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Thai Doctor and Foreign Patients Communication during the Medical Care: Case Study in Thailand

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					                                                           Thai Doctor and Foreign Patient Communication 1

           Thai Doctor and Foreign Patients Communication during the Medical Care:
                                   Case Study in Thailand
Abstract
        A busy practitioner can easily forget the obvious’ whenever people communicate, there are
multiple cultural influences on their interaction. Cultural background, health beliefs and expectations
affect health care encounters with every patient. To communicate effectively, it is necessary to avoid
stereotyping by responding to patients as individuals within their own cultural context. Health
professionals must also recognize the influence of their own cultural backgrounds and attitudes on
their communication with patients. Communication is sometimes more challenging with those who are
different from us. Cultural diversity is becoming increasingly more important in the workplace. This is
particularly true in hospitals facing demographic shifts in the patients served and their families. This
study serves to explain and describe the intercultural communication and the understanding of
interaction between doctor and patient during medical care. The aim pf this study was to examine
communication patterns of doctor-patient in different cultures. This study used interview and document
analysis as a methodology. The findings presented that the variations may reflect cultural differences,
whereas the similarities also reflect. Adequate awareness of these differences and similarities could be
used to educate Thai doctors about the best approaches to foreign patients from particular cultural
backgrounds.
บทคัดยอ
                                 ั้
        ในการสนทนาของมนุษยนนมักมีปจจัยเรื่องความหลากหลายทางวัฒนธรรมเขามาเกี่ยวของกับการ
ปฏิสัมพันธในแตละครั้ง พื้นฐานดานวัฒนธรรม ความเชื่อและความคาดหวังเรื่องสุขภาพไดสงผลกระทบตอการ
รับการรักษาของคนไข การกอใหเกิดการสื่อสารอยางมีประสิทธิภาพนั้นจําเปนจะตองคํานึงเรื่องความแตกตาง
                                                                ้
ดานวัฒนธรรมเปนสําคัญ โดยแพทยผูรักษาจะตองปฏิบัติตอคนไขบนพืนฐานดานวัฒนธรรมและทัศนคติดานการ
                                      ั
สื่อสารของคนไขคนนั้น ๆ ในปจจุบนความหลากหลายดานวัฒนธรรมในองคกรตาง ๆ ไดเพิ่มความสําคัญมากขึ้น
                                    ั   ้
โดยเฉพาะในโรงพยาบาล งานวิจยครั้งนีมีวัตถุประสงคเพื่ออธิบายและบรรยายถึงการสื่อสารขามวัฒนธรรมและ
                                                                                                 ั
สรางความเขาใจเกี่ยวกับปฏิสัมพันธระหวางแพทยไทยและคนไขตางชาติในระหวางการตรวจรักษา การวิจยใช
          ี ั
ระเบียบวิธวิจยเชิงคุณภาพในแงของการสัมภาษณและการทบทวนเอกสารที่เกี่ยวของ                    ั
                                                                                   ผลการวิจยพบวาใน
ระหวางการตรวจรักษาจะพบความแตกตางและความเหมือนดานวัฒนธรรมระหวางแพทยไทยและคนไขตางชาติ
     ้
ดังนันการตระหนักในประเด็นดังกลาวจะสงผลใหแพทยสามารถทําการรักษาคนไขไดอยางมีประสิทธิภาพ
                                                                     Thai Doctor and Foreign Patient Communication 2

Thai Doctor and Foreign Patients Communication during the Medical Care:
Case Study in Thailand
_____________________________________________________________________________
                                                                       Doungtip Chareonrook (Ph.D.) 1
Introduction
         Each of us has a cultural background, although some are more mixed that others. Our friends,
neighbors, coworkers, and patients also have their own cultural backgrounds. Cross-cultural
interaction occurs when two cultures come into direct contact with each other. A growing crisis in the
Thailand’s medical care system is the cultural gap between the medical system and huge number of
ethnic minorities it employs and serves (Galanti, 1991). Differences in beliefs about health and illness,
perceptions of appropriate treatment, and expectations about interaction in the medical setting
complicate the communication brings to the medical care setting and amalgam of modern and
traditional beliefs, values, and institutions that often conflict with and contradict each other (Kleinman,
1980).
         Because of the unique relationship between the doctor and the patient, it is essential to find an
effective way to communicate across cultures. While language differences are a significant barrier to
effective communication between doctor and patient, cultural differences go far beyond this initial
hurdle. Cultural background influences patients’ interpretation of disease, health, health care, and the
manner in which they relate to medical care providers, and the own cultural background influences the
way for interpreting the patients disease and treatment. In order to incorporate the patients’
perspective into the care provide, doctors need to appreciate the patient’s view of and approach t
medical care.
         Therefore, the meeting of healer and sick person is of importance to people in all cultures
around the world and Thailand. The literature has clearly documented the role of culture in regards to
individual’s beliefs and responses to illness and healing (Angel & Thits, 1987). Providers in the health
care setting; however, have more to learn about effects of culture on communication in the medical
setting particularly in regards to patient participation in the medical interview (Geist, 1997).




