"Educational Tools for Dealing with Trainees with Difficulties"

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Hofstede named this Power Distance (PD or PDI). It is the extent to which less powerful members expect and accept unequal power distribution. High PD cultures usually have centralized, top-down control but this is endorsed by followers as well. Low power distance implies greater equality and empowerment.


Hofstede named this Individualism versus Collectivism (ID or IDV). In an individual environment the individual person and their rights are more important than groups that they may belong to. In a collective environment, people are born into strong extended family or tribal communities, and these loyalties are paramount.


Hofstede named this Masculinity versus Femininity (MAS). It focuses on the degree to which “traditional” gender roles are assigned in a culture; i.e., men are considered aggressive and competitive, while women are expected to be gentler and be concerned with home and family.


Hofstede named this Uncertainty Avoidance (UA or UAI). It defines the extent to which a culture values predictability. UA cultures have strong traditions and rituals and tend toward formal, bureaucratic structures and rules.


Hofstede named this Long- versus Short-term Orientation (LTO). It is the cultural trait that focuses on to what extent the group invests for the future, is persevering, and is patient in waiting for results.

So what?

When working in other countries and with people from overseas, first research their national culture along these dimensions, and then check first whether the people use these. By default and when talking with national groups, take account of these factors.

India has Power Distance (PDI) as the highest Hofstede Dimension for the culture, with a ranking of 77 compared to a world average of 56.5. This Power Distance score for India indicates a high level of inequality of power and wealth within the society. This condition is not necessarily subverted upon the population, but rather accepted by the population as a cultural norm.

 India's Long Term Orientation (LTO) Dimension rank is 61, with the world average at 48. A higher LTO score can be indicative of a culture that is perseverant and parsimonious.

India has Masculinity as the third highest ranking Hofstede Dimension at 56, with the world average just slightly lower at 51. The higher the country ranks in this Dimension, the greater the gap between values of men and women. It may also generate a more competitive and assertive female population, although still less than the male population.

 India's lowest ranking Dimension is Uncertainty Avoidance (UAI) at 40, compared to the world average of 65. On the lower end of this ranking, the culture may be more open to unstructured ideas and situations. The population may have fewer rules and regulations with which to attempt control of every unknown and unexpected event or situation, as is the case in high Uncertainty Avoidance countries.

There is a high correlation between the Muslim religion and the Hofstede Dimensions of Power Distance (PDI) and Uncertainty Avoidance (UAI) scores.

The combination of these two high scores (UAI) and (PDI) create societies that are highly rule-oriented with laws, rules, regulations, and controls in order to reduce the amount of uncertainty, while inequalities of power and wealth have been allowed to grow within the society. These cultures are more likely to follow a caste system that does not allow significant upward mobility of its citizens.

 When these two Dimensions are combined, it creates a situation where leaders have virtually ultimate power and authority, and the rules, laws and regulations developed by those in power, reinforce their own leadership and control. It is not unusual for new leadership to arise from armed insurrection – the ultimate power, rather than from diplomatic or democratic change.

These are just examples of countries that provide a lot of trainees in the UK. 58 countries were studied and more detail is available at www.geert-hofstede.com

Guidance for Trainers with International Medical Graduate Trainees

Analysis of the statistics on candidates passing/failing the CSA exam in the first few years since its inception has revealed that candidates who trained outwith the UK are much more likely to fail the CSA. The reasons for this are multifactorial, and obviously individual to each candidate, but there are some common themes.

We have recently done some work with a group of International Medical Graduates (IMGs) who failed the CSA, to try to develop some insight. We discussed ways in which cultural differences may impact on performance in the CSA exam, and attempted to generate ideas for how trainers could best support their IMG trainee.

1. Broach the subject early

The IMG trainees we spoke to were very keen to discuss the issues around their having trained elsewhere. They wanted to be able to explain their cultural background and experiences to their trainer, and have a constructive discussion about how that may differ from the prevailing culture in general practice in the UK. There was a feeling that trainers were sometimes reluctant to discuss what might initially seem a sensitive issue.

