I.

ABSTRACT
The question regarding access to healthcare as a basic human right has been a central
topic of political debate in the United States, particularly in recent years. Healthcare policies in
the US are constantly evolving, as is access for underserved populations and attitudes toward
those requiring care. With this in mind, our group was intent on exploring the similarities and
differences between the US and the two countries we visited this summer, Germany and Spain.
Both countries healthcare policies are far different from those in our home country, and for this
reason our research proved very interesting. Our group was interested in factors that affect
healthcare access, both in terms of economic policies and other social issues, in the two new
cultures we experienced. While governmental policies directly affect healthcare access, other
factors such as unemployment, cultural differences, education, and mental health can limit ones
access to basic needs.
We approached this question from three different perspectives. Jane focused on the micro
level of patient-doctor interaction and the possible effects of cultural differences. The
understanding between patient and doctor is crucial in delivering effective quality of care, as
well as expanding equal healthcare access for all. Cultural differences often influence and define
the nature of interactions. With increasing globalization and immigrant population in the U.S.,
Germany, and Spain, strained interactions and cultural insensitivity can decrease healthcare
access. Through the interviews with immigrants and natural citizens, Jane has worked to create a
diverse narrative of cultural interactions, as well as the effect of education in both primary
schooling and medical training on cultural sensitivity.
Tarra focused on the more macro-level aspect of state policy and its varying impact on
society, with a specific emphasis on policies toward unemployed citizens and immigrants.
Within the economic community of the Eurozone, states with differing policies and approaches
have experienced varying responses to the recent economic crisis. A cautious comparison of
states universal healthcare systems and how service access has changed over the past decade
illustrates both striking commonalities and differences with regard to unemployment benefits and
health services afforded to immigrants. Theoretical and scholarly reading provided a foundation
for the observations of and interactions with citizens and immigrants from varying
socioeconomic statuses within Germany and Spain.
Juliana focused on discovering the attitudes, both positive and negative, surrounding
those who require health assistance of any kind. These groups of people ranged from refugees
and immigrants to the homeless populations in each country, as well as unemployed youth and
anyone experiencing poverty. This topic was interesting particularly in comparison to the US,
where universal healthcare is a relatively new phenomenon and those receiving government
assistance are often stigmatized. By interviewing both scholars and German/Spanish citizens as
well as performing observational research and extensive background reading, Juliana has
compiled some interesting findings regarding this issue.
Because of our multifaceted, interdisciplinary approach that incorporated students from
backgrounds of both natural and social sciences, we achieved a relatively holistic sense of the
healthcare situation in Germany and Spain. Our methodology mainly consisted of one-on-one,
face-to-face interviews, both structured and unstructured; observational research and
ethnographic field notes; and analysis of secondary texts. We encountered some challenges along
the way, and each group member has ideas of where the research could potentially lead in the
future.

II. QUESTION
I am particularly interested in patient-doctor interactions in healthcare settings and its
effect on healthcare access and quality. How do patients from disenfranchised background such
as low socioeconomic or racial status communicate with their doctors? I explored the methods of
interaction between doctors and patients with different backgrounds, as well as cultural
sensitivity and awareness of doctors. To understand the bigger question of how patient-doctor
interactions affect healthcare access and quality, I asked following questions throughout the
program: How do doctors respond to patients with different backgrounds and vice versa? What
techniques do doctors employ to effectively deliver the best quality of healthcare to patients?
How does the Eurozone crisis affect access to healthcare, such as funding for interpreters,
educative pamphlets, and duration of patient-doctor interaction? I also explored medical
education system and focused on emphasis on medical ethics, cultural sensitivity, and clinical
practice.
III. BACKGROUND
There are multiple factors influencing healthcare access and quality, including state
policy in addition to cultural and socioeconomic backgrounds. Access to healthcare services
further affects the wellbeing of a countrys inhabitants. As healthcare policies seek to reduce
disparities in access and quality, there needs to be a close investigation of the factors that
influence structural changes and effects in healthcare policies.
Healthcare in general is a relevant topic in the discussion of youth unemployment
because it is at the crux of the current crisis facing Europe. In addition to limited income for
necessities such as food and shelter, unemployment can also lead to other social side effects. In
times of economic distress, social welfare programs and healthcare services are often among the
first options to be cut or limited by the government. The topic of healthcare access is also
important to our generation of citizens and individuals. In the US, the ongoing battles of Social
Security, Medicare/Medicaid, and universal health care have exacerbated the issue of care
quality and affordability. In a more focused context, the Spanish state is one example of a society
facing serious cuts in healthcare, education, and employment opportunities especially for youth.
Healthcare spending cuts result in fewer doctors and less efficiency in healthcare spending,
decreasing the access and quality of care offered by public systems.
Tarras Background on State Policy (link)
Tarra has outlined past healthcare and social welfare policies in both Germany and Spain,
and how these transformed over time through the Eurozone Crisis.
Janes Background on Patient-Doctor Relationship
In addition to policy, the patient-doctor relationship is an important factor to consider in
healthcare access. While policies determine how healthcare will be delivered, doctors themselves
determine the effectiveness of healthcare. Even if a system allows for a universal healthcare,
miscommunication between patient and doctor can really diminish the quality and access of
healthcare. Though these issues are not discussed and considered as extensively when
establishing a healthcare system, a closer look at patient-doctor relationship can open new doors
to effectively expand healthcare access and to deliver high quality of healthcare equally across
culture. Individual actions and sensitivity creates context which affects the quality and access of
healthcare. I believe that investigating the effectiveness of healthcare delivery through cultural

