Noura A. Abouammoh

6.3.2 Different expectations between IMGs and patients

One of the challenges to building rapport in cross-cultural medical encounters that emerged from the data was the different interaction and relationship-building expectations that several IMGs reported.

It appeared that some IMGs had to change their rapport-building style to suit Saudi patients’ expectations. For example, an IMG from Bangladesh initially started applying her usual way of dealing with Bangladeshi patients, with her Saudi patients; however, she realised that adapting new strategies to deal appropriately with Saudi patients is important to make patients feel more comfortable with her. She stated that:

“What the patient wants from me is different here than in Bangladesh […] initially I was applying the techniques that I used to apply in Bangladesh, but then with the passage of time I came to know that I have to change a little from my side because what the patient expects from the doctor is different here than in Bangladesh” [sic]

(IMG18, Bangladeshi)

The findings showed that the relationship style preferred by Saudi patients, according to the IMGs, is a formal relationship, which can make it difficult for IMGs to probe aspects of patients’ lives that can help them to set a practical management plan for their health condition, and may preclude non-health related conversations, which can be a strategy to build rapport. For instance, the same IMG observed this:

“They [patients] don’t want me to probe. They want to be just to the point. “This is the problem and you just give us the solution!” […] as a family physician we need to explore the patient and know what the exact hidden agenda behind the symptoms is”[sic]

(IMG18, Bangladeshi)

According to another IMG from Egypt:

“Sometimes when I try to joke about something with Egyptian patients they laugh and take it easy but Saudi patients think the relationship should be more formal. They may find it inappropriate if the doctor joked about anything” [Translated]

(IMG16, Egyptian)

It appears from the findings that the IMGs are aware of the cultural differences and have adopted new approaches to meet Saudi patients’ expectations who, according to them, tend to appreciate a formal relationship with their doctors. Nonetheless, most of the IMGs in the study did not like this kind of relationship with their patients.

While the IMGs related Saudi patients’ preference of a formal relationship to their culture, the Saudi patients themselves stated that they avoid having non-health related conversations with IMGs, specifically, because they do not feel that their IMG physicians understand them easily. They described their relationships with Saudi physicians as less formal than those with IMGs because of the ease of communication and mutual understanding. For example, one patient from the hospital, who had the chance to see Saudi and IMG physicians, explained that Saudi physicians understand her without effort, which makes it easier for her to express herself and her concerns, enabling the Saudi physician to provide appropriate care. She noted:

“It is most of the times formal [the relationship with IMGs] […] I talk more with Saudi doctors because I know they understand me immediately and they are open to listen” [Translated]

(Patient 15)

Therefore, the findings showed that there are conflicting expectations between patients and their IMGs. While IMGs thought that patients wanted a formal relationship with their physicians, patients assumed that they have to deal with their IMGs formally as mutual understanding may not be easily accomplished.

6.3.2.1 Shared decision making

Shared decision making (SDM) is one of the key components of patient-centred care that strongly requires developing a partnership with the patient.

Regardless of its application in practice, it appeared from the findings that SDM could be influenced by the relationship between the IMGs and their patients.

This could be attributed to the power dynamic and the presence of prejudice in the medical relationship, which will be discussed later in this section (see 6.3.3 and 6.3.4). It appeared that when some patients were dominant over their physicians, there was no place for exchanging information, as the patient could impose his or her wishes over the physicians’ recommendations. For example, according to one IMG:

“Patients are either “passive” or “want to be the doctor”. Passive patients receive information from, but not share information with, the doctor. These patients may or may not follow your advice. The other type of patients wants to choose what they prefer from their observations outside the clinic, of their family and friends, without my help” [Translated]

(IMG12, Sudanese)

Despite some patients expressing their preference for SDM during medical interviews, most of the IMGs avoided presenting management plans for their patients to choose from, to avoid losing their patients’ trust. These IMGs assumed that patients might view their physicians as less professional and categorise them as less trustworthy if they shared treatment options with them. A small number of the IMGs tried to ascertain patients’ opinions regarding the treatment plan without letting them know their intention in an attempt to preserve the trust between them. One IMG stated:

“You cannot do this shared decision making directly with the patients here. I give them what I see as the best for them, then check with them if they can follow it or not. In this way I can involve them in making the decision without affecting their view of me” [Translated]

(IMG11, Syrian)

One of the IMGs from Pakistan believed that as rapport is difficult to build with local patients, SDM has no place during the medical interview. Additionally, she believed that patients are not as concerned about SDM as they are about getting their medication. She explained:

“That [SDM] I do in Pakistan. My patients are my friends. Here, patients will never be your friends, they don’t want to be. They want their medications, I give medications…” [sic]

(IMG14, Pakistani)

On the other hand a small number of patients preferred to discuss different options with their doctors. A 65 years old educated patient explained:

“Yes, I would love to discuss treatment options with the doctor because you need to choose what better suits your own lifestyle” [Translated]

(Patient 12)

The data showed conflicting expectations between IMGs and patients. While IMGs’ believe that they should not openly discuss options regarding management plans with their patients, as this could negatively affect trust, some patients expressed their preference of the SDM approach.