Doctors+and+Patients+-+Are+We+From+Different+Planets?

Lucinda Appleton n8094535 Tutor: Sarah Jordan

How culturally ‘clued-in’ are our primary and emergency service providers when it comes to sex, pain and death? This question is of vital importance in Australia due to our multi-cultural society. In 2010, the Australian Bureau of Statistics (ABS) predicted approximately 27% of the Australian population was born overseas (Australian Bureau of Statistics, 2011). This indicates that much of our society may be of a different culture and, therefore, as doctors are likely to be increasingly confronted by patients of different backgrounds (Schouten & Meeuwesen, 2006); the need for cultural competency in healthcare can be seen. To answer the question above, it is necessary to examine the doctor-patient relationship. This will be achieved by reviewing relevant literature and applying social and cultural analysis. In addition, a cultural artefact from society representing issues in the doctor-patient relationship will be presented and analysed.

**Cultural Artefact ** Society portrays issues surrounding the doctor-patient relationship in many different ways. An example of one of these ways can be seen in the cartoon below (Jeantheau, 2004). Although the author of the cartoon is unknown, it was featured on the popular website, the Grinning Plant. Containing perceived doctors and patients, this clever cartoon portrays an association that can be likened to a doctor-patient relationship.

**Public Health Issue **To examine how culturally ‘clued-in’ our primary health care providers are, matters surrounding the doctor-patient relationship will be the public health issue presented in this analysis. These issues include power balance, the importance of high quality communication (both intracultural and intercultural), the consequences of poor interactions and knowledge of each other’s culture including beliefs and values. These issues are of importance not only due to our multicultural society but because they often predict a patient’s satisfaction with the doctor, compliance to medical care and disease outcomes (Ferguson & Candib, 2002). This can be seen in relevant literature.

**Literature Review** Recent research has focused on the various issues surrounding the doctor-patient relationship mentioned above. Power issues in this relationship were examined in a study by Goodyear-Smith and Buetow (2001). These authors reviewed several articles and examined the sources and nature of power, power in the doctor-patient relationship and its misuse by either party. Initially they discussed its history and commented that previously, doctors had exclusive power over patients (paternalism), as they were usually males of a high social status with exclusive knowledge. Over time, this power imbalance has been disappearing, with a movement from paternalism to patient-centered approaches in response to social movements and society changes including feminism and technology booms. Feminism has sought to redress the power imbalance between male doctors and female patients and advances in technology have broken doctors’ monopoly, as patients are now able to gain information and resources for education. It was commented that these advances have seen the maturation of the doctor-patient relationship from adult-child to adult-adult and, therefore, patients now share high control over their health care by having different forms of power. These advances have enhanced the quality of care.

The quality of health care also depends on whether the doctor is able to communicate effectively with the patient and knows the patient’s beliefs and values. A paper written by Potiriadis and colleagues (2008) aimed to examine Australian patients’ satisfaction with health care provided by Australian general practitioners. This cross-sectional study used data from 7130 patients who completed the General Practice Assessment Questionnaire (GPAQ). Results showed that communication was rated highly at 84/100. However, there was no comment as to the ethnicities of the participants and patients who could not read English were excluded. Therefore, it is unclear whether satisfaction with and success of intercultural communication would be as high.

This limitation was addressed in an American review conducted by Schouten and Meeuwesen (2006). These authors aimed to gain an insight into the effects of patients’ cultural and ethnic backgrounds on medical communication by reviewing a vast range of literature. Most studies compared communication processes between White doctors and White patients and White doctors and ethnic minority patients. Analysis found that physicians were often less affective when communicating and had less empathy, rapport-building, responsiveness, expressiveness of positiveness, social talk and partnership building with ethnic minority patients. Furthermore, it found that doctors were rated less concerned when assessing different cultured people and ethnic minority patients felt more ignored in comparison to White patients. Same-cultured individuals also rated medical explanations higher. These findings were consistent with an independent review by Ferguson and Candib (2002). In an Australian context, one study examined by Schouten and Meeuwesen (2006) found that a shared understanding between Aboriginal patients and Australian doctors was rarely achieved. Patients barely got a say, having few opportunities to initiate discussion and having the doctor determine the conversation direction. In addition, this study also commented that differences in cultural beliefs and values were associated with gaps in doctor-patient communication. It was therefore concluded that the findings do suggest difficulties in communication between doctors and patients from different cultural and ethnic backgrounds.

