"Educational Tools for Dealing with Trainees with Difficulties"

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Using the concept of the Johari Window…..

Knowledge, Skills & Attitudes
KSA is the standard way that medical education has traditionally categorised all that has to be learnt by a trainee or any learner. These three categories can then be subdivided to match the various competencies outlined in the RCGP curriculum. Think of how you NEEDS ASSESS using perceived and unperceived needs and consider how you would then increase the Open Arena box in Johari.

Assessment Methods to identify Perceived Needs:

  • Confidence Self-Rating Scales – eg Wolverhampton Grid, NW Thames Grid, Oxford VTS Curriculum Guide, etc

  • PEP CD

  • Previous MRCGP papers – esp MEQ

  • Other commercial MCQs, eg Pastest

  • Honey & Mumford Learning Styles Questionnaire

  • PUNs & DENs*

  • Joint Surgeries

  • Personal Reflection*

  • Personal Portfolio*

  • Audit*

The FAÇADE can be opened by a good honest and open working environment where you as the trainer are a good role model and are seen to be looking at your work in a critical and open way.

Assessment Methods to identify Unperceived Needs

  • Manchester Rating Scale

  • Summative Assessment Trainers Report

  • Problem Case Analysis

  • Random Case Analysis

  • Significant Event Analysis*

  • Joint Surgeries with Trainer

  • Direct Feedback from Trainer

  • Watching GPR at work – live and videoed

  • Feedback from Staff

  • Feedback from patients

  • Formal 360 degree0 feedback from Practice Team*

FEEDBACK is the key to opening out the blind spot and should be non judgmental


(I noticed that 20 seconds into the consultation you asked the following closed questions. How might this have affected the consultation?)



(Is better than “Why did you interrupt the patient so early”)


(At 1, 3 and 6 minutes you spent time looking at the computer whilst they were talking. How would the patient know you were listening?)



(Is better than “You often don’t appear to be looking at the patient”)


(You were talking for 70% of the consultation. What issues might this raise?)



(Is better than “You’re a bit of a loudmouth with patients!”)


(Offer options of management so that the patient can share decision- making.)



(Most doctors after time will have clear opinions on how to manage a condition. They need to remember the patient should be involved and trainers should not just give one opinion to a learner.

  • Choose the time and give in a quantity that can be coped with.

  • Check feedback is understood.

  • Avoid collusion

Whether exploring Johari with learners or consulting with patients we get to the root of things and reach shared understanding by asking good questions.

WHAT ARE THE BEST QUESTIONS? (Either to suggest to trainees who are finding this difficult or to modify in the way you question or challenge trainees)

Open – from fully open (Tell me more) to more specific but still open (Tell me more about your headache)

Closed – It is ok for trainees to ask closed questions in a consultation and in particular to screen for red flag symptoms. But make them aware of different ways of asking closed questions. They can encourage an answer both in style and in giving time (Do you wake with a headache in the morning? ......) or make it more difficult for a patient in style and pace (You don’t get a headache in the morning, or feel sick, or get visual changes do you)

Awareness raising questions are particularly useful when exploring a trainees insight or understanding. They can be supplemented by What if questions to take learning into unexpected areas.

  • What did you think caused that?

  • When did it occur to you that those things were linked?

  • Where were you at the time?

  • How did that make you feel?

  • Who else does that affect?

  • You’ve suggested that you’d phone the patient with that abnormal result. What if the patient’s daughter answers the phone?

Clarification questions can both help a trainee ensure they understand the patient’s history but can be used to give them time to collect their thoughts before moving on.

  • Can I check I’ve understood you correctly?

  • When did that happen?

  • What did the nurse say to you?

Reflective questions. These can be used to reflect back one point but also as part of summarizing.

