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Cultural differences in managing information during medical interaction: How does the physician get a clue?
Ludwien Meeuwesen a,*, Fred Tromp b, Barbara C. Schouten c, Johannes A.M. Harmsen d
Utrecht University, Interdisciplinary Social Science Department, Research School Psychology & Health, P.O. Box 80.140, 3508 TC Utrecht, The Netherlands b University Medical Centre St. Radboud, Department of Postgraduate Training for General Practice, Nijmegen, The Netherlands c University of Amsterdam, Department of Communication, The Amsterdam School of Communications Research, Amsterdam, The Netherlands d Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands Received 7 December 2006; received in revised form 13 March 2007; accepted 14 March 2007
a

Abstract Objective: Consultations of ethnic-minority patients tend to result in poor mutual understanding between doctor and patient, which may have serious consequences for health care. For good communication, physicians have strong devices at their disposal to manage the information, such as agenda-setting and structuring the interview into segments. What are the cultural differences in the managing of information in medical conversation? What is the relation with level of mutual understanding? Methods: Data of 103 transcripts of video-registered medical interviews (56 non-Western and 47 Dutch patients) were sequentially analysed, focusing on relevant segments of the medical interview (medical history, diagnosis and conclusion) and on agenda-setting. Results: Physicians set the agenda and lead the conversation rmly forward, while a considerable number of patients (mainly Dutch) put on the brakes. The majority of the medical conversations was traditional (37%) or cooperative (37%), while another 25% was more or less conicting or complaintive in nature. Interviews of ethnic-minority patients were mostly traditional or cooperative, while Dutch patients showed a variety of types, especially in cases of poor mutual understanding. Further, conversational symmetry between patient and physician has increased over the years, due to the importance attached to patient autonomy. Conclusion: Physicians receive different conversational clues from Dutch and ethnic-minority patients in case of poor mutual understanding. Practice implications: This points to the necessity for physicians as well as patients to become culturally competent. # 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Intercultural communication; Doctorpatient communication; Agenda-setting; Information management; Ethnic minorities; Sequential analysis

1. Introduction It is well recognised that a persons cultural background has a profound effect on doctorpatient communication. Western physicians tend to show less affective behaviour when communicating with ethnic-minority patients, and Western patients behave more assertively and are verbally more expressive than ethnic-minority patients [14]. As a consequence, establishing good mutual understanding and rapport between doctor and patient is more difcult to realise in intercultural consultations [2,3,5]. Mutual understanding refers to both patient and physician knowledge about each others

* Corresponding author. Tel.: +31 30 253 6729; fax: +31 30 253 4733. E-mail address: l.meeuwesen@uu.nl (L. Meeuwesen). 0738-3991/$ see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2007.03.013

opinions [6], which is not necessarily synonymous with agreement. For good-quality care, mutual understanding between patient and physician is a prerequisite, because patients need to understand their physician and they themselves need to be understood [7]. Although it is more difcult to achieve adequate levels of mutual understanding in intercultural contexts [8], it is not clear at all how mutual understanding is actually established dynamically in medical interaction. Applying sequential analysis enables gaining insight into these dynamics, while explicitly focusing on the ow of conversation by studying specic initiatives and reactions of both participants. An important issue for good communication that lends itself for sequential analysis is the way physicians manage the ow of information during the interview, i.e. through agenda-setting and structuring the interview [9,1012]. Agenda-setting is the

