PROFESSIONALISM IN A CULTURAL CONTEXT. CULTURAL INFLUENCES ON MEDICAL PROFESSIONALISM Objectives: 1-...

PROFESSIONALISM IN A PROFESSIONALISM IN A CULTURAL CONTEXTCULTURAL CONTEXT

PROFESSIONALISM IN A PROFESSIONALISM IN A CULTURAL CONTEXTCULTURAL CONTEXT

CULTURAL INFLUENCES ON CULTURAL INFLUENCES ON MEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISMCULTURAL INFLUENCES ON CULTURAL INFLUENCES ON

MEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISM

Objectives: Objectives:

1- Recognize the environment1- Recognize the environment

2- Welfare, autonomy, justice 2- Welfare, autonomy, justice

3- Physicians as Models 3- Physicians as Models

4- Respect others beliefs4- Respect others beliefs

5- PEARLS Concept5- PEARLS Concept



Characteristics of ProfessionalismCharacteristics of Professionalism

CompetencyCompetency

ResponsibilityResponsibility

AttitudeAttitude

Conduct on the jobConduct on the job

ATTITUDES CENTRAL TO MEDICAL ATTITUDES CENTRAL TO MEDICAL PROFESSIONALISM IN CULTURAL PROFESSIONALISM IN CULTURAL

CONTEXTCONTEXT

ATTITUDES CENTRAL TO MEDICAL ATTITUDES CENTRAL TO MEDICAL PROFESSIONALISM IN CULTURAL PROFESSIONALISM IN CULTURAL

CONTEXTCONTEXT

• HumilityHumility

• EmpathyEmpathy

• RespectRespect

• SensitivitySensitivity

• Curiosity andCuriosity and

• Awareness of all outside influences Awareness of all outside influences including cultural on patients healthincluding cultural on patients health

FOCUSING ON KNOWLEDGE IN FOCUSING ON KNOWLEDGE IN CULTURAL CONTEXTCULTURAL CONTEXT

FOCUSING ON KNOWLEDGE IN FOCUSING ON KNOWLEDGE IN CULTURAL CONTEXTCULTURAL CONTEXT

1.1. It is important for a medical student or post It is important for a medical student or post graduate trainee to learn about the graduate trainee to learn about the surrounding community in which he/she surrounding community in which he/she practices or trains.practices or trains.e.g. Socio economic status, patterns of e.g. Socio economic status, patterns of housing nutritional habits, healing practices housing nutritional habits, healing practices and disease incidence and prevalence.and disease incidence and prevalence.

2.2. The knowledge taught has specific evidence The knowledge taught has specific evidence based impact on health care delivery.based impact on health care delivery.e.g. How Ramadan fasting affects Muslims e.g. How Ramadan fasting affects Muslims who are diabetic.who are diabetic.

FOCUSING ON SKILLS IN FOCUSING ON SKILLS IN CULTURAL CONTEXTCULTURAL CONTEXT

FOCUSING ON SKILLS IN FOCUSING ON SKILLS IN CULTURAL CONTEXTCULTURAL CONTEXT

With individual patients as teachers, learners With individual patients as teachers, learners should be encouraged to adjust their practice should be encouraged to adjust their practice styles accordingly to meet their specific needs.styles accordingly to meet their specific needs.

It is crucial to understand health beliefs of It is crucial to understand health beliefs of those who come from different cultures or those who come from different cultures or have different health care experiences.have different health care experiences.

MEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISM

Three fundamental principles:Three fundamental principles:

1.1. Patient welfarePatient welfare

2.2. Patient autonomyPatient autonomy

3.3. Social justiceSocial justice

PATIENT WELFARE INCLUDING PATIENT WELFARE INCLUDING AUTONOMYAUTONOMY

PATIENT WELFARE INCLUDING PATIENT WELFARE INCLUDING AUTONOMYAUTONOMY

1.1. Professional competenceProfessional competence

2.2. Honesty with patients -- integrityHonesty with patients -- integrity

3.3. Patient confidentialityPatient confidentiality

4.4. Caring attitudeCaring attitude

5.5. Scientific knowledgeScientific knowledge

6.6. Maintaining trustMaintaining trust

7.7. Setting and maintaining Setting and maintaining professional standards.professional standards.

SOCIAL JUSTICESOCIAL JUSTICESOCIAL JUSTICESOCIAL JUSTICE

1.1. A just distribution of finite A just distribution of finite resourcesresources

2.2. Managing conflict of interestManaging conflict of interest

3.3. Improving quality and Improving quality and access to careaccess to care

4.4. Respect for colleaguesRespect for colleagues

THE CENTRALITY OF PATIENT THE CENTRALITY OF PATIENT PHYSICIAN RELATIONSHIP TOPHYSICIAN RELATIONSHIP TOMEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISM

THE CENTRALITY OF PATIENT THE CENTRALITY OF PATIENT PHYSICIAN RELATIONSHIP TOPHYSICIAN RELATIONSHIP TOMEDICAL PROFESSIONALISMMEDICAL PROFESSIONALISM

Four Possible Consultation ModelsFour Possible Consultation Models

1.1. Physician as parent, imam or priest Physician as parent, imam or priest (paternalistic)(paternalistic)

2.2. Physician as a mentorPhysician as a mentor

3.3. Physician as a technician or contractorPhysician as a technician or contractor

4.4. Physician as a friend or CounselorPhysician as a friend or Counselor



Dependent on community’s social values Dependent on community’s social values and moral normsand moral norms

PATERNALISTIC MODELPATERNALISTIC MODEL



PHYSICIAN AS A PARENTPHYSICIAN AS A PARENTPATERNALISTIC MODEL:PATERNALISTIC MODEL:

Physicians are in the best position to judge Physicians are in the best position to judge what is best for their patients. In a strong what is best for their patients. In a strong form of this, physicians authoritatively form of this, physicians authoritatively order patients to assent (with coercion if order patients to assent (with coercion if necessary).necessary).

Culturally applicable in Chinese culture Culturally applicable in Chinese culture and partially in other Far East and South and partially in other Far East and South Asian cultures.Asian cultures.

CULTURAL INFLUENCESCULTURAL INFLUENCES CULTURAL INFLUENCESCULTURAL INFLUENCES

PHYSICIAN AS A MENTORPHYSICIAN AS A MENTORDELIBERATIVE MODELDELIBERATIVE MODEL

Physician objectively knows and Physician objectively knows and prioritizes patient’s personal and medical prioritizes patient’s personal and medical values.values.

The physician mentor’s grip on decision The physician mentor’s grip on decision making is more relaxed than the making is more relaxed than the physician / parent model but autonomy- physician / parent model but autonomy- conscious patients find it unsatisfactory.conscious patients find it unsatisfactory.

Culturally this is an option for some of Culturally this is an option for some of the patients in Eastern countriesthe patients in Eastern countries

CULTURAL INFLUENCESCULTURAL INFLUENCESCULTURAL INFLUENCESCULTURAL INFLUENCES

PHYSICIANS AS TECHNICIANS PHYSICIANS AS TECHNICIANS INFORMATIVEINFORMATIVE

ENGINEERING MODELENGINEERING MODEL

Physicians only provide value Physicians only provide value neutral medical information and neutral medical information and leaving patients to make decisions leaving patients to make decisions independently based on personal independently based on personal values (total patient auto-nomy).values (total patient auto-nomy).

Cont’d


Physicians treat diseases rather than Physicians treat diseases rather than patients and sick persons are patients and sick persons are “Consumers”.“Consumers”.

Culturally applicable To certain Culturally applicable To certain sections of Western and relatively less sections of Western and relatively less eastern popu-lation. eastern popu-lation.

Cont’d


PHYSICIANS AS FRIENDS OR COUNSELLORSPHYSICIANS AS FRIENDS OR COUNSELLORS

INTERPRETIVE/ COLLEGIAL MODELINTERPRETIVE/ COLLEGIAL MODEL

• Physician’s medical facts and patients personal Physician’s medical facts and patients personal values contribute to balanced medical decision-values contribute to balanced medical decision-making.making.

• This approach upholds patient autonomy This approach upholds patient autonomy without undermining the physician’s duty of without undermining the physician’s duty of beneficence.beneficence.

• Shared decision making culturally popular in the Shared decision making culturally popular in the West, increasingly accepted in the East .West, increasingly accepted in the East .