1
    Lecturer, Department of Communication Arts (International), Faculty of Communication Arts, Rangsit University
                                                               Thai Doctor and Foreign Patient Communication 3

         • The purpose of this study
         According to the reasons, which are above, this study focuses on the complex and dynamic
features of communication in a medical care context between Thai doctors and foreign patients in the
hospitals, which situate in Thailand, challenged by the culturally diverse expectations and behaviors of
individuals seeking medical care and look at problems beyond language to increase awareness of the
way in which cultural differences affect the Thai doctors and foreign patients’ communication efforts.
         According to the method of material collection, data are not only quantifiable and empirical,
there have been two primary source of materials. First, published materials, book reports and papers,
evaluations of schemes by research, and second, in-depth interview. Additional sources of information
included several in-hospital studies, which have not been published. Interviews with nurses and
pharmacists at the hospitals constituted the other major source of collecting data. These interviews,
mostly open ended, are largely informal conservation. Questions are primarily designed to seek their
views on the cross-cultural communication and interaction between Thai doctors and foreign patients.
These interviews not only served as sources of information, but also analysis.
         • Defining the terms for understanding this study
         A few definitions are in order. Terms that are frequently used in cross-cultural literature
between doctor and patient are cultural sensitivity, health belief model, cultural competence, and
ethnocentricity.
         Cultural sensitivity is learning to respect and honor other cultures. It is also ability to be open to
the ideas of these cultures as they impact the interactions and to have tolerance for beliefs and
traditions of others. The health belief model try to explain or predict behaviors toward health
specifically in the area of disease prevention in public health. It is based on the patient’s own
perceptions of his/her health rather than on objective measures or the judgment of health
professionals. It includes cultural factors that will influence the patient’s chosen action concerning
disease prevention, diagnosis, and compliance or acceptance of treatment. Cultural competence is
being able to respect and honor the beliefs, interpersonal styles, attitudes, and behaviors of another
culture essentially cultural sensitivity. The goal of doctors working in a multicultural environment should
be cultural competence. Ethnocentricity implies an awareness of and concern only with one’s own
culture. This works directly against communicating effectively with other cultures.
         In the hospital setting, cross-cultural medical care during hospitalization and at discharge can
be even more difficult due to the added stress of illness. Bilingual patients tend to rely on their native
                                                              Thai Doctor and Foreign Patient Communication 4