interactions will give a better insight on social issues, such as healthcare, education,
unemployment and etc., which resonate throughout Europe and the US.
It is important to recognize that patient-doctor relationship is two-way communication.
While doctors need to be aware and sensitive of their patients background history, patients also
need to be open-minded and be willing to trust doctors. The factors that influence the
relationship are changes in social statusamplified by state policies and Eurozone crisis, and the
focus on cultural sensitivity in both general education and medical training.
Symbolic interactionism theory defines how individuals action and understanding
influences reality of a situation and interaction. Individuals social definition and social
interaction evolves through individuals definition of situation and understanding of the both
party. The definitions of reality are social constructions, through individuals perception of the
situation (Stryker). The questions sociologist asks when observing interactions are: do the parties
in a group have the same understanding of the situation and how do their understandings
influence the reality? Studies in Symbolic Interactions suggest that individuals tend to have
similar definition of the situation if persons interact with one other over a period of time and in
a variety of situations (Vaughan, Reynolds). This idea can be applied to cultural sensitivity and
patient-doctor relationship. When a doctor and patients come from different backgrounds, the
understanding of each party will differ as their life experiences and values will not overlap.
Moreover, limited and short interactions between a doctor and patients can lead to great
disparities in understanding of a situation.
Another aspect of symbolic interactionism explains that individuals act purposefully
according to their understanding of a situation and identity. When individuals interact under
different understandings of a situation, individuals identities can be changed or reinforced.
Differences in culture, socioeconomic status, and power often influence ones identity. The
power dynamics of each player in the situation is further reinforced by the interaction as well.
(Ridgeway) This research project regarding patient-doctor relationship questions: How do
doctors, with high socioeconomic status and educated background, interact with patients who are
disenfranchisedunemployed, uneducated, or discriminated based on culture and language
barrier? When patient feels powerless, how is the interaction defined?
Education also has a great influence on cultural sensitivity of the general population and
doctors. In recent years, the field of medical ethics has taken a greater prominence in medicine.
One aspect of medical ethics strives to define equality and justice in healthcare. In the U.S.,
many universities now have established departments for bioethics and public health. In School of
Medicine of University of Washington, the Bioethics and Humanities department offers graduate
studies and undergraduate minors. Field of bioethics includes sociological, philosophical and
practical applications regarding ethics in scientific research and medicine, including equal access
of healthcare. A greater attention toward medical training in the U.S. has given since Howard
Becker, a sociologist, wrote Boys in White: Student Culture in Medical School (Laqueur). The
ethnographic study of medical schools in University of Kansas raises questions of gender
equality, disclosing medical error, cultural insensitivity toward racial minorities, language
barriers, religion, mental health and end-of-life questions (Laquer). These questions are still
being raised in medical communities and greater attention toward medical schooling system,
especially emphasis on cultural sensitivity, should be given.
In the American healthcare system, examples of patient-doctor mistrust resulting in
diminished quality of healthcare and limiting healthcare access can be found in non-fiction books
such as The Immortal Life of Henrietta Lacks (Skloot) and Spirit Catches You and You Fall

Down (Fadiman). With increasing globalization and diversity, doctor-patient relationships are
more complicated than ever before. Germany faces an influx of refugees from European Union
Border States. There are few refugee camps in all parts of Germany, including Berlin. Many of
these refugees are unable to work and to obtain legal residency in Germany, significantly
reducing the access to healthcare. The general perception of these refugees and misunderstanding
among government officials and refugees further complicate the issues of legalization and social
welfare. Also, Spanish government is facing cuts and changes in social welfare system due to the
economic crisis. Immigrants in Spain are the most vulnerable population in these social welfare
cuts, greatly reducing access to healthcare in both policy and practical settings. In strained
communication between a patient and a doctor due to language barrier and cultural differences
can affect the quality of healthcare as well. It is important to investigate the attitudes of patients
toward their healthcare system, as well as how doctors respond to patients mistrust and how
doctors cultural sensitivity affects healthcare quality and access given to disenfranchised
populations.
Julianas Background on Public Opinion, Social Stigma and Mental Health (link)
Juliana has outlined unemployment rates and theories behind public opinion and social
stigma on social welfare benefits
IV. METHODOLOGY
With two weeks in Berlin and three weeks in Spain (Madrid and Leon), I conducted my
research through a series of interviews, lectures, observations, and close reading of scholarly
journals and articles. In Berlin, I was able to conduct three interviews, both formal and informal,
and two lectures from an expert at Humboldt University and a lawyer from Contact and
Consultation Center for Refugees and Migrants in Kreuzberg were used to analyze my findings
from interviews. In Spain, I conducted seven interviews, and incorporated two lectures and
presentation to gather information for my research. In addition to lectures and interviews, I was
able to observe refugees in Berlin and protests in Spain. A close reading of texts, consisting of
newspapers, scholarly articles and statistical findings, aided in fulfilling gaps in missing
information from interviews and data analysis.
While interviews give valuable personal narratives, the limitation of this method is that
interviewees are more likely to give socially favorable answer. In Germany, many people
responded positively when asked questions about cultural sensitivity and healthcare system. It is
important to note that the responses are socially favorable. Because of their history, Germans are
very self-conscious of their words and actions. I needed to be aware of this when I conducted an
interview and analyzed my findings.
Lectures were really helpful throughout my research in Berlin and Spain. Though many
of the lectures did not directly relate with my research topic, I was able to learn multiple aspects
of the Eurozone crisis and youth unemployment. The lectures helped me to see the connections
between my research project and the Eurozone crisis.
Apart from the lectures and interviews, I expanded my research by observation and
reading of texts. In Berlin, I walked around the refugee camp to see what they do and what
conditions they live in. In Spain, I observed an eviction protest and see how others interact with
each other. While observations added a depth to my findings, I had to be aware of my own
biasesa perspective of an Asian American student who studies bioethics and science. I tried to
make sense of how people interacted with me (an Asian), but it was hard to assess the reality.

