Stephen Nickless considers the value of business cultural training within the context of patient communications in London.
London’s ‘multi-everything’ diversity can be overwhelming. Some incoming health professionals will have trained in ‘monocultural’ regional centres and rural areas where almost everyone looked the same, dressed the same, spoke the same language and worshipped the same god. They may have had very limited interaction with members of other social groups or with non-family members of the opposite sex. They may have little or no experience of communicating across cultural boundaries. What should healthcare employers do to help?
My most recent experience of ‘culture shock’ was during a course on cultural training in a business context. I had not realized how different business culture was from the values, attitudes and behaviours the ‘professional culture’ that I had internalized during my medical training and my years in general practice in London.
The course was not as useful as I had hoped. It did not deliver the new insights into cross-cultural communication that I wanted for my work with refugee doctors. Instead the teaching focused on business executives making short trips to negotiate contracts or manage overseas projects. The assumption was that they would be engaging with their peer-groups in mainly mono-cultural settings.
The big names in cultural training – Hall, Lewis, Hofstede and Mole – have described, measured and compared various dimensions of national cultures. Such ‘generalizations’ may be an improvement on the ‘Völkertafel stereotypes’1 used in the past, but they draw on limited and idiosyncratic data. Some terms they use, like power distance, sound objective but others, masculinity, indulgence, reference challengeable cultural assumptions.
The cultural training approach does provide useful concepts for talking about culture and frameworks for making comparisons. These can help doctors working in multinational teams to notice and adapt to differences in the way their colleagues organize themselves, present information, handle conflict and negotiate solutions.
My issue with this approach, however, is that it concentrates on behaviors. It does not attend to the underlying (unconscious) perceptual, emotional and cognitive processes that give rise to them. In this article I argue that interacting with patients is deeply relational as well as informational and transactional. It demands a different range of communication skills informed by a broader and deeper and awareness of culture. Such thinking needs to be informed by ideas about human evolution2, anthropology and child socialization.
Paleontologists tell us that our human ancestors could ‘do culture’ before they could ‘do language’. Successful human groups evolved cultures of cooperation, mutuality and compassion3. It was the need to make common meaning, to communicate it and to transmit it within groups and across generations that drove the development of language.
Each of us acquires our first language – our ‘mother tongue’ – and our first culture from our primary caregivers. We do this by watching, listening, copying, experimenting and responding to the reactions of others. We gradually adapt and conform until we fit in.
We develop our sense of self through our interactions with others4. Anthropologists have noticed that how closely babies are held, how they are comforted, how independent they are encouraged to be varies from culture to culture. This early unconscious programming of children is very powerful and persistent. It meshes with the kinds of behavior that their society will expect of them as adults5.
There are many ways of making sense of disease, insanity and death. Doctors do need some awareness of medical anthropology6 plus the curiosity and confidence to ask their patients very simple questions. ‘What do you think is wrong with you?’ ‘What effect is it having on your life?’ ‘Why do you think it happened?’ ‘How do you expect it to be managed?’ ‘Would you like to know what I think may help?’
Health professionals in ‘world cities’ like London care for people of all ages, genders, sexual orientations, educational levels and social classes. Hospitals serve large and diverse populations containing many different cultural groups – multi-cultures rather than mono-cultures. In the London district of Newham, for example, 72% of patients are from black or minority ethnic backgrounds and over 200 languages are spoken. Hospital staff cannot know everything about every culture. They simply need the kind of general cultural awareness that I describe above.
Detailed knowledge of a specific cultural group is more useful in primary care. Some districts are home to significant concentrations of one or two minority communities. Here doctors – and teachers, social workers and police – need a deeper understanding of their biggest minority cultures.
Doctors regularly discuss culturally sensitive issues – alcohol, sex and narcotics – with their patients. Culture also shapes attitudes to contraception, abortion and end of life care. Difficult conversations require good interpersonal skills and a sophisticated linguistic resource of appropriate emotional tone and register.
Years ago I encountered a wild horse near an abandoned village in Canada. Over ten minutes I moved slowly closer – maintaining eye contact, watching its reactions carefully, reading its state of fear or aggression, pausing if it seemed alarmed, and making reassuring noises. We finally made contact – nuzzles and apples were exchanged. I recognized that I was in the same state of heightened awareness that I enter during a difficult consultation – perhaps with a psychotic patient or a distressed child. Communication in those situations – and with ‘aliens’ from another culture – is challenging. Doctors need to be able ‘connect’ with patients at a human level. Patients need to feel safe and respected. People seem to recognize in an almost instinctive way whether they can trust someone with their anxiety, shame and need for advice and reassurance. This happens despite our cultural difference and because of our common humanity. In the same way that ELF speakers accommodate to each other in their use of English (tolerating variations in grammar, lexis and pronunciation) people tune-in to each other culturally. They modify their style and tolerate faux-pas which would be offensive if committed by someone who should know their rules. Good enough communication is more important.
Dr Stephen Nickless practiced as a General Practitioner in a linguistically diverse community in London. He now facilitates weekly educational sessions for refugee doctors preparing to work in the NHS.
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