Noura A. Abouammoh

6.4.2 Patients’ attitude to IMGs’ advice

It appeared from 6.4.1 that patients acknowledge neither the IMGs’ knowledge nor the effort involved in advising them.

Not acknowledging IMGs’ knowledge can be attributed to the difficulties patients face regarding acting upon some advice, such as physical exercise advice compared to dietary advice. For example, one patient noted:

“…It is always easier to control diet, I cannot commit to exercise” [Translated]

(Patient4)

This kind of attitude from patients could make them less likely to listen to IMGs’ advice regarding physical exercise, and hence less likely to remember it.

Most IMGs attributed patients’ attitudes of acknowledging neither the IMGs’ knowledge nor the effort involved in advising them, to patients’ preconceived stereotypical ideas about IMGs, including the notion that these physicians cannot provide culturally sensitive and practical advice, as they do not share the same culture as their patients. For this reason, no matter how much effort IMGs made to improve their advising strategy, patients may not see it or acknowledge it. One of the IMGs explained:

“As the patient enters the room, it's at the back of her mind that, "The person I am visiting is not Saudi. He doesn't belong to my culture; he or she doesn't belong to the environment where I'm living." So, if we try to maybe educate them, we try to convince them to change their lifestyle or do whatever is good for them, it's difficult for them to accept. Maybe, they might be thinking that he doesn’t know what their actual culture is, so the education that we are giving is not applicable, but if the same education is being delivered by their own Saudi nationals, they have in their mind that, "She is coming from the same background, she knows our background.  If we apply her teachings, it will be more convenient for us to apply."

(IMG18, Bangladeshi) Follow-up interview

It could be expected that this idea about Saudi patients may also drive IMGs to adopt inflexible approaches to advising patients (see section 6.4.3).

Additionally, language issues contributed to patients’ attitudes towards IMGs’ advice. IMGs explained that it could be difficult for patients to keep the information provided by their doctors, especially non-Arabic speakers, in their minds, as they did not receive it in an understandable accent or language. They believed that patients tend to memorise information better when it is presented in clearer or “more correct” Arabic.

6.4.3 IMGs’ approaches to advising patients

It has been noted that some IMGs were able to come up with new and acceptable strategies to help patients control their diabetes. They realized the importance of certain foods to their patients and adopted strategies to ensure that they could continue to consume them in a healthy way, in addition to finding ways to help them be physically active within the framework of their culture and everyday habits. On the other hand, despite their familiarity with cultural norms, local diets and food customs, a small number of the IMGs were inflexible in their advice. They were resigned to the fact that patients would not follow their advice and therefore did not make much effort to advise patients in this regard. For example, while some IMGs advised patients to avoid eating dates completely, as exemplified by this quote:

“I tell them “do not eat dates”. Even three pieces may affect your sugar level” [Translated]

(IMG16, Egyptian)

Other IMGs advised patients to reduce their date intake because it is not as harmful for diabetes patients’ health if it is taken in limited amounts:

“This is not a bad food also, just reduce the amount” [sic]

(IMG19, Pakistani)

The first quote exemplifies inflexible advice, while the second indicates that the physician tried to advise patients in culturally acceptable terms.

Those who adopt an inflexible strategy in terms of giving advice might feel compelled to do so because of the administrative pressure on consultation times, knowing that adopting a more flexible approach takes time for IMGs to apply. For example, one IMG from Pakistan reported that his colleagues and administrators in the centre blame him because he spends more time with the patients compared to other physicians in the same centre. He noted:

“I have this problem here from my staff, my colleagues, and my administration also. That you are giving too much time to the patients; we don't want patients sitting outside […] if the doctor finishes in half an hour…what can he offer?!”

(IMG19, Pakistani) Follow-up interview

The IMG however, defensively expressed the opinion that this pressure from the administration did not affect the quality of his performance and would not prevent him from exchanging information properly with his patients.

Additionally, according to one IMG, IMGs are assumed by their patients to be unfamiliar with the culture, which make some IMGs adopt inflexible approaches in dealing with their diabetic patients. According to her, these IMGs care more about completing paperwork by following the guidelines for treating T2DM than their patients’ actual needs. She also added that IMGs could be put-off by patients’ non-compliance as she explained:

“When you are working at a place which doesn't belong to you, so at time you have the attitude, "Whatever happens to these people, I have to do my work […] this might be because of the attitude of the patient. Maybe at the beginning they try to convince the patient, but maybe they were not professionally skilled to communicate properly with the patient, or the patients were really arrogant with them. So they say "To hell with everything. I have tried all my strategies but none is working, so let them do whatever they're doing, and I'll do whatever I want to do." [sic]

(IMG18, Bangladeshi)

Another challenge to providing flexible advice was the IMGs’ idea that managing T2DM is the responsibility of the patients themselves. One IMG believed that T2DM patients do not need detailed advice about diet and that they should find out how to manage to eat a healthy diet for themselves. This IMG, who demonstrated familiarity with the local diet, reported:

“I know they eat a lot of dates. But they should figure out how to work on that” [sic]

(IMG10, Indian)

However, his poor Arabic language ability may also have influenced his approach.

