PerspectMedEduc(2016)5:268275

DOI10.1007/s400370160288y

ORIGINALARTICLE

Interculturaldoctorpatientcommunicationindailyoutpatient
care:relevantcommunicationskills
EmmaPaternotte1FeddeScheele1,2ConnyM.Seeleman3LindsayBank1AlbertJ.J.A.Scherpbier4
SandravanDulmen5,6,7

Publishedonline:16September2016
TheAuthor(s)2016.ThisarticleisavailableatSpringerLinkwithOpenAccess.

Abstract

IntroductionInterculturalcommunication(ICC)
betweendoctorsandpatientsisoftenassociatedwith
misunderstandingsanddissatisfaction.Todevelop
ICCspecificmedicaleducation,itisimportanttofind
outwhichICCskillsmedicalspecialistscurrently
applyindailyclinicalconsultations.MethodsDoctor
patientconsultationsofDutchdoctorswithnonDutch
patientswerevideotapedinamultiethnichospitalin
theNetherlands.Theconsultationswereanalyzedusing
thevalidatedMAASGlobalassessmentlistin
combinationwithfactorsinfluencingICC,asdescribed
intheliterature.

ResultsIntotal,39videotapedconsultationswere
analyzed.Thedoctorsprovedtobecapableofpractising
manycommunicationskills,suchaslisteningand
empathiccommunicationbehaviour.Otherskillswerenot
practised,suchas

EmmaPaternotteemmapaternotte@gmail.com

DepartmentofHealthcareEducation,OLVGHospital,
Amsterdam,TheNetherlands

MedicalSchoolofSciences,VuUniversityMedicalCentre,
Amsterdam,TheNetherlands

DepartmentofSocialMedicine,UniversityMedicalCentre,
Utrecht,TheNetherlands

InstituteforMedicalEducation,FacultyofHealth,Medicineand
LifeSciences,MaastrichtUniversity,Maastricht,The
Netherlands

NIVEL(NetherlandsInstituteforhealthservicesresearch),
Utrecht,TheNetherlands

ClinicalpracticeReflectivepracticeCommunication
behaviourMedicaleducation

DepartmentofPrimaryandCommunityCare,Radboud
UniversityMedicalCentre,NIjmegen,TheNetherlands

Whatthispaperadds
FacultyofHealthSciences,UniversityCollegeofSoutheast
Norway,Drammen,Norway

Interculturalcommunicationischallengingfordoctors.

Itishoweversparselytrained.
beingculturallyawareandcheckingthepatients
languageability.
Manyinterculturalcommunicationskillsareknown.
ConclusionWeshowedthatdoctorsdidpracticesomebut
notalltherelevantICCskillsandthattheICCstyleofthe
doctorswasmainlybiomedicallycentred.Furthermore,
wediscussedthepossibleoverlapbetweenintercultural
andpatientcentredcommunication.Implicationsfor
practicecouldbetoimplementtherelevantICCskillsin
theexistingcommunicationtrainingordevelopa
communicationtrainingwithapatientcentredapproach
includingICCskills.

KeywordsDoctorpatientcommunication
InterculturalcommunicationCommunicationskills

Unknownis,however,whatinterculturalcommunica
tionskillsmedicalspecialistsapplyandwhatshouldbe
trainedmore.

Implicationsofthestudyarethepossibleoverlapbe
tweenpatientcentredcommunicationandintercultural
communication.

Thiscouldfacilitatedevelopmentandimplementationof
interculturalcommunicationskillsinmedicaleducation.

Interculturaldoctorpatientcommunication
269

Introduction

Effective,patientcentredcommunicationbetweendoctors
andpatientsisessentialfordeliveringhighqualitypatient
care[1].Competentcommunicationbydoctorsimproves
healthoutcomes,enhancespatientsatisfaction,andcon
tributestodoctorsjobsatisfaction[2].Inthecontextofa
multiculturalsociety,however,effectivecommunication
couldbehinderedbyculturaldifferencesbetweenthedoc
torandthepatient[3].Interculturalcommunication(ICC),
whichinthisarticleisdefinedascommunicationbetween
adoctorofthedominantethnicoriginandanethnicmi
noritypatient,potentiallycausesmisunderstandingandre
ducesinterpersonalinteractions,whichmayleadtoalower
qualityofcare[4].Napieretal.statedthatthesystematic
neglectofcultureinhealthandhealthcareisthesingle
biggestbarriertotheadvancementofthehigheststandard
ofhealthworldwide[5].

ThetheoreticalfundamentsofICCbetweendoctorsand
patientshavegainedattentioninthelastfewyears[68].
Inarecentreview,aconceptualframeworkofinfluencing
factorsinICCispresented.Thisframeworkisconstructed
basedon145includedarticleswithavarietyofevidence
aboutICCbetweenthedoctorandthepatient.Thefactors
influencingICC,suchastheroleofthefamilyinacon
versation,thedoctorsawarenessoftheeffectsofdiffer
encesinethnicbackground,orthepatientsexpectationsof
aconversationwiththedoctor,weretranslatedintocom
municationskills.Theseskillsareofgreatimportancein
dailyclinicalpracticeandhenceshouldbeimplementedin
medicaleducation[6].