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physicians task and involves meta communication, by making verbally explicit what will be talked about and in which sequence [11]. Since consultations are usually time-restricted, it is of great importance for the physician to structure the interview. The doctor not only tends to determine which topics are discussed, but also when they are discussed [9,13]. However, patients have become more active, competent and autonomous over the years, and the doctorpatient relationship has become more egalitarian [14]. This is reected in the diversity of forms in which the medical interaction takes place [7,9]. The long-recognised fact that Western patients bring their own agendas to the medical encounter [6,12,15] and negotiate with doctors about interpretation of symptoms and treatment is reected in the sequential structure of the interview, which will take the form of cooperation, negotiation or even consumerism [7]. Because patients of ethnic-minority groups behave less assertively on the whole and expect the physician to be in charge [16], one may argue that they will express their wishes and expectations less explicitly, which in turn may lead to less mutual understanding between doctor and patient [2,3,8]. This study aims at detecting differences in managing the ow of information in medical conversation between nativeborn patients and ethnic-minority patients. Because clear agenda-setting and adequate structuring will lead to better mutual understanding, it seems relevant to explore which sequential patterns will lead to good or poor mutual understanding. The following research questions will be addressed: 1. In what way do physicians and patients contribute to the agenda-setting and the structuring of the medical conversation? 2. Are there differences between native-born patients and ethnic-minority patients? 3. Do different communication patterns affect the level of mutual understanding? Does patients ethnicity play a role in it? 1.1. The managing of information exchange 1.1.1. Agenda-setting Although doctors are usually the ones setting the agenda and managing the exchange of information, a considerable number of patients hold an unvoiced latent agenda [17]. Sometimes their agenda comes up, their expectations may be unmet, or doctor and patient agendas may conict [18]. The way these potentially conicting agendas and agenda-setting are realised is reected in the way the conversation is structured and on the agenda negotiated between the two participants. 1.1.2. Structuring by segmentation In order to manage the conversation ow, the doctor has a strong device at his disposal by structuring the interaction according to a number of phases or segments. Generally accepted segments of the medical interview are medical history (presentation and elaboration of symptoms, anamnesis), physical examination and conclusion (diagnosis and advice) [19]. According to most prescriptive as well as descriptive

literature, these segments are presented chronologically and in that same straight order, and it is the doctor who is in charge [19,20]. In practice, structuring the conversation is much more complex though: a considerable number of interviews does not follow this chronological order, or it is the patient who takes the initiative to change segments. Especially the conclusion segment, where diagnosis and treatment are discussed, features more self-selection made by patients than other segments [9]. Fragment 1. From conclusion segment backward to medical history (patient with nervous complaints).
1 2 3 4 5 6 7 8 d: p: d: p: but it would be good to . . ., you may normally take them three times a day, but it is wise to take less of them on good days take less and on the . . ., yes that is . . ., let me say so if it really bothers you a lot and it is here too, I dont know if it is the same. Ive got it more often, here in my back, that all of a sudden it becomes locked up, I say

Fragment 1 shows an example of a segment shift from the preceding conclusion segment towards medical history, initiated by the patient (lines 68). The physician is giving advice, while the patient wishes to continue the conversation by elaborating on her symptoms. Fragment 2. From medical history towards conclusion segment (patient feels down).
1 p: 2 3 d: 4 5 p: yeah, I, I, (talks in a low voice) I really dont know . . . (speaks louder) listen, I nd life itself difcult so you must take these capsules three times a day, no matter if the weather is good or bad, okay? right, right, right

Fragment 2 illustrates a segment shift forward, from medical history towards conclusion (prescribing medication). The patient is elaborating on her symptoms (lines 1 and 2), followed by the physician initiating a shift forward to the conclusion, by prescribing medication (line 3). Our previous research from the 1980s, where comparable sequential patterns were analysed, has shown the existence of four types of interviews in general practice, (1) a traditional pattern (48%), where the physician is in charge and the patient is following obediently; (2) a pattern of cooperation (20%), where the relationship is on a fairly equal basis; (3) a conicting pattern (14%), where the agendas of doctor and patient do not synchronise; (4) a complaintive pattern (18%), where the doctor gives room to the patient to ventilate his worries [9,21]. Complaining is not regarded here with a negative connotation, but as communication, as a speech act [22]. Clearly, sequential patterns of managing information do not occur in a uniform way (see below under Section 2.2). These ndings make sense, because (literature about) medical communication in Western countries is dominated by concepts like patient autonomy, and shared decision-making, where the conversation will often take the character of a negotiation [12,23]. In ethnic-discordant interactions this variation in interaction rarely seems to be achieved, but we do not know for sure. The

