Modules

Cross-cultural communication

Introduction

The Communication and Cultural Competence program is based on case studies that give examples of everyday medical practice in Canada. These modules do not focus on diagnosis and treatment. Instead, they focus on communication between health professionals and patients. Please note that the modules are not intended to show the only way to deal with a situation. Instead, they are intended to provide guidance on how to approach and reflect on these different scenarios.
  • This module takes place in a teaching hospital. The theme is cross-cultural communication. The physician is a family medicine resident and her experiences are typical of those in a residency.

    Again, there are different types of interactive materials.

    The initial “Self-assessments” and the first “Reflective exercises” are intended to make you think about your own cultural background. Also, you will be asked to read some of the literature before doing the “Reflective exercises.” This is to give you some knowledge about the cross-cultural issues that you will need to use throughout the case. While some of the exercises have multiple-choice style responses, remember that often there is not one right answer, but just better, or not so good responses.

    And again there are links to a sentinel habit and to specific MCC role objectives, which should be studied as the case unfolds.

MCC role objectives

Communicator

  • Initiate an interview with the patient by greeting with respect, attending to comfort and to the need for an interpreter if applicable, orienting to the interview, and consulting with the patient to establish the reason for the visit (1.1)
  • When appropriate, facilitate collaboration among families and patients, while maintaining patient wishes as the priority, ensuring confidentiality, and respecting patient autonomy (1.5)
  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)

 

Professional

  • Negotiate between patient and family, respecting patient wishes as primary (2.3.1)
  • Recognize that attitudes to confidentiality may vary (Aboriginal peoples, minors) (2.3.3)

Sentinel habit

  • Incorporates the patient’s experience and context into problem identification and management

Entrustable professional activities

  • Lead and work within interprofessional health-care teams (8)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Establishes and maintains proficiency in clinical knowledge, skills and attitudes appropriate to Internal Medicine (2)
  • Seeks appropriate consultation from other health professionals, recognizing the limits of one’s own expertise (5)
  • Accurately elicits and synthesizes relevant information and perspectives of patients and families, colleagues and other professionals accurately (9)
  • Conveys relevant information and explanations accurately to patients and families, colleagues and other professionals (10)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care(12)
  • Demonstrates a commitment to their patients, profession and society through ethical practice (19)
  • Demonstrates knowledge of and applies the professional, legal and ethical codes for physicians (21)

Cultural diversity in Canada

Canada is one of the most culturally diverse societies in the world. Working in any of the health care professions almost anywhere in the country, physicians will interact with patients or other health care workers from the following backgrounds:

  • Indigenous peoples of Canada
  • Canadian-born, of western European heritage
  • Canadian-born, second or third generation from non-western cultures, with or without a knowledge of their heritage language and culture
  • Immigrants who have lived in Canada for many years, who have retained little of their heritage language and culture
  • Immigrants who have lived in Canada for many years, who have retained most of their heritage culture, including language, integrating little into Canadian society
  • Recent immigrants, unilingual, with little or no experience of other cultures
  • Recent immigrants who have a wide variety of intercultural experience and who may speak several languages

Cross-cultural education

  • Canadian training programs have recognized the necessity of educating learners — and teachers — in the knowledge, skills and attitudes of cross-cultural communication.
  • Cultural sensitivity and communication skills are two of the main themes of the MCC role objectives.
  • If, as many feel, physicians should approach every patient encounter as potentially cross-cultural, what skills and knowledge do they need? What attitudes are needed for good cross-cultural communication?
  • Many physicians and their training programs believe that the major task in developing greater cultural sensitivity is simply learning more about other cultures (Lingard, et al). Such a “cultural cookbook” approach is clearly impossible and trying it could also lead to cultural stereotyping.
  • Others might feel that, simply by having lived in or immigrated to another culture, they have acquired cultural competence or sensitivity. This is not necessarily true.