Also, as a science major, reading sociology papers was a big hurdle to overcome. With a help
from professors and peers, I was able to guide my research with some sociological theories. And
for news articles, I had to rely on translations. Though there were barriers to cross in gathering
secondary resources, I believe that reading of texts gave me a holistic view of my research data.
V. FINDINGS
Patient-Doctor Interaction time Comparison (Hope)
Germany: 7-8 minutes, 20 minutes wait
Spain: 3-5 minutes or 10-15 minutes, 30-45 minutes wait
US: 15-30 minutes, ~20 minutes wait
Germany (Lectures, Interviews, Presentations)
Multicultural studies in German Education System
Migrant youths have different interpretation of German history taught in class, especially
the holocaust. Students may choose to take the history personal either from victims point of
view or humanistic approach. In other instances, students have harder time finding connection to
the history being taught in classrooms, as they feel that it has nothing to do with their personal
identity. The answer to the questions of How do we frame history in classroom? and How
does history become personal? is to allow multiculuturalism in educationteachers should be
aware of their students cultural background and present the material (history) in relation to
students cultural identity.
Her findings led to training for cultural sensitivity in teacher education. There is also a
movement toward cultural sensitivity, especially in academics. They used the same model in
police training and it has been really successful. There are efforts in other professions (i.e.
healthcare) to incorporate diversity in education and training. In 1990, ethnic groups were
integrated into the summit in Berlin to investigate the questions of immigration. This is a great
example of Germanys sensitivity and integration of increasing diversity.
Contact and Consultation Center for Refugees and Migrants
There had been different migration laws for immigrants, asylum seekers, and refugees,
making it harder and confusing for immigrants to go through formal and legal process of
immigration. There are about 1 million illegal immigrants in Germany and about 80,000 in
Berlin alone. In 2007, Border States pressured EU to make changes in the migration laws to
prevent illegal immigrants from entering their country.
Once the refugees arrive at Border States of the EU, they can travel within the EU, but cannot
work or obtain legal residency in other EU states.The Border States would turn the refugees
away to a different country within the EU, and those refugees are stuck in a limbo, unable to
obtain a legal residency and a job. Also, many immigrants gain their citizenship by marrying a
citizen of Germany. This process requires the spouse to learn German, but this sometimes is
impossible. One example of this would be a woman in a remote town, where there are no
German classes nearby. To accommodate this, the law has recently changed. The newly changed
law requires the spouse to prove that he/she tried learning German for a year before getting
his/her residency in Germany.
The lawyer believes that everyone has a right to residence and right to obtaining the
rights of citizenship. The rights of citizenship include healthcare and social welfare, which are
also basic human rights. Also everyone should have the right to self-determination and be able to