Theimportanceoftheuseofcertaincommunicationskills
dependsontherelevanceofthatskillinthespecificcontext
[9,10].Ingeneral,however,professionalcommunication

requiresadaptationtothespecificcharacteristicsofthepatient
andthesituation.Therefore,differentcontexts,suchas
differencesinethnicoriginbetweenthedoctorandthepatient,
shouldbeexplicitlyaddressed[3,6,7,11,12].

WhilethetheoreticalknowledgeonICCskillsandthe
necessityofusingtheseskillshavebeenestablished[6,8,
13],severalresearchersarguethatthescientificfieldof
ICCbetweendoctorsandpatientsinrealpracticeisstill
toosmalltodevelopfocusedtraininginICC[7,14]and
thatjustgivingfeedbackdoesnotcoverthefullpictureof
skilledmedicalcommunication[15].Itis,forexample,
unknownwhichICCskillsarealreadyusedbydoctorsand
howtheyareused.TodevelopknowledgeabouttheICC
skillsused,andthereforealsotheskillsthattheydonot
practiceproperly,thereisaneedtofurtherexplorewhich
ofthesecommunicationskillsareapplicableintheclinical
setting,andwhichofthemarealreadybeingpractised[3,
13].

Inthispaper,weidentifywhichICCskillsmedicalspecialists
useinrealpracticeduringthosemomentsinthemedicalvisit
inwhichsuchskillsarejudgedtoberelevant.Weaddressed
thefollowingresearchquestion:WhichICCinfluencing
factorsdescribedinliteraturearerecognizableindoctors
communicationskillsinrealpractice?

Methods

Studydesign

Inthisobservationalstudy,doctorpatientconsultations
withethnicminoritypatientsanddoctorsoftheDutcheth

nicitywerevideotapedandanalyzed.Theanalysisfocused
onthedoctorswayofcommunicatingandconcentrated
specificallyonwhethertheICCskillsidentifiedinarecent
realistreviewwereappliedindailypractice[6].

Settingandparticipants

BetweenSeptemberandDecember2014,wevideotaped
conversationsofgynaecologists,internists,urologistsand
orthopaedicsurgeonsintheoutpatientclinicsoftheSint
LucasAndreasHospitalinAmsterdam,theNetherlands.
Thisdistrictteachinghospitalservesanurbanmultiethnic
area.AllDutchmedicalspecialistsoftheabovementioned
specialtiesoftheSintLucasAndreasHospitalwereasked
toparticipate.Medicalspecialistswerechosensincethey
arerolemodelsforresidentsandmoreexperiencedin
communicationwithpatients.Thepatientswithanon
Dutchoriginwereincludediftheyhadanappointmentfor
anewepisodeandthepatienthadnotbeenseenbythis

doctorforayearormore.Thesepatientscouldbeofany
originandwerenotaprioriselected.Theywereall
referredbyageneralpractitioner.Thepatientswereasked
abouttheirplaceofbirthandthatoftheirparentsbefore
theywereaskedtoparticipate.Informedconsentofboth
thedoctorandthepatientwasrequestedbythefirstauthor
whothen,ifinformedconsentwasobtained,installedthe
cameraandlefttheroom.Exclusioncriteriawerethe
presenceofaninterpreter,apatientwithDutchethnicity,a
doctorofnonDutchorigin,afollowupconsultationora
consultationthatwaspartlydonebysomebodyelse,for
exampleamedicalstudent.

MAASGlobalInterCulturalCommunication

SinceavalidatedobservationlistforICCdidnotexist,we
combinedtheMAASGlobal,avalidatedinstrumentfor
assessingpatientcentredcommunication[2,16,17],with

270

E.Paternotteetal.

