By Mohamed Al-Eraky, MD, PhD
M. Al-Eraky is assistant professor of medical education, University of Dammam, Saudi Arabia, and a founding member, Medical Education Development Centre, Zagazig University, Egypt.
In our recent article, my colleagues and I advocate the significance of cultural competency of physicians. The leading character in our vignettes, Amany, has encountered challenging situations that conflict with her perception of what makes a good doctor. Her fitness to practice as a physician was even questioned by her peers and supervisors, because she was not flexible enough to meet the expectations of her elderly patient who wanted to “die in peace.” When doctors like Amany move to practice in a different culture, they go through a stressful period of conflicts till they can (or not) manage to shift their professional identity.
As I have personally encountered different systems of education and health care in Egypt, the United Kingdom, the Netherlands, and Saudi Arabia, I have had to adapt to many situations during my studies and work. The vignette mentioned above portrays a vivid example of patient autonomy, where a patient is empowered to decide her treatment plan from the options provided by her doctors. It reminds me of an Egyptian colleague who was trained in the United Kingdom and came back home to practice in his private clinic. As part of each consultation, he used to explain the options and implications of proposed investigation and treatment with the associated risks and benefits. Failing to interpret that strange look in the eyes of his patients, he used to ask them at the end: “So, what do you like? Surgery or conservative?” A few weeks later, his clinic was almost empty. But why? In Eastern and Arabian societies, the power balance of the doctor-patient relationship leans more toward the doctor, that is, doctors have more authority in the decision-making process than patients. Such paternalistic relationships resonate well with an earlier study in 2012,1 where we reported professional autonomy of physicians (not patient autonomy) as a salient domain of medical professionalism in the Arabian context.
Reflecting on these types of experiences and our article, from the perspective of a reader, led me to ponder certain questions: What is North on the compass that guides our behaviors in a new land? What is the degree of flexibility that we expect from graduates who move to learn or practice in a different culture? Conceptually speaking, professional identity embodies a relatively stable “core” (like personality traits and belief systems) and a peripheral dynamic “shell” that can be flexible across contexts and cultures. But what is the ratio between these two components? And how can we teach flexibility, adaptability, and cultural understanding or competence in our medical schools?
Another delicate point: Medical professionalism represents the expected behaviors and attributes of physicians while serving their patients and societies in a specific culture. Yet, throughout my Master and PhD studies in medical professionalism for almost ten years, I wondered: How can we draw the boundaries of a culture? Is there a common “marco-culture” of a particular region (e.g., Arabian, South Asian, Western)? And/Or are there many “micro-cultures” in or within each country? Sometimes I even go further and spot “nano-cultures” across different institutions, where members share common values and ethos related to power distance, privileges, autonomy, and communication. How can we accommodate these diversities of culture(s)?
The differences across cultures are usually highlighted in research, practice, and the media, yet we need (also) to appreciate the shared humanistic values of professionalism that are universally accepted (such as respect, altruism, and accountability), yet perhaps interpreted variably across cultures. Speaking about similarities, the situation that Amany encountered with the patient who wanted to die in peace may be related to something in her/my culture. In terminal cases, such as advanced metastasis, patients may refrain from operations and chemotherapies and opt for being discharged to rest at home and pray for cure or peace from God. Physicians in Arabian culture usually respect these patients’ wishes to spend the last conscious moments of their lives blessed by their families, and not fenced by health professionals who barely know their names. Although these situations are not identical, they are still related.
To be successful learners, colleagues, and practitioners in a different culture, we need to learn the expectations, values, norms, belief systems, and legal regulations of that new society to survive the acculturation shift (and shock). As the saying goes, “When in Rome, ….” However, we should also expect Romans to help visitors to follow their customs and practices. A cultural orientation program, preferably one led by a colleague from the newcomer’s culture and background, may help people like Amany and my Egyptian colleague cope with the new system. I hope readers will find other insightful ideas in our article and invite them to share some of their stories of adaptation across cultures.
1. Al-Eraky MM, Chandratilake M. How medical professionalism is conceptualised in Arabian context: A validation study. Med Teach. 2012;34(Suppl 1):S90–S95.