Documente Academic
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Documente Cultură
DOI10.1007/s400370160288y
ORIGINALARTICLE
Interculturaldoctorpatientcommunicationindailyoutpatient
care:relevantcommunicationskills
EmmaPaternotte1FeddeScheele1,2ConnyM.Seeleman3LindsayBank1AlbertJ.J.A.Scherpbier4
SandravanDulmen5,6,7
Publishedonline:16September2016
TheAuthor(s)2016.ThisarticleisavailableatSpringerLinkwithOpenAccess.
Abstract
IntroductionInterculturalcommunication(ICC)
betweendoctorsandpatientsisoftenassociatedwith
misunderstandingsanddissatisfaction.Todevelop
ICCspecificmedicaleducation,itisimportanttofind
outwhichICCskillsmedicalspecialistscurrently
applyindailyclinicalconsultations.MethodsDoctor
patientconsultationsofDutchdoctorswithnonDutch
patientswerevideotapedinamultiethnichospitalin
theNetherlands.Theconsultationswereanalyzedusing
thevalidatedMAASGlobalassessmentlistin
combinationwithfactorsinfluencingICC,asdescribed
intheliterature.
ResultsIntotal,39videotapedconsultationswere
analyzed.Thedoctorsprovedtobecapableofpractising
manycommunicationskills,suchaslisteningand
empathiccommunicationbehaviour.Otherskillswerenot
practised,suchas
EmmaPaternotteemmapaternotte@gmail.com
DepartmentofHealthcareEducation,OLVGHospital,
Amsterdam,TheNetherlands
MedicalSchoolofSciences,VuUniversityMedicalCentre,
Amsterdam,TheNetherlands
DepartmentofSocialMedicine,UniversityMedicalCentre,
Utrecht,TheNetherlands
InstituteforMedicalEducation,FacultyofHealth,Medicineand
LifeSciences,MaastrichtUniversity,Maastricht,The
Netherlands
NIVEL(NetherlandsInstituteforhealthservicesresearch),
Utrecht,TheNetherlands
ClinicalpracticeReflectivepracticeCommunication
behaviourMedicaleducation
DepartmentofPrimaryandCommunityCare,Radboud
UniversityMedicalCentre,NIjmegen,TheNetherlands
Whatthispaperadds
FacultyofHealthSciences,UniversityCollegeofSoutheast
Norway,Drammen,Norway
Interculturalcommunicationischallengingfordoctors.
Itishoweversparselytrained.
beingculturallyawareandcheckingthepatients
languageability.
Manyinterculturalcommunicationskillsareknown.
ConclusionWeshowedthatdoctorsdidpracticesomebut
notalltherelevantICCskillsandthattheICCstyleofthe
doctorswasmainlybiomedicallycentred.Furthermore,
wediscussedthepossibleoverlapbetweenintercultural
andpatientcentredcommunication.Implicationsfor
practicecouldbetoimplementtherelevantICCskillsin
theexistingcommunicationtrainingordevelopa
communicationtrainingwithapatientcentredapproach
includingICCskills.
KeywordsDoctorpatientcommunication
InterculturalcommunicationCommunicationskills
Unknownis,however,whatinterculturalcommunica
tionskillsmedicalspecialistsapplyandwhatshouldbe
trainedmore.
Implicationsofthestudyarethepossibleoverlapbe
tweenpatientcentredcommunicationandintercultural
communication.
Thiscouldfacilitatedevelopmentandimplementationof
interculturalcommunicationskillsinmedicaleducation.
Interculturaldoctorpatientcommunication
269
Introduction
Effective,patientcentredcommunicationbetweendoctors
andpatientsisessentialfordeliveringhighqualitypatient
care[1].Competentcommunicationbydoctorsimproves
healthoutcomes,enhancespatientsatisfaction,andcon
tributestodoctorsjobsatisfaction[2].Inthecontextofa
multiculturalsociety,however,effectivecommunication
couldbehinderedbyculturaldifferencesbetweenthedoc
torandthepatient[3].Interculturalcommunication(ICC),
whichinthisarticleisdefinedascommunicationbetween
adoctorofthedominantethnicoriginandanethnicmi
noritypatient,potentiallycausesmisunderstandingandre
ducesinterpersonalinteractions,whichmayleadtoalower
qualityofcare[4].Napieretal.statedthatthesystematic
neglectofcultureinhealthandhealthcareisthesingle
biggestbarriertotheadvancementofthehigheststandard
ofhealthworldwide[5].