  • The words said but just reflecting the content back

  • The meaning of the words

  • The feelings behind the words or non verbal cues

Many trainees think reflecting back just means reflecting back the question. The patient says “I think the headache might be a brain tumour” = “So you think the headache might be caused by a brain tumour?” Next level reflection is “You used the word tumour and I wonder what that word means to you?” But there is also a deeper level to explore. “You mentioned the headache might be caused by a tumour and I wonder how this makes you feel?”

Linear – one after the other with no clear link or following a model which does not match what is needed. And this often leads to repetition, muddled thinking and poor time management.

Strategic – Have you thought of trying this? E.g. “have you thought of asking all patients about their ideas, concerns and expectations early on in a consultation to see if it helps you develop better shared management plans? This might help you prepare for the CSA.”

Hypothetical – I wonder if this would be a useful idea. E.g. “You don’t know what the rash is but it doesn’t appear to be serious. Why don’t you try cream X for a couple of weeks and see what happens?” Or at a different level – “If I were able to wave a magic wand and your symptoms got better what would your life be like?” “What do you think you’ll be doing in 5 years time?”

Circular – How change might affect other people. If you do that what would X do and if they agree how would that affect Y? What perspectives do the people in your life have about you?

It is possible to keep asking questions which build on the information given earlier and which look at the relationship between the person and others or between the person and the “illness/ disease”.

So instead of asking “What happens when you are depressed?” consider “What do your family or workmates do when you are depressed? Who notices first and who last? How does it affect them?

Reflexive – a question you and the patient or trainee don’t know the answer to but triggers them to start thinking about new perspectives. These questions can open unexpected avenues in the fourth Johari window that is hidden or “unknown or undiscovered potential” E.g. You are due to attend for an interview and you don’t know how to prepare for this. Your trainer tentatively asks “What would a recruitment consultant suggest you do?” – “I’ve no idea” – “Neither do I, but why don’t you find out?”

Helman’s Folk Model for the questions patients want answered

  • What has happened?

  • Why has it happened?

  • Why to me? Why now?

  • What would happen if nothing were done about it?

  • What should I do about it

  • Whom should I consult for further help?


  • Conceptual clarification questions to “tell me more” to get more depth of thinking

  • Probing the assumptions, rationale, reasons and evidence behind someone’s opinions

  • Challenging the viewpoints and perspectives

  • Probing the implications and consequences of an opinion

  • Questioning the questions

Heuristic – facilitative questions to challenge the learner’s curiosity and develop an independent learning style. E.g. You have put a lot of interesting cases on the e-portfolio but I wonder if you could identify how these have changed the way you make decisions as a GP?

Questions to challenge oneself

  • How would I be feeling in this patient's situation?

  • Could my attitude towards the patient be based on something to do with my own experiences, anxieties, or fears?

  • Why does this situation cause me difficulty?

  • What beliefs and values underpin my actions in this situation?

Solution focused questions aiming to look at the differences over time and use these to increase insight.

  • How do you feel and what do you do when you don’t have your abdominal pain?

  • Looking back over the last few days have there been times when you have been free of the problem? How can you explain that?

  • Can you remember a time when you could have given in to the problem but you didn’t? What happened then?

Non-verbal – using our non-verbal skills to encourage answers

Daft Laddie – Examining a patient and incidentally notice they have a rash they’ve not mentioned and saying “Is that a rash on your arm?” to trigger a response.

When asking questions try to tell the difference between ability (capability) and motivation (particularly if lack of insight) as the cause of difficulties. Indeed start not with a question but a statement of fact like “You arrived at 09.00hrs and your first patient was booked at 08.30.” Then wait to see what type of response you get. Is it apology and explanation or self justification and excuse? Develop plans to aid difficulties with ability with review or identify what change is needed with a deadline with clear consequences for failure to meet it.


If your trainee is from a different cultural background

  • You have a duty to help them understand the community they are working in and ensure they work effectively and appropriately with that community.

  • You should endeavour to understand their cultural background, previous style of medicine and their values and beliefs.