language during times of high emotional stress. Without effective communication between Thai doctor
and foreign patient regarding medical therapy, serious consequences could occur. Cross-cultural
communication is often needed between medical care professional as well. In this ever-shrinking
world, the need for the ability to communicate with people from various cultural backgrounds is
becoming essential.
Literature Review
        There are numerous empirical studies of cross-cultural communication, but theoretical
analyses are few and theory of two-way communication between patient and doctor is desirable.
However, there is a dearth of research that has explored the effects of patients’ cultures and cultural
orientations on patients’ abilities to actively participate in the medical encounter. As a step toward
conceptual integration, the study brings together extent empirical findings within a cultural framework.
        Human behavior is directly linked to attitudes and beliefs, and an individual’s predisposition is
controlled by the set of cultural beliefs that the individual has learned to associate with the object of
the predisposition and are associated with patient participation (Kim & Hunter, 1993). The culture
influences mediating processes that affect the communication with doctors. Similar mediation models
have been adopted for explaining communication process across cultures, including low- and high
context communication styles (Gudykunst et al., 1996) and the importance of conversational
constraints (Kim et al., 1996). To better understand the effects of culture, it must specify the cultural
dimensions and psychological variables that distinguish people who are from different cultures.
        In the following section, the study presents factors that related to communication between Thai
doctors and foreign patients: (a) the cultural dimension; (b) the foreign patient participation; (c)the role
of culture on foreign patient’s assertiveness; and (d) research studies related to this study.
        • The cultural dimensions
        When study cross-cultural communication between Thai doctor and foreign patient, it is helpful
to consider basic aspects or dimensions of cultures. Hofstede (1984) presents four dimensions of
cultural : power distance, uncertainty avoidance, individualism vs. collectivistic, and masculinity vs.
femininity. These dimensions pervade the vary fabric of culture, manifesting themselves in areas such
as family, school setting, and workplace. The concept of power distance deals with basic human
inequality. Hofstede (1984) defines power distance as a measure of interpersonal power or influence
between B and S as perceived by the least powerful of the two, S. This type of distance shows up not
only the existence of a human pecking order but also in the relative size of the space between person
                                                            Thai Doctor and Foreign Patient Communication 5

B and person S. The concept of uncertainty avoidance is rooted in human’s lack of knowledge about
what the future holds. Different people and different cultures of people, deal with uncertainty in various
ways. Way of coping with uncertainty belong to the cultural heritage of societies and they are
transferred and reinforced through basic institutions like the family, the school, and the state
(Hofstede, 1984). The third dimension of national culture is called individualism vs. collectivistic.
Individualistic cultures emphasize the self over the group and personal independence over social
interdependence. Those cultural values encourage self-expression and speaking one's mind freely. By
contrast, in collectivistic cultures, people grow up wedded more strongly to their groups and learn to
value interdependence more than personal independence. The fourth dimension is masculinity vs.
femininity, masculinity countries predominate where dominant values relate to success, money, and
things, while femininity countries predominate where dominant values relates to caring for others and
the quality of life. High femininity countries have more flexible sex roles and place greater emphasis on
cross-sex interaction and people in the achievement-oriented masculine countries tend to be
assertive, competitive and to take tough approaches to decision making while those in nurlurance-
oriented feminine cultures have a greater concern for co-operation, good working relationships and a
more sensitive approach to decision making for both men and women (Lustig & Koester, 1993).
        However, communication for business is complex and there is something not quite satisfying
about only four dimensions. Hofstede himself later added another dimension after collaborating with
Micheal Bond called Confucian dynamism (Kashima, 1986). It deals with a number of characteristics
of Hong Kong Chinese that are summed up as long-term orientation (which are persistence, value
placed on status) and short-term orientation (which are personal stability, high regard for truth).
        Moreover, Hall (1997) proposes that cultures vary in the extent to which communication is
influenced by context along a continuum from high to low context systems. He presents that members
of high context cultures appear to be more cautious, make more assumptions about strangers based
on their cultural background, and engage in less nonverbal behavior than members of low context
cultures. Further, members of high context cultures rely more on assumptions about strangers’
backgrounds to increase attributional confidence than do members of low context cultures.
        • The foreign patient participation
        The term patient participation has been used to encompass everything from information
exchange to challenging a doctor's opinion (Haug & Lavin, 1981). In this study, foreign patient
participation is conceptualized as the degree to which patients use communication to actively seek
                                                           Thai Doctor and Foreign Patient Communication 6

