COMMUNICATION,

CULTURE AND
RESPECT
WHAT IS CULTURE AND RESPECT?
Culture is the set of customs, traditions and values of a
society or a community, such as a particular ethnic
group or nation.

Respect is a positive feeling or action shown towards

someone important; it is also the process of honouring
someone by exhibiting care, concern, or consideration
for their needs or feelings.
WHY IS COMMUNICATION SO IMPORTANT?

 It allays patient anxiety and fear

 Aids in better diagnosis
 Establishes trust between doctor and patient
 Leads to greater patient satisfaction
 Poor communication with patients of diverse backgrounds
contributes to health disparities
Health disparities are differences in treatment provided

to members of different racial, ethnic or religious groups

that are not justified by the underlying health conditions

of the patient.
LEARN
The medical model vs. the patient model
L- Listen with sympathy and understanding to the patient’s
perception of the problem
E- Explain your perceptions of the problem
A- Acknowledge and discuss the differences and similarities
R- Recommend treatment
N- Negotiate a treatment plan
LEARN
54 year old housewife
Initially seen for management of diabetes
Now presents with numerous unexplained body aches
and pains and lethargy. No physical foci.
Sees numerous doctors for symptoms without relief.
On further inquiry by you she reveals family tension
with her sister-in-law and has espied a red candle next to
a picture of her in her sister-in-law’s room!!!
EXPLAIN
16 month old infant with recurrent URTI’s and noisy
breathing, especially while sleeping.
Had a febrile seizure 2 months ago.
Mother convinced that the child had “jaunders” which
was stifling him at night and wanted the child to get
“jaray”.
ACKNOWLEDGE
33 year old male had blood tests done 3 days ago.
Now complains of feeling weak with runny nose.
Feels that the removal of blood has compromised his
immunity and he now has COVID-19.
RECOMMEND
50 year old patient presents with haematuria.
Investigations reveal a large renal calculus in the upper
pole of the Right kidney.
A partial nephrectomy was scheduled.
Patient expressed considerable reluctance to have the
operation.
On questioning he revealed that he thought his “blood
was low” and that he would not survive the operation.
NEGOTIATE
66 year old patient with end stage renal failure
secondary to poorly controlled diabetes.
Has been managed conservatively but now requires
dialysis involving shunt insertion.
He declined haemodialysis, saying that he was a devout
Christian and that God would provide (salvation)
CULTURE AND RESPECT

 RACE
 GENDER
 SEXUAL ORIENTATION
 MENTAL ILLNESS
CULTURE AND RESPECT
Race: (those of Indian descent)
 They not educated
 They all from Debe or Penal
 They all involved in farming
 They all drink
 They all beat their wives
CULTURE AND RESPECT
Race (those of African descent)
 They not educated
 They all into drugs
 They all have multiple sexual partners
 They all have HIV
 They in a gang or a bandit
 They’re all zessers
CULTURE AND RESPECT
Race(those of Chinese descent)
 They real quiet
 They don’t speak English properly
 They in a mafia
 They prefer alternative medicine
 They eat anything
CULTURE AND RESPECT
Race(the Venezuelans)
 They can’t talk English properly
 They joining local criminals
 The women all had plastic surgery
 The women are all prostitutes
 They noisy
CULTURE AND RESPECT
How does all this affect your communication with the
patient?
 Encourages medical paternalism
 Unnecessary tests performed
 Doctors may unintentionally incorporate racial biases
and stereotypes into their interpretation of patients
symptoms and medical decision making
 The stereotype threat contributes to health care
disparities.
CULTURE AND RESPECT
The Stereotype Threat
 Classic social psychology experiment in 1995
 Black and white undergraduates given a test
 Half were told that it was an intelligence test and the
other half were told that it was not.
 Black students performed worse than whites when
the task was framed as an intelligence test, but
performed equally as well when it was not framed as
such.
CULTURE AND RESPECT
Stereotype threat occurs when cues in the environment
make negative stereotypes associated with an
individual’s group status salient.

It triggers physiological and psychological processes,

including anxiety, negative emotions, arousal, and
reductions in performance expectations, effort and
working memory capacity that have detrimental
consequences for behaviour.
CULTURE AND RESPECT
Another important point about stereotype threat is that
it can occur regardless of whether the clinician holds
negative racial stereotypes or manifests racial bias.

