Cultural competence in medical communication Conny Seeleman Academic Medical Center, dept. Social Medicine 10 th February 2006

Cultural competence in medical communication Program: Introduction Cultural dimensions – Hofstede Discussing a case-study Academic Medical Center, dept. Social Medicine

Introduction (1) Why our project? 2001: Inventory study medical faculties Need for educational material Aim of our project: Developing a book of case-studies about ethnic diversity Academic Medical Center, dept. Social Medicine

Introduction (2) What did we do? Identify problems in literature –Epidemiology –Migration history and contextual factors –Cultural differences –Communication Medical practice –Interviews with physicians –Interviews with patients Academic Medical Center, dept. Social Medicine

Introduction (4) Determine learning objectives  cultural competences Cultural competences: The attitudes, knowledge and skills a physician requires in order to adequately take care of migrant* patients (*migrant: first, second and third generation migrants) Academic Medical Center, dept. Social Medicine

Introduction (5) Cultural competences, some examples: Knowledge epidemiological aspects Awareness of influence of patient’s background on his/her perspective Awareness of own frame of reference Awareness of own prejudice, stereotyping Being able to transfer information in an ‘understandable’ manner Knowledge of legal rules and procedures Academic Medical Center, dept. Social Medicine

Cultural Dimensions Geert Hofstede Academic Medical Center, dept. Social Medicine

Cultural dimensions - Hofstede (1) Hofstede: Culture as mental programming: ‘software of the mind’ Cultural dimension: “a dimensions is an aspect at which a culture can be compared to other cultures” Academic Medical Center, dept. Social Medicine

Cultural dimensions - Hofstede (2) Method: Research project into national cultural differences at IBM 53 countries / 74 In 1967 – 1973 and later Survey to compare culturally determined values Academic Medical Center, dept. Social Medicine

Cultural dimensions - Hofstede (3) Five dimensions Power distance Individualism Masculinity Uncertainty avoidance Long term orientation How about our countries? Academic Medical Center, dept. Social Medicine

Power distance (1) Low power distance Inequality should be as small as possible Parents treat children as equal Teachers expect students’ initiative Subordinates expect to be consulted Academic Medical Center, dept. Social Medicine High power distance Inequality is wanted and expected Parents teach children to obey Teachers have all initiative Subordinates expect to be directed

Power distance (2) Power distance in medical practice Power difference between physician and patient –Initiative for communication –Expecting participation Academic Medical Center, dept. Social Medicine

Power distance (3) Power distance: how about our countries? High power distanceLow power distance Academic Medical Center, dept. Social Medicine

Power distance (4) Power distance: how about our countries? High power distanceLow power distance Academic Medical Center, dept. Social Medicine MAR T ITNL GB GER

Individualism (1) Individualism Consider oneself as ‘I’ Personal opinion is expected Virtue to be totally honest; confrontation can be beneficial Low context communication Guilt Academic Medical Center, dept. Social Medicine Collectivism Consider oneself as ‘we’ Opinions determined by group Harmony should be kept; confrontation avoided High context communication Shame

Individualism (2) Individualism in medical practice Importance group/family in decision making Meaning of ‘yes’ and ‘no’ Dependence vs. own responsibility Academic Medical Center, dept. Social Medicine

Individualism (3) Individualism vs. collectivism: how about our countries? Individualism Collectivism Academic Medical Center, dept. Social Medicine

Individualism (4) Individualism vs. collectivism: how about our countries? Individualism Collectivism Academic Medical Center, dept. Social Medicine GB NLITGER MART

Masculinity (1) Masculine Fathers handle facts, mothers handle feelings Girls may cry, boys should fight back Best student is norm Feminism: women get same opportunities as men Taboo on speaking about sex, more implicit symbolism Migrants should assimilate Academic Medical Center, dept. Social Medicine Feminine Fathers and mothers handle facts and feelings Boys and girls may cry, both should not fight Average student is norm Feminism: society should change Explicitness about sex, less implicit symbolism Migrants should integrate

Masculinity (2) Masculinity vs. femininity in medical practice Different ideas about good doctors Aggression Sexuality issues Academic Medical Center, dept. Social Medicine

Masculinity (3) Masculinity vs. femininity: how about our countries? Masculinity Femininity Academic Medical Center, dept. Social Medicine

Masculinity (4) Masculinity vs. femininity: how about our countries? Masculinity Femininity Academic Medical Center, dept. Social Medicine IT GB GER MARTNL

Uncertainty avoidance (1) High uncertainty avoidance Many and precise rules and regulations Aggression and emotions can be expressed if right time and place Difference is dangerous More sorrow about health and finances Confidence in specialists and technical solutions Prejudice against ethnic differences Academic Medical Center, dept. Social Medicine Low uncertainty avoidance Little and broad rules and regulations Aggression and emotions are not expressed Difference is interesting Less sorrow about health and finances Confidence in generalists and common sense Tolerance for ethnic differences

Uncertainty avoidance (2) Uncertainty avoidance in medical practice High Uncertainty avoidance  less subjective wellbeing Physicians essential for every task? Emotion expression in consultation Patients’ confrontation with discrimination Academic Medical Center, dept. Social Medicine

Uncertainty avoidance (3) Uncertainty avoidance: how about our countries? High uncertainty Low uncertainty avoidance avoidance Academic Medical Center, dept. Social Medicine

Uncertainty avoidance (4) Uncertainty avoidance: how about our countries? High uncertainty Low uncertainty avoidance avoidance Academic Medical Center, dept. Social Medicine TNLMARGERITGB

Time orientation (1) Short term orientation Short efforts with quick results Aggression and emotions are not expressed Old age is an unhappy phase, fortunately is starts late Academic Medical Center, dept. Social Medicine Long term orientation Perseverance leads to gradual results Thrift, deal with means sparsely Old age is a happy phase that starts relatively early

Time orientation (2) Long term orientation in medical practice Logic of preventive measures ? Academic Medical Center, dept. Social Medicine

Time orientation (3) Time orientation: how about our countries? Long term orientation short term orientation Academic Medical Center, dept. Social Medicine

Time orientation (4) Time orientation: how about our countries? Long term orientation short term orientation Academic Medical Center, dept. Social Medicine NLIT GER GB

Cultural dimensions - Hofstede Discussion What attracted your attention? What amazed you? Can such a theory as Hofstede’s be helpful in medical practice? Academic Medical Center, dept. Social Medicine

case-study: A dialogue with a Moroccan man and woman Academic Medical Center, dept. Social Medicine

Case-study What problems/difficulties occur in this case? What could cause these problems? What cultural competences (knowledge, attitudes, skills) does a physician need to prevent or reduces these kinds of problems? Academic Medical Center, dept. Social Medicine

Case-study Themes we discuss Communication: –exploring lists of concern, points of attention (skill) –language difficulties and causes of misunderstanding (knowledge) –leading a conversation, involving a third person Background information (knowledge): –contraception and Moroccan women –virginity and islam Awareness: –Influence own frame of reference –Limits of own competence Academic Medical Center, dept. Social Medicine