Differences in cultural values and beliefs and its influence on the doctor-patient relationship and health care, were also highlighted in a study by Street and Haidet (2010). One objective of this study was to discover physicians’ awareness of their patients’ health beliefs. The 207 patients and 29 physicians of this study completed the CONNECT instrument which looked at individuals perceptions about whether their condition has a biological cause, whether the patient is at fault, whether the patient can control the condition, whether non-traditional treatments can be used, whether the condition has significant meaning to the patient and whether the patient prefers being in a partnership with the doctor to manage the condition. The doctors completed two versions of this, one for their beliefs and one for what they thought the patients’ beliefs were. Across all of the above domains, patients and physicians health beliefs varied, showing that physicians had a relatively poor understanding of their patients’ health beliefs. In four of the six domains, the doctors thought their beliefs were the same of those of the patients, however, in two of these they were the exact opposite. In addition, the patients’ ethnicity was related to understanding in three of the domains. Physicians had less understanding of beliefs of patients of different cultures in the domains of preferences for partnership, meaning of the condition and control over the condition. These results suggest that physicians are not aware of the beliefs of their patients, which in turn may lead to misunderstandings, patient dissatisfaction and harmful situations.

The study by Street and Haidet (2010) also commented that a better awareness of patients’ beliefs could identify gaps between their understanding and offer treatments better suited to the patient. Understanding these beliefs is a key component of empathy, which can lead to more effective communication and increased patient satisfaction, adherence to treatment and outcomes of care.

An illustration of power imbalance, misunderstandings, patient dissatisfaction and harmful situations from a lack of doctors’ understanding of patients’ beliefs and cross-cultural miscommunication can be seen in a study conducted by Killoran and Moyer (2006). This study looked at cultural factors that influence the selection breast cancer treatments by Chinese-American patients and the presentation of treatment options by doctors. It used focus groups, semi-structured interviews and ethnographic observation of 69 Chinese-American women and 14 health professionals. Results showed that misunderstandings due to cultural differences led to dissatisfaction with the elected treatment plan. Some women felt powerless and pressured to undergo breast-conserving treatment (BCT) by their doctor. Furthermore, one of the participants had a preference to undergo modified radical mastectomy (MRM) because she did not want to keep the breast for ‘beauties sake’ but went with the advised BCT and afterwards felt fearful for her life. Some patients’ dissatisfaction with their doctors and their unwillingness to consider their preferences led to consideration of avoiding recommended treatment plans. A couple of the participants in this study also stated that, due to miscommunication, they did not know what treatment they were getting until after their ‘butchering’. For them, the doctors chose a BCT and this made the patient believe they did not have breast cancer. Others stated that they felt disempowered and had to really argue to get their preferential treatment respected.

Similar results were found in a study conducted by Nguyen, Barg, Armstrong, Holmes and Hornik (2007). This American study interviewed Vietnamese immigrants on cancer communication and learning in a health care setting. Results found some patients did not know what screening test they had just undertaken, accepted a paternalistic doctor-patient relationship and felt resistance and as though the doctor would yell at them when trying to engage in discussion. Findings also showed that patients felt most informed and as though they would get the right treatment when they saw a doctor of the same ethno-linguistic background. Some commented that they did not understand doctors of a different language, to the point where one patient asked a stranger to interpret for him. Surprisingly, even when the doctors were of the same ethnicity and spoke the same language, 70% of participants were still discussing issues with communication.