work legally. Many immigrants and refugees are hesitant to seek help in immigration center as
they believe that police might be there and they cannot speak German well. Refugees constantly
face the fear of deportation and language barrier, which makes it harder for them to deal with the
uncertain situation they are in.
Interview: Nurse at the refugee camp
Healthcare access for the refugees is very minimal. If the problem is something small,
then the nurse does it herself. There also is a free clinic, run by doctors doing probono work for
the refugees. If the situation is really serious, then they go to the emergency room. When the
refugee goes to a hospital, they often bring few others to help translate. In one instance, five
people had to come to help a refugee as they had to communicate through translating in five
different languages. Sometimes doctors and nurses would dismiss refugees, even when he/she
can speak perfect English or German. One time, the patient was flustered and could not
communicate properly. The nurse had to sit down for a long time to explain every single thing
because the doctors do not have enough time to explain everything. Even for Germans, they have
to actively ask because doctors are busy. Although there is a public support for the refugees,
most keep their distance. She is also very busy and she seemed really tired during the interview.
During the interaction between the nurse and the refugee, the refugee complained of his
ribs. Both the nurse and the patient used broken English to communicate. The first question the
refugee asked when the nurse told him that he could go to the Emergency Room for an X-ray
was: Is there going to be a police? It seemed that patients are really comfortable coming up to
the nurse and talking to her. But once the refugees are in the hospital, the refugees are more
nervous. The appointments at the camp are very unconventional, as refugees just come up to her
whenever needed.
Interview: Refugees
Many refugees came from Sudan, Chad, Libya, Niger and Nigeria. Most of them came in
boats to Italy to seek asylum. A refugee from Libya told me: it is very hard to talk about the
situation, it is so sad. Everyone is forced to pick sides. However, if he stood with the
government, then the rebels would kill him; if he picked the rebels, then the government would
try to kill him; if he stayed neural though, then both sides would be against him. He said he came
to Europe and Germany for democracy, but he asked where is democracy? I cant work and
have my own life. He was also very skeptical of all authorities and said leaders are evil.
Many just sit at the benches, letting time pass by. Some refugees kept themselves
occupied by fixing bikes at the camp. The refugees at the camp come and go, and many also stay
at nearby school.
Medizinischer Dienst der Krakenversicherung: Berlin-Brandenburg
Medizinischer Dienst der Krarkenversichenrung is an independent organization evaluates
and give advice for both healthcare facilities and social health insurance. The review gets sent to
the social health insurance for healthcare quality control purposes; however, the organization
cannot intervene or make changes.
The organization helped to put Turkish nursing homes, but it did not work. There simply
were not enough registrations from the Turkish communities. Most of the elders in Turkish
community are more likely to stay with the family or to go back to Turkey during the last few
years of their life. There are a high number of Russian nursing homes. For home care services,

the patients can hire their own doctors. However, there had been shortage of nurses working at
these healthcare facilities. Employing foreign nurses is under private care and the state is
discussing about integrating foreign nurses into the state healthcare system. The organization
does not believe that use of foreign nurse diminishes healthcare quality. However, defining the
qualification for foreign healthcare professionals is difficult, as different states use different
education and qualification system.
Spain (Lectures, Interviews, Presentations)
Spanish Economic Crisis
The Spanish government freed up land for privatization and development in 1998, which
led to housing boom in 2002. However, in 2008 the housing bubble burst and economy crisis
began, resulting in near 50% youth unemployment rate. The government supported banks and is
silent about the crisis. There are a lot of corruptions within the government as economy
continues to suffer. Healthcare and education suffer as a result of economic crisis. The presenter
thinks that the government should stop trying to please the German government, but rather focus
on Spanish citizens. The problem is not about having enough money, but about how the money
should be distributed among the three pillars.
Since the crisis and 15M movements, there became a greater unity among Spanish citizens, In
Spain, family and culture are really important. There is a loss of confidence and trust in the
government and Spaniards are protesting to have their voices heard and to protect their human
rights. Since the crisis and cuts in healthcare system, doctors work way more than usual and
there are many patients to accommodate in public hospitals.
Interview: Sociologist in Madrid (Mid-age)
There are interpreters at the hospital and pamphlets in multiple languages. However, with
economic crisis and recent cuts in healthcare system, she is not sure if there are enough
interpreters at the hospital anymore. She commented that most immigrants go to their private
doctor within their own communities. She said: if a doctor opens up a practice in their own flat,
who knows? Most drugs do not need prescription, so anyone can technically start their own
practice and treatment. At hospital, appointments are only 3-5 minutes long. There is rarely no
time to ask questions, especially for immigrants who cannot speak Spanish. Doctors are held at a
prestigious status and it is considered absurd to question the doctors.
Spain has a universal healthcare system and anyone can go to the hospital. Many who can afford
choose to have both public and private healthcare insurance. Public healthcare used to cover a lot
of treatments and examinations, but the coverage has decreased since the crisis. The interviewee
has both public and private health insurance. For minor checkups and treatment, she would
choose the public because it is not too crucial. However, for things that are more important or
serious disease, she would choose to go see a private doctor. For expensive procedures and
treatments, she would choose public because public would be cheaper.
Interview: Recent University Graduate (Youth)
She would usually go to public doctor in most cases; however, if she were to have serious
problems, such as cancer, she would choose to go to the private doctor. She would not trust
herself with public doctor with a very serious treatment. However, going to public doctor is nice
because they have all the family history and charts available to them. Public health system has
become really stringent because of economic cuts and increasing number of patients. There are