thefactorsinfluencingICCasfoundinarecentreview[6].
Validationofanymeasureisapermanentprocess[18].
Thestrongbaseoftheitemsscoredintheorysupportsthe
contentvalidityofthemeasure.SincetheMAASGlobal
wasdevelopedintheNetherlandstoassesscommunication
skillsofgeneralpractitionerresidentsinrealpractice,we
considereditasuitableinstrumenttousefortheobser
vationofcommunicationskillsofdoctorsinthehospital[
19].TheMAASGlobalhasbeenusedinresearchsettings
aswell[20].Combiningthetwoprotocols,i.e.thefactors
influencingICCandtheMAASGlobal,waspossible
becausethereisanoverlapbetweenthecategoriesofthe
MAASGlobalandthoseusedtoclassifytheinfluencing
factorsinthereview.ThecombinationoftheMAAS
GlobalandtheICCinfluencingfactorsprovidedaframe
workforcodingICCskills,whichcouldthenbeobserved.
Theresultingobservationalscale,theMAASGlobalICC
(Appendix),includes52communicationskillstobeana
lyzedonadichotomousscaleaspresentorabsentanda
4pointLikertscaletoindicatetherelevanceofeachskill
fortheconsultationunderobservation.Thisobservation
andanalysingisdonepersectionofthecommunication,e.
g.openingorexplorationofreasonforencounter(Ap
pendix).Intheresultssection,wereportontherelevant
skillswhichwerepresentorabsent.BecausetheMAAS
GlobalICCisanextensivelist,containingmanyitems,the
resultsectionincludesthecommunicationskillsofthe
MAASGlobalICCthatwerefoundtoberelevantas
absentorpresentinatleast40%oftheconsultations.

Measuresandanalysis

TheadaptedMAASGlobalICCwastestedonfacevalidity
withintheprojectteam,whichconsistedofspecialistsfrom
differentfieldsofexpertise(medical,culturalcompetence,
communicationinhealthcare,medicaleducation).Thefirst
author(EP)observedandanalyzedalltheincludedvideo
tapedconsultations.Thevideotapedconsultationswerealso

Table1Characteristicsofthevideotapedconsultations

independentlyobservedandanalyzedbyoneoffoursecond
observers(CS,LB,LR,TA),whoallwatched910
videotapedconsultationseach.Afterthefirstindependently
observedconsultation,theintraclasscorrelationcoefficient
(Cohenskappa)wascalculatedanddiscussedbetweenEP
andeachsecondobserver.Thereafter,EPandthesecond
observerindependentlyscoredthreeconsultations,andonce
againtheintraclasscorrelationcoefficientwascalculated.If
theCohenskappawasbelow0.6,thevideotapedconsul
tationandscoringwerediscussedtocheckiftheobservers
couldreachahigherlevelofagreement.Beforediscussion,
themeanCohenskappabetweentheobserversrangedfrom
0.47to0.59.Afteradiscussionbetweentheobservers,the
meanCohenskapparangedfrom0.67to0.82.Scoringofthe
videotapedconsultationswasanalyzedwithSPSS21.

Aftereachconsultation,doctorswereaskediftheywere
satisfiedabouttheconsultation.Also,doctorshadtowrite
downiftheyhadenoughtimefortheconsultation.

Results

Intotal,18doctorswereaskedtoparticipateand17
doctorsagreedtoparticipate.Onedoctorrefusedbecause
hefounditdifficulttoaskhisoncologypatients.Ofthese
17doctors,69consecutivepatientsofnonDutchorigin
wereaskedtoparticipate.Ofthesepatients,41gave
informedconsent.Theother28patientsrefusedto
participate,mostlybecauseofprivacyreasons.Twoofthe
41videotapedconsultationswereexcluded,onebecause
thedoctorwasofnonDutchoriginandtheotherone
becausethevideotapelackedsound.

Table1showsthecharacteristicsofthe39included
videotapedconsultations.Furthermore,Table2presentsthe
relevantcommunicationsskillsdemonstratedbythedoctors.
Table3liststhecommunicationskillsthatwerenotusedby
thedoctorsbutthattheobserversconsideredtoberelevantin
thespecificcontextofaninterculturalconversation.Afterthe
consultation,alldoctorsnotedthatthey

Numberofconsul
Ethnicity
Gender
Mean
Meanyearsofprac
Meanlength

tations(n=39)
a

(nonWestern /
(M/F)
age(y)
ticeasmedicalspe
videos

Western )n=39

cialist(y)
(min)
Patientsincluded(%)

32/7(85/15)
21/18
46.3

(54/46)

Specialtyofthedoctor

Gynaecology&Obstetrics
7

2/3
46.0
12.4
17.4
Internalmedicine
15

5/1
44.3
16.0
14.6
Urology
5

3/0
57.7

21.0
7.8
Orthopaedics
12

4/0
52.5
15.8
13.0

Afghanistan,Turkey,Morocco,Surinam,Nicaragua,Nepal,Nigeria,Cuba,Pakistan,China Poland,GreatBritain,Germany,Belgium,
Australia,Hungary
c

DoctorswereallofDutchorigin

Interculturaldoctorpatientcommunication
271

Table2Anoverviewofskills,presentinatleast40%ofthe
consultations,thatthedoctorsused:presentcommunicationskills

Explainsreferraltootherhealthcareworkers

Listensactively
Presentcommunicationskills

Thedoctor...

