160428P - DEALING WITH PATIENTS OF DIFFERENT SOCIO-CULTURAL BACKGROUNDS

Presentation at a ‘Department Grand Round Topics’ Small Auditorium, King Fahad Medical City, Riyadh on 28 April 2016 by Professor Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Faculty of Medicine, King Fahad Medical City

INTRODUCTION: 2 Main Themes Of Cross-Cultural Interaction:

• All humans have the same biological and social origin. There are some minor biological, social, and cultural differences that are part of Allah’s scheme to make an interdependent world by enabling people to identify and know one another. These differences cannot be denied neither can they be misused for any other purpose other than for which they exist.
• Cross-cultural communication: We must understand socio-cultural variation among patients: age, gender, education, social class, and health-related behavior. These differences can create socio-cultural barriers to doctor-patient communication unless mitigated. 

Common Biological Origin:

• All human beings are from Adam. Modern discoveries about DNA and the molecular basis of life prove that there is a biological commonality that must have been caused by a common origin.
• Unity of humanity (wahdat al basahariyat) is based on a common biological origin.
• As far as we know all offspring of Adam are on planet earth. It is however possible that some of them live on some other planets; science has yet to settle this doubt.
• Although humans are from the same biological origin, there are observable differences among them. These differences coincide to a large extent with the geographical habitat in which they live. It is better to classify humans on the basis of ethnicity and not a race. The word race is non-scientific and is difficult to define and operationalize accurately.

Common Social Origin:

• Humans started as one family that of Adam. They were at one time one community or nation (ummat wadihat) but differences developed between them and they became many groups (p 152 5:48…42:8). Because humans all arose from one primordial civilization, we can detect many similar social institutions in people living in different parts of the globe.
• Differences in social organization arose as humans moved to live in different environments. The environment has a decisive effect on social life and social behavior. Social organizations and behaviors differ by the habitat: forests, deserts, and open plains.

Biological Similarities and Differences - 1:

• Biological similarities among humans: basic biological similarity among races: chemical, genetic (DNA), inter-breeding. The cell is the basic building block. There is specialization among cells therefore they differ in structure and some of their physiological functions. 
• Humans are a spectrum and not discrete groups with clear boundaries. Colors and physical features merge at the interfaces of human contact. 
• The Qur’an has talked about differences in skin color and languages (ikhtilaaf al alwan & ikhtilaaf al alsinat p 79 30:22) as well as differences in tribes and nations (ikhtilaaf al qabail & ikhtilaaf al shu’ub (p 79 49:13).
• The first major classification of humans is that based on gender. Males and females are different biologically, psychologically, and emotionally. These differences do not indicate superiority or inferiority. They are rather part of Allah’s scheme for a balanced society. The differences enable the man and woman to have specialized functions that complement one another. 

Biological Similarities and Differences - 2:

• Basic biological differences among humans: color, languages, races (Caucasian, mongoloid, negroid). These differences were created by Allah and did not arise as passive adaptations to the environment. There are gradations and different shades of color even within one race.
• Skin color is due to melanin and carotene. The darker races have more melanin. The mongoloid races have more carotene. Melanin protects the body from dangerous ultra-violet rays. Albinos are humans with a genetic defect that causes a deficiency of melanin; they have to wear eyeglasses or other protective body clothing to be able to walk in the sun.
• There is no pure race living on earth today. Humans have mixed a lot. DNA studies are likely to show this diversity of humans.

Social Similarities and Differences:

 Variations among humans can be at the ethnic, family, or individual level.

 Customs differ from community to community. Customs are ways of living followed by a great many people. They are transmitted from generation to generation. A custom starts when people find an easy and convenient beneficial way of doing something. Some customs come from religion. Some are short-lived whereas some continue for a long time. Customs is a factor of similarity within the community and factors of differences between communities.

 Language differences are among Allah’s signs. Allah created differences in languages. Languages change continuously as they adapt to different needs of communities.

The individuality of Every Person:

• Each individual has a unique biological and spiritual identity.
• Not all people will be the same even when given equal opportunities. Some individuals will achieve distinction because of: intelligence, special aptitudes, motivation, personality, and travel. These differences do not by themselves confer any superiority.
• The only true criterion of human excellence is taqwa and only Allah (SAW) can determine an individual’s level of taqwa.

What is Culture?

• Definition,
• Relativity,
• Underlying value systems and world view,
• Different is not the same as wrong,
• Non-western cultures including the Islamic one are holistic in outlook. 

Healthcare Worker’s (HCW) Respect for Other Cultures:

• HCW should be aware of his cultural values and avoid imposing them on others.
• HCW should avoid a stereotyped conceptualization of other’s cultural values it is better to ask rather than assume.
• HCW should respect the cultural values of the interviewee regarding disease definition, disease causation, and disease treatment and should build further communication on this understanding.
• HCW should identify cultural values and practices that can interfere with scientific medical treatment and try to find a midway solution.

Why HCW’s Fear Raising Cross-Cultural Issues:

• Fear of being called prejudiced,
• Feeling inadequate or inexperienced,
• Ignorance of the culture,
• Fear of misunderstanding,
• Fear of rejection,
• Uncertainty about patient’s cultural background (Lloyd and Bor p 89).

Advice on Cross-Cultural Communication:

• Be aware of your cultural values,
• Learn the cultural background,
• Learn which cultural differences affect treatment,
• Show patients, you respect cultural differences,
• Build on what is common between you and the patient,
• Be open-minded about unfamiliar cultural differences, 
• Accommodate cultural ideas if they do not compromise treatment,
• Explain you are not an expert in cultures (Lloyd and bor p. 89).

Cultural Do’s?

• Use open questions,
• Explore cultural differences only if necessary,
• Be honest about what is not clear to you,
• Show respect to cultural differences. (Lloyd and bor p.90)

Don’ts of Cross-Cultural Communication:

• retend to understand cultures unclear to you,
• Being judgmental, 
• Making assumptions,
• Assuming cultural issues are unimportant (Lloyd and bor p.90).

Common Mistakes in Language Use:

• Misunderstanding/misinterpretation of common terms and phrases,
• Technical vs common language,
• Formal vs colloquial language,
• Meanings of words determined by the local context,
• Words with different philosophical/conceptual origins and implications.
• Distorted translations by the family of official interpreters who say what they think the patient should have said.

Common Mistakes in Manner of Speaking:

• Speed of speaking vs speed of information processing: variation by gender, social class.
• A volley of questions with no time to digest and respond.
• Interviewer and interviewee speaking at the same time.

Common Mistakes in Body Language / Non-Verbal Communication:

• Eye contact,
• Touching

Dealing with the Family:

• Who speaks and decides for the patient?: individualistic vs communalist approaches

Reference:

• Managing the cross-cultural interview ‘advice on cross-cultural communication with patients’ in Lloyd M and Bor R (2nd edition) Communication Skills in Medicine. Churchill Livingstone London 2004.