long lines at the hospital because many old patients go to doctors for minimal problems, making
it harder for doctors as they commit more hours than usual.
The interviewee now teaches computer technology to students of age 12. One of the
classes she had was really hard because there were a lot of immigrants and gypsies. The students
had hard time concentration and doing their work. She understands that they have other problems
outside of school with their family, but understanding their problem does not make her job easier.
She had to adjust by spending more time with each student if they have trouble reading and
writing. Sometimes, she has to draw pictures instead of writing to help them understand.
Interview: Mother and grown-up daughter (age ~60 and ~30)
Public healthcare system is free and cheap; however, private healthcare is better with
more resources. The daughter believes that patient-doctor relationship is better in private hospital
settings. Private doctors see less patients and are able to spend more time with patients. Also,
public doctors have fewer exams to pass than private doctors. Since the crisis, there are less
doctors in the public hospitals, but more patients. There seem to be no changes in private
healthcare.
Interview: Mother
She believes that healthcare system in Spain is the best and when she had her kid (about
age 5), the doctors were really nice. She does not know much about the crisis and politics,
especially how the crisis affects healthcare system.
However, she had better experiences at the hospital in Madrid than Leon, and she went to
the hospital in Madrid for her maternal care. In Leon, people are not as friendly and they act as
they do not have any time for you. However, in Madrid, people are really friendly and they act as
they have known you entire life. This made her visit to the hospital in Madrid much more
pleasant. She believes that doctors and nurses in the hospital are really friendly.
Interview: Spanish Teacher for Immigrants at Sierra Pembley Foundation
Three years ago, everyone, including illegal immigrants, has an access to public hospitals.
The public healthcare system is funded and paid through taxes from jobs and sales tax. Because
of the economic crisis, only basic appointments are covered for everyone. However, if a
procedure such as scans or blood test, then illegal immigrants are required to pay. This is a form
of discrimination against immigrants. Some hospitals have a computerized translation system for
immigrants. In some parts of Spain, doctors only speak English and German. For immigrants,
they usually bring a friend or family who can speak Spanish to help translate for doctors.
He doesnt think there is direct discrimination against immigrants or low-socioeconomic
populations because there is universal healthcare. And most doctors want to help people. Since
the crisis, there had been cuts in healthcare system for immigrants. Many are protesting against
this, because if the government start cutting healthcare, next thing will be cutting care for
citizens. The concept of paying for healthcare is hard to understand. The government is also
reducing the number of doctors and this creates a huge problem in rural areas of Spain. Once
doctors finish their trainings and pass their exams, they usually want to become public doctors
because of good job security, reputation, and pay.
There is not much opportunity for Spaniards to interact with immigrants and older
generations usually have a negative perception of immigrants. Media portrays a negative image
toward immigrants, but once Spaniards interact with immigrants, they change their perception.

The Sierra Pembley foundation offers job training classes for both Spaniards and immigrants.
The funding for these classes are diminishing due to the crisis, reducing the number of
opportunities for Spaniards to meet immigrants.
Interview: Leon Program Coordinator
As a director of multiple study abroad programs in UW Leon, he had to take students to
doctors multiple times throughout the years. The director serves as a translator if the student does
not speak Spanish, and doctors rarely speak English. Many Spanish people think that they know
less English than they actually do, and doctors are not comfortable speaking English because
medical terms are very specific. Many doctors and Spaniards say If I had more time, I would
speak English.
In Leon, there are only about 2-3 doctors in the private clinic that students go to. Doctors
are usually really nice and the coordinator knows them personally. Because the private
healthcare clinic is really small, patients sometime have to go to the public hospital. In most
cases, if you (as a foreigner) have insurance, insurance will pay for the cost, if you dont the state
will pay.
Most Spanish people are proud of their public healthcare system and not many have
private insurance. The wait time for appointments is about the same in both public and private
healthcare. The appointments are usually 10-15 minutes long, and the wait time is about 30-45
minutes depending on a day.
It is harder to become a public doctor. To become a doctor, everyone takes a state-exam.
Passing a state-exam does not guarantee a job. To become a public doctor, he/she needs to pass
with exam with a higher score.
Medical Education (Secondary resources)
Comparative Medical Education

(Nara, Nobuo, Toshiya Suzuki, and Shuji Thoda. "The Current Medical Education System in the
World." )
In the U.S., medical students receive their medical training after college, starting age 22.
After receiving a medical degree, students are required to complete 2 years of residency training
before practicing and/or going into specialty. In both Spain and Germany, students receive their
medical degree after 6 years of medical school, starting at age 18. In Spain, students have to
complete 2 years of residency after medical school and pass a national exam to practice. In
Germany, students can receive specialty training, concurrently with residency training, right after
medical school. Patient interviews and clinical rotation occurs in last two years of medical school
in all U.S., Germany and Spain. Up until clinical rotation, the coursework focuses on theory,
lecture, seminars and sciences. Early start in clinical training is encouraged
Focus on medical ethics seems minimal and not much information is given on their
curriculum. In all three countries, medical students learn the skills of interaction through their
clinical rotations.

