Changes in situations and significant actors
Before the classes, the situation the participants imagined was when doctors met foreign patients with interpreters in large hospitals (Appendix 1). Specifically, Korean doctors diagnosed and treated foreign patients with/without interpreters or carers in large Korean hospitals, culturally inappropriate settings full of Korean patients, carers, and healthcare professionals. Language barriers, religious customs, surrounding people’s discrimination, socioeconomic and biological factors of patients, and knowledge were significant actors. They assumed that the patients were foreigners with different languages, religions, and biological backgrounds. To them, patients’ culture might disrupt treatment: Their focus was the diseases.
After the classes, the situation changed to when the participants, as doctors, meet patients regardless of their nationality in their clinics (Appendix 2). Specifically, as doctors, they met international and Korean patients, together with the patients’ different companions and healthcare workers in hectic Korean clinical settings. Influential actors were their biases with preconceptions, Korean clinical settings with cultural factors, doctors’ discriminative care with avoidance, and reflections with direct experiences. They assumed that the patients were from various cultural backgrounds, not focusing on whether they were foreigners or not; simply approaching them as individuals experiencing pain. They recognised that silent discourses, including biases, cultures of all, and surrounding structures, might hamper patients’ access to clinics.
Furthermore, they expressed terms of situations and actors more clearly, richly, and authentically after the CS classes. For example, before the course, the participants merely commented on ‘carers’, but they used more specific terminology such as ‘husbands’ or ‘employers’ after the classes. Additionally, before the classes, they used terms such as ‘empathy’, which in Korea, is a concept students learn through academic lectures and texts. However, after the course, they used colloquial words widely used by Koreans in daily life, such as ‘soeong-sim- seong-eui’ (heartfelt sincerity).
Black boxes related to CSC before the CS program
Before the classes, the participants assumed that ‘culture’ was about nationality, language, and religion, and the service was for foreign patients. They believed ‘CSC’ to be a culturally customised treatment with humanistic approaches and the best medical practice that might enhance patients’ compliance for good clinical outcomes and prevent harm (Fig. 2). They weighed the importance of doctors’ curer role in treating diseases as scientists. They felt that they should study languages, acquire knowledge about cultures, and develop clinical competence in international patient care.
[Figure 2]
Culturally customised treatment
The participants believed that doctors should customise medical treatments for foreign patients with tolerance and language proficiency for CSC. Meanwhile, they believed that ignoring patients' cultural customs and taboos in culturally inappropriate facilities would influence patients’ compliance.
The participants regarded tolerance of cultural customs as significant, expecting tolerance to influence rapport building, enhance patients’ compliance, and produce good clinical outcomes. They thought that doctors should accept foreign patients as they are: the cultural customs of foreign patients’ nations and religions. They considered open-mindedness without prejudice as principal because ‘difference’ does not mean ‘wrong’. They believed that medical care should be holistic to understand patients based on their cultures. Thus, they felt that experiencing cultures through media, books, and travelling abroad would help reduce their prejudice.
CSC is to accept that there are different cultures from mine and admit differences as different, not incorrect. Ways of thinking and cultures evolve differently because geographical and cultural environments differ. We should respect other cultures because I always become a stranger if I visit other cultural regions. If time permits, I could acquire knowledge about many cultural regions through travelling, books, and TV. When my understanding of other cultural regions increases, I think my understanding of multicultural patients will increase, and the doctor-patient relationship will improve. (A65)
To get [good treatment outcomes] beyond rapport building and increase patients’ compliance, we should know how patients’ culture influences their health. For example, the treatment for Koreans taking Korean herbal medicine and Canadians not taking it would be different. (C16)
The participants assumed that language proficiency was primary for culturally customised treatment. They considered English, interpreters, and nonverbal communication as alternative communication tools. This was because they thought that foreigners could not speak Korean and could only speak English. Furthermore, even though they could speak Korean, they would experience difficulty, because Korean medical terminology would be different and unfamiliar to language used in daily life. They considered the language barrier the most challenging obstacle for patients and doctors. They were concerned about doctors’ difficulties in diagnosis and treatment because they could not wholly understand the patients and build rapport due to language differences. Consequently, they felt that they should develop linguistic abilities, especially in English, and learn to utilise interpreters.