ThetheoreticalfundamentsofICCbetweendoctorsand
patientshavegainedattentioninthelastfewyears[68].
Inarecentreview,aconceptualframeworkofinfluencing
factorsinICCispresented.Thisframeworkisconstructed
basedon145includedarticleswithavarietyofevidence
aboutICCbetweenthedoctorandthepatient.Thefactors
influencingICC,suchastheroleofthefamilyinacon
versation,thedoctorsawarenessoftheeffectsofdiffer
encesinethnicbackground,orthepatientsexpectationsof
aconversationwiththedoctor,weretranslatedintocom
municationskills.Theseskillsareofgreatimportancein
dailyclinicalpracticeandhenceshouldbeimplementedin
medicaleducation[6].
Theimportanceoftheuseofcertaincommunicationskills
dependsontherelevanceofthatskillinthespecificcontext
[9,10].Ingeneral,however,professionalcommunication
requiresadaptationtothespecificcharacteristicsofthepatient
andthesituation.Therefore,differentcontexts,suchas
differencesinethnicoriginbetweenthedoctorandthepatient,
shouldbeexplicitlyaddressed[3,6,7,11,12].
WhilethetheoreticalknowledgeonICCskillsandthe
necessityofusingtheseskillshavebeenestablished[6,8,
13],severalresearchersarguethatthescientificfieldof
ICCbetweendoctorsandpatientsinrealpracticeisstill
toosmalltodevelopfocusedtraininginICC[7,14]and
thatjustgivingfeedbackdoesnotcoverthefullpictureof
skilledmedicalcommunication[15].Itis,forexample,
unknownwhichICCskillsarealreadyusedbydoctorsand
howtheyareused.TodevelopknowledgeabouttheICC
skillsused,andthereforealsotheskillsthattheydonot
practiceproperly,thereisaneedtofurtherexplorewhich
ofthesecommunicationskillsareapplicableintheclinical
setting,andwhichofthemarealreadybeingpractised[3,
13].
Inthispaper,weidentifywhichICCskillsmedicalspecialists
useinrealpracticeduringthosemomentsinthemedicalvisit
inwhichsuchskillsarejudgedtoberelevant.Weaddressed
thefollowingresearchquestion:WhichICCinfluencing
factorsdescribedinliteraturearerecognizableindoctors
communicationskillsinrealpractice?
Methods
Studydesign
Inthisobservationalstudy,doctorpatientconsultations
withethnicminoritypatientsanddoctorsoftheDutcheth
nicitywerevideotapedandanalyzed.Theanalysisfocused
onthedoctorswayofcommunicatingandconcentrated
specificallyonwhethertheICCskillsidentifiedinarecent
realistreviewwereappliedindailypractice[6].
Settingandparticipants
BetweenSeptemberandDecember2014,wevideotaped
conversationsofgynaecologists,internists,urologistsand
orthopaedicsurgeonsintheoutpatientclinicsoftheSint
LucasAndreasHospitalinAmsterdam,theNetherlands.
Thisdistrictteachinghospitalservesanurbanmultiethnic
area.AllDutchmedicalspecialistsoftheabovementioned
specialtiesoftheSintLucasAndreasHospitalwereasked
toparticipate.Medicalspecialistswerechosensincethey
arerolemodelsforresidentsandmoreexperiencedin
communicationwithpatients.Thepatientswithanon
Dutchoriginwereincludediftheyhadanappointmentfor
anewepisodeandthepatienthadnotbeenseenbythis
doctorforayearormore.Thesepatientscouldbeofany
originandwerenotaprioriselected.Theywereall
referredbyageneralpractitioner.Thepatientswereasked
abouttheirplaceofbirthandthatoftheirparentsbefore
theywereaskedtoparticipate.Informedconsentofboth
thedoctorandthepatientwasrequestedbythefirstauthor
whothen,ifinformedconsentwasobtained,installedthe
cameraandlefttheroom.Exclusioncriteriawerethe
presenceofaninterpreter,apatientwithDutchethnicity,a
doctorofnonDutchorigin,afollowupconsultationora
consultationthatwaspartlydonebysomebodyelse,for
exampleamedicalstudent.