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doctor tends to steer the conversation rmly, and patients often act politely, e.g. saying yes when they mean no [24]. 1.2. Hypotheses Based on previous literature [14,79,17,18,2124], a number of hypotheses can be formulated. We expect physicians to take most of the initiatives to set the agenda and to lead the consultation rmly forward to the conclusion segment, while patients will take most of the initiatives to lead the consultation backward, e.g. to elaborate again on their symptoms (rst hypothesis). We also expect Dutch patients to take more initiatives than ethnic minority patients (second hypothesis). Next, it is expected that consultations with ethnic-minority patients will show a traditional pattern more often, while consultations with Dutch patients will show more negotiation, e.g. cooperation or conict (third hypothesis). Further, we expect that conicting patterns and conicting agendas will lead more often to poor mutual understanding (fourth hypothesis). 2. Method 2.1. Subjects and procedure Analyses were based on data of the Rotterdam Intercultural Communication in the Medical setting study (RICIM), a project in which nearly 1000 patients from general practices in Rotterdam with a multi-ethnic population and 38 GPs participated [2]. All GP visits were recorded on video; all patients were interviewed at home in their preferred language 38 days after the GP consultation, and doctors lled out questionnaires regarding the specic interview with these individual patients, by informed consent. For practical and nancial reasons, 25% of these interviews were randomly selected for further analysis of doctorpatient communication. For purposes of the present study, which focuses on the concept of mutual understanding, a further selection was made, based on the lowest and highest quartiles of level of mutual understanding (see Section 2.2). This resulted in a dataset of 103 patients (56 patients from non-Western ethnic-minority groups and 47 Dutch patients) and 29 doctors. Of the nonWestern patients, 20% had a Turkish background, 8% was Surinamese, 6% Cape Verdian, 3% Antillean, 2% Moroccan and 16% had other backgrounds (mostly Eastern European), categorised according to their own and their parents country of birth [25]; 45% was Dutch. All GPs were Dutch, 22 male and 7 female, and most were between 40 and 55 years of age. The GPs had a minimum professional work experience of 5 years, the majority more than 10 years. Transcripts of all the medical interviews were made according to conversation analytical conventions, which were adapted for the aim of this study [26]. 2.2. Measures In order to answer the research questions, data were needed of communication variables (i.e. agenda-setting, segment

shifting and typology of medical conversation) and level of mutual understanding between doctor and patient. 2.2.1. Agenda-setting It was inventoried who took the initiative in the beginning and in what way the patient was invited to start communicating his reason for the encounter. All meta communication regarding agenda-setting in the entire interview, which included information for checking the reason for the encounter, was noted too. Physicians check the agenda and invite the patient to start talking, and this functions as a structuring device [11]. 2.2.2. Segment shifts To gain further insight into the sequential pattern of the medical interview, a reliable method developed by Meeuwesen was used which has been validated in the context of primary care [9]. The unit of analysis is the segment of the medical interview, i.e. the medical history (1A = presentation of symptoms; 1B = clarication of symptoms) and the conclusion (2A = diagnosis, cause of the symptom; 2B = advice, prescription or referral). The physical examination segment was not included, as this segment was always initiated and nished by the physician, and did not occur in about a third of the consultations. The segments of the consultations were identied and it was also assessed who initiated it, patient or physician. For the sequential analysis, the segments per se are not as much of interest as the change of segmentsthe segment shifts. These shifts occur in two directions, forward (e.g. from clarication of symptoms towards diagnosis) or backward (the other way round) (Fragments 1 and 2 offer illustrations). To quantify these shifts in a weighted manner [9], the following scoring rules were applied: one point was given to a shift within a segment (e.g. from 1A to 1B, or 2A to 2B, or backward). In the case of shifts over segments (e.g. from 1B to 2A or 2B, or the other way around), two points were given. The latter shifts, which happen over segments, were given more weight than the former, which happen within the same segment. This implicates that the latter shifts are less closely connected sequentially. Because the coding takes into account the preceding segments and the current ones, as well as the initiator, it reaches sequential relevance. 2.2.3. Typology of medical interviews Not only the occurrence of the shifts was noted, but also if it happened in a responsive way or not [27] in terms of conversational coherence [28,29]. Conversational coherence can be dened as an indication of how closely the sentence (of the shift) is related in topic and content to the immediately preceding utterance. A conversation is considered coherent if the conversational ow is realised in an easy exchange of information [28]. An important element of conversational coherence is that the topic discussed will be pursued in some way instead of introducing a completely new topic without any reference to the content of the preceding speaking turn. Applying both these decision rules (number of shifts and conversational coherence) enabled identication of four different patterns of the medical interview [9]:

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1. The traditional pattern: The physician is predominantly shifting segments forward (occasionally backward), the patient does not shift segments or does so but not more than once. 2. The cooperation pattern: This pattern is characterised by the fact that both physician and patient shift segments forward and eventually backward. In these consultations, the doctor patient relationship is on a fairly equal basis. 3. The conicting pattern: The third pattern is characterised by the physicians initiatives to shift the segments forward frequently, with the patient doing so maximally twice forward and minimally four times backward. The segment shifts do not generally occur in a responsive way (patient: but it makes you feel depressed, hmm, always that headache, if only I could stop it for a while, if I could recover for a moment, I eh (sniffs); doctors reaction: thus, a few more suppositories . . . besides, you need some more Valium pills, is that right?; see also doctors reaction in Fragment 2). 4. The complaintive pattern: The same segment shifts as in (3) occur, but here the shifts predominantly occur responsively (patient: but in the last few weeks Ive been feeling bad; doctors reaction: yes, do you know what I think is causing all this, Hubert?). The coding of all consultations according to these decision rules resulted in an in interrater reliability of 84%. 2.2.4. Mutual understanding The effectiveness of the communication in terms of mutual understanding was measured with the Mutual Understanding Scale (MUS), which was developed and validated by a multiethnic and multidisciplinary expert panel using nominal group technique [8]. The panel compared the answers of doctors and patients regarding roughly ve components of the consultation: main symptom, cause of the illness, diagnosis, examination and prescribed therapy. This procedure resulted in an overall score of level of mutual understanding for each consultation on a scale between 1 (very low) and +1 (very high). In the present study, consultations with scores in the lowest and highest quartiles were selected. This resulted in 45 consultations with poor mutual understanding (scores were between 1.0 and 0.4 for 18 Dutch and 27 ethnic-minority patients) and 58 consultations with good mutual understanding (scores between +0.55 and +1 for 29 Dutch and 29 ethnicminority patients). 2.3. Analyses Differences between physicians and patients regarding segment shifts were tested using paired-samples t-tests. Differences in segment shifts between native-born and ethnic-minority patients, as well as between good and poor mutual understanding, were tested with independent-samples ttests. The relation between ethnicity, patterns of the medical interview and mutual understanding were analysed with a x2test. As there were no effects of patients age, gender or