Changes in Medical Education in Spain

Majority of Spanish Medical education is based on lectures and seminars during
preclinical years. There had been a reform in medical schools in 1994, which includes less
number of theoretical lectures, earlier patient contact and practical training. The new curriculum
includes an elective program that allows students to delve into specialized field and research, or
study abroad.
While new curriculum encourages more clinical training, the effects of the new medical
education are yet to be determined. However, there is a growing movement toward unifying
medical education among European nations, allowing students to receive training anywhere in
the European Union. This will allow students to be more culturally aware, further improving the
healthcare system both in home countries and abroad.
Germany Medical Education
Charit is a biggest medical university in the Europe and was the first in Germany to
reform medical curriculum in 1999. The new reform includes a greater emphasis on linking
theoretical and clnical instruction, reduction of lectures and more clinical training, examination
reform, and constant evaluation of teaching methods. Six years of medical school are broken
down into 2 years of basic science, 3 years of clinical science and 1 year of clinical years. During
clinical science years, students go through 12 different interdisciplinary teaching modules, one of
which includes History, theory, ethics of medicine. Twenty-nine European countries, including
Germany, adopted Bologna declaration, to unify medical training system within Europe. This
increases mobility between medical students, allowing students to experience multi-cultural
training.
VI. ANALYSIS and CONCLUSION
Group Conclusion
As a whole, our group has learned that though more research and data is needed and the
future is uncertain, the recent economic crisis has impacted policies regarding healthcare and
social welfare programs within Germany and Spain. Interestingly, the public and private
healthcare divide poses an important question regarding the ethics of having both programs
available. It will be crucial to observe any structural changes in the future and how these public
and private changes might affect healthcare access for disadvantaged populations. The
relationship between Germany and Spain through the Eurozone crisis is an interesting factor as
much Spanish debt is owed to the Germans, who are also providing jobs for Spaniards who seek
employment. On a micro level, there seems to be a growing movement toward cultural
sensitivity and improving healthcare access and quality. However, disadvantaged minorities,
both immigrants and refugees alike, do not feel included in the national healthcare system both
structurally and culturally, despite both Germany and Spains universal healthcare system.
Julianas research suggests that Spaniards are more accepting of disadvantaged populations. This
may be attributed to the fact that there is a higher percentage of immigrants in Spain compared to
Germany. However, more data is needed to provide a substantive conclusion. Budgetary cuts
will continue to reduce healthcare quality and access, and policies change constantly. In the
coming years, will the economic divide between Germany and Spain widen or narrow, and how
will this in turn affect healthcare policies and the publics opinion of those on social welfare?

While the future is uncertain, we will need to pay close attention to how policies will impact
healthcare access and quality, beyond what is outlined in texts and statistics.
Tarras Analysis on Policy Change and Response (link)
Janes Analysis on Patient-Doctor Relationship
Before drawing a further conclusion, I must state that the data and findings are still its
preliminary stages. More interviews and research is needed to confirm and adapt to new findings.
While I tried to gather a comprehensive data from a diverse population, I was limited to the
amount of time and resources throughout the program. It is important to note that the findings
and conclusion in this paper might not truly reflect the realities of German and Spanish
healthcare system. However, these findings can serve as foundations for further studies.
Overall responses I got in Germany indicate that there is a growing movement toward
cultural sensitivity toward people with different backgrounds, and there is an effort in the field of
medicine to increase quality of healthcare beyond its policies. However, from personal
observation and interviews with the refugees, there still is a problem in healthcare access, both in
terms of policy and patient-doctor relationship.
Germanys efforts to constantly evaluate and improve the efficiency of healthcare are
clear with the establishment of Medizinischer Dienst der Krakenversicherung. Through
collaborative efforts, the long-term care insurance reform led to the establishment of immigrant
nursing homes, and allows patient to choose their own doctors. Growing number of Russian
home care services indicates increasing healthcare access and quality for immigrant families.
However, unsuccessful attempts to establish Turkish nursing homes also illustrate that better
methods of integration are needed to provide highest-quality of healthcare to certain minorities.
Allowing patients to choose and hire their own doctors can reduce distrust and misunderstanding,
and improve the relationships between a patient and a doctor. Through constant assessments of
healthcare facilities and more attention toward patient-doctor relationships, healthcare access and
quality of Germany can be improved significantly.
In addition, there seem to be a growing movement toward cultural sensitivity in German
classrooms and an effort toward integrating minorities narrative in history is slowly increasing.
This continuing effort to increase cultural sensitivity in classroom is spreading toward including
diversity training in other job professions, especially in healthcare. While there is an apparently
effort to integrate immigrants in academics and policy-making, the effect of this movement is
still unknown as the immigration in Germany increases exponentially. Heavily influenced by its
history, openness to diversity is deeply rooted in German ideology. The responses from Germany
were mainly socially desirable, which could indicate two very different outcomes: Germanys
consciousness toward diversity can reduce misunderstanding among cultures, or Germanys
reluctance to discuss discrimination can hinder the movement toward diversity and cultural
sensitivity.
Despite Germans effort to improve healthcare quality and increase cultural sensitivity,
more attention should be given toward disenfranchised minority. With several visits to the
refugee camp and interviews, minorities still do not feel at ease with authorities and live in a
constant fear of uncertainty. Healthcare access is minimal for these refugees, not only because of
their legal status, but also because of general distrust, the feeling of powerlessness, and the fear
of authorities. The refugees I have interviewed found it hard to talk about their situation and to
effectively communicate with authorities in high-stress situations. Being in a hospital and