From the opposite point-of-view, a study by Babitsch, Braun, Borde and David (2008) examined the influence of ethnicity on emergency doctors’ satisfaction with the doctor-patient relationship. Two thousand four hundred and twenty-nine data sets, including a short questionnaire completed by the emergency doctor and medical records, were analysed. Results found that communication issues, related to ethnic differences, were the principle cause of doctor dissatisfaction in the relationship. It concluded that good communication, seen as satisfactory to both the patient and doctor, is essential for providing medical care. The findings of this study also align with research conducted by Schouten and Meeuwesen (2006) who found that doctors rate consultations with ethnic minority patients more emotionally demanding.

**Social and Cultural Analysis** As can be seen in the literature presented above, society and culture play major roles in the doctor-patient relationship. Changes in society such as women gaining rights due to feminist movements and booms in technology have seen patients gain more autonomy in relation to their health care. As technology has boomed over the past decades, patients now have a vast amount of resources to turn to for information about their situation. This had led to doctors losing some of their power, as they now do not have exclusive knowledge, and patients being empowered and having control over their own health care.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">The evidence has illustrated that culture differences have led to several issues surrounding the doctor-patient relationship. The study conducted by Killoran and Moyer (2006) was based on physicians from the Northern California region who treat Chinese-American patients. Aesthetics is often a large focus in the culture of the American society, as portrayed by the media and Hollywood, and hence it is a possibility that these womens' beliefs of not keeping their breasts for ‘beauties sake’ was disregarded by the doctors due to their own culture and what they see as ‘normal’. This cultural difference may have been the force that led to the perceived pressure from the doctors.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Cross-cultural communication and its effects on patient satisfaction and treatment, as highlighted in the literature, also justifies why culture plays a major role in the doctor-patient relationship. As highlighted in the study by Schouten and Meeuwesen (2006), that examined the effects of culture on medical communication, Aboriginal patients and Australian doctors rarely achieved a mutual understanding. As being able to treat patients requires doctors to know what’s wrong, how are people of different cultures suppose to get the best medical advice and treatment possible if doctors can not comprehend what is being presented to them? In the larger picture, this is indicating that our primary health care providers are not culturally ‘clued-in’ in regards to communication.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">This issue is pertinent not only to Australia but to all countries to which people travel. Ethnic minority groups everywhere are likely to be affected by this issue as they are not part of the dominant culture or speak a different language. They may not be understood or their beliefs may be seen as ‘silly’ as they do not conform to what that culture sees as ‘normal’. As people deserve to receive the best medical care possible, no matter where they are situated on the globe, this analysis has shown a clear need for public health experts ensure that doctors are culturally competent in both languages and beliefs and values.

<span style="color: #000080; display: block; font-family: 'Times New Roman',Times,serif; font-size: 240%; text-align: center;">**Analysis of the Cultural Artefact** <span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Many of the issues presented in this analysis can be represented by the cultural artefact presented above. Being of a different culture and speaking a different language to your doctor can make you feel as though you are ‘from a different planet’. Humorously, this cartoon can be likened to a doctor-patient relationship where the doctor is the main alien and the human is the patient. As these two beings are from different places, they are likely to exhibit forms of miscommunication and may not know each other’s values or beliefs. The patient’s face shows elements of fear and confusion which are emotions that can be likened to a poor doctor-patient relationship. In addition, the doctor appears ‘evil’ which may be the perspective of a patient who has no idea of the ‘strange’ words the doctor is flooding them with.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">From the perspective of someone who has never experienced life as a member of an ethnic minority group, before completing this assignment I did not realise the extent to which medical staff did not understand different cultures and what this could lead to. I was shocked to learn of the consequences of miscommunication and cultural unawareness and find it hard to comprehend why topics such as this don’t make prime media coverage as it is, in my opinion, more relevant than most broadcasted ‘first world’ problems. I have, however, experienced alienation in the doctor patient relationship, as depicted in the cultural artefact, when I saw a doctor of a different culture who did not acknowledge my beliefs. Because of this, I dismissed the advice she gave and saw another doctor who took my opinions on board. From this first-hand experience and the knowledge I have gained from completing this assignment, I now realise the absolute importance of cultural competency and aim to be prepared when I enter the health care field.