Similarly, one patient believed that it was not the IMG’s responsibility to provide dietary advice, believing that it was the patient’s responsibility to evaluate their own food and decide what was healthy for them. He stated:

“If he [the IMG] asked me to reduce sugar intake, I should know what the sources of sugar in my food are and stop them or reduce them” [Translated]

(Patient 2)

This attitude was unexpected from a patient participant, but may be attributed to the patient’s view on IMGs in general, as patients believe that people who do not share the same language and culture may not be able to provide appropriate information. It could also be attributed to this patients’ level of education, as his responses reflected good knowledge about diabetes and its management.

An Indian IMG with 4 years experience working in SA provided the following example of the difficulty of communicating information:

“When I talk to you in your mother tongue in your own dialect, you would understand more than if I talk in a weird accent, even if it’s your own language” [sic]

(IMG10, Indian) follow-up interview

As expected, language appeared to be an obstacle to adopting a flexible approach, as sometimes IMGs, especially non-Arabic speakers, were not able to express themselves to their patients, as mentioned earlier in 6.2.1.

On the other hand, IMGs who had a flexible approach to advising patients acknowledged that it could be difficult for patients to follow their advice so they modified their approach to better suit the culture of the community. For example, IMG 15 advised her patients to cut each date to four pieces so they can feel that they ate larger amount of dates. According to them, the ability to do this develops with more experience in interacting with Saudi patients. In the words of one IMG:

“Both [IMGs with both strategies] do their best. There are differences in the knowledge of how culture is deeply rooted in the Saudi community. Doctors with more experience can give more practical advice than doctors with less experience, who will eventually change with time, when they see less compliant patients and speak to them” [translated]

(IMG11, Syrian) Follow-up interview

This IMG, along with other IMGs, believed that those who follow a flexible or inflexible approach are doing their best to deliver the optimum care they can deliver within the limitations of their skills.

Providing general advice without paying much attention to cultural specifications was believed by one IMG to be the best way of advising patients. This may explain why some IMGs who adopt an inflexible approach believe that they are helping their patients. As one IMG commented:

“I just tell them the main things that you should stop is the sweets. You should stop the bakery items. You should take tea or coffee, if you were taking without sugar in moderation and continue rest of the things […] if you say you just eat this, this, this, this, this, they think that we are getting this restricted things to eat? But if you say just restrict these things and eat everything, then they will think that there are lots of options available for us” [sic]

(IMG18, Bangladeshi)

The belief that handling one’s health condition is the absolute responsibility of the patients, and pressure from the administration to finish their clinics on time were some of the proposed reasons given by the IMGs for adopting a more inflexible approach to advising patients regarding their lifestyle. Patients’ preconceived ideas about their physicians, IMGs’ inability to communicate information and the lack of the experience needed to enable them both to provide culturally sensitive advice and alternatives to the standard lifestyle advice, may result in patients acknowledging neither their IMGs’ knowledge, nor their ability to provide culturally sensitive advice. Additionally, rather than considering providing inflexible advice to patients to be poor practice, in their follow-up interviews, the majority of the IMGs expressed the view that inflexible or more flexible strategies when advising patients were adopted, according to what they felt worked best for this specific community.

6.4.3.1 The effect of IMGs’ stereotypical views towards patients on the provision of lifestyle advice

Because IMGs’ stereotypical views appeared to directly affect IMGs lifestyle advice, it will be discussed under this theme.

Most of the IMGs who took a more inflexible approach towards advising patients appeared largely to believe that the nature of living in SA would restrict people from following their advice. In a country such as SA, where the only entertainment is in social gatherings, restaurants are found in abundance, food is cheap and people do not exercise, advising patients about changing their lifestyles was frequently judged by these IMGs to be pointless. For example, one IMG noted:

“We cannot combat it because people have too much money to spend. Food is very cheap they can take as much as they want […] so it is destined to be a failure. It is a futile exercise” [sic]

(IMG3, Kashmiri) Focus group interview

Some of the patients also reported that they had not received advice about exercise, merely dietary advice. This can also be attributed to the fact that IMGs may have a preconceived idea that Saudi patients tend to have a sedentary lifestyle, which makes advising them in this regard ineffective. One IMG noted:

“This is one of the difficulties also, getting patients to exercise […]. We have sedentary lifestyle; most of the Saudis are not used to exercise”

(IMG9, Pakistani)

IMGs’ perception of the needs of their Saudi diabetes patients could also lead to adopting an inflexible approach to giving advice. A small number of IMGs believed that patients’ main goal when visiting their physicians was to obtain diabetes medication. In other words, they did not assign the same value to the advice they received from their doctors regarding lifestyle changes. An IMG explained:

“The patients’ main concern is taking their medication. They feel that this is the most important thing in managing the disease. Even if I tell them that all these factors [related to lifestyle] are equally important in order to manage their condition, they would stress on taking medication, as if the medication will cure them completely from diabetes” [Translated]

(IMG7, Sudanese)

In general, the IMGs’ stereotypical views of their patients’ lifestyles and needs from the medical interview may negatively affect the quality of care they provide to local patients.