information and participate in mutual decision-making with health professionals regarding their
medical condition and treatment. To ensure that patients fully understand the medical diagnosis and
implications, patients should regard the physician as a potential source of information (Phillips &
Jones, 1991). Further, foreign patients must disclose any reservations or preferences to the Thai
doctor when choosing a medical treatment. Overall, active patient participation in collaborative
medical practice means doctors and patients share responsibility and share decision-making (Haug &
Lavin, 1981).
        • The role of culture on foreign patient’s assertiveness
        Foreign patient participation relies heavily on patient assertiveness or the ability to make
requests, actively disagree, express positive or negative personal rights and feelings, initiate,
maintain, or disengage from conversations, and stand up for one's own. In the foreign patient-Thai
doctor relationship, if needed, foreign patients must be able to initiate questions, express personal
values and needs, and even say "no" to their Thai doctor. Assertiveness is defined as behaviors which
enable people to act in their best interest, or stand up for themselves without undue anxiety, and to
express their rights without denying the rights of others (Infante & Rancer, 1996). At least within the
U.S. context, assertiveness has been viewed as a measure of social or interpersonal communication
competence. However, assertiveness is not viewed similarly across cultures. Although the cultural
norms that rule against assertiveness are not well studied, some scholars attribute low assertiveness to
an effort to maintain group harmony (Fukuyama & Greenfield, 1983). Additionally, there are cultures
that respect silence, which illustrates respect through passive, deferential behavior.
        Assertiveness has typically been treated as a unidimensional construct, but different types of
assertiveness may play varied roles in different contexts. Recent evidence by Goldberg and Botvin
(1993) supports the concept of assertiveness as a multidimensional construct but also provides
evidence for situation-specific, assertive skills. Individuals of high interdependence may demonstrate
a clear pattern of avoidance of communication, particularly such threatening communication
experiences as medical interviews, public speaking, and interviewing with an influential person more
so than among individuals of high independence.
        • Research studies related to this study
        Finnegan and Viswanath (1990) found that between 1983-1987, professional patient
relationships was the most studied topic in health communication research. Researchers have
confined their questions to the nature and seriousness of illness either by considering the site of the
                                                           Thai Doctor and Foreign Patient Communication 7

decision making (Lewis, Pantell, & Sharp, 1991) or the impact of individual demographics, such as
education, and gender (Haug & Lavin, 1981). Absent from the literature is the impact of cultural
contexts in doctor-patient communication and theoretical work articulating the role of cultural
orientations on patients' ability and willingness to actively participate in the medical encounter.
         Much discussion has focused on the importance of viewing the doctor-patient relationship as a
collaboration in which two-way communication between patient and doctor is vital for doctors to
adequately treat patients and for patients to carry out medication recommendations. Nevertheless,
some cultures discourage assertive behaviors, which make it extremely difficult for certain individuals
to act assertively with their doctor; thereby, impacting people's ability to engage in a collaborative
relationship with their doctors.
         Fishers (1986) suggested that crosscutting all interactions between providers and patients is
an ideology that supports the authority of the medical perspective over the patient's perspective.
Consequently, the asymmetry of the medical relationship creates difficulties for patients in raising
topics of interest to them and/or providing information they see as relevant (Fishers, 1986). Knowing
how culture influences verbal participation could shed light on how to produce culturally sensitive
intervention programs designed to build collaborative medical practice (Young & Mingle, 1996). One
of the basic principles that guides this investigation is the belief that culture is one of the major
influences contributing to patients' motivations for communication approach and avoidance in medical
interviews. This belief is founded on the well-accepted fact that culture shapes one's perceptions of
reality and programs the structure of one's thoughts, feelings, and actions.
Thai doctors and foreign patients communication during medical care
         • Background of foreign patients, interaction, problems and solutions between Thai doctors
and foreign patients during medical care
         From the study, it presents that the kind of information that Thai doctors should obtain about
the cultures represented in the foreign patients such as medical problems, language, religious beliefs,
cultural traits, traditional concepts of disease and health, types of medicine practiced, and attitudes
toward medical care.
         Religions represented among foreign patients may also impact the way the patient views
disease. Traditional folk medicine, Chinese medicine, and Western medicine are all practiced to
varying degrees by patients in this group. Typical diseases among almost foreign patients in Thailand
are more often those seen in older patients. Diabetes, arthritis, and heart disease are common reasons
                                                            Thai Doctor and Foreign Patient Communication 8