MAASGlobalInterCulturalCommunication
SinceavalidatedobservationlistforICCdidnotexist,we
combinedtheMAASGlobal,avalidatedinstrumentfor
assessingpatientcentredcommunication[2,16,17],with
270
E.Paternotteetal.
thefactorsinfluencingICCasfoundinarecentreview[6].
Validationofanymeasureisapermanentprocess[18].
Thestrongbaseoftheitemsscoredintheorysupportsthe
contentvalidityofthemeasure.SincetheMAASGlobal
wasdevelopedintheNetherlandstoassesscommunication
skillsofgeneralpractitionerresidentsinrealpractice,we
considereditasuitableinstrumenttousefortheobser
vationofcommunicationskillsofdoctorsinthehospital[
19].TheMAASGlobalhasbeenusedinresearchsettings
aswell[20].Combiningthetwoprotocols,i.e.thefactors
influencingICCandtheMAASGlobal,waspossible
becausethereisanoverlapbetweenthecategoriesofthe
MAASGlobalandthoseusedtoclassifytheinfluencing
factorsinthereview.ThecombinationoftheMAAS
GlobalandtheICCinfluencingfactorsprovidedaframe
workforcodingICCskills,whichcouldthenbeobserved.
Theresultingobservationalscale,theMAASGlobalICC
(Appendix),includes52communicationskillstobeana
lyzedonadichotomousscaleaspresentorabsentanda
4pointLikertscaletoindicatetherelevanceofeachskill
fortheconsultationunderobservation.Thisobservation
andanalysingisdonepersectionofthecommunication,e.
g.openingorexplorationofreasonforencounter(Ap
pendix).Intheresultssection,wereportontherelevant
skillswhichwerepresentorabsent.BecausetheMAAS
GlobalICCisanextensivelist,containingmanyitems,the
resultsectionincludesthecommunicationskillsofthe
MAASGlobalICCthatwerefoundtoberelevantas
absentorpresentinatleast40%oftheconsultations.
Measuresandanalysis
TheadaptedMAASGlobalICCwastestedonfacevalidity
withintheprojectteam,whichconsistedofspecialistsfrom
differentfieldsofexpertise(medical,culturalcompetence,
communicationinhealthcare,medicaleducation).Thefirst
author(EP)observedandanalyzedalltheincludedvideo
tapedconsultations.Thevideotapedconsultationswerealso
Table1Characteristicsofthevideotapedconsultations
independentlyobservedandanalyzedbyoneoffoursecond
observers(CS,LB,LR,TA),whoallwatched910
videotapedconsultationseach.Afterthefirstindependently
observedconsultation,theintraclasscorrelationcoefficient
(Cohenskappa)wascalculatedanddiscussedbetweenEP
andeachsecondobserver.Thereafter,EPandthesecond
observerindependentlyscoredthreeconsultations,andonce
againtheintraclasscorrelationcoefficientwascalculated.If
theCohenskappawasbelow0.6,thevideotapedconsul
tationandscoringwerediscussedtocheckiftheobservers
couldreachahigherlevelofagreement.Beforediscussion,
themeanCohenskappabetweentheobserversrangedfrom
0.47to0.59.Afteradiscussionbetweentheobservers,the
meanCohenskapparangedfrom0.67to0.82.Scoringofthe
videotapedconsultationswasanalyzedwithSPSS21.
Aftereachconsultation,doctorswereaskediftheywere
satisfiedabouttheconsultation.Also,doctorshadtowrite
downiftheyhadenoughtimefortheconsultation.
Results
Intotal,18doctorswereaskedtoparticipateand17
doctorsagreedtoparticipate.Onedoctorrefusedbecause
hefounditdifficulttoaskhisoncologypatients.Ofthese
17doctors,69consecutivepatientsofnonDutchorigin
wereaskedtoparticipate.Ofthesepatients,41gave
informedconsent.Theother28patientsrefusedto
participate,mostlybecauseofprivacyreasons.Twoofthe
41videotapedconsultationswereexcluded,onebecause
thedoctorwasofnonDutchoriginandtheotherone
becausethevideotapelackedsound.
