How do national cultures influence lay people’s preferences toward doctors’ style of communication? A comparison of 35 focus groups from an European cross national research

The long-lasting and multifaceted phenomenon of internationalization of heath care, has led to the development of an increasing number of educational courses that targeted at international clientele and has promoted the dissemination of cross-national medical curricula [1]. In a similar way, clinical practice has also started to implement worldwide guidelines in healthcare delivery [2]. The evidences that inspire and foster these teaching programmes and clinical recommendations, are often based on national studies. Papers are written from the implicit assumption that there are no significant differences between countries in the way doctors and patients relate to each other. However, it is unclear whether this is a valid approach. For example, a partnership doctor-communication style, that is thought appropriate in most of Western medical schools and generally advocated by Western patients in their contacts with doctors, appears to be quite difficult to apply in a South-East Asian culture. There conflict avoidance and accepted social differences leads to a one-way, paternalistic, doctors’ style of communication prevailing [3]. How far the results from such single-country studies can be transferred and how applicable these results are in other countries is hardly ever discussed as a potential limitation of the reported studies. This leads to concerns about the quality and the trans-cultural consistency of the existing evidence. Several studies have demonstrated systematic and relevant differences between countries in medical communication [4‐7]. Patients’ ethnic/cultural background -meant here as the expression of belonging to a specific ethnic group - [8, 9], or their linguistic proficiency [10], have been demonstrated to have an impact on clinical outcomes and patients’ expectations. Cross-national differences in doctor-patient communication have been attributed to the characteristics of the health care system, in particular GP’s gatekeeping role [11], or to cultural difference [12]. Among the key predictors of communication factors related to culture suggested by Schouten [13], is the Hofstede model [14, 15]. It is one of the most frequently used to highlight differences in cultural values, as it enables a quantification of the dimensions that characterize this complex concept. Hofstede’s theory on national cultures, identifies four culture dimensions: power distance (PDI), uncertainty avoidance (UAI), individualism verses collectivism (IDV), masculinity verses femininity (MAS), later supplemented with a fifth dimension: long term vs short term orientation (LTO) [15].

In the present study this model will be applied in order to interpret national differences in the preferences regarding doctor’s behaviour when communicating. These were expressed by lay people in 35 country-specific focus groups, in four different European countries, Belgium, the Netherlands, United Kingdom and Italy. The immediate purpose of the study is to test whether or not cross-national differences exist. These relate both in terms of favorite topics, because they are most frequently discussed, and preferences relating to doctors’ communication performances. The ultimate aim is to provide evidence on how applicable results from single-country studies on doctor-patient communication are to other countries.

In particular the research questions explored are as follows:

All the participants comments, stratified by judgment value (positive, neutral and negative), content (Guliver coding system – sub-category level) and country are listed in Table 1.

The study has shown more similarities than differences in positive and critical opinions expressed by our sample of European citizens. This suggests that doctors’ performance in communication is valued more or less the same in the four participating countries. Most of doctors’ communication behaviours and attitudes were commented upon positively by the whole sample, with only few exceptions. Regression analysis indicated a cross-cultural positive appreciation in particular of four types of intervention: Doctors attitudes (both Task-Oriented and Affective/Emotional), Structuring, Providing solution and Giving Information. This combination of elements embodies a balance between doctors ability in setting up an empathetic relationship (Affective-oriented attitudes) and showing competency in the solution or management of the problems and symptoms presented by the patient. Competency can be demonstrated in three ways: by interacting with the patient in a professional and self-confident manner (Task-oriented attitudes), by offering information and hopefully solutions to the problems presented (Giving Information and Providing Solutions) and by following a flexible approach (Structuring).