Cross-cultural bioethics
The increasing awareness of cultural issues in health care has profoundly influenced the field of bioethics, another of the main themes in the MCC role objectives. The standard western, principle-based approach taught in medical schools is being challenged. For instance, the feminist movement has changed the way we think about the care of patients, especially in gendered and reproductive issues. Further, the globalization of society, especially in health care, has resulted in the need to approach bioethics from a cross-cultural perspective. This raises many problems and issues. If my values differ from those of my patient, how should I act? Must I accept the behaviour of another culture toward certain groups in society, such as women, if I find that behaviour unethical from my cultural perspective? Do I act according to accepted Canadian standards toward a patient who clearly prefers his or her own cultural norms?

In this case and the “Reflective exercises” that arise from it, we will examine three aspects of culture, bioethics and the interaction of the two:

  • Self-awareness and self-reflection about one’s own culture, both personal and medical — this is the attitude part
  • The skills involved in cross-cultural communication
  • The Canadian medical culture and how it may differ from your previous experience — this is the knowledge part

Although intended primarily for graduates of non-Canadian medical schools, Canadian-trained physicians who want to improve their cross-cultural skills can also benefit from this information.

Self-assessment quiz

There are two “Self-assessment” quizzes and one “Reflective exercise.” They are designed to help you assess your knowledge, skills and attitudes about cultural issues in the medical domain and, as such, there are no right or wrong answers.

  • Exercise 1

    Write a brief definition or description of the following terms (without looking them up), then compare them to those provided in the literature.
    • Ethnocentrism
    • Diversity
    • Cultural competence
    • Stereotyping
    • Cultural sensitivity
    • Bioculturalism
  • Exercise 2

    Read the following scenarios, each of which ends with the questions “What would you do?” and “How comfortable would you feel in responding to this situation?” There is nothing to submit for “What would you do?” but think about how you would respond. If you have encountered one of these situations before, reflect on what you did and if you think you could have acted differently. For the second question, indicate your response according to the following scale:

Reflective exercise 1

Read “Becoming interculturally competent” by Milton J. Bennett.

In this article, Bennett describes six stages of “intercultural sensitivity.” It is generally accepted that the acquisition of such skill is necessary in order to function as a professional in a cross-cultural environment. After reading the article, do the following exercises. Think about the level of intercultural sensitivity that is exhibited in each scenario. Where do you think your level would be if you were involved in a similar situation? What level do you think is needed by a physician in Canada?

Exercise 1

  • A physician has admitted an elderly Chinese man who has had a severe cerebrovascular accident. He is responsive only to pain and the physician feels he is unlikely to recover. The patient’s wife speaks no English and his son and daughter both live out of town. The physician has read that in the Chinese culture the eldest son takes responsibility and makes the decisions for the parent in such situations. He therefore decides not to ask for an interpreter to speak to the patient’s wife, but to wait for the son to arrive.

Exercise 2

  • Resident to supervisor:
    “I’m having trouble managing this Indian man with diabetes. His records from India say his blood sugar was well controlled on oral hypoglycemics but they do not seem to be working now. I do not understand why.”

    Supervisor:
    “Hyperglycemia is the same no matter where you live. Think about this case the way you would any other. What are the usual causes of poor control?”

Exercise 3

  • A nurse brings a complaint to the hospital ombudsman saying that nurses from the Caribbean are discriminated against by nursing supervisors. She describes an instance in which a white nursing manager told Caribbean nurses to speak “proper” English so that patients and colleagues could understand them. She overheard her later make a remark to another nurse about “uneducated immigrants,” which she thought referred to the Caribbean nurses.

Exercise 4

  • Psychiatrist to colleague:
    “I saw an interesting patient the other day, a Latin American man who had been treated unsuccessfully for depression with selective serotonin reuptake inhibitors. He was labeled as non-compliant, which is probably true, in a way. He was certainly somatizing, as so many of them do, but he had been in Canada a long time and in many ways was quite acculturated. So he was a fascinating mixture of old and new. Maybe under stress he was reverting to his first culture. I could see how he was torn sometimes between his wife and his other relatives. Anyway, it was not clear, given his externalization of issues, whether he should be treated with medication or psychotherapy. Basically I think convincing him to accept medication will probably be best.”

 

Next: Part 1

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