Contd

CULTURAL INFLUENCESCULTURAL INFLUENCES

While providing professional care physician mustWhile providing professional care physician mustnot impose his / her view on a patient’s---not impose his / her view on a patient’s---

• Life style, culture, beliefs, raceLife style, culture, beliefs, race

• Sex, age / sexualitySex, age / sexuality

• Social status / economic worthSocial status / economic worth

Physicians must be prepared to explain and justifyPhysicians must be prepared to explain and justifyhis / her actions and decisionshis / her actions and decisions

Contd


CONFIDENTIALITYCONFIDENTIALITY

Confidentiality concept Confidentiality concept may not be the same in the may not be the same in the East as in the West. East as in the West. However its principles are However its principles are applicable in most settings.applicable in most settings.

Physicians must be honest Physicians must be honest and trust worthyand trust worthy

Contd

SPECIAL CULTURAL ISSUES IN SPECIAL CULTURAL ISSUES IN PROFESSIONAL CARE IN PAKISTAN / REGIONPROFESSIONAL CARE IN PAKISTAN / REGION

SPECIAL CULTURAL ISSUES IN SPECIAL CULTURAL ISSUES IN PROFESSIONAL CARE IN PAKISTAN / REGIONPROFESSIONAL CARE IN PAKISTAN / REGION

CONSULTATION / CONFIDENTIALITYCONSULTATION / CONFIDENTIALITY

Insistence on eye contact?Insistence on eye contact?

Uncovering of face in some femalesUncovering of face in some females

Undressing of female patients?Undressing of female patients?

Sharing of confidential information with spouses, relatives?Sharing of confidential information with spouses, relatives?

History taking of female adults from parents or husbands?History taking of female adults from parents or husbands?

Giving information to patients in a way they can Giving information to patients in a way they can understandunderstand

SPECIAL CULTURAL ISSUESSPECIAL CULTURAL ISSUESSPECIAL CULTURAL ISSUESSPECIAL CULTURAL ISSUES

CONFLICT OF INTERESTCONFLICT OF INTEREST

• Patients best interest–lack of appro-Patients best interest–lack of appro-priate referral system may have priate referral system may have adverse effects on patient care.adverse effects on patient care.

• Inducements / incentives for Inducements / incentives for referralsreferrals

Contd


• The way you prescribe for, refer The way you prescribe for, refer or follow-up patients should not or follow-up patients should not be affected if you have financial be affected if you have financial or commercial interests in or commercial interests in organizations providing health organizations providing health carecare

• Honesty is a must in financial Honesty is a must in financial and commercial matters relating and commercial matters relating to physician’s workto physician’s work

Contd


ACCEPTING GIFTS OR OTHER INDUCEMENTSACCEPTING GIFTS OR OTHER INDUCEMENTS

You should not ask for or accept any material You should not ask for or accept any material rewards, except those of insignificant value rewards, except those of insignificant value from representatives of pharmaceutical from representatives of pharmaceutical companies.companies.

Help with conferences and educational Help with conferences and educational activities may be acceptableactivities may be acceptable

Contd

CULTURAL ISSUESCULTURAL ISSUESCULTURAL ISSUESCULTURAL ISSUES

SIGNING CERTIFICATES AND OTHER SIGNING CERTIFICATES AND OTHER DOCUMENTSDOCUMENTS

• One must not sign certificates or One must not sign certificates or documents which one believes to be false documents which one believes to be false or misleading.or misleading.

• Same principles apply with references.Same principles apply with references.

Contd


ADVERTISINGADVERTISING

• Physicians must not exploit patient’s Physicians must not exploit patient’s vulner-ability or lack of medical vulner-ability or lack of medical knowledge.knowledge.

• Only factual information should be Only factual information should be provided.provided.

Contd


RESEARCHRESEARCH

• Research should not be contrary to the patient’s interest Research should not be contrary to the patient’s interest e.g. exploitation of developing countries patients.e.g. exploitation of developing countries patients.

• Research protocol should be approved by a research Research protocol should be approved by a research ethics committee.ethics committee.

• This committee may be non existent in many settings.This committee may be non existent in many settings.