  • They should meet the requirements of good medical practice in the UK

Statistically if a doctor has trained abroad they will do less well in the College Exam and in particular if they are male and sitting the CSA. Since this is now the endpoint assessment this can create great anxiety. Consider discussing at an early stage that they might have particular disadvantages in adapting to UK GP and explore solutions with them. Explore this by understanding them as an individual.

Particular difficulties are that they may not be used to “Patient centered care” and English may not be a first language.


Research by Albert Mehrabian in the late 1960s shows that communication of feelings and attitudes is;

7% What we say

38% The way the words are said (Para-linguistics)

55% Non verbal

LANGUAGE IS MORE THAN JUST WORDS (which might help understanding of how difficult it is for some trainees to cope with the English Language and non verbal cues.)

by Alix Henley & Judith Schott (9)

On the surface, language consists simply of words, linked by grammatical rules to convey meaning. In fact, there are many other devices that also help indicate and support meaning. These include:

paralinguistic features such as intonation, emphasis, volume and pace;

non-verbal norms such as physical distance, touch and eye contact;

cultural features, for example ways of indicating agreement, of being polite.

Although we usually use and interpret these devices unconsciously, they are a crucial part of the message we give (Mares, Henley and Baxter 1985). They are also very important clues for health professionals trying to understand people's physical and emotional needs.

When people learn a second language they usually retain certain paralinguistic, cultural and non-verbal features of their mother tongue. As a result, they may unintentionally offend or give the wrong impression. These misunderstandings can be difficult to sort out because their cause is rarely recognised. We assume that people sound how they mean to sound. Misunderstandings are particularly likely when people are anxious, distressed or under pressure.

Difficulties can also occur when people speak a different variety of English, for example Indian English, Caribbean English or West African English. Each of these has its own particular paralinguistic features - intonation, rhythm, accent and vocabulary - as well as cultural and non-verbal devices. These often differ from those of British English so, even though people who speak different varieties of English use the same words, they may misunderstand each other's intentions or attitudes. British-English speakers also sometimes assume that other forms of English are inferior and that people who speak them are stupid or under-educated. In fact, each is a complete and fully developed language in its own right (d' Ardenne and Mahtani 1989).

'I was simple enough to think that the British people were all the same, all speaking the same sort of language, the language which I learnt at English school in India. I was surprised I couldn't understand the English nurse and was even more surprised because she did not understand English - my English!'
Indian man (Ahmed and Watt 1986)

Paralinguistic features


To see how paralinguistic features work, try saying this sentence, ‘She says she’s been in agony for three hours’ in four different ways:

As a straight statement

As a question

Indicating that you don’t believe her

Indicating that you are shocked that this has been allowed to happen


 Notice how your intonation, emphasis and volume differed each time, so that although you used exactly the same words and grammar, you conveyed very different meanings. In British English, certain paralinguistic features convey the speaker's intentions and feelings, including politeness, apology, anger, sorrow, anxiety, uncertainty, interest or lack of it, disagreement, criticism or urgency. People who do not understand the paralinguistic features of British English may not perceive these messages and may seem insensitive, rude or stupid. Their own use of paralinguistic features may clash with British expectations, and they may be wrongly perceived as angry, resentful, uncertain, excited or uninterested.

Emphasis and pace

British English uses emphasis to signal important or new information, or to contradict: for example, 'I told her to take it three times a day', 'Mrs Smith is coming on Monday'. Emphasis also indicates emotions such as anger or excitement. In other languages, importance may be indicated by speaking faster or more slowly, by adding words or phrases, by repetition or by lowering the voice (Mares, Henley and Baxter 1985). Again, there is a good deal of room for mutual misunderstanding.

Linguistic tunes

Each language has its own intonation or tune. In British English it is normal for the voice to rise and fall in friendly conversation. Changing the tune can also modify the meaning of a phrase or sentence. A raised tone at the end of a statement can turn it into a question: 'You've done your urine sample?' And raising the tone of the whole sentence is often associated with intense emotion such as anger, shock or excitement: 'You've won the Nobel prize!' or 'You've flooded the whole ground floor!' In other languages a raised tone over the whole sentence may indicate importance or friendliness rather than intense emotion.