for seeking medical attention. Patient characteristics may be different as well, with older patients. From
the Western viewpoint, these patients often overemphasize symptoms and have a poor regard for
standard procedures, such as making appointments (Young & Mingle, 1996). To understand such
patients, it is important to recognize the medical-care system that the patient was accustomed to in
his/her home country.
           Some countries, foreign patients have to travel long distances to a hospital with the required
equipment in many cases (Young & Mingle, 1996). This situation encouraged patients to make their
case sound more difficult and complex in order to receive a better quality of care. In some hospitals, it
was not uncommon for bribes from family members to be accepted by hospital staff to ensure that the
ill relative was given attention (Young & Mingle, 1996). People who grew up within this system of care
often have difficulty adjusting and hold on to the old ways of trying to getting efficient, high-quality
care. Other experiences of these patients that affect their expectations of the health-care system
include the length of hospital stay and the case obtaining treatments, including drugs.
           Foreign patients and their families will often try hard to avoid discharge by claiming new or
renewed symptoms. As with many diagnostic and interventional devices, drugs were often hard to
come by in these countries. Because these treatments were restricted to the most ill or most wealthy
patients, the case of obtaining them can cause concern. Some patients may believe that a therapy
easily obtained is either inferior or implies a terminal illness. Eastern European patients often have
traditional attitudes toward health and health care (Kleinman, 1991).
           The relationship between Thai doctor and foreign patient is authoritarian, with the patient
accepting the doctor's words. Thai doctor must behave appropriately as well, and preferably be an
older male. The foreign patients’ experiences of medical care in their home country and their
expectations of health professionals can have important impacts on Thai doctor's relationship and
ability to communicate effectively with them. Because of their experience with their native medical-care
systems, they may ignore refill procedures or orderly lines in the outpatient medical care. Their
expectations of health-care professionals may make them uncomfortable with Thai doctors' questions
that imply the patient can make decisions regarding his/her own therapy. They may also distrust
young, especially female doctors. And lists of possible side effects may indicate to them that the
doctor is unsure what will happen.
           In order to provide medical care, Thai doctor must communicate with the foreign patient in a
number of ways. For example, in the community setting, when a Thai doctor presents a prescription to
                                                             Thai Doctor and Foreign Patient Communication 9

the foreign patient, three main avenues of communication are required. First, Thai doctor must obtain
specific information from the foreign patient, such as allergy and drug histories. Second, Thai doctor
must impart specific information to the foreign patient about the drug therapy, such as route of
administration, dose, side effects, and duration of therapy. Third, Thai doctor must ascertain the
foreign patient's level of understanding of the information given and discover any questions he/she
may have. Each of these processes can be hindered by cultural differences, which include but are not
limited to language differences.
         When working with cross-cultural patients, it is important for Thai doctors to learn and
understand where their attitudes originate. With this understanding, Thai doctors can then start to
adapt their own behavior. Instead of long lists of potential side effects, give those specific instructions
on what to do if a specific side effect occurs. By communicating with the foreign patients more on their
terms, Thai doctors can gain acceptance and start to negotiate some understanding of how the
system works here. Foreign patients from many cultures expect instant diagnosis and quick treatment
decisions. Diagnostic facilities in their home countries were usually crude, with diagnosis and
treatment decisions made quickly with limited information. The time it takes to go through the
diagnostic procedures and the process of determining treatment in some cases can cause fear and
distrust in foreign patients from other cultures.
         Within the Southeast Asian population, for example, patients may speak Vietnamese, Chinese,
Laotian, and others. Some patients may have only a English spoken, not written. Moreover, European
people speak English, French, Italian etc. These issues will clearly impact a choice of interpretion and
method of communication. When the Thai doctor and the foreign patient speak same language such
as Thai, English, there can be problems with communication based on the cultural system of beliefs in
place. It is often necessary to change Thai doctors’ approach to communication based on the specific
culture with which foreign patients are dealing. One example would be a Thai female doctor interviews
a Chinese male about symptom. Given the Thai doctor's gender, the patient would expect to be
approached respectfully, in both verbal tone and mannerism. If the Thai doctor were to scold the
patient, thereby taking on a parent role, the patient would be unlikely to respond. Similarly, if the Thai
doctor is male and the patient is a American female patient, Thai doctor should not assume American
patient is not listening if patient fails to make eye contact with him. As a representative of the medical-
care system, the doctor may be seen as someone to be respected in many cultures (Northouse &
Northouse, 1998).
                                                            Thai Doctor and Foreign Patient Communication 10