Showsconcern,isinvitingandsincere,commiseratesbymeansofeye
contactandnonverbalbehaviour,showscompassionforthepatient

Listens
Commiserateswithverbalreactions
Demonstratesreliability(beingfriendlyandhavinganopenattitude)
Hasanopenattitude(showspossibilitiesverbal/nonverbaltogive
thepatientspacefortheirstory)
Makesappointments:who,what,when

Respondstononverbalbehaviourandkeywords
Takesthetime

Givesinformationinsmallamounts
Hasanunprejudicedattitude

Triestoempathizewiththepatientsemotions
Showsempathicbehaviour

Appliesanadequatetimeschedule

Explainscauseandrelationofthecomplaintwithinthecontextofthe
expectationsofthepatient

Givesconcreteexplanations

Reflectsonthefeelingsofthepatient

Showsrespectforthepatient

Usesdifferentwaystogiveexplanations

Usesconcretelanguage

Announcesstagesoftheconversation

Checkexpectationsregardingtheconsultation/healthcare
Treatsthepatientwithcareandrespectduringphysicalexamination
Askaboutthepatientsfeelings
Checksifthepatientand/orrelativesunderstandtheexplanation
Askabouttherelativesemotions
a

Theskillsinthetablearepresentedfrommosttolesspresent
Showawarenessofhisownculturalandprofessionalcontext

weresatisfiedwiththeconsultationandthattheythought
theyhadenoughtimefortheconsultation.

Checkforeknowledgeofthepatientaboutdiagnosisorexpectedpol
icy

Observedcommunicationskills
Summarizethepatientsstory

DoctorsshowedavarietyofICCskillsthatfacilitatedthe
communication.Forexample,inmostconsultations
doctorsadequatelyemployedconcretelanguage,listening
andempathicbehaviourtowardthepatients,suchas
reflectingthepatientsfeelingsanddemonstratingconcern.
Also,doctorsgaveconcreteexplanations,forexample
usingdrawingstoexplainanXray.Mostconversations
werenothurried,andmostdoctorshadanadequatetime
schedule.Allthesepresentskillswereconsideredrelevant
bytheobserversbecause,inthiswayrespect,reliability
andanunprejudicedattitudewereshown.

Explorethereasonfortheconsultation,wishesandexpectations

Explorereactionofinformationtransfertothepatientscontext

Demonstratebeingalerttopossibleculturalaspectswhenaskingfor
thereasonfortheconsultation

Showawarenessofculturaldifferences

Inmanyconsultationsthedoctorsusedabiomedicalstyle
ofcommunication,inwhichtheyfocusedontheirown
agendawithbiomedicallystructuredquestionsandfewer
possibilitiesforthepatienttogiveinput.

Showtohavelearnedfrompreviousconsultationswithethnicminor
itypatients

Askifthepatientunderstoodtheinformation
Table3Anoverviewofskills,absentinatleast40%ofthe
consultations,thatthedoctorsdidnotusebutthatwererelevantwithin
thecontextoftheseconsultations:absentcommunicationskills

Checkifthepatientand/orfamilyunderstoodtheexplanation

Absentcommunicationskills

Adaptculturaldifferencesindiagnosisandpolicy
Thedoctordidnot...

Observeculturaldifferences

Checkthelanguageabilityofthepatient

doctorsayssomethingabouttreatmenthabitsinthe
Netherlandsorasksthepatientabouthis/herculturalhabits
forthespecificdisease,andadaptationofthediagnosisand
treatmentpolicytothecontextofthepatient,e.g.thedoctor
asksiftheprescriptionuseofthemedicationispossibleand
satisfactoryforthepatient,wereconsideredrelevantbecause
theseskillsfacilitatemutualunderstandingandrespect.

Reactadequatelytopossibleculturaldifferences

Theskillsinthetablearepresentedfrommosttolessabsent

Absentcommunicationskills

ICClanguageskillsincludecheckingthepatientslanguage
ability,whichwasabsentin17consultationswhereitwould
havebeenrelevanttodo.In37consultationsthemainlan
guagespokenwasDutch.IntwoitwasEnglish.AbsentICC
skills,suchasawarenessofculturaldifferences,e.g.the

TheseICCskillsweresometimesdifficulttoscore,be
causetheywereelusiveandnotexplicit.Forexample,the
doctordidnotalwaysdirectlyaddressapatientscultural
background,buttriedtogetinsightintothepatientsper
spectivebyfiguringoutwhatthepatientthoughttobethe
causeofthecomplaint(e.g.pain).Also,manydoctorsdid
notchecktheforeknowledgeofthepatientaboutthe
diagnosisandtreatmentpolicy.Therelevanceofattention
toculturaldifferenceswasemphasizedinthedoctorsex
plicitcommunication.Forexample,doctorsdidnottake
thepatientscontextintoaccountwhenproposingapolicy,

272

E.Paternotteetal.

suchasmedicationintakeordietaryadvice,andtheyhad
difficultiesshiftingfromtheirbiomedicalcommunication
styletothecontextandexpectationsofthepatient.When
theconversationwasmainlybiomedical,itwasdifficultto
determineifthedoctorswereawareoftheirowncultural
andprofessionalcontext.Inafewconversationsthedoc
torsmentionedtheirownculturalorigin,forexampleby
explaininghowatreatmentiscarriedoutintheNether
lands.This,however,didnotlinearlycausedoctorstopay
attentiontoculturaldifferences.Summarieswerenotoften
usedintheconversation,althoughthiscouldhavestruc
turedtheconversationanditcouldhavehelpedboththe
doctorandthepatienttocheckifspecificinformationwas
understoodcorrectly.