British English and other northern European languages use a relatively limited range of tunes in normal speech: speakers of other languages and other forms of English may use a far greater range. To British-English speakers, they may sound excitable and excessively emotional, even unreliable. To other people, British-English speakers may sound uninterested, insincere, bored or condescending.

In tonal languages such as Chinese, Vietnamese and Thai, the tune or tone is part of each word. Changing the tone of a word completely changes its meaning. So, for example, the sound 'ma' in Vietnamese m.ay mean 'ghost', 'horse', 'appearance', 'cheek, 'rice seedling', 'but', 'which' or 'tomb', depending on whether it is said with a high rising, low falling, low rising, low broken, high broken or mid-level tone (Mares 1982). People speaking a tonal language have to get the tone of each word absolutely right in order for a word to mean what they want it to mean. The flexible rising and falling tones that British-English speakers use in a sentence to indicate friendliness are not possible. Friendliness is indicated in other ways. But to British-English ears, the tunes of tonal languages may sometimes sound brusque, imperious or angry.


Normal volume varies a good deal in different cultures. British English speakers speak very quietly in relation to most of the rest of the world. They often feel disconcerted or upset by people who seem to be shouting. They may feel that the other person (who is speaking perfectly normally in their own terms) is angry, over-emotional, threatening, irrational or simply bad-mannered. In tonal languages (see above), raising the volume is one way in which people indicate the importance of what they are saying.

Structuring conversation

In most European languages it is customary to state the main point in an argument first, and then to illustrate or expand upon it. In many other languages it is common to set out the preliminary arguments and illustrations first, working up to the main point as a conclusion. British-English speakers, used to hearing the main point early on, may become bored and impatient when listening to a patient or colleague who uses the other system. They may conclude that he or she has nothing important to say or is stupid and switch off before the key point is reached (Roberts 1985).

Turn-taking and listening signals

Conversation requires people to take turns. Different languages use different conventions to indicate when one person has finished and another can begin. For example, person A may lower their voice and slow down to indicate that it is person B's turn; they may begin to repeat themselves; or they may pause for person B to begin. Latin Americans generally take and expect very short pauses; North-American-English speakers take slightly longer pauses; British-English speakers take still longer ones. Problems arise when people use different turn-taking signals. Person B may feel that they are never given a chance to talk; person A may wonder why person B isn't saying anything. They may then label each other pushy, shy, unco-operative or unfriendly (Tannen 1992).

In British English it is considered normal and polite for only one person to speak at a time and for people to pause to allow each other to speak. In some cultures talking at the same time as another person and talking over them ('high-involvement style') is regarded as friendly and polite, and proof that you are really listening; in Northern Europe it is generally regarded as aggressive and pushy (Tannen 1991).

In British English it is also important to indicate that you are listening by nodding occasionally and making encouraging noises. It is also important to make intermittent eye contact. In some languages people show that they are listening by keeping still and remaining completely silent. They may also look away. English speakers used to eye contact and other signals during conversation may feel that they are not being listened to if these are absent (Lago and Thompson 1996).


Silence is tolerated more in some cultures than in others. It also means different things. In some cultures younger and more junior people use silence to indicate respect and affection. In some it is normal for people to sit in silence for long periods before they say anything, or to take long pauses while they are speaking; this indicates that matters are being taken seriously. In English culture silence is generally most acceptable between people who are close; in other circumstances it can feel awkward or rude and people may feel impelled to speak (Lomax 1997).

Misunderstandings and blame

The key point about paralinguistic features is that most of us wrongly assume:

that the cues and features we are used to and their meanings are universal; and

that they reliably tell us something about a person's behaviour or their personality.