Hofstede’s model, and the translation of its cultural dimensions into communication styles, might offer a possible cultural explanation of this juxtaposition of communication features. All European nations here selected, scored high on the dimension ‘Individualism vs Collectivism’, which is characterized by a tendency towards autonomy and the exaltation of the individual and his personal resources and goals. In an earlier study, this dimension proved to be the most important in cross-national differences in doctor-patient communication [12]. This finding can be translated into a clinical approach that takes into account patient’s needs and that actively promotes his or her involvement in the decision-making process [12]. To boost this trend, there is also another cultural aspect that seems shared to a fair degree within our sample. This is the low score in the scale of ‘Power distance’, which denotes a validation of patient initiative and a reduction in the dominance of the doctor in the doctor-patient relationship [14]. Taking the assumption that participants moved from a common cultural background that oriented them to take an active role in the healing process, one might wonder why they choose among their favorite interventions, Giving Information or Providing solution, which can be considered directive doctor’s intervention and why Patient involvement did not result in being significantly more appreciated that other interventions.

The shift from the patient’s expectation of involvement and their acceptance of doctors’ suggestions may probably, have been made possible by the synergistic coexistence of the other four elements composing our five-point structure. Thus, patients are willing to accept solutions that come from an external source, the doctor, only to the extent that these are perceived as the fruit of a competent, flexible, empathetic and careful listening [25‐27].

The wide cross-national appreciation of affective interventions does not find an immediate explanation in the scores of another Hofstede dimension usually correlated to ‘emotional expression’: Masculinity/Femininity. In this scale, the Netherlands is placed in the polarity Femininity, diverging from the other three countries with an higher grade for Masculinity. In communication terms, Masculinity is assumed to be translated in instrumental, or curing behavior, disease centred communication and biomedical talk, while Femininity is related to caring behavior [14]. In a previous study, using Hofstede’s dimensions for predicting cross-national differences in doctor-patient communication, the Masculinity-Femininity dimension also was the odd one which did not fit within the predicted pattern [12]. One possible hypothesis that might explain this absence of differences in country’s orientation towards Affective-oriented attitudes based on Hofstede scores, is that cultural differences might emerge at the micro-level of specific skills used to deliver the emotional content. Indeed, participants from the Netherlands, which has the highest scores of Femininity, often discussed Reassurance, which requires a high emotional involvement of the doctor in order to be perceived as being authentic by the patient [28]. By contrast, the UK and Italy, with higher scores in the scale of Masculinity, were, in their comments, more oriented towards Showing interest and a Pleasant attitude, which imply a lower level of personal or emotional participation by the doctor, who is asked in this case to be polite, gentle and attentive but not necessarily compassionate [29]. However, Belgium has the same tendency to Masculinity as the UK and Italy have, and yet its study participants behaved more like the Dutch did, commenting positively on the way doctors practices Reassurance.

Of course much more can be said about the impact of national cultures on how doctor and patient communicate in the medical consultation room, and what is, or is not, appreciated by people from different countries. The literature on this issue is still scarce although the pressure to internationalize paths of care and education is growing. Our results suggest that at a macro-level, citizens present quite similar preferences towards doctors’ communication styles, and therefore, teaching programmes and clinical guidelines that stick to general recommendations might not require cultural adaptations if applied in the four countries selected here.

Anyway, previous studies [3] have highlighted that the implementation of a communicative approach (i.e.partnership relationship) in different cultures (i.e. Western versus Southeast Asian), although generally acknowledged, requires adaptations when shifting to the microlevel of doctors’ specific actions carried out during the consultation, as they can have a different impact according to the nationality of the patient. In the sample here analysed, this might be the case of doctors’ affective expressions, where how far, what patients consider, a “good intervention” can be generally applicable seems to be affected by their cultural background, and consequently, a more careful approach should be followed in the implementation of cross-national clinical and educational interventions on “patient’s emotion handling”.

International comparative cross-cultural studies based on a wider range of cultural backgrounds that assess citizens’ preferences on doctors’ communication styles, according to the specific functions of the clinical encounter, would encourage the development and promotion of culturally competent health care [30‐32].

The project was approved by the Medical Education Research Ethics Committee of the University of Liverpool. Informed consent of the participants was obtained in all four countries.

A combination of elements, emboding a balance between doctors ability in setting up an empatheticrelationship and showing competency in the management of patients’ symptoms, has been cross-culturallyvalued.Teaching programmes and clinical guidelines that stick to general recommendations, based on thiscombination of communication skills, might not require cultural adaptations if applied in the four countrieshere selected.International comparative cross-cultural studies based on a wider range of cultural backgrounds wouldencourage the development and promotion of culturally competent health care.