Table1showsthecharacteristicsofthe39included
videotapedconsultations.Furthermore,Table2presentsthe
relevantcommunicationsskillsdemonstratedbythedoctors.
Table3liststhecommunicationskillsthatwerenotusedby
thedoctorsbutthattheobserversconsideredtoberelevantin
thespecificcontextofaninterculturalconversation.Afterthe
consultation,alldoctorsnotedthatthey
Numberofconsul
Ethnicity
Gender
Mean
Meanyearsofprac
Meanlength
tations(n=39)
a
(nonWestern /
(M/F)
age(y)
ticeasmedicalspe
videos
Western )n=39
cialist(y)
(min)
Patientsincluded(%)
32/7(85/15)
21/18
46.3
(54/46)
Specialtyofthedoctor
Gynaecology&Obstetrics
7
2/3
46.0
12.4
17.4
Internalmedicine
15
5/1
44.3
16.0
14.6
Urology
5
3/0
57.7
21.0
7.8
Orthopaedics
12
4/0
52.5
15.8
13.0
Afghanistan,Turkey,Morocco,Surinam,Nicaragua,Nepal,Nigeria,Cuba,Pakistan,China Poland,GreatBritain,Germany,Belgium,
Australia,Hungary
c
DoctorswereallofDutchorigin
Interculturaldoctorpatientcommunication
271
Table2Anoverviewofskills,presentinatleast40%ofthe
consultations,thatthedoctorsused:presentcommunicationskills
Explainsreferraltootherhealthcareworkers
Listensactively
Presentcommunicationskills
Thedoctor...
Showsconcern,isinvitingandsincere,commiseratesbymeansofeye
contactandnonverbalbehaviour,showscompassionforthepatient
Listens
Commiserateswithverbalreactions
Demonstratesreliability(beingfriendlyandhavinganopenattitude)
Hasanopenattitude(showspossibilitiesverbal/nonverbaltogive
thepatientspacefortheirstory)
Makesappointments:who,what,when
Respondstononverbalbehaviourandkeywords
Takesthetime
Givesinformationinsmallamounts
Hasanunprejudicedattitude
Triestoempathizewiththepatientsemotions
Showsempathicbehaviour
Appliesanadequatetimeschedule
Explainscauseandrelationofthecomplaintwithinthecontextofthe
expectationsofthepatient
Givesconcreteexplanations
Reflectsonthefeelingsofthepatient
Showsrespectforthepatient
Usesdifferentwaystogiveexplanations
Usesconcretelanguage
Announcesstagesoftheconversation
Checkexpectationsregardingtheconsultation/healthcare
Treatsthepatientwithcareandrespectduringphysicalexamination
Askaboutthepatientsfeelings
Checksifthepatientand/orrelativesunderstandtheexplanation
Askabouttherelativesemotions
a
Theskillsinthetablearepresentedfrommosttolesspresent
Showawarenessofhisownculturalandprofessionalcontext
weresatisfiedwiththeconsultationandthattheythought
theyhadenoughtimefortheconsultation.
Checkforeknowledgeofthepatientaboutdiagnosisorexpectedpol
icy
Observedcommunicationskills
Summarizethepatientsstory
DoctorsshowedavarietyofICCskillsthatfacilitatedthe
communication.Forexample,inmostconsultations
doctorsadequatelyemployedconcretelanguage,listening
andempathicbehaviourtowardthepatients,suchas
reflectingthepatientsfeelingsanddemonstratingconcern.
Also,doctorsgaveconcreteexplanations,forexample
usingdrawingstoexplainanXray.Mostconversations
werenothurried,andmostdoctorshadanadequatetime
schedule.Allthesepresentskillswereconsideredrelevant
bytheobserversbecause,inthiswayrespect,reliability
andanunprejudicedattitudewereshown.
Explorethereasonfortheconsultation,wishesandexpectations
Explorereactionofinformationtransfertothepatientscontext
Demonstratebeingalerttopossibleculturalaspectswhenaskingfor
thereasonfortheconsultation
Showawarenessofculturaldifferences
Inmanyconsultationsthedoctorsusedabiomedicalstyle
ofcommunication,inwhichtheyfocusedontheirown
agendawithbiomedicallystructuredquestionsandfewer
possibilitiesforthepatienttogiveinput.