If a person raises their voice and talks faster, for example, we may conclude that they are angry or hostile. If their voice goes up and down a lot we may conclude that they are excited or over-reacting, or we may simply be puzzled. If they are silent we may think they are disapproving, unco-operative, insolent or withdrawn. But such judgements are unreliable when people speak different first languages or different forms of English (Tannen 1992). The paralinguistic features of a different language are the most difficult thing to learn. Native speakers are generally unaware of them and rarely explain them to people who get them wrong, partly because it is often unclear whether a person is using them intentionally.

'I have been working in Britain for years and my English is pretty good. But I know that in difficult situations, where I have to be sensitive to people's feelings or have to convey something carefully so as not to give offence, I often get it wrong. I can't always pick up the implications behind what they say and I am not sure that I come across as I want to. It's a horrible feeling; you know people have misunderstood you but you don't know how to put it right. In my own language I'm much more confident even after all these years!'
German doctor

Non verbal signals

Non-verbal signals can also cause problems across cultures, leading people to misinterpret each other's feelings and intentions.

'I shall never forget a misunderstanding when I was a student nurse. Three of us were laughing and joking in the treatment room while sister was doing a ward round with the doctors. She suddenly appeared and told us off for making a noise. I felt really terrible because in my culture we are brought up to respect and obey our elders. My absolute horror must have shown on my face; and she thought I was being insolent and exaggerating, just pretending to be horrified. She berated me for being sarcastic and told me I would certainly never get a job at that hospital. She completely misinterpreted my reaction; there was nothing I could ever do to change her view.
British-Nigerian nurse


Some cultures use a lot of gestures and movements when talking; others do not. The significance of different gestures varies. 'Yes' may be indicated by moving the head up and down, by moving it from side to side, or by dipping it sharply downwards {Collett 1993). Gestures such as shrugging the shoulders, making a fist, making a thumbs up sign or clicking the tongue are perfectly acceptable in some cultures but offensive in others. In certain cultures, including those influenced by Islam, it is rude to offer something with the left hand. The left hand is reserved for necessary but dirty chores (see also Chapter 12 Practical care).

I realise that the left hand has no significance for English people, but when someone hands me something with their left hand I can hardly bear to take it. It goes right back to my childhood when if I gave or took something with my left hand I got a real scolding from my mother or one of my aunts for being so rude.'
Somali woman

Facial expressions

Health professionals often use patients' facial expressions to help them assess physical and emotional well-being, the need for pain control and so on. Across cultures this can be far more difficult. For example, whereas in English culture a smile may indicate happiness, or an attempt to please, in Japanese culture it may mask embarrassment, anger or grief. In Japan happiness is more commonly indicated with a straight face (Stewart and Bennett 1991).

Eye contact

In some cultures, looking people in the eye is assumed to indicate honesty and straightforwardness; in others it is seen as challenging and rude. Most people in Arab cultures share a great deal of eye contact and may regard too little as disrespectful (Argyle 1975). In English culture, a certain amount of eye contact is required, but too much makes many people uncomfortable. Most English people make eye contact at the beginning and then let their gaze drift to the side periodically to avoid 'staring the other person out'. In South Asian and many other cultures direct eye contact is generally regarded as aggressive and rude. This can cause problems, for example, for some overseas-trained South Asian doctors taking oral examinations in Britain. Lowering their eyes as a sign of respect may be wrongly interpreted as a sign that they do not know the answer or are guessing (Sami 1989).

'I trained in Switzerland and I was astonished when a Swiss doctor told me that I would be considered to be telling a lie if I did not look straight into a person's eyes.'
Pakistani doctor

In some cultures and religious groups eye contact between men and women is seen as flirtatious or threatening. Men of these communities who do not make eye contact with women are not usually rude or evasive, but respectful.

