Serving Patients Through a Cultural Lens

"He was in tears, saying he did not know what to do. He'd been sent into the delivery room to take care of deliveries ... and he had never even seen a lady with her clothing off."
Supervising physician

"In some countries, males look after males and females look after females. [But] we can't be selective in the kind of patients that our physicians end up treating. If you're not familiar with the anatomy of the opposite sex, it's very difficult to end up in the delivery room and deliver a baby."
Olga Szafran, associate research director, University of Alberta, family-medicine department

 


Previously, in years past, there was much head-shaking and hands-wringing at the plight of foreign-trained medical doctors arriving as immigrants to Canada, able to find employment only in unskilled jobs, shut out of practising medicine in their new country because their professional training did not match the kind of exposure that produced practising doctors for the Canadian public. Standards of the licensing bodies in Canada meant to authorize medical practitioners had to be met, and foreign-trained doctors were expected to put in several years at Canadian teaching institutions to enable them to qualify as physicians in Canada.

Now, it seems, things are looking up for many of those foreign-born-and-trained doctors who have taken the required steps to achieve Canadian recognition as health professionals. On the other  hand, while their professional qualifications have been updated to reflect Canadian medical practise and values, the realization is sinking in that there may yet be significant areas of medical professionalism as practised in Canada that remain foreign to them. Just as there are culture clashes when people migrate from one culture to another, those cultural differences can show up in professions like medicine.

A newly released study out of Alberta examined the situation and released the findings. Many of the "international medical graduates" [IMGs] though highly educated, have cultural perspectives informing them, as well as reflecting their own strong character traits, according to the report where colleagues surveyed for the study had been interviewed, their views sought, to gain perspective. Some of the foreign graduates who have undergone two-year family[medicine residencies balk when being taught by female doctors. They find English language nuances difficult to interpret. And their body language can be inappropriate.

They can be, moreover, less inclined to feel comfortable dealing professionally with mentally ill patients; another new experience. And they can be unfamiliar with the concept of patient confidentiality, according to the researchers. Leading to a recommendation that these consistent difficulties should be recognized and dealt with by incorporating "medico-cultural" education into curricula. Graduates from medical schools outside North America now make up about a quarter of practising physicians in Canada. They are relieving a situation where too many Canadians were unable to find family physicians.

Typically, medical schools at universities in Canada reserve a number of residency places for foreign doctors. While Dr. Szafran, the study's lead author, did not specifically name countries of origin, it is known that the top five sources of IMGs in Canada, derived from 2012 figures, were from South Africa, India, Libya, the United States and Pakistan, according to a Canadian Medical Association report.The Alberta study team interviewed or held focus groups with doctors supervising family medicine trainees, and with nurses and other health professionals, along with both Canadian and international medical residents.

The positive aspect of the IMGs is their place in giving service to a growing multicultural patient demographic. Difficult-to-interpret accents and the mastery of English can often impact the level of patient communication, a process that "makes life difficult and diagnosis difficult and affects everything", the researchers were advised by one physician-trainer. Cultural-informed body language such as bypassing eye contact with patients, or invading their personal space, was cited as another problem. Subtleties in communication to spare patients' feelings over their health conditions if they are considered self-induced are not recognized.

Study participants pointed out IMGs being unfamiliar with common mental-health conditions such as depression, addiction, anxiety and panic attacks, as the types of social and individual problems that were never seen in the IMGs' countries of origin since patients tend not to seek out medical help for these conditions in their home countries. Some foreign graduates refuse to shake hands with patients of the opposite sex, let alone to acknowledge that a female doctor might have authority over them. "They tend to walk over you a bit, and  you have to stand your ground and push back and just remind them about gender equality", noted one female physician.

Interim chair of the University of Toronto's medical department, Dr. David White, spoke of his experience with a male medical graduate from southwest Asia who had never in his career before coming to Canada treated women or children. He was left with "knowledge gaps you could drive a truck through". Yet Dr. White felt that such knowledge gaps could be closed by teaching these doctors individually, for example, how to conduct a pelvic exam. Perhaps it is Dr. White who needs some updating himself.