Showtohavelearnedfrompreviousconsultationswithethnicminor
itypatients
Askifthepatientunderstoodtheinformation
Table3Anoverviewofskills,absentinatleast40%ofthe
consultations,thatthedoctorsdidnotusebutthatwererelevantwithin
thecontextoftheseconsultations:absentcommunicationskills
Checkifthepatientand/orfamilyunderstoodtheexplanation
Absentcommunicationskills
Adaptculturaldifferencesindiagnosisandpolicy
Thedoctordidnot...
Observeculturaldifferences
Checkthelanguageabilityofthepatient
doctorsayssomethingabouttreatmenthabitsinthe
Netherlandsorasksthepatientabouthis/herculturalhabits
forthespecificdisease,andadaptationofthediagnosisand
treatmentpolicytothecontextofthepatient,e.g.thedoctor
asksiftheprescriptionuseofthemedicationispossibleand
satisfactoryforthepatient,wereconsideredrelevantbecause
theseskillsfacilitatemutualunderstandingandrespect.
Reactadequatelytopossibleculturaldifferences
Theskillsinthetablearepresentedfrommosttolessabsent
Absentcommunicationskills
ICClanguageskillsincludecheckingthepatientslanguage
ability,whichwasabsentin17consultationswhereitwould
havebeenrelevanttodo.In37consultationsthemainlan
guagespokenwasDutch.IntwoitwasEnglish.AbsentICC
skills,suchasawarenessofculturaldifferences,e.g.the
TheseICCskillsweresometimesdifficulttoscore,be
causetheywereelusiveandnotexplicit.Forexample,the
doctordidnotalwaysdirectlyaddressapatientscultural
background,buttriedtogetinsightintothepatientsper
spectivebyfiguringoutwhatthepatientthoughttobethe
causeofthecomplaint(e.g.pain).Also,manydoctorsdid
notchecktheforeknowledgeofthepatientaboutthe
diagnosisandtreatmentpolicy.Therelevanceofattention
toculturaldifferenceswasemphasizedinthedoctorsex
plicitcommunication.Forexample,doctorsdidnottake
thepatientscontextintoaccountwhenproposingapolicy,
272
E.Paternotteetal.
suchasmedicationintakeordietaryadvice,andtheyhad
difficultiesshiftingfromtheirbiomedicalcommunication
styletothecontextandexpectationsofthepatient.When
theconversationwasmainlybiomedical,itwasdifficultto
determineifthedoctorswereawareoftheirowncultural
andprofessionalcontext.Inafewconversationsthedoc
torsmentionedtheirownculturalorigin,forexampleby
explaininghowatreatmentiscarriedoutintheNether
lands.This,however,didnotlinearlycausedoctorstopay
attentiontoculturaldifferences.Summarieswerenotoften
usedintheconversation,althoughthiscouldhavestruc
turedtheconversationanditcouldhavehelpedboththe
doctorandthepatienttocheckifspecificinformationwas
understoodcorrectly.
Otherskillsthatwereabsentbutrelevantlayinthefieldof
expectationmanagement,showinginterestinthepatients
familyandcheckingifthepatientunderstoodthe
informationgivenbythedoctor,whichwasrelevantasit
mighthavehelpedtoclarifypossiblemisunderstandings.
Anexampleofexpectationmanagementisexploringthe
patientsviewonthereasonfortheconsultationorthepa
tientsexpectationoftheconsultation.However,ifdoctors
usedquestionsaimedatclarifyingthepatientsexpecta
tions,whichwasnotdonein62%butusedin38%ofthe
consultations,thisprovedtofacilitateICCanddirectthe
communicationintoamorepatientcentredapproach,de
pendingonthewaytheywerephrased.Forexample,after
listeningtoacomplexaccountofthepatientscomplaints,
onedoctorasked:Whatdoyouexpectfromme?Would
youlikemetoreducethepain,orisitsomethingelse?