Different cultures also vary in the amount that it is acceptable to watch other people. Collett (1993) calls these high-look and low-look cultures. British culture is a low-look culture. Watching other people, especially strangers, is regarded as intrusive. People who are caught 'staring' usually look away quickly and are often embarrassed. Those being watched may feel threatened and insulted. In high-look cultures, for example in southern Europe, looking or gazing at other people is perfectly acceptable; being watched is not a problem. When people's expectations and interpretations clash, irritation and misunderstandings can arise.


Posture that is perfectly normal and neutral in one culture may seem aggressive or withdrawn in another. Most cultures also have gender rules for posture. It may be completely acceptable, for example, for men to sit with their legs apart but not for women. Standing or sitting with folded arms is seen as relaxed and friendly in many cultures but is often interpreted as hostile or defensive in the West.

'In Thai culture it is deeply offensive to point the soles of one's feet at people, for example when sitting. Younger people or people of lower status should also try to keep their heads below those of people of higher status, if necessary by bending the knees. It is extremely rude to pass between two adults who are talking without bending down so that one's head is below theirs. In British culture none of this is an issue and most British people in Thailand cause terrible offence without ever intending to or realising it.'
English teacher

Physical distance

In English culture, partners, and parents and children are generally comfortable standing fairly close to each other; friends stand further apart, and acquaintances still further. Northern Europeans tend to stand further apart than people from the Middle East, Greece or Turkey {Morain 1986). Most people try to maintain the distance they find comfortable; if their cultural conventions differ, one speaker may constantly move backwards to try to gain space, while the other 'pursues' them to get closer.


Cultures vary in the extent to which physical contact is allowed and between whom. In low-contact cultures, including British and other northern European cultures as well as Japanese culture, touch occurs only under restricted conditions, such as within the family and in close relationships, sometimes in greetings, and in certain specified settings such as health care. Touch in other situations can cause great anxiety and tension. It is seen as imposing upon a person's privacy (Kagawa-Singer 1987). In contrast, in high-touch cultures, physical contact is seen as friendly and positive. People may touch frequently while they talk. When people from cultures with different touch levels interact, the low-contact person may be seen as aloof, cold and unfriendly, whereas the high-contact one may be seen as intrusive and even perverted (Furnham and Bochner 1990).

Gender also affects the rules of touch. In some cultures it is acceptable for members of the same sex to touch each other in public; in others it is acceptable for members of the opposite sex. The amount of touch expected also varies. In a study of the number of times heterosexual couples touched each other in cafes, it was found that in Puerto Rico they touched 180 times per hour, in Paris 110 times, and in London, about 200 miles away, not at all (Argyle 1975).

'You don't always get it right and you have to try to pick up people's reactions. Some of my patients love it when I sit on their bed and have a chat, even put an arm round them. Others just shrink inside or even get angry; they're much more comfortable if I sit in a chair and keep my distance.'
English staff nurse

Misunderstandings and blame

We rarely notice other people's non-verbal behaviour except when it feels wrong or makes us uncomfortable. However, non-verbal behaviour is learnt in childhood, used unconsciously and hard to change. The rules are rarely made explicit and never taught to newcomers. Because people who use inappropriate non-verbal behaviour are generally assumed to be rude and unpleasant, their non-verbal behaviour is not discussed with them.


Cultural rules of polite behaviour enable people to get on together. Some cultures value formal politeness more highly than others. Again, failure to follow the local rules of polite behaviour is almost always assumed to be intentional rudeness.

Please and thank you

In British English the words 'please' and 'thank you' are extremely important. Although the amount they are used differs between men and women and in different situations, people who do not say please and thank you are regarded as arrogant and intentionally ill-mannered. Please and thank you are particularly important between people of different status and in formal situations.

In many other languages, including most Asian and African languages, politeness is managed differently. For example, instead of the formulaic please and thank you, politeness may be indicated by a different choice of verb form or pronoun (like tu or vous in French), or by a different tone of voice. In some cultures please and thank you are not used to people who are doing their job; omitting them is not regarded by either side as at all impolite (Bowler 1993).

