp review.
This isn’t just inefficient, it’s dangerous.
Culture, Communication, and the Care Gap
Let’s break down a few ways culture changes what pain looks and sounds like at the bedside:
High-Context vs. Low-Context Cultures
In the U.S., we expect directness: Tell me how bad it is. But in high-context cultures (many Asian, Arab, and Indigenous communities), messages are indirect. A patient may say they’re “fine” while their body says otherwise. If we take the words at face value, we miss the meaning.
Display Rules and Emotional Suppression
Ekman’s research on emotional display shows that many cultures — and many men across cultures — learn to hide pain. Not showing pain becomes a badge of strength. But when caregivers wait for a patient to ask for meds, the stoic patient gets left behind.
Pain as Emotional and Social
Pain is never just a nerve signal. It’s amplified or soothed by emotion. A patient left alone, especially in cultures where family is central to healing, may experience pain as abandonment. The call light isn’t just about a physical need — it’s a cry for presence.
When the 1–10 Scale Fails
The 1–10 scale can be limiting, especially across cultures that favor indirect or nonverbal communication. Here are some supplemental ideas:
- Open-ended questions: “How is this pain affecting your movement?”
- Functional benchmarks: “Can you walk to the bathroom?”
- Observational data: grimacing, guarding, holding breath
- Comparisons: “Better or worse than yesterday?”
These aren’t just good bedside techniques — they’re culturally adaptive communication strategies.
What It Feels Like at the Bedside
Here’s what I’ve seen:
I recently cared for someone who clearly wasn’t at baseline. Normally energetic, he stayed in bed, used the urinal instead of walking to the bathroom, and moved in a way that showed he was guarding his surgical site. He refused anything beyond his scheduled meds, even when it was obvious he was experiencing sharp pain with movement. He insisted he was fine, but his body told a different story. Everything technically cleared for discharge — but he went home in more pain than he needed to.
Some patients show up often: same symptoms, same faces, same patterns. Around the nurses’ station, you might hear them called a “frequent flyer.” When a patient is young, expressive, or has a history staff view with skepticism, their pain often gets downplayed. I’ve seen real problems missed until much later, found only after transfer, when earlier assumptions had already shaped their care. Just because discomfort is expressed frequently doesn’t mean it’s not real.
I cared for a patient who used the call light constantly, not because her pain was uncontrolled, but because something deeper was unsettled. She was alone, though her family had clearly been a strong presence earlier in her care. Every small discomfort became urgent. It felt like there were needs just beneath the surface that she couldn’t clearly name, and I couldn’t quite reach. The communication gap wasn’t just linguistic, it felt cultural, emotional, maybe both. Whatever the reason, she was distressed, and our usual ways of checking in didn’t seem to land.
This Isn’t “Soft” — It’s Clinical
Being able to interpret pain across cultures isn’t about being nice. It’s about being accurate.
It takes intercultural competence, the humility to ask instead of assume. It takes emotional intelligence, noticing tone, posture, silence. It takes mindfulness, something I’ve learned to bring with me before entering any room. Noticing breath, pace, mood. Asking myself: What am I reading into this moment that might not be there?
This kind of care isn’t optional. Miscommunication leads to suffering. And when patients don’t feel understood, they stop trusting us.
Conclusion: Pain Has a Culture
If we want to deliver ethical, equitable care, we have to listen in more than one language. Not every culture says “8/10.” Not every patient will ask for what they need in ways we’re trained to recognize. But the pain is still there. The message is still being sent.
We just need to learn how to hear it.
References
Craig, K. D. (2009). The social communication model of pain. Canadian Psychology, 50(1), 22–32. https://doi.org/10.1037/a0014772
Ekman, P., & Friesen, W. V. (1969). The repertoire of nonverbal behavior. Semiotica, 1(1), 49–98.
Hall, E. T. (1976). Beyond culture. Anchor Books.
Mesquita, B., & Walker, R. (2003). Cultural differences in emotions. Personality and Social Psychology Review, 7(4), 292–301. https://doi.org/10.1016/s0005-7967(02)00189-4
Zborowski, M. (1952). Cultural components in responses to pain. The Journal of Social Issues, 8(4), 16–30. https://psycnet.apa.org/doi/10.1111/j.1540-4560.1952.tb01860.x
David Rose 