Cultural Diversity: Walking the Biomedical Tightrope (Reflection on Simpson I)

Emergency Medicine Registrar Miriam Saey Al Rifai reflects on Bob Simpson’s essay, ‘Cultural Diversity: Walking the Biomedical Tightrope’.

Communication Skills days were always welcomed as light relief in the medical school curriculum. We would work through example scenarios in small groups and consider and reconsider how information could be effectively and sensitively given to patients and their loved ones – “breaking bad news,” for example. Led by a trainer in Communication, we would act out model responses to difficult situations. At first, I found the acting element quite daunting, but quickly playing the ‘role’ became second nature to me.

At times it struck me how prescriptive medical communication could be. We rehearsed over and over the “correct” response to situations. This involved the “correct” words of comfort to use, the “correct” way to hold our hands and so on. We were all taught the same method, so irrespective of how we entered medical school and from where we came, we all left the same: “I’m so sorry to hear that; it must have been so hard for you.”

I remember sometimes feeling embarrassed at the start of my career when thrown into “real life,” situations and “comforting” the patients with the methods that I had been taught. Yes, it was appropriate to convey sorrow and sympathy, but the formula we were trained to use was also very empty; empty of me.

Bob Simpson’s piece brings to mind how I mostly only use my first name at work. It is how I ask patients to address me, mostly because my surname is considered a mouthful and hard to pronounce. Also, I prefer to make the patient encounter less formal. However, in the earlier parts of my career, I think my preference for patients to use my first name was also because I did not want to be judged by the patient. I wondered what influence my name would have on their expectation of me and the care that I would give them. My concern was that I be pigeonholed as a frequently misrepresented and poorly portrayed ‘Muslim Woman’. I worried that patients might think that I would judge them, or not be able to relate to them.

Naturally, these anxieties could cause me to play another role, trying hard to overcompensate, connect with the patient and create common ground, despite being a Londoner like most of my patients and having a very tangible connection and common ground with them. Simpson states, “No doctor comes to his/her practise from nowhere.” In my case – and perhaps because I originally came from “somewhere else,” as my name confirmed – I would find refuge in the cultural anonymity of the more robotic style of communication. This helped me to navigate the doctor-patient relationship more straightforwardly, even if the human touch – me – was the first victim of this approach and the patient’s feeling the second.

Over the years, I overcame this problem and developed a more sincere communication style. I am convinced that when I bring more of myself into my language and expression, my patient feels more at ease with me and the process they are going through. I hope that it gives my patient comfort that I am a human and my care for them is genuine.

Simpson’s metaphor of a tight rope resonates. On one side is protocol and guidelines and a “correct” way of explaining and dealing with matters. It feels like the safe route. On the other side of the tightrope is me acknowledging that I am caring for someone with their own unique needs. It is acknowledging myself, my thoughts, my natural body language and reactions. It is my urge to hug someone, my own experiences, the time my friend found themselves in that situation, the way she reminds me of my aunt.

It is what humanises us and, importantly, those we deal with. If you traverse the tightrope delicately you can bring an element of yourself to your practice whilst adhering to guidelines. It is not easy and it is not taught. Sometimes on a tough shift, when I am tired and less linguistically creative I do just find myself saying “I’m sorry to hear that.” And it is true. The more tired you are the easier it is to revert to prescriptive medicine, autopilot. It is a safety net itself I suppose, for when you do not have the energy to walk the tightrope.

I also recognise my fortune in being a sort of ‘outsider from within’, and the unique privilege this affords me, having been brought up in London and familiar with the so called dominant cultural background of UK medicine but also raised within a mixed heritage household with strong Irish/Middle Eastern and religious customs. This has given me a particular insight into what can get lost in translation between immigrant doctors in the UK and those who were born here. I can utilise this insight at times to act as a bridging role between both UK and non UK born doctors of which cultures I am familiar and sometimes between non UK born doctors and patients themselves.

Simpson gives the example of the GP that displayed a large picture of the Madonna and Child above their desk. A clear show of their belief system and who they are. My more junior doctor-self may have shied away from this display of the self, but now I feel rather different about it. More and more, I find myself sharing my full name and revealing more of the person I am.

My urge to show my patients who I am appears to have grown over my career; my willingness to express myself increased. A world away from the initial communication skills training.

Perhaps I like to challenge the preconceptions I believe some patients may have of me. It is not because I think that my patients’ understanding of who I am personally is essential for me delivering good care to them. It is more that I want my patient to feel and know that they are being cared for by a human, like them, and with them. I hope that this sincerity only strengthens our professionalism in the eyes of the public.

Miriam Saey Al Rifai is an Emergency Medicine doctor from London. Follow Miriam on Twitter @saey_al.