Language issues are the most challenging. It would be tough for patients to correctly talk about their symptoms and conditions in incommunicable situations. Doctors may not take necessary histories well and have limited patient education. Even with an interpreter, communicating accurately would be hard because of the big risk of interpreters’ arbitrary distortion. I need to study foreign languages a lot. (B9)
The participants focused on the cultural etiquettes and taboos related to the medical practice of the patients’ countries or religions to customise their treatment accordingly. They believed that patients had the right to be respected about their medical beliefs and precautions even though doctors could not understand them. They expressed that the inappropriate service systems and facilities in Korean hospitals, such as the lack of worship areas, might deepen patients’ discomfort, misunderstanding, and loneliness. Concerned that they might make cultural mistakes due to their lack of knowledge and inexperience of unfamiliar patients’ cultures, they were also worried about the increase of burden on doctors in terms of the additional time and effort needed to care for international patients than Korean patients. They believed that they should acquire knowledge on other cultures’ medical customs and related dos and don’ts and on the profiles of multicultural populations.
CSC is to respect things I cannot accept by medical common sense, such as Jehovah’s Witnesses’ transfusion refusal or female Muslim patients’ unacceptance of body exposure to male doctors. Although such cultural customs may appear different and inconsequential to me, those customs might have a mountain of meanings, more valuable than their life, to them. (C91)
The biggest problem is that doctors cannot rapidly solve patients’ difficulties and obstacles. It would be hard for doctors because they need time and effort to communicate with them, find new medicines, and understand their ways of thinking. Doctors also have difficulties relating to having to study more to receive such patients. (A55)
A humanistic approach
The participants considered that surrounding people’s and healthcare professionals’ discriminatory attitudes would influence patients’ compliance. They believed that doctors should empathise with foreign patients’ vulnerable circumstances, treating them as human beings.
The participants assumed that the discriminatory gaze of surrounding people and healthcare professionals against the patients, seeing them as strangers in multi-person rooms and the wards, might be influential factors: Expulsion would enhance patients’ non-compliance, resulting in harmful practices. They thought that the patients might feel daunted, alienated, and unsatisfied due to close-minded people and healthcare professionals. Thus, they commented on the importance of a non-discriminatory gaze and not using discriminatory words.
I anticipate that the patients would receive unwelcome glances from people who think conversations would be difficult. They might be inappropriately treated, have to wait longer to receive treatment, or be rejected. Additionally, it would be hard to ask questions or receive answers. (C46)
The participants regarded empathising with vulnerable foreign patients’ circumstances and maladaptation to afford clinical care in unfamiliar clinical settings as meaningful to the humanistic approach. They assumed that foreign patients would struggle with issues such as poor financial status, no health insurance, and undocumented status. They also supposed that non-supportive systems and facilities (e.g. different clinical care payment processes, complex hospital facilities with confusing signs, transportation difficulties without adequate carer support) might worsen foreign patients’ experiences in Korean care systems, which might deepen their fear, tension, confusion, and discomfort. Thus, they thought that doctors should provide considerate care with a supportive approach and improve facilities for foreign patients by exploring their difficulties and finding solutions. They felt that they should acquire knowledge of different healthcare systems in patients’ countries and the supportive systems for multicultural patients in Korea.
Not all, but many multicultural families in Korea have low incomes. Thus, they could not afford the treatment they wanted or could not receive health insurance benefits because of visa problems. (C6)
If they are inpatients in hospitals, they need time to adapt to staying with Koreans and our diets, besides [Korean style of] clinical encounters, because of unfamiliar environments. Considering my language and behaviours, I will prepare to make them comfortable in an unfamiliar place. Also, I will get acquainted with social work/hospital systems aligned to their treatment. (B17)
The best medical practice
The participants believed that doctors should pursue the best medical practice in foreign patient care because the patients have the right to receive the best treatment. As they regarded correct diagnosis and treatment as vital, they focused on effectively dealing with unscientific patients with defensible strategies.