needing treatments leads to high-stress and rigid interactions, especially in a short 7-8 minutes
interactions with doctors. The Symbolic Interactionism theory can be applied as strained
interaction will further reinforce the power dynamic between refugees and authority-figures (i.e.
doctors), creating a greater gap in understanding and communication. Also short appointment
times between a patient and a doctor does not allow for them to get to know each other, creating
a bigger disparity. This ineffective communication leads to limited access and quality of
healthcare, doing more harm toward patients physical health.
To alleviate the burdens of the refugees, there is a collective support from the public;
however, these supports are minimal and futile. Though there is a nurse who visits and
volunteers at the refugee camp, she is over-worked, tired, and constrained by language barriers.
On a bright side, refugees seem comfortable interacting with the nurse and the language barriers
do not prevent refugees from communicating with the nurse. However, this limited data is
insufficient to conclude and generalize the patient-doctor relationship among disadvantaged
populations. Also, Contact and Consultation Center for Refugees and Migrants provides
support for refugees and immigrants to obtain legal residency in Germany. However, the EUs
immigration policies do not align with each states immigration process. Many refugees in
Germany are left in a limbo without a proper solution. Also, integration and naturalization
process do not seem to be conscious of different cultures, as requirements of obtaining legal
residency through marriage in Germany requires immigrants to go against their own cultural
values and practice.
While German ideology toward diversity and freedom allows room for the movement
toward cultural sensitivity, a closer attention to disadvantaged minority communities is needed.
The efforts to improve healthcare access and quality will be futile if healthcare cannot be
delivered effectively. More data and findings are needed to conclude further; however, it seems
that more resources need to be geared toward directly helping the disenfranchised population,
more than focusing on cultural sensitivity training for the general population.
The findings in Spain demonstrate that there is no outright discrimination against patients with
disenfranchised and immigrant background; however, the economic crisis and social welfare cuts
pose a dangerous potential in creating a greater disparity between doctors and patients of
immigrant background.
Among the general Spanish populations, there is a positive consensus toward healthcare
system. Many Spaniards take pride in their healthcare system as it is renowned as one of the best
healthcare systems in the world. This sense of pride can obscure a critical evaluation of the
quality and access of healthcare. Many interviewees gave positive responses toward Spanish
healthcare system without a second thought; however, some would retreat their answers
afterwards, as they were given the opportunity to critically evaluate their own healthcare system.
The findings suggest that patient-doctor relationship is better in private hospitals. This can be
explained by rational choice theory, as private doctors are paid through incentive system,
whereas public doctors have job protections, regardless of their performance (Hedstrm and
Stern). This raises an interesting question: should doctors be paid based on their performance in
order to ensure an efficient delivery of healthcare? Also, many interviewees also have concluded
that they were more satisfied with performance of private healthcare system, though many would
still choose to go to public hospitals for economic reasons. General satisfaction toward private
healthcare may be correlated with better patient-doctor relationship, as found by my research.
While there seem to be no evidence against doctors discrimination toward
disenfranchised populations as everyone in Spain has an access to healthcare, the recent cuts in

healthcare access for illegal immigrants can be characterized as a beginning of a structural

discrimination against disenfranchised minorities. Social welfare cuts as a result of the economic
crisis also include reduced clinic hours, the number of doctors and hospitals, and funding for
healthcare resources. Cutting clinic hours and the number of available doctors and hospitals
greatly reduces the duration of patient-doctor interactions, as the patient-doctor ratio would still
remain the same. Shorter interaction time reduces opportunities for patient to ask questions and
have a better understanding of the situation. Also, reduction of hospitals worsens the common
problems of rural healthcare: limited resources and access, forcing patients to travel longdistances and taking away opportunities for patients to form connections with their doctors.
In certain parts of Spain, many doctors only speak Spanish, requiring patients to either
speak Spanish or bring their own translator. In parts of Spain where there are a lot of retirees
from Europe, doctors will often speak English or German, and sometimes never speak Spanish.
While this could improve the quality and access of healthcare through effective communication,
it also reduces healthcare access for Spaniards. This data is interesting, as Spain has four official
languages and many immigrants with different language backgrounds, adding another layer of
the complexity of this research. Though my limited data cannot draw a full conclusion, further
studies regarding language barrier issues in hospital settings will give us a greater insight in
patient-doctor communications and relationships.
Despite the economic crisis and social welfare cuts, there still is a potential for improving
patient-doctor relationship. Along with 15M movement and general disappointment toward the
government, there has been a greater unity among Spanish populations. The 15M gathering and
group protests allow Spanish population to come together and interact with one and other. This
unity will create better understanding among different cultures and regions of Spain, facilitating
a better communication with each other and reducing social disparity among citizens and
immigrants alike. In the case of Sierra Pembleys job training class, Spaniards and immigrants
were able to interact with each other. Because of their unified goal (finding a job) and interaction,
students were better able to understand each other, despite their language and cultural barrier.
This is a great example of Symbolic Interaction theory: the difference in understanding of a
situation is reduced when individuals interact with one and other in a similar setting (Vaughan
and Larry). Through protests and gathering, Spanish population can use this opportunity to better
understand each other and become more culturally sensitive. This will lead to equal access to
healthcare among different social groups, even in the time of economic crisis.
Medical education system in both Spain and Germany seem to strive toward a great
emphasis on clinical training, cultural sensitivity and medical ethics. The European Unions
effort to unify medical training system to increase mobility among students will allow doctors in
training to be more culturally aware. The reform in medical education across European states
will improve the access and quality of healthcare, as doctors will be able to connect and interact
with their patient more effectively. Better communication will lead to greater patient-satisfaction,
which will increase positive outcomes of healthcare treatment. While hopes are high, this reform
has been implemented about fifteen years ago, and the effectiveness of the medical education
reform cannot be concluded.
Overall, there is a growing movement toward cultural sensitivity in healthcare and in
medical training. However, a long and arduous journey toward healthcare equality only has
started and there is a long way to go. While cultural sensitivity and openness to diversity are
apparent in academic settings, disenfranchised minority populations still do not feel at ease with
the general population. Because of the Eurozone crisis, changes in policy and social welfare cuts

