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Lost in translation? Clinical challenges in cross-cultural psychiatry

Globalization, with a growing number of migrant patients calls for better cross-cultural competence among health care workers. Hospitals and outpatient clinics have become multicultural and ethnic diversity among the staff is at present the norm. In Norway psychiatry is the medical discipline with the highest proportion of practicing International Medical Graduates (IMGs).



Studies of culturally diverse working environments have highlighted advantages but also challenges in these workplaces. We have recently published a study on this issue in Transcultural Psychiatry (1) and will here provide an extract of this paper. The aims of the study were to explore what clinical challenges IMGs and native-born Norwegian doctors training in psychiatry perceived when treating patients from other cultures, and what factors may be associated with such challenges. The ultimate goal of our research was to inform a future voluntary mentoring group intervention about transcultural clinical challenges. Transcultural psychiatry is the psychiatric discipline that pays extra attention to cultural awareness and sensitivity.


Multicultural patients, - and doctors


In Norway the immigrant population now comprises 965 000, (17,5% of the total population). The proportion of IMGs among practicing psychiatrists is 24%. This leads to a situation where immigrant patients, and native Norwegian patients as well, will be treated by doctors who belong to a culture different from their own. Both language- and cultural barriers may arise. Language barriers will always be important and influence performance and clinical skills in cross-cultural encounters, but cultural barriers might be as important (2).


There has been a lack of empirical studies on what specific clinical challenges doctors face when they diagnose and treat patients from a culture different from their own (3). Numerous studies have described specific psychiatric symptoms, such as depression, dissociation and hallucinations in a cross-cultural perspective (3-5). Other authors have focused on the need for more cross-cultural training of professionals in the psychiatric field (6). But few studies have focused on what clinical challenges and needs of specific skills doctors in psychiatry are experiencing in their cross-cultural consultations. And we do not know if the IMGs and the native doctors experience these cross-cultural consultations differently. Research on IMGs in western countries has mostly focused on the need for overcoming integration barriers, professional isolation, cultural differences in communication style, gender roles, and difficulties related to language (7, 8, 1, 9).


Tools, -and lacking tools


The Culture Formulation Interview (CFI) was included in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by The American Psychiatric Association in 2013 (10). The intention was to support culturally informed categorization of mental disorders and to respond to the cultural backgrounds and contexts of patients (11). Use of the CFI has been shown to lead to major revisions of clinical psychiatric diagnoses (12, 13, 14). Short training programs on DSM-5 CFI have also been shown to improve general cultural competence in psychiatry residents (15). But the CFI may not fully meet psychiatry trainees´ specific needs related to cross-cultural skills in psychiatric assessment of patients.


Previous studies have demonstrated that work-related stress and overload, like “having too much work in too little time” and emotional overload, have been associated with doctors´ difficulties in their patient work (16, 17, 18). We therefore hypothesized that such factors might also impact the doctors` perception of challenges in cross-cultural consultations. We wanted to examine if stage of career in psychiatry training, former experience of cross-cultural consultations, support from colleagues, workload (number of working hours), perceived stress in the workplace, and personality were associated with perceived clinical challenges in cross-cultural consultations.


There has been a lack of empirical studies on what specific clinical challenges doctors face when they diagnose and treat patients from a culture different from their own.

Perceived transcultural clinical challenges


Two hundred and thirty-three doctors training in psychiatry were asked to complete an inventory regarding “Perceived clinical challenges in cross-cultural consultations”. The response rate was 93%, most likely because two of the researchers distributed, collected questionnaires and answered questions to clarify possible misunderstandings in person. Of the respondents, 17% were IMGs and 83% native Norwegian doctors, women constituted 68% of the sample. An IMG was defined as a doctor who had a medical education from abroad and a first language (mother tongue) other than Norwegian. We developed, by psychometric methods, an index to measure perceived transcultural clinical challenges. The index included the items “Assessment of psychosis”, “Lacking tools in cross-cultural consultations”, “Assessment of suicide risk”, “Assessment of violence risk”, “Development of individual treatment plans” and “Psychiatric service is not relevant and sufficient for cultural minorities”.


The most challenging clinical situations


“Assessing psychosis” and “Lacking tools in cross-cultural consultations” were the two single clinical items that both native Norwegian doctors and IMGs found most difficult. “Psychiatric service is not relevant and sufficient for cultural minorities” was considered a major challenge among the IMGs than among the native Norwegian doctors.


