Doctors, culture and patient compliance

My first year at Baylor I wrote a theory paper about what happens within a patient/physician interaction when there is a larger and smaller spread between the two people's cultural background.  So if the patient is very poor and is struggling in life, the world that they know and how it works has a very different feel and nature to it that the physician, whom we would assume is not struggling - at least in the same sense.  I got to thinking about these issues again today at the eye doctor.

Our eye doctor (or mine - Sara doesn't need to go... yet) clearly has a different cultural background that I do.  It is in a very nice neighborhood, in a building whose rent cannot be cheap, and I am betting serves a certain kind of client that is from the upper end of the socio-economic ladder.  Much of this makes me feel uneasy being there - not because I am intimidated by them or something like that, but I feel as though I am merely a dollar sign and has a feel to it like I would imagine a used car lot would.  The conversation they have with me, the words they use, the seemingly memorized lines that are 'answers' to my questions and the assumption that I am more than willing to pay out of pocket for additional and seemingly unnecessary stuff.  The highly visible diplomas of the doc on the wall, despite the fact that she has an office.  The clothing they all wear - stilettos (yes, literally designers super high heels) and matching everything that I guarantee is not at Old Navy.  All of it are symbols that communicate a cultural background foreign to me.

As such, I am on high alert for things that it seems that they are trying to 'get' me on (it happened no less than 4 times today).  Because I am on high alert, I am halfway listening to what they have to say about my eye care (which is only a notch above nothing) and halfway defending my wallet.  This naturally makes the conversation borderline adversarial most of the time, which spurs them to try and reassert their position as the expert in the room.  I am sitting there trying to not elevate their defensiveness because I am aware of the fact that this will not help either of us, but can't shake the feeling of a disconnect between myself and them.

All of this leads me back to the patient/doctor interaction and patient compliance.  We know that rapport with a patient increases the information the patient will supply to help the physician solve and problems or figure out a diagnosis, but past interactions also play in.  If they know the patient from past interactions, it only helps - unless the interaction is breaking down.  This is why continuity is such a big deal when it comes to medical care, but also why attempts to reduce the cultural gulf between patient and physician is crucial.  All of this leads up to the point at which the patient leaves the office or the hospital.  Are they going to follow the advice?  Will they do it willingly or begrudgingly - both of which will impact outcomes for either the better or the worse.  Are they able to follow the advice?  Did they understand the advice given, and relatedly, did the physician know whether or not they communicated successfully?  Medicine is a pretty hard job - because it really is almost never just medicine.