Discussion
Inthisobservationalstudy,wefocussedonrelevantICC
skillsofmedicalspecialistsinrealpractice.Themedical
specialistsinthisstudyprovedtobecapableofpractising
manycommunicationskills,suchaslistening,showing
empathiccommunicationbehaviourandbeingopenandre
spectfultothepatient.Otherskillswerenotpractisedal
thoughtheywererelevantintheinterculturalcontext,such
asbeingculturallyaware,checkingthepatientslanguage
ability,checkingifthepatientunderstoodandexploring
thereasonfortheconsultation.Thecommunicationstyle
ofthedoctorswasoftenabiomedicalstyle.
Theuseofabiomedicalstyleintheseinterculturalcon
versationsissurprising,sinceICCrequiresapatientcentred
focuswithspecificattentiontothepatientsbiopsychosocial
needs,becauseofthevulnerabilityformisunderstandingsof
ethnicminoritypatients[13,21].Ourstudyshowedthatthe
doctorsdidnotproperlyapplyanumberofspecificICC
skills,suchasadaptingdiagnosisandtreatmentpolicytothe
culturalcontext.However,theyalsodidnotpractice
certaingenericcommunicationskills,suchasexploringthe
reasonfortheconsultationorcheckingthefeelingsofthe
patient,whichisstrikingbecauseweincludedmedicalspe
cialistswhocouldbeexpectedtohavelearnedhowto
practicethesecommunicationskillsintheirundergraduate
andpostgraduatetrainingThisisavaluablefinding,as
medicalspecialistsfunctionasrolemodelsfor
postgraduatetrainees[22],whichis,however,notalways
trueduetothetransferproblemsofcommunicationskills
fromtrainingtotrainee[23].Inallmedicalspecialty
trainingprogrammesintheNetherlandsthereissome
formalcommunicationtraining.However,thisusually
takesplaceduringpracticeandnotasadditionaltraining.
Thecommunicationtrainingismostextensiveforresidents
ofthetrainingtobecomeageneralpractitioner[23].
Nowadays,doctorsinWesterncountriesaretaughttousea
patientcentredcommunicationstyle[8,13,21,24].Patient
centredcommunicationhassimilaritieswithICC,suchasthe
responsibilityofthedoctorforthenonmedicalor
interpersonalaspectsofthecommunication[25].The
interpersonalaspectsofcare,forexampletrust,respectand
empathy,arekeydeterminantsofpatientsatisfaction[13,21].
Aswasmentionedabove,wefoundmissinggeneric
communicationskills,suchasexploringthereasonforthe
consultation,checkingifthepatientunderstood,andex
pectationmanagement.Theseareskillsofpatientcentred
communicationaswell[21].Inaninterculturalcontext,
patientcentredcommunicationisprobablyevenmoreim
portant,becausethebalanceintheinterpersonalaspectsofthe
communicationishardertofindwhendoctorandpatienthave
differentnormsandvalues.Interculturalandpatientcentred
communicationhavenotbeenformallyintegratedtogetherin
medicaleducation,althoughthefunctionofbothintercultural
andpatientcentredcommunicationistoimprovehealthcare
qualityinsimilarwaysandtheusedskillsforpatientcentred
communicationandICCshowsimilarities.Therefore,
patientcentredcommunicationandICCshouldbe
incorporatedinmedicaleducation,sothatdoctorswillnot
havetolearntwodifferentapproaches[13].
Itwasstrikingthatthedoctorsallsaidtheyweresatisfied
withtheirconversation,whiletheobserversconcludedthat
doctorsdidnotpracticetherelevantICCskills.An
explanationcouldbethatthedoctorsneedtobeconfronted
withtheircommunicationbehaviourbeforetheycanim
provetheircommunicationskills[15].Finally,weneedto
saythatthecomplexityofICCcannotbegraspedinalist
ofdosanddonts.Itisnotamatteroflearningonlyone
skillforICCbutoflearningacompletesetofskillsand
beingabletoapplytheseintherightwayattherighttime.
Itisthecompletesetofbehaviourswhichmakesadoctor
agoodinterculturalcommunicator,andcommunication
trainingisnotaonesizefitsalltraining[5].