The participants considered epidemiology and biological factors by detailed history taking as central to correct diagnosis and treatment. They were concerned about other diseases more prevalent among those with certain geographic and racial/ethnic characteristics, but rare in Koreans. They were also worried that different clinical features and physical structures might impact doctors’ accurate diagnosis. Additionally, genetic factors influencing enzyme activation, disease progress, and physiologic reactions to therapies might affect doctors’ decisions in choosing appropriate treatments and estimating prognosis. Therefore, they felt that they should learn about common diseases in patients’ countries and the various biological factors of patients to prevent misdiagnosis and treatment failure.
They would have different DNA from Koreans. Consequently, their clinical features might differ slightly, prevalent diseases may differ, and appropriate medicines may differ. In the case of other races/ethnicities or nationalities, we should pay more attention to diagnosis/treatment. Increasing interest in racial studies focused on other countries would be desirable. (A40)
The participants believed that doctors should allow patients’ opinions within medical principles to guide the best medical practices because doctors must adopt scientific approaches. They felt that doctors should judge correct treatment by ethical and legal standards for patient safety. They had strong repulsion against alternative remedies or treatment refusal but took them for granted because of the ethical code to respect patients’ self-determination. While regarding patients as active participants in clinical care, they were concerned about non-compliant patients who assert only their culture, ignore Korean cultures, and disrespect Korean doctors. Their experiences of being discriminated against in foreign countries encouraged them to worry about them. They valued informed consent with sufficient and understandable explanations. Although it might be impossible to persuade unscientific patients, they still felt they should convince them as best as possible to uphold medical principles. They considered building a trusting rapport and eloquence to prevail over patients as helpful strategies. They commented that they should acquire knowledge of ethico-legal evidence and communication skills.
CSC is to understand patients but persuade them for their treatment within the boundaries that they do not disregard patients’ cultures, although the patients make decisions based on incomprehensible thoughts from doctors’ perspectives. CS is important because treatment, after all, is for patients. (C73)
CSC is making patients follow doctors’ therapeutic decisions without reluctance and building rapport by respecting patients. It would be difficult to build a strong rapport with patients. I will prepare myself to admit and respect other cultures and develop eloquence to make patients understand and participate in [doctors’] treatments without discomfort. (C8)
New actor-networks of CSC after the CS program
After the classes, the participants recognised that ‘culture’ was beyond language, nationality, and specific religions, and CSC was for all, including Korean patients. They defined ‘CSC’ as making patients feel at home, tailoring care individually, and serving patients indiscriminately as ordinary Koreans for medical care accessibility (Fig. 3). They realised that doctors are healers who treat humans, not diseases; thus, respecting culture is meaningful in patient care. They concluded that medical care comprises more than just providing treatment. They felt that they needed reflections and practice for CS through direct experiences, including global ones.
[Figure 3]
Making patients comfortable
The participants explained that CSC would make international patients feel comfortable, as they would feel back home. They realised that deep understanding with an openhearted and warm approach could make the patients feel that they are in a familiar environment. Conversely, they recognised that some unconscious non-verbal habits could unintentionally make patients feel unpleasant, which might prevent the patients from visiting clinics, although they could access clinics easily. They noticed similar unconscious patterns in themselves, which were influenced by their cultural backgrounds and preconceptions. Thus, for international patients’ comfort, they decided to sincerely understand patients’ perspectives, provide consolation and solicitude from their hearts, and reflect on their preconceptions and unconscious cultural habits influenced by their cultural backgrounds.
The participants realised that deeply understanding international patients as they are and welcoming them as humans are fundamental to making them feel at home. They noticed that CS started by sincerely sensing the hearts of patients in their hearts. They discovered that deep awareness of patients’ perspectives could make them understand their illnesses, including emotions. They admitted that their perspectives could prevent them from understanding patients wholly. They recognised that patients’ culture signifies their life experiences and personal characteristics such as lifestyles. They decided to pay complete attention to patients to understand all about them as humans.