• Your conduct in the research must not be influenced by Your conduct in the research must not be influenced by pay-ments or gifts.pay-ments or gifts.

• Record your research results truthfullyRecord your research results truthfully

Contd

CULTURAL CONTEXT IN UNDER-CULTURAL CONTEXT IN UNDER-GRADUATE MEDICAL EDUCATION GRADUATE MEDICAL EDUCATION

CURRICULUMCURRICULUM

CULTURAL CONTEXT IN UNDER-CULTURAL CONTEXT IN UNDER-GRADUATE MEDICAL EDUCATION GRADUATE MEDICAL EDUCATION

CURRICULUMCURRICULUM

• The goal of the curriculum should be to prepare The goal of the curriculum should be to prepare students to care for patients from diverse social students to care for patients from diverse social and cultural backgrounds including racial, ethnic and cultural backgrounds including racial, ethnic and gender biases.and gender biases.

• The foundation of cross cultural care is based in The foundation of cross cultural care is based in the attitude central to medical professionalism.the attitude central to medical professionalism.

CONCLUSIONCONCLUSIONCONCLUSIONCONCLUSION

Patients are entitled to good standards of Patients are entitled to good standards of professional practice and care in all cultural professional practice and care in all cultural settings.settings.

The essential elements of this medical professiona-The essential elements of this medical professiona-lism are:lism are:

1 -1 - Professional competenceProfessional competence2 -2 - Good relationship with patients and Good relationship with patients and colleaguescolleagues3 -3 - Observance of professional ethical obligationsObservance of professional ethical obligations

Medical teachers should be a role model’ in Medical teachers should be a role model’ in application of these essentials application of these essentials

Professionalism in Different Professionalism in Different Cultural ContextsCultural Contexts

Cultural CompetencyCultural CompetencyRespectRespectAssess/AffirmAssess/AffirmSensitivity/ Self AwarenessSensitivity/ Self AwarenessHumilityHumility


Help students and others to Help students and others to incorporate elements of cultural incorporate elements of cultural competence into their practice.competence into their practice.


ListenListenExplainExplainAcknowledgeAcknowledgeRecommendRecommendNegotiateNegotiate


PartnershipPartnershipEmpathyEmpathyApologyApologyRespectRespectLegitimizationLegitimizationSupportSupport


Listen with sympathy and Listen with sympathy and understanding to the patient’s understanding to the patient’s perception of the problemperception of the problem

Explain your perceptions of the Explain your perceptions of the problemproblem

Acknowledge and discuss the Acknowledge and discuss the differences and similaritiesdifferences and similarities

Recommend treatmentRecommend treatment Negotiate agreementNegotiate agreement


PPartnership: Working with the patient to accomplish a artnership: Working with the patient to accomplish a shared outcomeshared outcome

EEmpathy: Recognizing and comprehending another’s mpathy: Recognizing and comprehending another’s feelings or experiencefeelings or experience

AAnalogy: Being willing to acknowledge or express nalogy: Being willing to acknowledge or express regret for contributing to a patient’s discomfort, regret for contributing to a patient’s discomfort, distress, or ill feelingsdistress, or ill feelings

RRespect: Non-judgmental acceptance of each patient espect: Non-judgmental acceptance of each patient as a unique individual; treating others as you would as a unique individual; treating others as you would have them treat you.have them treat you.

LLegitimization: Accepting patient’s feelings or egitimization: Accepting patient’s feelings or reactions regardless of whether or not you agree with reactions regardless of whether or not you agree with those perceptions.those perceptions.

SSupport: Expressing willingness to care and be helpful upport: Expressing willingness to care and be helpful to the patient however you can.to the patient however you can.


What do you call your problem? What What do you call your problem? What name does it have?name does it have?

What do you think caused your What do you think caused your problem?problem?

Why do you think it started when it did?Why do you think it started when it did? What does your sickness do to you? What does your sickness do to you?

How does it work?How does it work? How severe is it? Will it have a short or How severe is it? Will it have a short or

long course?long course?


What do you fear most about your What do you fear most about your disorder?disorder?

What are the chief problems that your What are the chief problems that your sickness has caused for you?sickness has caused for you?

What kind of treatment do you think What kind of treatment do you think you should receive?you should receive?

