Culture ClashThe Case of the Culture Clash presented a conflict within a multi-cultural team of doctors. Mary, a registrar was unable to effectively teach all her interns, who had diverse personal and professional backgrounds. Working in teams with many cultural and linguistic difficulties is becoming more and more common worldwide. This month we asked about personal experiences of difficulties with multi-cultural teams, how to overcome these difficulties, and how we as educators can improve our teaching of learners from different backgrounds.

This month Dr. Teresa Chan (@TChanMD) and I (@annestir) explored this issue with insights from the ALiEM community and 3 experts.

This follow-up post includes:

  • The responses of our medical education experts, Drs. Almero Oosthuizen and Heike Geduld
  • A summary of insights from the ALiEM community derived from the Twitter  and blog discussions
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
[su_spoiler title=”Expert response 1: One of these is not like the other” style=”fancy” icon=”chevron-circle”]

Heike Geduld MBChB, DipPEC, MMed, FCEM(SA)
Head of Education for Emergency Medicine, Cape Town, South Africa
There is an increased awareness of diversity in clinical practice. However, it is not just our patients who are different, it is also our colleagues. Increasing numbers of international medical graduates are moving to new health systems for opportunity, lifestyle or even just a change of scenery. (1)
We are constantly reminded to be understanding and empathetic to patients and their families with languages, cultures and belief systems different than our own, it is harder to remember that these cultural differences may apply to our colleagues as well. This may be due to our reliance on the idea that medical culture supersedes all – that no matter where you trained, once you are a doctor you share the common professional beliefs and attitudes of the medical professional. While this may be true to a degree, it does not smooth over all of the differences.

Unfortunately, developing cultural competence is not easy. None of us come from a neutral base – we all have cultural attitudes and biases that shade our interactions.(2) Mary admits that she finds it easier to ask Jane the questions because the response she receives is predictable and familiar. As humans we subconsciously respond to and seek out individuals who are similar to us because we understand the nuances of communication that make it easier to engage.

Communicating in a pressured environment is often difficult for speakers in their second language, and the colloquial terms and abbreviations of medicalese make it worse. In this case, Irina’s difficulty with communicating may be interpreted as a refusal to communicate and creates tension. In the same way, the perception that Jane is dominating the group creates distance between her and her colleagues. It is safer and easier for Irina and Shamila to simply stay quiet. This tendency may result in failure to ask for clarification or speak up to disagree with another clinician. (1)

Many of us have an unspoken belief that those moving to our country should try to be more like us and interact in the way we do, and that a failure to do so is their fault, not ours. However, as humane, empathetic clinicians and educators it is our responsibility to make sure that all members of our team are valued and included.

So what can we do? For faculties and hospitals, faculty development interventions and mentorship programs can help.

In day to day interaction

  • Create clear expectations about knowledge, behaviors, attitudes and skills.
  • Allow learners time to integration comments and circle back to questions later
  • Create structure to interactions by allowing preparation time or standard opportunities to demonstrate knowledge
  • Debrief teaching sessions to encourage reflection on interactions
  • Remember that humor can often be culturally specific and can be confusing for non-native speakers
  • Diversity in the medical profession is well worth the effort that it takes to achieve harmonious relations with our colleagues from various cultures.


  1. Walsh A. International Medical Graduates-Current Issues (pdf). The Future of Medical Education in Canada. 2011.
  2. Fox R. Cultural Competence and the Culture of Medicine. NEJM 2005:353;1315-1319.
[/su_spoiler] [su_spoiler title=”Expert response 2: Dealing with Culture” style=”fancy” icon=”chevron-circle”]

Almero Oosthuizen MBChB DipPEC Mmed FCEM(SA)
Emergency Physician and Educator, Cape Town, South Africa

Whenever I meet new people, I find I get along with them faster and easier when we have at something in common. This effect is obvious for some fundamental traits, like language, but if often true for shared interests like sports or art as well. The more we share on a fundamental level (language, world view, social practices, values) the easier it becomes to understand and interpret each other when we interact – it can be tough to have a conversation with someone if I am not sure whether it is OK for me to make eye contact, or even be in the same room. Our beliefs and traits make up our personalities as individuals. When groups of people share such commonalities, it is called their culture [1, 2].

When all the members of a group share the same culture, they share a common set of fundamental beliefs and practices. This facilitates (but does not guarantee) easy communication and interaction in the group.

In diverse groups where the members do not know and understand each other’s cultures, communication and interaction can be more challenging [3, 4]. Problems range from the seemingly trivial (in many African cultures, formal greetings and salutation is very important. and neglecting them can result in unexpected tension) to the serious (in some North African and Middle Eastern cultures, any physical contact, and sometimes even eye contact, with an unmarried person of the opposite sex may give great offense).