Rather, stereotype activation is aroused by the patients

activation of a specific stereotype about a social group
to which he/she belongs.
CULTURE AND RESPECT (stereotype effects)
Adherence to treatment- the reduction in memory
capacity and cognitive performance translates into
diminished ability to process information and
follow treatment instructions. The lower effort
translates into lower motivation to adhere to
prescribed treatment plans.
CULTURE AND RESPECT
Communication- the increase in anxiety and
arousal impairs the patient’s ability to
communicate, reducing fluency and response to
clinician’s questions.
CULTURE AND RESPECT
Discounting Feedback- a diabetic patient
experiencing stereotype threat might ignore
feedback about elevated HbA1C levels, or a smoker
might ignore information about the negative
effects of smoking.
CULTURE AND RESPECT
Disengagement- the unpleasantness of stereotype
threat may lead to avoidance of the perceived
threat. If going to the doctor engenders feelings of
inferiority, the patient will avoid it.
CULTURE AND RESPECT
Disidentification- patients cease to identify with the
domain in which they consistently experience the
threat. So a patient will detach his/her identity
from the value of living a healthy lifestyle. This
translates to reduced motivation to adhere to
medication, diet and lifestyle recommendations.
CULTURE AND RESPECT
Reinforcing of stereotypes- if after experiencing
stereotype threat the patients behave in ways that
are consistent with stereotypes, then the
clinician’s racial stereotypes are likely to be
reinforced. Thus a vicious cycle is perpetuated.
CULTURE AND RESPECT
Gender- the patient
 Chronemics- patterns of deference and
dominance during a conversation. Men are
more likely to try and dominate a conversation
and interrupt the other speaker.
 Gender preference- some women prefer to be
seen/examined by male/female doctors.
CULTURE AND RESPECT
Gender (the patient)
 V ictim blaming- in the setting of domestic
abuse, alcohol abuse or unwanted pregnancy
 Stereotyping the single female- is she gay?
 Medical paternalism- the stereotype of women
as soft, weak.
CULTURE AND RESPECT
Gender-the medical student/doctor
 Women in medicine experience more problems
with abusive and discriminatory behaviour.
 Specialty bias- women seen as having poor
manual dexterity so unfit to be surgeons.
 Benevolent sexism?- being given tasks based on
their perceived weakness.
 Women more likely to be sexually harassed
(patients and doctors!!!)
CULTURE AND RESPECT
Gender- the medical student/doctor
 Female doctors conduct longer medical
consultations and employ more empathetic
non-verbal signals
 Female doctors also engage in more counselling
and questioning; this leads to greater patient
satisfaction.
CULTURE AND RESPECT
The LGBTQIA patient
Classification
Lesbian- a woman whose primary sexual and
affectional orientation is towards people of the
same gender.

Gay- a sexual and affectional orientation towards

people of the same gender
CULTURE AND RESPECT
The LGBTQIA patient (classification)

Bisexual- a person whose primary sexual and affectional

orientation is towards people of the same and other
genders

Queer/Questioning- historically has been used as a slur

against people whose sexuality did not meet cultural
norms.
CULTURE AND RESPECT
The LGBTQIA patient (classification)
Transgender- describes a wide range of identities and
experiences of people whose gender identity and/or
expression differs from conventional expectations based
on their sex at birth.
i) Someone whose behaviour or gender expression
does not match their assigned sex at birth
ii) A gender outside the man/woman binary
iii) Having no gender or multiple genders
CULTURE AND RESPECT
The LGBTQIA patient (classification)
Intersex- naturally developing primary or secondary
sexual characteristics that do not fit neatly into society’s
definition of male or female. There are about 20
variations so far.

Asexual- a sexual orientation generally characterised by

not feeling sexual attraction or a desire for partnered
sexuality.
CULTURE AND RESPECT
The LGBTQIA patient (communication barriers)
 Clinician attitudes- patients receive suboptimal
treatment in encounters with doctors who feel
uncomfortable, lack knowledge, and/or exhibit bias.
 Lack of medical training
 Clinician level of skill and confidence
 Incorrect clinical assumptions
CULTURE AND RESPECT
The LGBTQIA patient (common assumptions)
 About the patient’s sexual orientation
 About gay and lesbian sexual behaviours
 About messages sent via the medical practice
 About the family structure of gays and lesbians
CULTURE AND RESPECT
The LGBTQIA patient (strategies)
 Use gender neutral language
 Clarify why such personal details need to be asked
 Elicit a more detailed sexual history
 Become more familiar with the common sex practices
of the LGBTQIA patient and common terminology
 Emphasize patient confidentiality
 Educate colleagues and staff
 Evaluate non-verbal cues in the practice environment
CULTURE AND RESPECT
The LGBTQIA doctor/student
 Discrimination by colleagues
 Discrimination by senior doctors
 Impact on family life
 Increased levels of stress, anxiety and
depression
 Failure to cope and suicidal ideation
CULTURE AND RESPECT
Mental Illness (the patient)
 Fear of the patient
 Health disparities
 Major mental illnesses are all conditions that
impede communication
 Somatic symptoms may be dismissed or
misdiagnosed as psychiatric symptoms.
CULTURE AND RESPECT
Mental Illness (the student/doctor)
 Fear of stigmatization
 Fear of being removed from the medical register
 Reluctance to seek help
 Depression, anxiety, substance abuse, eating
disorders.