should be examined carefully, as the disenfranchised populations are the most vulnerable.
Though my data and studies are insufficient to predict the future outcome of the economic crisis
on healthcare, a closer look at patient-doctor relationship and cultural sensitivity can guide us to
ensuring equality in healthcare.
With only two weeks in Berlin and three weeks in Spain, I was able to collect a small
sample of data. In order to be able to draw more comprehensive conclusion, more extensive
interview with multiple populations (both disenfranchised and general), a field observation of
hospitals and patient-doctor interactions, and direct interaction with doctors and patients are
needed. Also, in-depth studies of medical training and medical student culture can give me a
better insight on the issues of patient-doctor relationship through cultural sensitivity.
As a student minoring in Bioethics and Humanities and pursuing a career in medicine, it
will be important to keep the lessons from this study in mind. When I interact with others,
whether in healthcare settings or elsewhere, I want to be more culturally aware and be able to
effectively communicate with others. Through my rigorous academic journey to become a doctor,
I will not forget the reasons behind my career goalto ensure that everyone has an equal access
to healthcare beyond policies and to become a doctor who can effectively deliver the highest
quality of healthcare.
Julianas Analysis on Public Opinion and Social Stigma (Link)
VII. REFERENCES
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Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American
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Gomez, J. M., and R. Pujol. "Changes in Medical Education in Spain." Academic Medicine 73.10
(1998): 1076-080. Print.
Hedstrm, Peter, and Stern, Charlotta. "Rational Choice and Sociology." The New Palgrave
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Sahuquillo, Maria R. "6.700 Millones Menos Para Sanidad." EL PAS. N.p., 16 Feb. 2013. Web.
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Skloot, Rebecca. The Immortal Life of Henrietta Lacks. New York: Crown, 2010. Print.
Snchez, Juan L. "El Privilegio De Los Que Tenemos Papeles." Eldiario.es. N.p., 18 June 2013.
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American Sociologist 3.3 (1968): 208-14. Print.
VIII. CULTURAL SENSITIVITY
Throughout my 5-weeks journey in Europe, I experienced a constant influx of mixed
emotions. Each lecture was followed by amazement and a self-reflection; a successful interview
was followed by feeling of success and uneasiness; random encounters brought the feeling of
excitement; the process of research provoked curiosity and insecurity. This intensive academic
experience taught me more than any other classroom would have, not only did I learn about
methodology of sociology research and the Eurozone crisis, but more importantly, I encountered
countless stories of people who I would otherwise have not met.
The most memorable and impactful event was going to the refugee camp in Oranienplatz,
Kreuzberg. Especially when one of the interviewee asked Juliana and me if we knew anything
about the war in Libya, I felt a swarm of guilt of not having a full knowledge of the refugees
situation. Also, he was very reluctant to tell us about his journey to Germany as he said it was
too hard to talk or think about it. Not only had their stories allowed me to realize that I need to be
more globally aware, but also how privileged and lucky I have been in my life. Their smiles and
kind eyes taught me how I should be thankful and appreciate those around me, and the power of
genuine kindness and open heart. It was the lesson I carried throughout the program, as I
continued to interact with people.
Through my general interaction with people in Europe, I was more self-conscious of who
I am and where I am. Living in Seattle for 6-years made me immune to being a racial minority;
however, I was very self-conscious of my own race, especially when so many people would
shout out ni-hao or konichiwa to me. Not only have that made me realized how
underrepresented Asians are in Europe, especially Koreans. It was weird feeling like a minority
and an outsider. While my experience was masked by being an American student, I had a
glimpse of what it would be like to live as an underrepresented population in Europe. I felt
misunderstood a lot, not only because of my race, but also because of my language barriers as
well. The research experience allowed me to explore my self-identity, a Korean American, who
never seemed to fit any description of just American or Korean Immigrant in the U.S.
I was able to explore what kind of doctor I want to be after college: more culturally aware
of who I am and who others are, being aware of how my actions will affect the quality of
healthcare I am delivering. I will use my experience in Europe to further discover myself and
other cultures as well.