education or physicians gender, the analysis is just focused on patients ethnicity. To gain further insight into the sequential pattern and the dynamics of the conversation, two text fragments are presented, escorted by analytical comments. 3. Results 3.1. Who sets the agenda? In most of the cases (86%), it was the doctor who started with invitations like (will you) just tell me, what can I do for you, how is it with . . . (e.g. your u)?, calling the patients name, or saying so, okay. In another 14% it was the patient who just started telling about the reason for the encounter. Only in seven interviews did physicians explicitly check the agenda, by saying thats what youre coming for? (3), thats your question?, no other symptoms?, what is your second complaint?, anything else, what I can do for you?, or any other complaints or just this?. There was no relation with ethnicity or level of mutual understanding. 3.2. Segment shifts As expected, the physician took the initiative to lead the conversation towards the conclusion segment most often, while patients initiated more segment shifts back toward the medical history (Fig. 1) (rst hypothesis). Further, Table 1 shows that Dutch patients initiated signicantly more backward-directed segment shifts compared to ethnic-minority patients (M = 2.94 versus M = 1.52) (t = 3.342; p < 0.01). Dutch patients also took more initiatives in shifting in forward direction, but the difference was not statistically signicant (second hypothesis). Patterns of segment shifts in the poor mutual understanding group were not different than those in the good mutual understanding group (data not shown). However, when mutual understanding was poor, Dutch patients initiated signicantly more segment shifts directed forward (M = 2.50) than ethnicminority patients (M = 1.11) did (t = 2.441; p = 0.02). A rst conclusion to be made is that ethnic differences in patients segment shifts become more pronounced when mutual understanding is poor.

Fig. 1. Mean number of segment shifts of physician and patient (N = 103). ttests; *p < .05; ***p < .001.

L. Meeuwesen et al. / Patient Education and Counseling 67 (2007) 183190 Table 1 Mean number of segment shifts of physician and patient (N = 103) for the two patient groups Ethnic minority patients (N = 56) Shifts Shifts Shifts Shifts forward, physician forward, patient backward, physician backward, patient 7.79 1.23 1.39 1.52 Dutch patients (N = 47) 8.23 1.74* 1.55 2.94**

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t-tests. * p < 0.1. ** p < 0.01.

3.3. Typology of medical interviews The majority of the medical conversations was traditional (37%) or cooperative (38%) in nature, while another 25% was dominated by a more or less conicting (9%) or complaintive (16%) character, as shown in Fig. 2. Consultations of ethnic-minority patients were signicantly more traditional (45%) than those of Dutch patients (28%). On the other hand, Dutch patients showed relatively often the conicting pattern, which was absent in the immigrant group (19% versus 0%). Ethnic-minority patients also showed considerable cooperation though. There is partial support for the third hypothesis here. Contrary to expectations, a conicting pattern did not lead to poor mutual understanding more often (fourth hypothesis). No relation was found between typology of medical interviews and level of mutual understanding (data not shown). Separate analyses for level of mutual understanding showed no differences in typology between the ethnic groups in case of good mutual understanding (Fig. 3a), but differences between the two patient groups became signicant in case of poor mutual understanding (Fig. 3b). When mutual understanding was poor, consultations of Dutch patients were equally divided among the four conversation types, while in that case the majority of consultations of ethnic-minority patients were of a traditional or cooperative type. Especially when it came to poor mutual understanding, the differences between the two patient groups became much more pronounced: with Dutch patients there was more of a

Fig. 3. (a) Ethnic differences in typology in the case of good mutual understanding (N = 58). x2 = 4727; p = 0.19. (b) Ethnic differences in typology in the case of poor mutual understanding (N = 45). x2 = 11,010; p = .01.

conicting or complaintive type of conversation, while with ethnic-minority patients we see that the conict type is absent. 3.4. Cultural differences in communicating chest pain To illustrate the main ndings (ethnic differences in case of poor mutual understanding), two excerpts of transcripts from the conclusion segment will be discussed in more detail. To compare, the examples chosen were as similar as possible in the sense that both patients had chest pain and both were male. The interaction of the GP with the ethnic-minority patient follows the traditional pattern. By contrast, the consultation of the Dutch patient presents a conicting pattern (Box 1). In Fragment 3, the patient is left unsure of the cause of his symptoms but asks no questions (even when the physician is explicitly doubting the effect of prescription, in line 16), and does not bring up other symptoms or complaints either. He mostly gives minimal answers as a reaction to the GP explaining the eventual diagnosis and prescription. This kind of interaction is typical for the traditional pattern: the physician takes the initiative and the patient follows in a docile way by saying yes. In contrast with this pattern is Fragment 4, which refers to a Dutch patient (Box 2). Here the GP communicates several times that he thinks the problems are not caused by the heart, but the patient clearly seems unconvinced; this is illustrated by the fact that he keeps bringing up symptoms again and again (e.g. line 22). If we realise that in both cases the mutual understanding between the two participants was poor, we see that the Dutch