Otherskillsthatwereabsentbutrelevantlayinthefieldof
expectationmanagement,showinginterestinthepatients
familyandcheckingifthepatientunderstoodthe
informationgivenbythedoctor,whichwasrelevantasit
mighthavehelpedtoclarifypossiblemisunderstandings.
Anexampleofexpectationmanagementisexploringthe
patientsviewonthereasonfortheconsultationorthepa
tientsexpectationoftheconsultation.However,ifdoctors
usedquestionsaimedatclarifyingthepatientsexpecta
tions,whichwasnotdonein62%butusedin38%ofthe
consultations,thisprovedtofacilitateICCanddirectthe
communicationintoamorepatientcentredapproach,de
pendingonthewaytheywerephrased.Forexample,after
listeningtoacomplexaccountofthepatientscomplaints,
onedoctorasked:Whatdoyouexpectfromme?Would
youlikemetoreducethepain,orisitsomethingelse?

Discussion

Inthisobservationalstudy,wefocussedonrelevantICC
skillsofmedicalspecialistsinrealpractice.Themedical
specialistsinthisstudyprovedtobecapableofpractising
manycommunicationskills,suchaslistening,showing
empathiccommunicationbehaviourandbeingopenandre
spectfultothepatient.Otherskillswerenotpractisedal

thoughtheywererelevantintheinterculturalcontext,such
asbeingculturallyaware,checkingthepatientslanguage
ability,checkingifthepatientunderstoodandexploring
thereasonfortheconsultation.Thecommunicationstyle
ofthedoctorswasoftenabiomedicalstyle.

Theuseofabiomedicalstyleintheseinterculturalcon
versationsissurprising,sinceICCrequiresapatientcentred
focuswithspecificattentiontothepatientsbiopsychosocial
needs,becauseofthevulnerabilityformisunderstandingsof
ethnicminoritypatients[13,21].Ourstudyshowedthatthe
doctorsdidnotproperlyapplyanumberofspecificICC
skills,suchasadaptingdiagnosisandtreatmentpolicytothe
culturalcontext.However,theyalsodidnotpractice

certaingenericcommunicationskills,suchasexploringthe
reasonfortheconsultationorcheckingthefeelingsofthe
patient,whichisstrikingbecauseweincludedmedicalspe
cialistswhocouldbeexpectedtohavelearnedhowto
practicethesecommunicationskillsintheirundergraduate
andpostgraduatetrainingThisisavaluablefinding,as
medicalspecialistsfunctionasrolemodelsfor
postgraduatetrainees[22],whichis,however,notalways
trueduetothetransferproblemsofcommunicationskills
fromtrainingtotrainee[23].Inallmedicalspecialty
trainingprogrammesintheNetherlandsthereissome
formalcommunicationtraining.However,thisusually
takesplaceduringpracticeandnotasadditionaltraining.
Thecommunicationtrainingismostextensiveforresidents
ofthetrainingtobecomeageneralpractitioner[23].

Nowadays,doctorsinWesterncountriesaretaughttousea
patientcentredcommunicationstyle[8,13,21,24].Patient
centredcommunicationhassimilaritieswithICC,suchasthe
responsibilityofthedoctorforthenonmedicalor
interpersonalaspectsofthecommunication[25].The
interpersonalaspectsofcare,forexampletrust,respectand
empathy,arekeydeterminantsofpatientsatisfaction[13,21].
Aswasmentionedabove,wefoundmissinggeneric
communicationskills,suchasexploringthereasonforthe
consultation,checkingifthepatientunderstood,andex
pectationmanagement.Theseareskillsofpatientcentred
communicationaswell[21].Inaninterculturalcontext,

patientcentredcommunicationisprobablyevenmoreim
portant,becausethebalanceintheinterpersonalaspectsofthe
communicationishardertofindwhendoctorandpatienthave
differentnormsandvalues.Interculturalandpatientcentred
communicationhavenotbeenformallyintegratedtogetherin
medicaleducation,althoughthefunctionofbothintercultural
andpatientcentredcommunicationistoimprovehealthcare
qualityinsimilarwaysandtheusedskillsforpatientcentred
communicationandICCshowsimilarities.Therefore,
patientcentredcommunicationandICCshouldbe
incorporatedinmedicaleducation,sothatdoctorswillnot
havetolearntwodifferentapproaches[13].