<span style="color: #000080; font-family: 'Times New Roman',Times,serif; font-size: 240%;">**References** <span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Australian Bureau of Statistics. (2011). 3412.0 Migration, Australia 2009-10. Retrieved 28 September, 2011 from http://www.abs.gov.au/ausstats/abs@.nsf/Products/1197BC920F1A28E5CA2578B00011976A?opendocument

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Babitsch, B., Braun, T., Borde, T., & David, M. (2008). Doctor’s perception of doctor-patient relationships in emergency departments: what roles do gender and ethnicity play?. //BMC Health Services Research, 8//, 82-92. doi: 10.1186/1472-6963-8-82

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Ferguson, W.J., & Candib, L.M. (2002). Culture, language, and the doctor-patient relationship. //Family Medicine, 34//(5), 353-361.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Goodyear-Smith, F., & Buetow, S. (2001). Power issues in the doctor-patient relationship. //Health Care Analysis, 9//, 449-462.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Jeantheau, M. (2004). Doctor/Patient Cartoon. Retrieved 28 September, 2011 from http://www.grinningplanet.com/2004/05-27/doctor-probe-copyright2.gif

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Killoran, M., & Moyer, A. (2006). Surgical treatment preferences in Chinese-American women with early-stage breast cancer. //Psycho-Oncology, 15//, 969-984. doi: 10.1002/pon.1032

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Nguyen, G.T., Barg, F.K., Armstrong, K., Holmes, J.H., & Hornik, R.C. (2007). Cancer and communication in the health care setting: experiences of older Vietnamese immigrants, a qualitative study. //Journal of General Internal Medicine, 23//(1), 45-50. doi: 10.1007/s11606-007-0455-2

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Potiriadis, M., Chondros, P., Gilchrist, G., Hegarty, K., Blashki, G., & Gunn, J.M. (2008). How do Australian patients rate their general practitioner? A descriptive study using the General Practice Assessment Questionnaire. //The Medical Journal of Australia, 189//(4), 215-219.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Schouten, B.C., & Meeuwesen, L. (2006). Cultural differences in medical communication: a review of the literature. //Patient Education and Counseling, 64//, 21-34.

<span style="display: block; font-family: 'Times New Roman',Times,serif; font-size: 120%; text-align: left;">Street, R.L., & Haidet, P. (2010). How well do doctors know their patients? Factors affecting physician understanding of patients’ health beliefs. //Journal of General Internal Medicine//, 26(1), 21-27. doi: 10.1007/s11606-010-1453-3

<span style="color: #000080; font-family: 'Times New Roman',Times,serif; font-size: 240%;">**Reflections** <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Wiki: Each time you sleep with someone, you're also sleeping with his past

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Title: An interesting read!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Comment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Great job on the wiki- thank you for a very informative read. In particular I found it very interesting that society has started to accept homosexuality more and this has possibly lead to increased STIs. Not so long ago there was an fairly conservative advertisement promoting condom use among homosexuals that had to be removed due to complaints. In response, there was a facebook campaign which explained the stories of the people pictured and appeared to have great support. Assuming that the majority of facebook users are in Gen Y, this does show an increase in acceptance of homosexual people. However, how are rising STI rates suppose to drop in this group if advertising safe practices is not allowed? Just as your cultural artefact has shown, there are much less conservative advertisements allowed for heterosexual relationships. A very controversial topic!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Lucinda

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Wiki: Obesity is a Capitalist Disease

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Title: Great Wiki!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Comment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">I thoroughly enjoyed reading your wiki - great job. I find the impact of social marketing of food interesting and loved the way you presented it. In particular the Coco Cola example was highly relevant to today as they have just presented a new marketing strategy with 'share a coke with...' and I have seen many adults get excited about finding their name. Imagine the response by children - scary thought.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">Lucinda