Fig. 2. Medical interview typology and patients background. x2 = 13,421; p < .01.

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Box 1. Medical conversation fragment of ethnic minority patient with chest pain (d = doctor, p = patient)
Fragment 3.

1 d: 2 p: 3 d: 4 p: 5 d: 6 7 p: 8 d: 9 10 p: 11 d: 12 13 14 15 p: 16 d: 17 18 p: 19 d: 20 21 p:

it doesnt seem to be asthma. [no [no it could be your stomach yes heart problems are not very likely because your symptoms dont worsen when you strain yourself but I cant exclude it hmm in any case, I want you to make an appointment for an X-ray of your lungs, just to be sure ye yes? (GP gives further explanation) this is a pill you put under your tongue. should your symptoms worsen, so if you get a lot of chest pain, you could take one tablet and melt it under your tongue, lets see the effect, so let it melt under your tongue yes yes? I dont think these pills will have any effect, but let us try it ne so if you have any pain in your chest take these pills and see if it has any effect ok

remains unclear, no single statement or advice from the GP is challenged by the patient. The patient does not give a clue, even when the doctor is verbalising his own doubts. This notwithstanding, through this interaction the GP is able to manage the ow of information quite straightforwardly. 4. Discussion and conclusion 4.1. Discussion Physicians set the agenda and lead the conversation rmly forward, while a considerable number of patients put on the brakes conversationally. If patients feel they have not yet nished their story, or if they have the feeling of not being acknowledged, they start elaborating on their symptoms again (rst hypothesis), especially the Dutch (second hypothesis). It seems that Dutch patients decide more frequently which topics (e.g. symptoms and treatment) will be discussed and when they will be discussed together with the physicians. In this manner, patients express some autonomy [14]. Further, the medical conversation was largely traditional (37%) or cooperative (38%) in nature, while one in four interactions had a conicting (9%) or complaintive (16%) character. Consultations of ethnic-minority patients were more likely traditional, and the conicting pattern was absent. Both ethnic groups show considerable cooperation (third hypothesis partly conrmed). It was not conrmed that a conicting pattern will automatically lead to poor mutual understanding (fourth hypothesis). However, when there is poor mutual understanding, the ethnic differences in medical conversation types become more pronounced: Dutch patients show more of a conicting pattern. In ethnic-discordant consultations doctors tend to steer the conversation rmly, while the patient reacts minimally [24]. An additional nding is that the relationship between patient and physician has become more egalitarian over recent decades. This is concluded by comparing the present results with our previous research (from 20 years ago) mentioned in the introduction, where the same method was applied on 85 medical interviews in similar general practices [9,21]. At that time, a division was found of traditional (48%), cooperative (20%), conicting (14%) and complaintive (18%) interviews, which is signicantly different from the division of the present study (x2 = 7.630, p = 0.05). It is seen that the cooperative pattern has nearly doubled over the years, indicating that the relationship between doctor and patient has become more egalitarian indeed; this is manifest in the importance given to concepts like patient autonomy and shared decision-making [7,14,23,30]. This study was not meant to make generalisations or representative statements regarding ethnic minority groups the ethnic-discordant conversation is too complex and the research sample too small. The study does intend to provide more understanding of ethnic differences in relevant interactional mechanisms in conversation, especially in the case of poor mutual understanding [8]. The selection of transcripts of

Box 2. Medical conversation fragment of Dutch patient with chest pain (d = doctor, p = patient)
Fragment 4.