         Nonverbal communication is very important in conveying respect and status, and some
cultures typically rely on it more than others, depending instead on shared history and experiences
and the implied messages they provide for basic communication. These cultures are known as "high-
context" cultures; their communication is heavily dependent on the context of what is being
communicated rather than on specific words. Examples include Asian, African-American, Hispanic,
and Native American cultures (Galanti, 1991). Especially, Thailand is a high-context country. Directly
opposite to these high-context cultures are those known as "low-context". These include "non-Hispanic
whites" such as, Swiss, German, and Scandinavian cultures. These cultures depend much more
heavily on precise, direct, and logical spoken communication and less on an assumed understanding.
         High-context cultures sometimes have belief systems that relate illness to the weather, the
social environment, or eating habits. Because of this, foreign patients may spend a large amount of
time describing the circumstances surrounding their illness rather than focusing on the illness itself. In
the practice of Western medical care, such discourses are discouraged and seen as distracting. For
the foreign patient, however, providing such seemingly anecdotal information may put them at ease
(Vanservellen, 1997). Paying attention and allowing the foreign patient to tell Thai doctor what is
important to them may also help the doctor to gain their trust. Major difficulties occur when patients
from a low-context culture interact with doctors from a high-context culture. Expectations and
understandings vary between the two cultures, and knowledge on both sides is needed to facilitate the
communication experience.
         In addition, the nonverbal messages that Thai doctors send to their foreign patients affect their
willingness to participate in communication with them and to comply with the drug therapy that Thai
doctors are giving them. Whether Thai doctors are speaking the same language or using an
interpreter, patients can tell if Thai doctor is really interested in them and their health. Taking the time
to let the patient see that Thai doctors are genuinely interested, and that Thai doctor care, is important.
When a language barrier exists. Language differences may be the most obvious barrier to providing
medical care to foreign patients of different cultural backgrounds. Depending on Thai doctor practice
setting, Thai doctors may frequently have to interact with foreign patients who speak English, little or
no English. In this situation, Thai doctors may become quite good at dealing with language barriers. If
Thai doctor’s situation is not quite so multicultural, the occasional patient who does not speak English
can present a desperate situation in which it seems virtually impossible to provide adequate
                                                            Thai Doctor and Foreign Patient Communication 11

counseling. Learning a phrase or two in the language of foreign patient will go a long way in
preventing alienation. Even bilingual patients find this practice to be positive and respectful.
         Some English words have no direct translation in the target language. Language register is
also a common problem for interpretation. Moreover, Thai doctors often use medical slang when
discussing therapeutic issues with other health professionals. These words can creep into their
language when doctors counsel patients, making it especially difficult for interpreters to pass accurate
messages on to the patient.
         To conclude, effective interpersonal communication between foreign patients and Thai doctor
in medical care providers is widely recognized as a prerequisite to patient satisfaction with medical
care. Although foreign patients tend to be reluctant to question or to ask doctors for explanations,
clarity of communication leads to higher patient ratings of satisfaction and patients who ask direct
rather than indirect questions are more satisfied with their medical encounters. Thai doctors must do
the best they can for the foreign patients, whatever the circumstances. Learn to say other than English.
         Cross-cultural communication is difficult, yet it is essential and rewarding. It is often a case of
one step forward, two back. To be successful with this skill, Thai doctors must keep trying and keep
adjusting and learning from mistakes or misadventures. Be aware of cultural surroundings as it shifts
and changes. Be sensitive to each foreign patient as an individual, not just as part of a group. One of
the most difficult things about a multicultural practice is that each foreign patient behaves as an
individual, all the while representing some or many traits of a cultural or ethic group. Finally, Thai
doctors should treat the foreign patients as best they can.
Recommendations for Future Research
         It is important for Thai doctor to ask open-ended rather than yes/no questions. Thai doctors are
all familiar with the nodding syndrome, where the patient nods to show cooperativeness, not
necessarily understanding. It is essential to good interpreting to ask the foreign patient to back
translate what was said. At the end of the medical care session, Thai doctor should ask the foreign
patient to repeat what he or she told, hopefully uncovering any misunderstandings.
         Finally, Thai doctors must be more aware of women’s cultural and religious backgrounds when
giving treatment.
                                                         Thai Doctor and Foreign Patient Communication 12

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Description: Abstract A busy practitioner can easily forget the obvious’ whenever people communicate, there are multiple cultural influences on their interaction. Cultural background, health beliefs and expectations affect health care encounters with every patient. To communicate effectively, it is necessary to avoid stereotyping by responding to patients as individuals within their own cultural context. Health professionals must also recognize the influence of their own cultural backgrounds and attitudes on their communication with patients. Communication is sometimes more challenging with those who are