South-west Scotland to West Bengal: where does patient expectation fall?

There is firm evidence that the NHS is treating an increasingly diverse population with a service built from an equally diverse global workforce.¹

In addition to attaining linguistic competencies, a challenge to international medical graduates (IMGs), is adjusting to patient expectations, which can vary widely across patient populations. One PCT, NHS Dumfries and Galloway offer a generous Travelling Fellowship to doctors in training. One of its central objectives is to improve understanding of the challenges faced by international colleagues coming to the UK.

We had the opportunity as part of the Travelling Fellowship 2014 to undertake a 2 week project in Kolkata, (formerly Calcutta), India. We studied clinic-level doctor–patient interaction looking at communication and shared decision-making. One aim was to compare patient expectations of a medical consultation in the private (pay at delivery) urban environment of Kolkata with that of a NHS regional hospital in semi-rural Southwest Scotland.

Patients were requested to quantify on a scale of 1 (lowest) to 10 (highest), their expectations prior to scheduled clinic consultations, based on five key statements (a modified ‘CARE’ questionnaire):²

Our results (Table 1) demonstrate lower expectations of involvement in decision-making in the Indian cohort compared to their Scottish counterparts. As clinic-observers, these results correlate with our first-hand experiences. For example, many patients would confer respect to the doctor by remaining standing until invited to sit down, and would only speak when spoken to. Often gifts were given in addition to full cash payment to court favour.

We believe cultural diversity plays a significant role in the dissimilarity of patient expectation. Lower mean scores reflect a more deferential patient attitude to the Indian medical professional, in keeping with inherent class-based societal norms.

Wider socioeconomic and educational inequalities in India, might explain lower expectations of patient contribution to consultations and treatment plans. Moreover, this disparity could underpin a belief that ‘Doctor knows better’: explaining why Indian doctors operate under lower expectation to elaborate on their patient management styles.

Differing expectations may have its roots in the medical undergraduate curriculum. Until the 2012 Revision by the Medical Council of India Medical Education Regulations,³ communication skill assessment was largely informal — often centred on a ward-round debrief.⁴ Though yet to impact the UK medical workforce, successful medical undergraduates must now: ‘demonstrate an ability to communicate with patients, colleagues, and families in a manner that encourages participation and shared decision-making’.³

Our survey and observations illuminate some of the additional challenges IMGs can face on arrival to the UK. These include the need to develop:

• broader treatment options independent of patient affordability;

• cultural awareness;

• a less paternalistic attitude;

• an appreciation of patient autonomy; and

• working relationships with new colleagues.

While the GMC have well-established linguistic and clinical competency assessment units, do individual hospitals do enough to prepare new IMGs to their locale? A tailored induction, focusing on ‘soft skills’ would improve the clinical effectiveness of IMGs, particularly in the clinic or primary care setting. This is supported by earlier studies linking patient-centred consultations to improved patient outcomes.⁵

Mentors of IMGs also play a crucial role in the provision of additional support: particularly where communication training has been in short supply. Enhanced communication skills have additional benefits, such as improving clinician wellbeing.⁶ In addition to reducing susceptibility to patient complaint, refined verbal connection can assist with integration into new cultural environments. In turn, wider appreciation of global variation in patient expectation and cultural diversity may enhance staff recruitment and retention by improving career progression for IMGs.

• © British Journal of General Practice 2016