Interculturaldoctorpatientcommunication
273
Conclusion
Weshowedthatdoctorsdidpracticesomebutnotallthe
relevantICCskillsandthattheICCstyleofthedoctorswas
mainlybiomedicallycentred.Hence,itisunlikelythatpost
graduatemedicaltraineeswillacquirealltherequiredICC
skillsmerelybymodellingtheirbehaviourontheexampleof
theirclinicalsupervisors.Furthermore,wediscussedthe
possibleoverlapbetweeninterculturalandpatientcentred
communication.Thisoverlapandtheabsenceofskillsinboth
thesedomainssuggestthatintegratingpatientcentred
communicationandICCtrainingmaycontributesubstan
tiallytothedevelopmentofmedicaleducationforpostgrad
uatesandmedicalspecialists.
Strengthsandlimitations
Thisobservationalstudyprovidedtheopportunitytoexamine
theapplicationofICCskillsinrealpractice.Astrengthofthis
studywasthefocusonspecialistsinsteadoftrainees,because
medicalspecialistsfunctionasrolemodelsforpostgraduate
trainees.Anotherstrengthwasthattheconsultationswere
videotapedbeforetheywereanalyzed,andthatthetapeswere
analyzedbyobserversfromdifferentareasofexpertise,so
thatthedatacouldbeviewedfromseveralperspectives.Since
thegroupsofmedicalspecialistsweresmall,itwasnot
possibletofurtheranalyzetheinfluenceofageandyearsof
experience.Besides,thestudypopulationwastoosmallto
assessdifferencesincommunicationstylesbetweenthe
doctors.
Anotherlimitationwasthatwedidnotaskthepatientsfor
theiryearsofresidenceintheNetherlands.Theexact
influenceofthisonICCishardtodetermine.Ononehand,
beingintheNetherlandsforalongerperiodcouldpositively
suggestaninfluenceoftheICCwithanativedoctor.Onthe
contrary,manypeoplecontinuetoidentifythemselveswith
theircountryoforigin[26],whichcouldsuggestthatyearsof
residenceintheNetherlandsislessimportant.
Implicationsformedicaleducation
Basedontheresultsofourobservationalstudyofdaily
outpatientcareandthepointsmentionedinthediscussion,
wewouldadvisetoextendthealreadyexistingcommu
nicationtrainingforpostgraduatemedicaleducationwith
ICCspecificskills,suchasaskingaboutthelanguagepro
ficiencyofpatientsorcheckingiftheproposedtreatment
planfitsintotheculturalhabitsofthepatient.Elaborating
ICCtrainingcouldincludediscussionofdoctorsown
videoconsultationswithpeersinthepresenceofacom
municationexpert.Besides,wewouldadvisethatmedical
specialistsalsoembracetheconceptoflifelonglearning
andthattheyattendcommunicationtrainingfocusedon
patientcentredcommunicationthatincludesICC.
Futureresearch
ManyoftheelementsoftheMAASGlobalICCthatwe
usedseemedtoberelevantforcommunicationwithevery
patient.Futureresearchcouldstudywhetherthisistrue,
andshouldfurtherexploretheoverlapbetweenICCand
patientcentredcommunication.Inthepresentstudy,we
focusedonthedoctorfromthethirdperson,theobserver.
Also,itappearstobeimportanttoevaluatedoctorsneeds
forICCskillsandpatientspreferencesandsatisfaction
withtheirdoctorscommunicationskills.Furtherresearch
couldbeareflectivepracticestudywithdoctorsbasedon
theirvideotapedconsultations.Anotherfurtherresearch
possibilityistocomparethepatientcentredcom
municationskillsandICCskillsofdoctors.Thiscould
facilitatethedevelopmentoftrainingfocusedonrelevant
communicationskills.
AcknowledgementsWearegratefultoallthepatientsanddoctors
whoparticipatedinthisstudy.SpecialthanksareconveyedtoLotte
RoosendaalandTugbaAydin,whohelpedwithobservingthedata.
WewishtothankLisettevanHulstforeditingthemanuscript.
Funding/SupportNone
ConflictofinterestE.Paternotte,F.Scheele,M.C.Seeleman,L.
Bank,A.J.J.A.ScherpbierandS.vanDulmendeclarethattheyhave
nocompetinginterest,nofinancialcompetinginterestsandnonon
financialcompetinginterests.