'In Somali there is no equivalent for please; people usually use relational terms such as brother, sister, uncle etc at the beginning or end of requests. There is an equivalent for thank you but not for the response, the equivalent of "You're welcome".' 
(Kahin 1997)

Alternatively, gratitude may be indicated non-verbally, by a gesture or a change in facial expression. In some cultures it is common to show gratitude by giving presents or money. People who are used to one particular convention often feel extreme offence or anger when faced by different behaviour. They may find it hard to accept that the other person did not mean to be rude.

'While working in a foreign country an Englishman noted that the words please and thank you were seldom used to accompany requests or instructions. Curious about this and not believing that the whole country was rude, he asked someone of the host culture about this.
"The trouble is, Colin," he was told, "you use please and thank you far too often. How can people believe that you are sincere when you use the words so often that they lose their meaning? If a person of my country says thank you, they really mean it. "
"So do I," protested the Englishman.
"Then use them less," said the other man.'

Unknown source


In many cultures it is extremely important to greet a person every time one meets them, and especially the first time each day. Some cultures also use gestures, for example shaking hands, smiling, bowing or joining the palms of the hands. In English culture greetings are often omitted, especially in work situations. This can seem rude to people used to a more formal system.

'In Switzerland everyone shakes hands when they meet and when they part, certainly the first time each day. You always shake hands with the doctor, the nurse, the dentist and so on. Colleagues shake hands when they arrive and when they leave work. Children shake hands with their teachers at the beginning and end of the school day. They also shake hands with each other from the age of about ten. When you shake hands with someone it is very important to look them in the eye. Many Swiss people find the English rude and off-hand even though they don't intend to be.'
English woman

Saying no

In some cultures saying no directly, particularly to a person of higher status or to a guest, is offensive and unpleasant. There are other indirect but polite ways that are normally understood by both sides and which a person can use to refuse a request or answer a question negatively. These include not responding to the request, changing the subject, asking for time to think, making a non-committal reply, or using a special polite phrase that means no but does not explicitly say it. Unfortunately, it can be difficult to translate these phrases into English, and when people try they are often misunderstood.

'It is particularly impolite to answer "no" to someone older or of higher status than oneself. In the Vietnamese language there is an expression which avoids this-da khong (South), or thua khong (North). It translates literally as "yes, no" but it is used in the sense of "I'm afraid not" or "I'm sorry to say no".' 
(Mares 1982)

In some cultures, people who avoid saying no directly are regarded as hypocritical or lying. Directness is valued and is thought to indicate moral integrity. English culture lies somewhere in the middle; there are variations on the basis of class and gender. In general, however, English culture is relatively indirect, expecting people to understand unstated messages, especially when there is any awkwardness. Most English speakers tend to avoid conflict and often try to defuse situations by avoiding or changing a difficult subject, giving a non-committal reply, making a joke or apologising. This can be confusing and even seem deceitful to people of other, more direct, cultures.


English people traditionally avoid showing anger, reserving overt anger for very serious or intolerable situations, often as a last resort. Although it is thought to be sometimes necessary, it often leaves deep scars. In Chinese and Japanese cultures, the expression of anger is traditionally regarded as completely unacceptable and destructive. The idea that it is important to express anger, and that unexpressed emotions are harmful, may be seen as ridiculous or even dangerous (Kagawa-Singer 1987). In some other cultures anger is more lightly expressed, received and forgotten. Fierce argument and confrontation may be seen as a positive sign of friendliness and engagement. Here again there is a good deal of opportunity for misunderstanding and mutual resentment.

