downloadOur hospitals are abound with international citizens who travel across the globe to learn about medicine. Frequently, individuals complete some aspect of their training in another country, bringing with them their own cultural perspectives. This month in the MEdIC Series, we invite you to discuss a case of culture clash and how consider how our learners’ backgrounds can affect their medical education. Join Mary in her tribulations as she considers how to approach the very different styles of her learners: Jane, Irina, and Shamila.

The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them!

If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Culture Clash

by Dr. Anne Smith (@annestir)

It was a typical post intake ward round in the emergency department in Townsville, England. The Irish registrar, Mary, was starting her usual series of questions. ‘What is the pathophysiology of acute cardiac failure in this patient?’

Jane glanced at her colleagues – Irina and Shamila – after seeing the same thing for three months she knew how this was going to go. But she was hoping that, somehow, today would be different.

Irina, the intern started… ‘I think it’s…’ and she trailed off into nothing. What the others could not tell was that she knew the pathophysiology concepts, but could not command her mouth to use English words to describe them clearly enough. She had studied basic science in her home language, Swedish, and often got confused with medical terminology.  She opted, instead then, just to keep quiet.

Shamila, a recent addition to the team, stood quietly at the back and stared intently at her feet. Coming to England had been a huge change for her – in her home country she was never expected to question and argue in public and it was considered rude for her to speak back so directly, especially to a senior in a position of authority.

Mary, an avid teacher, surveyed her erstwhile band of trainees and sighed. For three months, this group of interns had frequently shuffled around answers, avoiding her gaze. All except for her go-to-girl Jane. She wished she could engage the others, but in the end, she just had to keep things moving along.  Almost reluctantly, she glanced towards Jane.

“Jane, could you tell us?”

Jane was well accustomed to talking through things on ward rounds, since similar teaching methods were used in her home country. She did her best and Mary went on to give her a great tutorial on managing acute heart failure, and complimented her on her knowledge and treatment of the patient. The other two doctors stood quietly at the back and seethed quietly.

‘If only I could you tell what I know- this was an easy question and anyway Jane didn’t get it all right!’ thought Irina.

Meanwhile, Shamila reflected: ‘I don’t know why Mary seems so frustrated at me – I am doing my best and trying to be respectful, and yet somehow that doesn’t seem to matter. She likes Jane, and doesn’t’ seem to mind her flagrant boastfulness.’

As they moved onto the next patient, Mary wondered to herself: ‘Was this method of teaching truly effective?’ From what she could gather,  she seemed to only be reaching one third of her team. They all got along well in social settings, and in their off time, she quite liked Shamila’s stories and Irina’s reflections. The professional interactions, however, were constantly strained.

Key Questions

  1. As a teacher, how do you ensure that you are an effective teacher to people of different ethnic and cultural backgrounds? What other methods of teaching could Mary have tried with Irina and Shamila?
  2. As a learner, how do you ensure that your teacher understands what you are comfortable with and how you have been previously taught?
  3. In your hospital, residency program, or medical school have you experienced difficulties dealing with diverse groups and how did you overcome them? How have communication difficulties impacted patient handovers and patient care?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published (on March 7, 2014).

Click HERE for a link to the Expert & Community responses, which include words from:

  • Dr. Heike I. Geduld  (@heikegeduld), Head of Education for Emergency Medicine in Cape Town. She directs EM training at the University of Cape Town and Stellenbosch University.
  • Dr. Almero Oosthuizen (@EMCapeTown), an emergency physician and educator in Cape Town, South Africa. He is particularly interested in the use of collaboration and innovation to increase both our education and service delivery footprints in resource limited settings. He is the man behind the #FOAMed YouTube Channel (EM CapeTown).


All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.  Also, as always, we will generate a curated community commentary based on your participation below and on Twitter.  We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Image Photo Credit: Flags of the world by Daniel Orth. Used via Creative Commons license Attribution-NoDerivs 2.0 Generic (CC BY-ND 2.0)

Teresa Chan, MD, MHPE
ALiEM Associate Editor
Emergency Physician, Hamilton
Associate Professor, McMaster University
Assistant Dean, Program for Faculty Development, McMaster University Ontario, Canada
Teresa Chan, MD, MHPE


ERDoc. #meded #FOAMed Own views expressed. Contributor to @ALiEMteam, @WeAreCanadiEM, ICE Blog, #FeminEM. @MedEdLIFE founder. Works @McMasterU & @HamHealthSci