Itwasstrikingthatthedoctorsallsaidtheyweresatisfied
withtheirconversation,whiletheobserversconcludedthat
doctorsdidnotpracticetherelevantICCskills.An
explanationcouldbethatthedoctorsneedtobeconfronted
withtheircommunicationbehaviourbeforetheycanim
provetheircommunicationskills[15].Finally,weneedto
saythatthecomplexityofICCcannotbegraspedinalist
ofdosanddonts.Itisnotamatteroflearningonlyone
skillforICCbutoflearningacompletesetofskillsand
beingabletoapplytheseintherightwayattherighttime.
Itisthecompletesetofbehaviourswhichmakesadoctor
agoodinterculturalcommunicator,andcommunication
trainingisnotaonesizefitsalltraining[5].

Interculturaldoctorpatientcommunication
273

Conclusion

Weshowedthatdoctorsdidpracticesomebutnotallthe
relevantICCskillsandthattheICCstyleofthedoctorswas
mainlybiomedicallycentred.Hence,itisunlikelythatpost
graduatemedicaltraineeswillacquirealltherequiredICC
skillsmerelybymodellingtheirbehaviourontheexampleof
theirclinicalsupervisors.Furthermore,wediscussedthe
possibleoverlapbetweeninterculturalandpatientcentred
communication.Thisoverlapandtheabsenceofskillsinboth
thesedomainssuggestthatintegratingpatientcentred
communicationandICCtrainingmaycontributesubstan
tiallytothedevelopmentofmedicaleducationforpostgrad
uatesandmedicalspecialists.

Strengthsandlimitations

Thisobservationalstudyprovidedtheopportunitytoexamine
theapplicationofICCskillsinrealpractice.Astrengthofthis
studywasthefocusonspecialistsinsteadoftrainees,because
medicalspecialistsfunctionasrolemodelsforpostgraduate
trainees.Anotherstrengthwasthattheconsultationswere
videotapedbeforetheywereanalyzed,andthatthetapeswere
analyzedbyobserversfromdifferentareasofexpertise,so
thatthedatacouldbeviewedfromseveralperspectives.Since
thegroupsofmedicalspecialistsweresmall,itwasnot
possibletofurtheranalyzetheinfluenceofageandyearsof
experience.Besides,thestudypopulationwastoosmallto
assessdifferencesincommunicationstylesbetweenthe
doctors.

Anotherlimitationwasthatwedidnotaskthepatientsfor
theiryearsofresidenceintheNetherlands.Theexact
influenceofthisonICCishardtodetermine.Ononehand,

beingintheNetherlandsforalongerperiodcouldpositively
suggestaninfluenceoftheICCwithanativedoctor.Onthe
contrary,manypeoplecontinuetoidentifythemselveswith
theircountryoforigin[26],whichcouldsuggestthatyearsof
residenceintheNetherlandsislessimportant.

Implicationsformedicaleducation

Basedontheresultsofourobservationalstudyofdaily
outpatientcareandthepointsmentionedinthediscussion,
wewouldadvisetoextendthealreadyexistingcommu
nicationtrainingforpostgraduatemedicaleducationwith
ICCspecificskills,suchasaskingaboutthelanguagepro
ficiencyofpatientsorcheckingiftheproposedtreatment
planfitsintotheculturalhabitsofthepatient.Elaborating
ICCtrainingcouldincludediscussionofdoctorsown
videoconsultationswithpeersinthepresenceofacom
municationexpert.Besides,wewouldadvisethatmedical

specialistsalsoembracetheconceptoflifelonglearning
andthattheyattendcommunicationtrainingfocusedon
patientcentredcommunicationthatincludesICC.

Futureresearch

ManyoftheelementsoftheMAASGlobalICCthatwe
usedseemedtoberelevantforcommunicationwithevery
patient.Futureresearchcouldstudywhetherthisistrue,
andshouldfurtherexploretheoverlapbetweenICCand
patientcentredcommunication.Inthepresentstudy,we
focusedonthedoctorfromthethirdperson,theobserver.

Also,itappearstobeimportanttoevaluatedoctorsneeds
forICCskillsandpatientspreferencesandsatisfaction
withtheirdoctorscommunicationskills.Furtherresearch
couldbeareflectivepracticestudywithdoctorsbasedon
theirvideotapedconsultations.Anotherfurtherresearch
possibilityistocomparethepatientcentredcom
municationskillsandICCskillsofdoctors.Thiscould
facilitatethedevelopmentoftrainingfocusedonrelevant
communicationskills.

AcknowledgementsWearegratefultoallthepatientsanddoctors
whoparticipatedinthisstudy.SpecialthanksareconveyedtoLotte
RoosendaalandTugbaAydin,whohelpedwithobservingthedata.
WewishtothankLisettevanHulstforeditingthemanuscript.

