Consultations skills: Multicultural consultations

Culture can dramatically affect how patients interact with health services.

Patients from different cultures may have different expectations about their management (Photograph: SPL)
Patients from different cultures may have different expectations about their management (Photograph: SPL)

Multicultural consultations are becoming more common in the UK and there is also more diversity within the NHS.

Equality and diversity is a section of the GP curriculum and most GPs will experience elements of it although there are local variations. The impact of multicultural consultations varies but is heavily influenced by the clinician's ability to be aware of and deal with the implications.

With sufficient honesty most doctors will remember situations where their own views interfered with the quality of care they provided for somebody of a different culture.

Incorrect preconceptions, such as 'multicultural consultations are always difficult and difficult consultations take longer' or 'the average state of health in ethnic minorities is always worse than that of the majority', are likely to lead to rushed and superficial consultations.

Ignorance or denial regarding differences of culture is equally damaging. Of course, there is no need to be perfect and absolutely impartial towards every single patient and colleague, but it is important to be aware of one's own restrictions in order to handle these as best we can.

We should not forget that our own values, biases or personal concerns can change dramatically within a short time in response to experiences or decisions.

Cultural competence or cultural sensitivity is the ability to overcome one's own restrictions, resentments and any significant sense of vulnerability, and to deal flexibly with people from different walks of life, with no focus on any particular groups.

The quality of communication skills will be high and there should be awareness that people's perspectives can differ significantly.

It is not easy to devise a plan on how to achieve or 'teach' this and even personal experience, for example medical professionals who come from minorities themselves, does not automatically improve understanding of all the perspectives and needs of other minorities.

The complexity of culture
Many seminars for 'diversity training' concentrate on differences of race rather than attitudes and are often confused with 'ethnicity', or the belonging to a certain race.

However, ethnicity is not defined by skin colour but could be regarded as the identification of an individual with a social group on grounds of common origin, shared history or culture.

Talking about culture can hardly be free of a degree of judgment and comparison of perceived values. We are, strictly speaking, all multicultural and will keep changing throughout our lifetime and circumstances.

Some elements of our personal culture are fixed, for example gender, age or language, whereas others are more fluid and can be influenced by factors, such as choice of occupation, sexual orientation, political values, religion, health or disability.

Culture in itself is therefore a complex and somewhat vague and dynamic social phenomenon, based on physiology and genetics but more so on beliefs, values and attitudes that can bring people together and influence their behaviour as members of a cultural group.

Awareness of this is highly important as the effects of culture on people can influence many areas of their life, including communication style, health beliefs (for example, aetiology of problems, likely outcomes, what is normal or abnormal, the impact of certain life events in some cultures), diet, lifestyle, rituals, taboos, family roles and set-up, decision-making processes, interaction with health care professionals, clinical presentation (especially mental illness) and response to medical or non-medical interventions.

Patients' expectations may differ from what we usually expect in terms of management, from the style of history taking to the examination and the decision for or against further investigations. Demands of different patients can vary widely.

Cultural competence
To achieve a degree of cultural sensitivity a clinician must develop awareness of the elements of culture and the differences, and be able to adjust successfully using skill, experience and factual knowledge (for example, Muslim patients will not take tablets or medicines in the fasting hours during Ramadan, or patients with an Afro-Caribbean background are at higher risk of cardiovascular disease). However, most cultural competence has to do with attitude and sensitivity acquired by self-reflection rather than academic study.

Ethnic minorities have in many ways similar patterns of health behaviour and disease compared with the surrounding community.

However, asylum seekers may have issues with post-traumatic stress either from experiences in their home country or from challenges and isolation after arrival in the UK.

Also, certain conversion symptoms due to psychosomatic conflicts over specific moral values can differ between cultures, as may the ability to gain insight to overcome them.

Multicultural consultations can run easier if we remain genuinely curious about other cultures, if we are not afraid to ask when in doubt, if we are aware of our own limitations or assumptions and keep questioning ourselves about them, and if we accept that some difficulties might be unsolvable. However, it is important to make the effort to overcome barriers as best as possible.

A patient-centred consultation style with careful acknowledgement of verbal and non- verbal signs is more likely to ensure positive outcomes, better understanding, compliance and motivation. Language barriers and tools to overcome them may require additional planning, for example professional interpreters or language lines.

Multicultural consultations can be challenging and frustrating, but also rewarding and enriching in terms of opening our perspective and knowledge of the world and the problems we share but deal with differently. We do not usually need to change ourselves or others fundamentally to make these consultations work quite well.

  • Dr Jacobi is a GP in York.

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Provide multilingual information materials, such as practice leaflets or information sheets.
  • Identify the ethnic mix of your practice population and whether there are any related significant events or complaints.
  • Identify particular skills required for multicultural interactions and consider further training and role development for all staff members.

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