CSC is thinking and understanding what patients set a high value on, how they have lived, and their ways of thinking and behaviours. It is seeing and respecting the inside, more than what meets the eye. Thus, it is of greater importance because ‘culture’ eventually represents patients. We meet ‘human beings’, not ‘diseases’. I will pay attention to patients with all my heart, seeing them as persons as they are. (BB66)
The participants recognised that warm consolation with solicitude could make international patients feel more at home. They identified that togetherness with true hearts, not with communication guidelines or manuals, was essential. They found that they could share and ease the patients’ pain and sorrow with warm words of compassion because they empathised with ill patients’ feelings of fear and being lost in other lands. They discovered that providing comfort by putting themselves in patients’ positions and attentively listening to their voices could alleviate patients’ illness and sadness. While regretting that they had neglected the importance of rapport, they noticed that their cultural custom of no friendly expressions might prevent them from providing warm consolation and solicitude. Consequently, they decided to warmly express their compassion and share patients’ sufferings ‘from the bottom of their hearts and souls’ through practice and observing senior clinical teachers during clinical placements.
What international patients need the most is doctors’ compassion and sincere care, not only verbal communication. It will enable humanistic communication, transcending cultural barriers. I may not know beforehand about all cultures, but I will try to provide humane solicitude and consolation. (CC11)
The participants recognised that proper non-verbal habits from international patients’ perspectives were basic, while some cultural behaviours of doctors might evoke unpleasant feelings in patients. They discovered that nonverbal etiquette or manners of Korean traditions, regions, or personal habits (e.g. ‘awkward smile when feeling embarrassed’) might cause unintentional misunderstanding. They found that they had similar patterns during the dialogues with international guests. They realised that not only explicitly rude manners but also ordinary culturally different non-verbal behaviours with good intentions might hurt and upset international patients. Therefore, they were concerned about making unintentional mistakes because of their unconscious cultural non-verbal habits. They were motivated to explore widespread nonverbal patterns that could hurt the patients and learn culturally safe non-verbal etiquette to provide patients with a pleasant experience.
I deeply felt that our unconscious behaviours and thoughtless smiles marked international patients for life. I should mind that my sayings and doings, which we take for granted, unintentionally hurt them. I usually murmured ‘foreigner’ when I saw them. I will mind my p’s and q’s and attitudes from now on. (CC52)
Tailoring care individually
The participants defined CSC as individually tailored services in culturally safe cultures and systems. They realised that considering patients as diverse individuals and respecting patients’ values with sufficient discussion could be fundamental to individualised care. Conversely, they recognised that uniform services with generalised stereotypes disrespected patients, a critical obstacle to accessing medical care in Korea. They noticed similar disrespectful attitudes with stereotyping in themselves. They also found influences of their cultures and prejudice, science-centred medical cultures, hierarchical Confucian cultures, contradictory Korean NHIS, and the myth of a single ethnicity in Korea. Thus, they were motivated to consider diversity and respect patients’ values by ensuring longer clinical encounters and flexible medical services. They decided to explore their stereotypes with preconceptions and Korean medical cultures through direct experiences and reflective exercises.
The participants realised that considering persons as diverse individuals was foundational to individually tailored care, which implied respecting differences. They recognised that Korean patients were also unique individuals, meaning CS was for every patient, including Koreans. They discovered that each patient had different needs despite having the same diseases and nationalities, and they should consider all aspects of patients’ characteristics. They identified their prejudice against differences and preconceptions (e.g. ‘CS was for international patients’, ‘Koreans were the same’, and ‘culture was about nationality and religion’), which prevented them from considering patients’ individuality. Thus, they were inspired to go beyond acquiring knowledge about national or religious cultures. They decided to learn more about diverse cultures and directly interact with various people to gain experiences.
I thought that CS covered international patients, but I noticed today that it also includes Koreans and those from other religions and sexual orientations. I should consider not only the national dimension of cultures but also everything about patients, always. (AA35)
Before the classes, I considered nationality and race as different cultural customs. I learned today that people are different, not racially but individually. I should approach them differently according to individuality. I felt that directly meeting and experiencing is important to understand individual patients. (AA103)
The participants also realised that respecting patients’ values could enhance individualised care. They found that forcing doctors’ values would invade patients’ rights to participate in their care. They discovered that an equal footing was the key to appreciating different opinions and beliefs. They noticed that patients complained more about the inequality between doctors and patients than they thought: The unilateral decisions and judging patients’ views notably frustrated patients, because they did not acknowledge patients as principal agents of care. They discovered that hierarchical Confucian cultures and their prejudice against deviant cultures prevented them from respecting patients’ values. They recognised that their science-centredness and medical knowledge, perspectives from their religion of Protestantism, and conservative and closed Korean cultures considering harmony as virtue acted as standards influencing their prejudices. Thus, they were inspired to let the patients participate in the clinical process and, therefore, decided to explore their values with prejudice and the influences of their cultural backgrounds.