Funding/SupportNone

ConflictofinterestE.Paternotte,F.Scheele,M.C.Seeleman,L.
Bank,A.J.J.A.ScherpbierandS.vanDulmendeclarethattheyhave
nocompetinginterest,nofinancialcompetinginterestsandnonon
financialcompetinginterests.

ThestudywasperformedaccordingtoDutchprivacylegislation.Ap
provaloftheDutchmedicaleducationethicsboardwasobtainedfor
thisobservationalstudy(NVMOERB355).Beforehand,allpartici
patingdoctorsandpatientswereinformedabouttheaimandthepro
cedureofthestudy.Allparticipantssignedaninformedconsentform
beforetherecordingoftheconsultationwasstarted.

OpenAccessThisarticleisdistributedunderthetermsofthe
CreativeCommonsAttribution4.0InternationalLicense(http://
creativecommons.org/licenses/by/4.0/),whichpermitsunrestricted
use,distribution,andreproductioninanymedium,providedyougive
appropriatecredittotheoriginalauthor(s)andthesource,providea
linktotheCreativeCommonslicense,andindicateifchangeswere
made.

274

E.Paternotteetal.

Appendix

Table4MAASGlobalICCobservationscale

Thedoctor...

Opening

ChecksthelanguageabilityofthepatientCheckswhoistheformal
speakerofthefamily

Explainscauseandrelationofthecomplaintwithinthecontextofthe
expectationsofthepatient

Checksifthepatientand/orrelativesunderstoodtheexplanation

Policy

Adaptculturaldifferencesindiagnosisandpolicy

Checkswiththerelativesiftheyunderstandthechoiceofpolicy
Makesappointments:who,what,when

AskstotherelativesfortheirconnectionwiththepatientListens

Explainsreferraltootherhealthcareworkers
Reactsadequatelytopossibleculturaldifferences

Explore
ReasonForEncouter

Demonstratesbeingalerttopossibleculturalaspectswhenasking
forthereasonfortheconsultation

Checksreasonsofencounteroftherelatives

Checksexpectationsregardingtheconsultation/healthcare

PhysicalExamination

Treatsthepatientwithcareandrespect

Exploresthereasonforconsultation,wishesandexpectations
Explorestheperceptionoftherelatives

RecognizesmisunderstandingcausedbyalanguagebarrierExplores
thereactionofinformationtransfertothepatientscontextResponds
tononverbalbehaviourandkeywords

Respondstocues/keywordswhicharerelatedtoculturaldifferences

Emotions

AsksaboutthepatientsfeelingsReflectsonthefeelingsofthe
patientAsksabouttherelativesemotionsListensactively

Diagnosis
Triestoempathizethepatientsemotions

Announcesstagesoftheconversation
InformationTransfer
Empathy
Checkstheforeknowledgeofthepatientaboutdiagnosisorexpected
policy

Showsconcern,isinvitingandsincere,commiseratesbymeansofeye
contactandnonverbalbehavior,showscompassionforthepatient

GivesinformationinsmallamountsGivesconcreteexplanations

Usesconcretelanguage

Commiserateswithverbalreactions

AsksifthepatientunderstoodtheinformationUsesdifferentways
togiveexplanationsPaysattentiontopronunciation

Observesculturaldifferences

Showsempathicbehavior
Usesattributesforexplanation

Hasanopenattitude
Summarize

Showsrespectforthepatient
SummarizesthepatientsstorySummarizesinhisownwords,
conciseAttempts
ConsultEvaluation

Hasanunprejudicedattitude
Table4MAASGlobalICCobservationscale(Continued)
Demonstratesreliability
Thedoctor...
Showsawarenessofhisorherownculturalandprofessionalcontext
Structure
Showsawarenessofculturaldifferences
Appliesanadequatetimeschedule
Speaksmorelanguagesofwordsofanotherlanguage
Takesthetime
Showstohavelearnedfrompreviousconsultationswithethnicminor
itypatients

PaternotteE,vanDulmenS,vanderLeeN,ScherpbierAJJA,
ScheeleF.Factorsinfluencinginterculturaldoctorpatientcommu
nication:Arealistreview.PatientEducCouns.2014;doi:10.1016/
j.pec.2014.11.018.

References

TeutschC.Patientdoctorcommunication.MedClinNorthAm.
2003;87:111545.

SchirmerJM,MaukschL,LangF,etal.Assessingcommunication
competence:Areviewofcurrenttools.FamMed.2005;37:18492.

BetancourtJR,GreenAR,CarrilloJE,ParkER.Culturalcom
petenceandhealthcaredisparities:Keyperspectivesandtrends.
HealthAff(Millwood).2005;24:499505.

FergusonWJ,CandibLM.Culture,language,andthedoctorpa
tientrelationship.FamMed.2002;34:35361.

NapierAD,AncarnoC,ButlerB,etal.Cultureandhealth.Lancet.
2014;384:160739.

SchoutenBC,MeeuwesenL.Culturaldifferencesinmedical
communication:areviewoftheliterature.PatientEducCouns.
2006;64:2134.

