Intercultural Communication in Medical Practice: Understanding High and Low Context

2. Objectives • Introduction to Intercultural Communication • High and Low Context • Formal and Informal Contextual Learning • Importance of Intercultural Communication to medical practice and communication training • Skills training – Teaching about context as a component of communication training

3. Premise of talk Patients and families experience illnesses as high-context events. Clinicians too often deal with illnesses as low context events. When this happens, clinicians, patients and families become ‘out of synch’ and serious miscommunication occurs.

4. Intercultural Communication Key Concept: Context is part of communication, not just a box within which communication occurs Aspects of context: Setting Space (Proxemics) Time Relationships Subtexts

5. High and Low ContextsDefinitions • High Context Communication: An episode of communication in which much meaning is embedded in the situational context • Low Context Communication: An episode of communication in which meaning is primarily expressed through explicit spoken or written code, not context. High and low context communication exist as relative, not absolute states

6. Low Context CommunicationExamples • Computer code • Math • Instruction manuals • Scientific writing • Giving street directions Low context communication tends to be task-oriented

7. High Context CommunicationCharacteristics • Human, not technical issues • Subjective more than objective • Issues are both personal/private and public, involving other people • In-group – Out group We and them • Implicit danger (taboo) and reward High context communication: not just an issue of ethnicity

8. High Context Topics Sex Death... Sex Sex And serious illness Among others

9. Setting • Location • Time of day • Lighting • Props • Sound effects What more do you need to say?

10. ICU Setting

11. Space • Spatial distance and grouping contains much contextual meaning • Space divided into formal, friendly and intimate distances • Proper use of space varies by group – ethnicity, gender, age, etc.

12. Formal Space

13. Friendly Space

14. Intimate Space

15. Intimate Space and Medicine Intimate Strangers

16. Time • Experienced and used differently by different people in different situations • Low context : time measured and spent • High context: time use often focused on relationship building • With age time experienced as moving more quickly • While objectively older people move more slowly

17. Relational Issues • Background • Trust - Mistrust • Respect - Disrespect • Obligation – Lack thereof • Affective milieu: love, anger, friendship, antagonism • Roles • Role clarification – what script defines proper roles? • Dominance – subordinance • Decision making approach

18. Time, Relationships and Decision Making • Low Context: ‘Get to the point, Get down to brass tacks, The bottom line’… values linear, task oriented approach • High Context: Time used to explore and establish roles – prior to decision making In high context situations the shortest distance between two points is a curve

19. Subtexts • Relational and Emotional Subtexts • Often not addressed by clinicians • Ambiguity – purposeful? • Protective of participants, when on dangerous ground • Compressed meaning • Requires participants to share understandings of complex issues • Example: Jokes

20. The Biomedical World • Overtly low context • Northern European, low context roots • Technologically oriented • Industry driven concern with productivity • Predominantly young work force Covertly, as Medicine involves people in intense relationships, many interactions are high context

21. The World of the Very Sick and Dying • Varied ethnic backgrounds • Elders predominant (patients and families) • Illness extremely personal in terms of: • Values • Understanding of illness in terms of life narrative • Suffering • Bodily functions (sexuality and excretion) • Decision making • Dependence upon others

22. High Context Learning • Formal • Explicitly modeled and then imitated • Competence socially sanctioned with formal feedback • Informal • Observed surreptitiously • Part of “Hidden Curriculum” • Competence requires practice within contextually appropriate situations, informal feedback

23. Educational Approaches to High Context Communication in Medicine • Determine what should be formally vs. informally taught • Example: death pronouncement • Where formal: • Instruct, model, give formal feedback • Where informal, facilitate the creation of proper contexts within which learning can take place

24. ‘Teaching’ about High Context Issues • Start low context, then move progressively higher in terms of context • Teach low context learners what context is • Present high context ‘tasks’ in low context terms • ‘Mindfulness’ excercises • Practice high context tasks • Role plays • Real-life situations

25. Example: Sharing Bad NewsLow Context Approach • Find a non-distracting place • Silence beeper • Inquire, briefly, as to news recipient’s condition • Warning shot • Pause • Listen…

26. Non-distracting place Silence beeper Inquire, briefly, as to news recipient’s condition Warning shot Pause Listen… Setting Relationship, Coming into Synch Synch, ritual Synch, evaluate Synch, slow down, respect Sharing Bad News High Context Issues Low Context Tasks

27. Establishing Proper Learning Contexts • Curriculum that stresses high context learning • Proper settings • Enough time • Balance between formal and informal learning Trainees need: Facilitating high context learning often requires programmatic change that alters the context within which learning occurs

28. CASE PRESENTATION • 80 Man with respiratory failure admitted to ICU and found to have metastatic cancer on a ventilator • When told further support was futile and when asked for permission to d/c ventilation, patient refused, saying he wanted “everything done.” What barriers to communication exist?

29. The Patient’s Story … • In the process of writing a book – wants a year to finish • Was unaware that he was this ill • Trying to come to grips with prognosis – all happening too fast Question:“What can we do for you?” Answer: “Give me TIME

30. Entrainment as a Communication Skill Like gears must touch, but not crowd • Spacing • Gears must be synchronized • Aligned temporally • Work toward a common purpose • Shared narrative construction Patient and ICU staff were spacially and temporally out of synch. Both working from very different story lines.

31. Techniques used as consultant • Separately synch’d with ICU (standing, sped up during rounds) and patient (sitting close, slow down) • Inquired regarding their understandings of situation • Looked for potential common ground • Worked to slow down ICU staff, speed up patient • Suggested alternative goals compatible with storyline

32. SUMMARY • If high context issues are not acknowledged and addressed by low context healthcare workers, serious miscommunication is inevitable • Learning to address high context issues requires balancing formal and informal training • Communication skill training could be improved by explicitly incorporating training about context into curricula