I must not apply my culture and values to patients as a doctor. I should understand cultural differences. Each patient has different values. I will become a doctor who respects patients’ opinions so that they can be involved in the diagnosis and treatment process. (BB29)
The participants identified that sufficient discussion between doctors and patients is requisite to individualised care, which needs satisfactory explanation and conversation in horizontal relations. They understood doctors’ difficulties in busy clinical settings relating to spending time dealing with the various needs of patients with uncommon diseases and language barriers. They had been proud of advanced Korean medical services but noticed that patients complained more seriously about Korean medical cultures of short clinical encounters than they thought. They identified the contradictory Korean NHIS policy as a serious obstacle to more extended discussions. They recognised the reality that the Korean medical services could not handle the diverse values of the patients. Thus, they were motivated to explore contradictions in the Korean medical systems and traditions that might interfere with sufficient discussions. They decided to develop clinical competence to perform longer consultations.
People of different cultures might feel uncomfortable with our medical system, which is specialised for the Korean mentality of speed. I realised patients had difficulties expressing their stories because of short clinical encounters. I had thought our [fast] medical system was right and other countries’ systems were inefficient. I will form habits to explain kindly to patients and to discuss with them. (BB62)
The participants noticed that flexible medical services with alertness were necessary for individually tailored care, while uniform services with Korean-targeted medical knowledge might make patients feel insignificant. Providing the same service to all neglects patients’ individuality. They recognised that being alert and sensitive to each individual was crucial. They found that the Korean culture of a single ethnicity, preconceptions that ‘foreigners speak English’ or ‘patients would be like them,’ and nationality stereotypes might keep them from regarding individuality. They were motivated not to rush to assume or judge patients’ cultures, including languages, and ask the patients and learn from them. They decided to explore uniform services based on the single-ethnic Korean culture and nationality stereotypes through reflective practices and direct experiences with people because they realised that indirect resources, such as media, might deliver stereotypical information.
The most important thing is to approach without stereotyping. Not everyone has the same thoughts, even in the same cultural regions. People may have similar thinking, although their cultural regions differ. We cannot identify individuals with the cultures to which they belong. As one from an Islamic country could believe in Christianity, I learned stereotyping puts a person in a cultural box. (AA39)
Treating them indiscriminately as ordinary Koreans
The participants stated that CSC would serve international patients as ordinary Koreans by providing adequate consideration. Meanwhile, doctors’ avoidance and regional discrimination made patients refuse to visit clinics. They noticed similar patterns of inadequate thinking, avoidance, and discrimination in themselves. Thus, they decided to explore their behaviours, prejudices, stereotypes, and preconceptions through reflective practice from direct experiences.
The participants realised that providing adequate consideration was decisive for indiscriminate service. Conversely, they discovered that doctors’ considerate behaviours, in their perspectives based on stereotypes and preconceptions, resulted in discrimination. They noticed that international patients felt discriminated against when doctors showed behaviours that they never did to Koreans. For example, Korean doctors did not interact with international patients using honorific and kind language, while they spoke politely to Korean patients speaking in the same manner. They understood the good intention of Korean doctors to respect the patients’ liberal and individualistic cultures based on their perspectives that ‘foreigners dislike respect and rapport because they are different from Koreans’. However, they found that the patients felt disregarded because the patients knew and expected Korean manners. They recognised that everyone is the same in their sufferings regardless of nationality and culture. Thus, they were inspired to treat international patients the same as Koreans. They decided to reflect on their biases about ways of respecting foreigners.