'I find the English deceitful. If you say that you are angry about something they all agree, but when you want to go and confront the person responsible they melt away.'
Belgian woman

Embarrassing words

Every language has a range of polite and impolite words for most different bodily functions and parts of the body. In British English, words of Latin origin are generally more acceptable in polite conversation than words of Anglo-Saxon origin. There are also a large number of euphemisms and words regarded as bad or derogatory, which may vary in different parts of the country. Certain words, such as stool, urine and intercourse are used mainly in medical contexts. All this poses major problems for people whose first language is not English. It can be extremely embarrassing and difficult to find out the acceptable words for these things in a new language. People may also unintentionally cause offence by using an offensive lay or slang word in a medical context.

'When my son started school he came back with all these new English words. Then the old lady next door came and told us she had heard him using some words that were extremely rude. Did we know? We didn't even know what the words meant, and nor did he. All his friends used them. But they knew where not to use them, and he didn't!'
Croatian woman

Suspending your automatic responses

'Try to remember that they may not mean what you heard them say.' 
(Tannen 1991)

Misunderstandings about other people's personality or intentions are inevitable when we have different linguistic and cultural conventions. Our reactions to the way people speak and behave are largely automatic and often very strong. There are no easy solutions. It is, however, always important:

to be aware of the reasons why things may go wrong;

to monitor and try to suspend your automatic responses; and

to assume, at least until other clear evidence emerges, that the other person does not wish to irritate or offend you.

If you know each other well, it may be possible to discuss your reactions tactfully, find out whether the other person realises how they appear, and possibly and with great respect suggest modifications in their approach. Try to find out about other cultures' conventions of non-verbal behaviour and politeness. There may be things that you automatically do that cause offence to others; try to find out if you are being misunderstood and whether it would be helpful to adapt some aspects of your approach.

The Kiddy Ring Interview Structure (10)

A well planned structured interview may help when assessing the information from an interview with a trainee at induction. Many trainers will cover these areas in an unstructured way and that is fine as long as it gets done. Induction is mainly regarded as a way of ensuring the trainee gets to know the practice and personnel. Getting to know the trainee can get neglected and The Kiddy Ring is an approach that tries to look at the trainee as a whole person. It hopefully identifies strengths as well as things that need developed.

Starting with recent jobs puts the trainee at ease. From here on, the interview follows a circular route covering the main areas of the registrar’s life. However it should be used be used as a guide and don’t get stuck with a rigid structure. Above all be sensible and safe and for example ensure the questions are safe. For example it might not be appropriate to ask about someone’s early life. Also you might want to expand the questions so that for example discussion about education could ask about their experience of inspirational teachers and how they like to learn.

About 45 minutes to an hour is needed to adequately cover the cycle.

The information derived from each area should be divided into factual and evaluative aspects

Present Job

Facts: main job, task likes and dislikes approach to tasks, relationships and how handled, decisions, achievements.

Evaluative: motivation, level of energy, resilience to stress, ability to handle relationships, communication skills, clinical competence, standard of work, progress in career to date.

Aspirations and interests

Facts: Short/medium/long term plans, plans for achieving ambitions, reason for applying for the job.

Evaluative: Type of interests, sports, pastimes etc, what they reflect about the candidate, potential incompatibility with or enhancement of proposed job.


Facts: location, mobility, family circumstances and constraints.

Evaluative: mobility, domestic stability, financial stability.

Early Life / Upbringing

Facts: place of birth and childhood, parental occupations, values and characteristics, parental expectations of children, siblings, their occupations and achievements; significant events.

Evaluative: emotional stability, supportiveness of upbringing, implication of negative events.


Facts: type of secondary school, exam results, interests and achievements at medical school.

Evaluative: Academic progress and performance, level of ability and intellect, causes and results of any failure.

Work History

Facts: detail of previous jobs, likes and dislikes, main relationships.

Evaluative: Significance of jobs, type of work, experience gained, range and depth of experience, relevance to proposed job.

Geert Hofstede, a Dutch cultural anthropologist, analyzed cultures along five dimensions. He rated 58 countries on each dimension on a scale from 1 to 100. (This can be a useful guide but the key is to remember to understand the individual whatever their culture) (11)
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