What are the most important results What are the most important results you hope to receive from the you hope to receive from the treatment?treatment?


Culture: The importance of shared values, Culture: The importance of shared values, perceptions, and connections in the perceptions, and connections in the experience of health, health care, and the experience of health, health care, and the interaction between patient and interaction between patient and professional.professional.

Respect: Understanding that demonstrations Respect: Understanding that demonstrations of respect are more important than gestures of respect are more important than gestures of affection or shallow intimacy, and finding of affection or shallow intimacy, and finding ways to learn how to demonstrate respect in ways to learn how to demonstrate respect in various cultural contexts.various cultural contexts.


Assess: Understanding that there are Assess: Understanding that there are tremendous ‘‘within-group tremendous ‘‘within-group differences,’’ ask about cultural differences,’’ ask about cultural identity, health preferences, beliefs, identity, health preferences, beliefs, and understanding of health and understanding of health conditions. Assess language conditions. Assess language competency, acculturation-level, and competency, acculturation-level, and health literacy to meet the health literacy to meet the individual’s needs.individual’s needs.


Affirm: Recognizing each individual Affirm: Recognizing each individual as the world’s expert on his or her as the world’s expert on his or her own experience, being ready to listen own experience, being ready to listen and to affirm that experience. Re-and to affirm that experience. Re-framing cultural differences, by framing cultural differences, by identifying the positive values behind identifying the positive values behind behaviors we perceive as ‘‘different.’’behaviors we perceive as ‘‘different.’’


Sensitivity: Developing an awareness Sensitivity: Developing an awareness of specific issues within each culture of specific issues within each culture that might cause offence, or lead to a that might cause offence, or lead to a breakdown in trust and communication breakdown in trust and communication between patient and professional.between patient and professional.

Self-Awareness: Becoming aware of our Self-Awareness: Becoming aware of our own cultural norms, values, and ‘‘hot-own cultural norms, values, and ‘‘hot-button’’ issues that lead us to mis-button’’ issues that lead us to mis-judge or miscommunicate with others.judge or miscommunicate with others.


Humility: Recognizing that none of us Humility: Recognizing that none of us ever fully attains ‘‘cultural ever fully attains ‘‘cultural competence,’’ but instead making a competence,’’ but instead making a commitment to a lifetime of learning, of commitment to a lifetime of learning, of peeling back layers of the onion of our peeling back layers of the onion of our own perceptions and biases, being own perceptions and biases, being quick to apologize and accept quick to apologize and accept responsibility for cultural mis-steps, and responsibility for cultural mis-steps, and embracing the adventure of learning embracing the adventure of learning from others’ first-hand accounts of their from others’ first-hand accounts of their own experience.own experience.


‘‘‘‘An integrated pattern of learned core An integrated pattern of learned core values, beliefs, norms, behaviors and values, beliefs, norms, behaviors and customs that are shared and transmitted customs that are shared and transmitted by a specific group of people. by a specific group of people.

Some aspects of culture, such as food, Some aspects of culture, such as food, clothing, modes of production and clothing, modes of production and behaviors, are visible. behaviors, are visible.

Major aspects of culture, such as values, Major aspects of culture, such as values, gender role definitions, health beliefs gender role definitions, health beliefs and worldview, are not visible.’’and worldview, are not visible.’’


Recognizing the role of culture in Recognizing the role of culture in health means an acknowledgment of health means an acknowledgment of the importance of shared values, the importance of shared values, perceptions, and beliefs related to perceptions, and beliefs related to health.health.

Culture is directly related to health Culture is directly related to health promotion, disease prevention, early promotion, disease prevention, early detection, access to health care, detection, access to health care, trust and compliancetrust and compliance


Respect implies that each individual Respect implies that each individual has a right to receive respect has a right to receive respect according to his or her own personal, according to his or her own personal, individual, family, and socio-historical individual, family, and socio-historical perspective.perspective.

We must learn to demonstrate our We must learn to demonstrate our respect to individual patients in ways respect to individual patients in ways that each person will receive or that each person will receive or perceive as being respectful.perceive as being respectful.

Professionalism in Professionalism in Different Cultural Different Cultural

ContextsContextsTHANK YOUTHANK YOU

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