However, culturally diverse groups have the potential to add value to both the group and its members [5, 6]. These benefits include: reduced uncertainty, increased adaptability, access to a wider perspective, increased active participation and ownership and many more. This requires cultural awareness that can be developed by learning about each other’s cultures (cultural awareness) and the personal understanding that occurs when we learn about each other as individuals. A strong knowledge of a friend/colleague’s culture can be the entry fee to the main event: getting to know him/her as a person. Neither cultural awareness nor effective personal communication happens automatically: we have to make a conscious choice to do make them happen.

In the case Mary is in a position to be a teacher and mentor to Jane, Irina and Shamila. She is clearly aware that there is a problem and she should take the lead by learning about Irina and Shamila’s cultures (anyone with internet access can do this!). Once she has done so, she can have an honest conversation with each of them as individuals. This conversation would hopefully both identify issues and be the first step to a better relationship.

The responsibility can’t be Mary’s alone, though. Irina and Shamila both find themselves in a situation where, on the surface, they don’t have a lot in common with the culture that they are immersed in. They should also learn about their host culture and to talk to Mary (or someone else) about their concerns.

Functional culturally diverse groups are some of the most stimulating environments to work and learn in, but there are no shortcuts to success: we have to actively learn about the cultures of those we interact with, and then get to know them as people.


  1. Wikipedia. Culture.
  2. Hoebel, Adamson. Anthropology: Study of Man.
  3. US Department of Commerce. Best practices in achieving cultural diversity (pdf).
  4. Dogra et al. Culural diversity training and issues of uncertainty: the findings of a qualitative study. BMC Medical Education 2007 7:8.
  5. Whitla et al. Educational benefits of diversity in medical school: a survey of students. Acad Med. 2003 May;78(5):460-6
  6. Josh Greenberg. Diversity in the workplace: Benefits, challenges and solutions.
[/su_spoiler] [su_spoiler title=”The Case of the Culture Clash: curated from the community” style=”fancy” icon=”chevron-circle”]

Curated by Anne Smith, Peer Review and Member Check by Teresa Chan & Brent Thoma

Most participants agreed that effective cross cultural communication was important, but several commented that it was not something that they had thought about often. Many who commented mentioned that they worked in units where there was diversity in both cultural and language backgrounds, highlighting the importance of this discussion.

Thanks to the participants (in alphabetical order) for all of their input: Teresa Chan, Esther Choo, Meenal Galal, Lucy Hindle, Louis Jenkins, Sa’ad Lahri, Shannan McNamara, Anne Smith, Brent Thoma, and Kamil Vallabh

Some pointers from the community on improving multi cultural communications and handovers

1. People have different cultural backgrounds

Do not make assumptions about people based on the way they look or the language they speak – this is a recipe for misunderstanding and miscommunications. Looks can be very misleading in multicultural societies! A better strategy is to invest some time and energy in getting to know team mates a bit better by in a more informal setting, or simply during day to day ‘small talk’.  Taking an interest in where people come from personally and professionally goes a long way to improve the way you can work with and teach them. This can lead to an unseen benefit of closer team relationships in the working environment.

Comparisons between medicine and other industries

There are obvious parallels between the ‘business’ of medicine and other industries- e.g. aviation. These industries learned long ago that outcomes and safety can be improved by using the power of culturally diverse teams and making cross cultural communication a priority. Medicine has a lot to learn from the way big business approaches international relations.

Individualizing Education goes beyond Culture

Educators need to listen and to respond to each learner. Learners may have specific  needs that are unrelated to their cultural background and educators should try and work out the most effective methods to reach the individual.  Some specific tactics an educator could try with reticent or shy learners are:

  • one-on-one sessions:
  • giving advance notice about a specific topic of discussion  to enable those who are learning in second or third language time to prepare adequately.

Educators should use self-reflection and feedback to improve their teaching style

Frequent reflection on recent teaching sessions and requesting honest and constructive feedback from learners is so important to ensure that you are being effective as an educator. Asking students or peers how they perceived your teaching style will give you tips on where you can improve things.

Do not let language get in the way

Most hospitals now are a melting pot of many different languages – with one or two most likely being the dominant medical language. As an educator and team leader you need to ensure that language does not become a barrier to communication. Avoid this by using clear instructions and getting to know what languages your learners are comfortable with.

Set the example

As educators in Emergency Medicine we need to set a good example to junior staff about the right way to approach a multi cultural team. Being aware of our own prejudices and biases is an essential step in overcoming cross cultural miscommunication. The idea of of ‘cultural code switching’ was mentioned – as a good educator you should be able to modify your behavior in specific situations to accommodate various cultural norms.


Case and Responses for Download

Click Here (or on the picture below) to download the case & responses as a PDF.

medic document

Anne Smith, MBChB

Anne Smith, MBChB

Emergency Physician
George Hospital
Cape Town, South Africa