When assessing psychosis language competence as well as knowledge about culture-bound syndromes and culturally based ideas and health beliefs are all required. A culturally sensitive understanding of the patient is a necessary competency for the therapist, to understand what reality is or is not in the patients´ perceptions (4). Since the 1950s, research in medical anthropology and sociology has documented the ways in which culture influences the boundary between normal and abnormal behaviour, the patterning of symptoms, how patients narrate their symptoms and the way clinicians narrate their symptoms and interpret symptoms into psychiatric diagnoses (19). It is also well known and experienced that culture affects patients’ explanatory models as well as their help-seeking patterns (19).


išnaša


The second highest rated challenge by both groups was “Lack of tools in cross-cultural assessment. The CFI in the DSM-5 has been used in several countries to enhance assessment of patients with a different culture (20). A meta-analysis of 25 peer reviewed studies showed that the CFI improved clinical rapport (12). The CFI helps to disclose the patient’s perspective, but despite its obvious benefits it is not frequently used, including in Norway. The CFI may be regarded as too time-consuming to use during hectic workdays. Although doctors training in psychiatry in Norway are all trained in the use of CFI, our study suggests that they may need additional tools, especially when it comes to cross-cultural assessment of psychosis and suicide risk.


Assessment of suicide risk was reported as an important challenge in cross-cultural consultations, especially among the native doctors. Evaluating suicide risk is generally found to be one of the most difficult tasks in psychiatric work (21). This is partly due to the problem of extrapolating risk factors from a statistical group level to an individual level. Completed suicide is quite rare, with a complex nature and is in general perceived as challenging due to the possible fatal consequences of misjudgement. Cultural attitudes to suicidal behaviour differ cross-culturally and makes evaluating suicide-risk in a cross-cultural context particularly complicated. Religious beliefs as a protective factor against committing suicide and patients´ methods in this action may differ across cultural and social contexts. The last, partly because of different access to tools, like firearms and self -poisoning agents like medications and pesticides/insecticides (22, 23, 24).


IMGs perceived lower levels of cross-cultural clinical challenges


The only two factors being significant when controlled the index for all other variables in a multiple regression analysis were “being a native Norwegian doctor” and “experiencing work-home conflict”. This means that the IMGs reported lower levels of perceived cross-cultural clinical challenges when treating patients.


The finding that IMGs reported lower levels of the combined index “Perceived clinical challenges when treating patients from a culture different from their own”, is in line with what we found in a previous qualitative study (25). By contrast, the native-born Norwegian doctors in that former study experienced that some of their IMG colleagues could misunderstand Norwegian culture, interpret clinical situations differently, and that their medical assessment might differ from their own.

A possible explanation of the finding in our current study that the IMGs training in psychiatry experienced fewer clinical cross-cultural challenges than their native Norwegian colleagues did, might be that many of them had lived in Norway for several years and might have known the dominant cultural norms well. The IMGs may also have been more experienced as practicing physicians before emigration. The IMGs may also be more aware and conscious of the actual cultural diversity of which they are a part (6). Their experiences of being immigrants themselves may have promoted awareness and better understanding of immigrant- or ethnic minority patients. But it should also be noted that self-reported clinical competency is not necessarily valid (26). Answers can also have been given in a socially and work-related acceptable way.


Native Norwegian doctors are not exposed to other cultures to the same degree, and this can have limited their cultural awareness and skills. Fewer experiences with cross-cultural consultations and feelings of incompetence might lead to withdrawal from clinical encounters with patients from a foreign culture, thus compounding the problem (27).


Assessment of suicide risk was reported as an important challenge in cross-cultural consultations, especially among the native doctors.

Work/home interference


Work/home interface conflict was the only independent variable that significantly predicted perceived cross-cultural clinical challenges in this study. High work/home-conflict has also been found among Canadian foreign residents in psychiatry and surgery (28, 29) Difficulties in balancing work and home life have also been shown to be the only type of work-related stress to increase during the first years of specialty training among Norwegian doctors (30). Studies have shown that work/home conflict was an independent predictor of burnout, emotional exhaustion, in physicians (31, 32, 33). To our knowledge, the current study is the first to show that work-home interference also impacts doctors` perceptions of difficulties in psychiatric clinical work with patients from a different culture.


Implications


Our study suggests that mentoring and training programs in psychiatry should focus more on specific clinical challenges experienced by doctors working in cross-cultural settings. IMGs and native doctors seem to experience cross-cultural encounters differently and can possibly benefit from mutual learning.

The findings from this study suggests that work-related factors, like work-home conflict may impact doctors´ perceptions of difficulties in cross-cultural clinical work. Training programs should also include ways in which doctors can balance home life and work, to help to reduce the impact experienced work-home conflict interferes with their cross-cultural performance. □


References


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