1 d: 2 p: 3 4 d: 5 6 7 p: 8 d: 9 10 p: 11 12 d: 13 14 d: 15 p: 16 d: 17 p: 18 d: 19 20 p: 21 d: 22 p:

let us start with the pain in your chest very serious if I move my arm like this, the pain gets worse, and it is in the area of the heart I cant nd anything, well, I dont think the problems are caused by your heart, it is just a bit of trouble of the joints between your ribs and the breastbone yes well I . . . at rst I was afraid that it could be something very serious, but I cant nd anything, honestly (talks loudly) when I visited my cardiologist he thought it might be a heart valve yes (patient further elaborates on symptoms, doctor does examination) at this point yes? yes here? yes, here look, this is really the joint between the rib and your breastbone so, it has nothing to do with my heart valve? no, nothing at all here it hurts

patient gives many overt signs to the doctor by explicitly expressing opinions or doubts, so the GP will probably know that the communication is a bit troublesome. The doctor has to make many efforts to manage the ow of information and convince the patient by talking loudly (line 9) or using words like really (line 18), he underlines his opinions about the diagnosis. In the case of the ethnic-minority patient the conversation continues smoothly, and even though much

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the lowest and highest quartiles of level of mutual understanding enabled detection of relevant ethnic differences, and the descriptive analysis revealed the pitfalls in medical interaction with ethnic-minority patients. The differences may be the result of behavioural interaction of both patients and physicians. Physicians may be focussing more on their structuring tasks partly because, when dealing with ethnicminority patients, they are unopposed when seeking to impose their structure. This focus may be at the expense of affective tasks, which is known from other studies [1,3,4]. Attending to affective tasks may be particularly difcult with ethnicminority patients because physicians are not as skilled in interpreting the affective meanings of non-verbal behaviour of ethnic-minority patients. Moreover, ethnic-minority patients may be more reluctant to share their feelings and reveal their disagreements with physicians because they perceive the power distance between themselves and physicians to be greater than that perceived by Dutch patients [4]. As a result, physicians do not always get clues from ethnic-minority patients that are comparable with those from Dutch patients reactions to which they got used over the years. These co-constructed interaction patterns may lead to non-engagement [31]. The reasons for these non-engaged forms of medical conversation are mainly associated with cultural and linguistic barriers [24]. Poorer language prociency seems to be relevant for the evaluation of communicative interaction, and cultural barriers seem to be more relevant for the evaluation of cultural views on matters of health and illness, which matter in the medical interview [2,4,32]. 4.2. Conclusion During the medical conversation, Dutch patients often give a clue to the physician that mutual understanding is not optimal. Obviously, physician and patient have not claried the reason for the encounter fully, which might lead to problems [33]. In consultations with ethnic-minority patients, physicians are not given this kind of clue. Doctors might incorrectly assume that mutual understanding is good while the conversation is going on smoothly (in a traditional or cooperative way), and as a result they will not attempt to optimise mutual understanding by checking, for instance, if the patient has any questions left or has brought up everything he wanted. As poor mutual understanding often results in non-compliance with the prescribed therapy [2,33], it is important to achieve as much mutual understanding as possible. 4.3. Practice implications Doctors need to become aware of the pitfalls of intercultural communication by strengthening their intercultural competencies [4,32]. Although ethnic-minority patients play a more passive role in the medical consultation, they may be wishing to receive more information and understanding than physicians assume. For example, physicians should check patients reasons for the encounter and agenda explicitly, as well as their understanding of the important issues talked about in the

consultation. The patients responsibility is to gain more knowledge of and insight into the possible conversational styles in the medical context. The health care system also needs to facilitate the use of interpreters or mediators when serious language barriers exist [34]. Only by paying attention to both cultural and linguistic barriers can mutual understanding be improved considerably, which might ultimately result in better quality of health care in a multicultural medical context. References
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