Before the classes, I thought that CS was understanding and accepting of their cultures, but now I think the same treatment as Korean patients without discrimination is also CS. I had thought foreign residents didn’t know Korean culture, but this was inaccurate. (CC59)
I thought that foreign patients were special. The biggest worry of international patients may be doctors’ feeling of burden because they consider the patients special. They are humans, after all. They are similar in thinking and feeling. I will practice, considering them as usual patients, the same as me. (AA37)
The participants identified doctors’ avoidant behaviours with effortless attitudes to communicate as a pivotal obstacle to indiscriminate service. Conversely, doctors’ solid will and efforts to approach patients directly were indispensable. They understood that doctors’ lack of confidence in unfamiliar care with different languages and religions might cause panic about mistakes and misunderstandings. They discovered similar feelings in themselves due to preconceptions about complex international and Muslim patient care. They also realised their prejudice against foreigners and Islam stereotypes. However, they empathised with the patients’ feelings of alienation when doctors preferred interpreters or Korean companions. They found that the third person might intervene in patient-doctor interactions, alienating doctors. They noticed that their preconceptions, considering the language barrier too much, and their silent self-effacement culture might weaken their motivation to direct contact. Insights that they are doctors inspired them to try their best to communicate directly. They decided to prepare themselves to prevent panicking by becoming familiar with other cultures while hoping to feel confident by upgrading their language proficiency.
The biggest obstacle would be the feeling of separation of doctors from international patients. Doctors’ internal issues, difficulty initiating a conversation, and feelings of fear might be the biggest challenges. The most important thing is not to have preconceptions and prejudices. As a doctor, I make efforts to treat them. (AA34)
Despite language barriers, doctors’ attempts to see patients may help and comfort them. Doctors tend to ask fewer questions and offer fewer explanations when patients are foreigners. I will try my best so that patients do not feel neglected, although languages differ. However, the best thing is good communication. Thus, I need to study languages. (AA78)
The participants realised that discrimination against people from less developed regions might aggravate inequity. They recognised that even ordinary people, including them, could commonly discriminate against others. They discovered they had unconsciously looked down on people from developing countries, rural areas, North Korean defectors, or Korean Chinese, although they had determined to treat them equally. They found that they evaluated, judged, and belittled the patients based on geographical stereotypes and prejudices (e.g. asking superfluous questions regarding patients’ regional origins, such as ‘Where are you from?’, or providing cheap treatment assuming that patients from less-developed regions are poor). Thus, they decided to mind their unconscious biases.
Patients might have experienced difficulties because they were judged and treated differently according to their cultures. They were asked whether they had money or refused. We should not discriminate against people according to nationality. (C46)
I expected people’s intellectual levels and compliance to be high. I felt tense when I encountered middle-aged male patients from province regions with rough accents of dialects and nonstandard language. (AA86)
Major debates related to CS among the participants
Target of interest
The participants changed their positions from being wary of the ‘outside’ to embracing all ‘inside’ (Fig. 4). Before the CS classes, they blamed doctors or foreign patients because they believed that they had no biases, but others did. They focused on doctors and foreigners and regarded them as others. Their job was to study knowledge and skills because they considered themselves students. Thus, they valued indirect experiences such as media and books to acquire information about cultures and ethico-legal knowledge.
[Figure 4]
However, after the CS classes, the participants reflected on their biases and explored Korean medical settings from patients’ perspectives. They found that they were biased and influenced by surrounding cultures. They also discovered that contradictory Korean medical systems would deepen patients’ suffering. They realised that international patients were the same persons as themselves and Koreans: They are us. Therefore, their job changed to personal and professional development for CSC because they are doctors, and CS is a process for better care. They preferred direct experiences such as meeting people because studying from media and books might not help in real-life care contexts. They noticed that patients wanted doctors’ attention, not knowledge.
Appropriate scope of CSC
The participants’ views on the scope of CSC can be divided into four categories based on how they perceive patients’ cultures (Fig. 5). Before the classes, many participants believed that doctors should accept all patients’ cultures, sacrificing their culture, whereas some insisted that foreign patients must follow Korean culture. Others suggested that doctors should allow patients to express their cultures within the boundaries of ethics and safety. Finally, some students argued that patients and doctors should compromise.
[Figure 5]
After the classes, however, many participants recognised that doctors should not force their cultures, and mutual respect between patients and doctors is important because they felt the strong influences of doctors’ cultures. However, they were still uncertain about how much care could ensure mutual respect without sacrificing doctors’ culture.