ThestudywasperformedaccordingtoDutchprivacylegislation.Ap
provaloftheDutchmedicaleducationethicsboardwasobtainedfor
thisobservationalstudy(NVMOERB355).Beforehand,allpartici
patingdoctorsandpatientswereinformedabouttheaimandthepro
cedureofthestudy.Allparticipantssignedaninformedconsentform
beforetherecordingoftheconsultationwasstarted.
OpenAccessThisarticleisdistributedunderthetermsofthe
CreativeCommonsAttribution4.0InternationalLicense(http://
creativecommons.org/licenses/by/4.0/),whichpermitsunrestricted
use,distribution,andreproductioninanymedium,providedyougive
appropriatecredittotheoriginalauthor(s)andthesource,providea
linktotheCreativeCommonslicense,andindicateifchangeswere
made.
274
E.Paternotteetal.
Appendix
Table4MAASGlobalICCobservationscale
Thedoctor...
Opening
ChecksthelanguageabilityofthepatientCheckswhoistheformal
speakerofthefamily
Explainscauseandrelationofthecomplaintwithinthecontextofthe
expectationsofthepatient
Checksifthepatientand/orrelativesunderstoodtheexplanation
Policy
Adaptculturaldifferencesindiagnosisandpolicy
Checkswiththerelativesiftheyunderstandthechoiceofpolicy
Makesappointments:who,what,when
AskstotherelativesfortheirconnectionwiththepatientListens
Explainsreferraltootherhealthcareworkers
Reactsadequatelytopossibleculturaldifferences
Explore
ReasonForEncouter
Demonstratesbeingalerttopossibleculturalaspectswhenasking
forthereasonfortheconsultation
Checksreasonsofencounteroftherelatives
Checksexpectationsregardingtheconsultation/healthcare
PhysicalExamination
Treatsthepatientwithcareandrespect
Exploresthereasonforconsultation,wishesandexpectations
Explorestheperceptionoftherelatives
RecognizesmisunderstandingcausedbyalanguagebarrierExplores
thereactionofinformationtransfertothepatientscontextResponds
tononverbalbehaviourandkeywords
Respondstocues/keywordswhicharerelatedtoculturaldifferences
Emotions
AsksaboutthepatientsfeelingsReflectsonthefeelingsofthe
patientAsksabouttherelativesemotionsListensactively
Diagnosis
Triestoempathizethepatientsemotions
Announcesstagesoftheconversation
InformationTransfer
Empathy
Checkstheforeknowledgeofthepatientaboutdiagnosisorexpected
policy
Showsconcern,isinvitingandsincere,commiseratesbymeansofeye
contactandnonverbalbehavior,showscompassionforthepatient
GivesinformationinsmallamountsGivesconcreteexplanations
Usesconcretelanguage
Commiserateswithverbalreactions
AsksifthepatientunderstoodtheinformationUsesdifferentways
togiveexplanationsPaysattentiontopronunciation
Observesculturaldifferences
Showsempathicbehavior
Usesattributesforexplanation
Hasanopenattitude
Summarize
Showsrespectforthepatient
SummarizesthepatientsstorySummarizesinhisownwords,
conciseAttempts
ConsultEvaluation
Hasanunprejudicedattitude
Table4MAASGlobalICCobservationscale(Continued)
Demonstratesreliability
Thedoctor...
Showsawarenessofhisorherownculturalandprofessionalcontext
Structure
Showsawarenessofculturaldifferences
Appliesanadequatetimeschedule
Speaksmorelanguagesofwordsofanotherlanguage
Takesthetime
Showstohavelearnedfrompreviousconsultationswithethnicminor
itypatients
PaternotteE,vanDulmenS,vanderLeeN,ScherpbierAJJA,
ScheeleF.Factorsinfluencinginterculturaldoctorpatientcommu
nication:Arealistreview.PatientEducCouns.2014;doi:10.1016/
j.pec.2014.11.018.
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EmmaPaternotteisaMDandaresearcherinmedicalcommunica
tion
FeddeScheeleisagynaecologistandaprofessorinhealthsystems
innovationsandmedicaleducation
AlbertJ.J.A.ScherpbierisaMDandaprofessorinquality
improvementinmedicaleducation
ConnyM.Seelemanisaresearcherinthefieldofculturalcompetence
SandravanDulmenisapsychologistandaprofessor
communicationinhealthcare
LindsayBankisaMDandaresearcherinmedicaleducation