TealCR,StreetRL.Criticalelementsofculturallycompetentcom
municationinthemedicalencounter:Areviewandmodel.SocSci
Med.2009;68:53343.

EssersG,vanDulmenS,vanWeelC,vanderVleutenC,KramerA.
Identifyingcontextfactorsexplainingphysicianslowperformance
incommunicationassessment:Anexplorativestudyingeneral
practice.BMCFamPract.2011;12:138.

EssersG,DielissenP,vanWeelC,vanderVleutenC,vanDulmenS,
KramerA.Howdotrainedraterstakecontextfactorsintoaccount
whenassessingGPtraineecommunicationperformance?An
exploratory,qualitativestudy.AdvHealthSciEducTheoryPract.
2015;20:13147.

EssersG,vanDulmenS,vanEsJ,vanWeelC,vanderVleutenC,
KramerA.Contextfactorsinconsultationsofgeneralpractitioner

Interculturaldoctorpatientcommunication
275

traineesandtheirimpactoncommunicationassessmentintheau
thenticsetting.PatientEducCouns.2013;93:56772.

VeldhuijzenW,RamP,vanderWeijdenT,WassinkM,vander
VleutenC.Muchvarietyandlittleevidence:adescriptionof
guidelinesfordoctorpatientcommunication.MedEduc.
2007;41:13845.

RobertsC,MossB,WassV,SarangiS,JonesR.Misunderstandings:
Aqualitativestudyofprimarycareconsultationsinmultilingual
settings,andeducationalimplications.MedEduc.2005;39:46575.

HobmaS,RamP,MuijtjensA,vanderVleutenC,GrolR.Effective
improvementofdoctorpatientcommunication:arandomised
controlledtrial.BrJGenPract.2006;56:5806.

SahaS,BeachMC,CooperLA.Patientcenteredness,culturalcom
petenceandhealthcarequality.JNatlMedAssoc.2008;100:1275
85.

MeadN,BowerP.Patientcentredness:Aconceptualframeworkand
reviewoftheempiricalliterature.SocSciMed.2000;51:1087110.

SahaS,BeachMC.Theimpactofpatientcenteredcommunication
onpatientsdecisionmakingandevaluationsofphysicians:A
randomizedstudyusingvideovignettes.PatientEducCouns.
2011;84:38692.

vandenEertweghV,vanderVleutenC,StalmeijerR,vanDalenJ,
ScherpbierA,vanDulmenS.Exploringresidentscommunication
learningprocessintheworkplace:Afivephasemodel.PLoSONE.
2015;10:e0125958.

RamP,GrolR,RethansJJ,SchoutenB,vanderVleutenCP,KesterA.
Assessmentofgeneralpractitionersbyvideoobservationof
communicativeandmedicalperformanceindailypractice:issuesof
validity,reliabilityandfeasibility.MedEduc.1999;33:44754.

RamP,vanThielJ,vanDalenJ.MAASGlobalManual2000.
Maastricht:MaastrichtUniversity;2003.

StreinerDL,NormanGR.Healthmeasurementsscales:Apractical
guidetotheirdevelopmentanduse,4thed.NewYork:Oxford
UniversityPress;2008.

WatlingC,DriessenE,vanderVleutenCP,LingardL.TheAccred
itationsCouncilforGraduateMedicalEducation(ACGME).Med
Educ.2012;46:192200.

vandenEertweghV,vanDulmenS,vanDalenJ,ScherpbierAJ,van
derVleutenCP.Learningincontext:Identifyinggapsinresearchon
thetransferofmedicalcommunicationskillstotheclinical
workplace.PatientEducCouns.2013;90:18492.

BallJW,DainsJE,FlynnJA,SolomonBS,StewartRW.Cultural
competency.In:Mosby,editor.Seidelsguidetophysicalexami
nation,8thedn.Amsterdam:Elsevier;2014.pp.219.

GrolR,deMaeseneerJ,WhitfieldM,MokkinkH.Diseasecentred
versuspatientcentredattitudes:comparisonofgeneralpractitioners
inbelgium,britainandthenetherlands.FamPract.1990;7:1003.

HofstedeG,HofstedeGJ.Allemaalandersdenkenden.Omgaanmet
cultuurverschillen,BusinessContacted.Amsterdam:Business
Contact;2005.

EmmaPaternotteisaMDandaresearcherinmedicalcommunica
tion

FeddeScheeleisagynaecologistandaprofessorinhealthsystems
innovationsandmedicaleducation

AlbertJ.J.A.ScherpbierisaMDandaprofessorinquality
improvementinmedicaleducation

ConnyM.Seelemanisaresearcherinthefieldofculturalcompetence

SandravanDulmenisapsychologistandaprofessor
communicationinhealthcare

LindsayBankisaMDandaresearcherinmedicaleducation