Agree that it is important to acknowledge that IMG trainees are at a disadvantage, discuss this early and develop a strategy to help that individual trainee. At the same time it is useful to provide community orientation about the practice and its area including a cultural history. So for example consider a tour of the practice area, use of local history booklets, visits to local providers like the pharmacist or funeral director etc. Respect the individual and be aware that feedback suggests this does not happen in some hospital posts and that your support might be needed during these.

2. Emphasise patient-centredness

Being trained in more doctor-centred or paternalistic medical cultures can make it difficult to shift focus to being more patient-centred. There was some confusion over what exactly was meant by patient-centredness, and a lack of insight as to how this could improve their consulting and patient care. They mentioned feeling uncomfortable with this new style of consulting, as patients’ expectations of a ‘good doctor’ are very different in different parts of the world. We learned that in many cultures in which our cohort of doctors trained the prevailing practice is to be doctor-centred and this more paternalistic approach is actually preferred by the majority of patients. It was felt that more specific feedback on how to be patient-centred and developing truly shared management plans would be appreciated. It is apparent when looking at the RCGP feedback from the CSA exam that some IMG trainees have struggled with this. They have tended to use stock phrases to demonstrate patient-centredness rather than engaging in a true dialogue with the patient, and so clearly more work needs to be done in this area.

In the SE deanery group the following things worked well

  • Thinking conversation rather than consultation so for example pair up and “have a 10 minute conversation about music and at the end feedback what you have learnt about your colleague”

    • Only ask questions. “Trainees bring cases and pair up. They each have 10 minutes to find out as much as possible about their colleagues case and are only allowed to ask questions” Then brainstorm “What are the best questions?”

    • Only listen. “Trainees prepare scenarios with clinical and psychosocial elements and present them to a colleague for 5 minutes. The colleague is then allowed to ask clarification questions. At the end they then summarise what they have heard and how it made them feel”

    • Bring cases where you have identified a patient’s ideas, concerns and expectations and discuss how it helped you develop a shared management plan.

    • Look at a video with the main aim of looking at cues, psychosocial understanding and non verbal communication. And discussion about how they knew whether the patient was happy or not

    • Use Peter Tate’s 10 questions and the disease-illness model of the consultation as initial models to follow

3. More support in dealing with ‘non-medical’ consultations

IMG trainees often feel unsure about family/social/work structures in the UK, and would appreciate more guidance in dealing with patients with relationship/housing/social problems. We found that asking the trainees to write a sample case for the CSA which incorporated psychosocial issues was a useful tool to initiate discussion. They also felt under confident in dealing with multifactorial problems or medical complexity in the time allocated as they tended to adopt the more medical model of consulting, forming a diagnosis and excluding red flags, and were more rigid in their consulting. They often tried to cover all the different aspects thoroughly at the initial consultation, thereby running over the allocated 10 minutes.

Consider using the level of agreement/degree of certainty graph to explore complex cases and uncertainty. Use your and their Puns and Dens to explore cases and try using a Discomfort log. Look at videos and stop after a minute and discuss and then stop and start at appropriate points to discuss choices. When they observe you consulting make sure you explain why you did what you did and excluded alternatives. If necessary include the patient in this discussion! (I did this a lot and patients mainly liked to do this)

4. Reassure them that there is no need to ‘prove’ their extensive medical knowledge

There was a notion amongst the IMG trainees that they are seen as representatives or ambassadors of their country’s medical education system, and as such they are keen to make it clear that their medical knowledge is good. This can result in very doctor-centred consultations, listing facts to prove their knowledge. It is important to emphasise that their intelligence is not being questioned and that this is a very different method of assessment than the AKT.

When being observed, or discussing discomfort or Puns and Dens identify that much of what you are doing is not about how much you know. Many of these trainees struggle to reflect on what they have done and mainly identify a knowledge list of facts that need to be found out about. Keep using the experiential learning cycle to help trainees reflect on their experiences and monitor how they put this into action. Advise the CSA is about consulting with the patient not demonstrating to an examiner

5. Language

The trainees described that when they feel unsure of their fluency in English they often err on the side of caution and become ‘extra-polite’, which can come across as cold or under-confident. They also resort to using the more traditional medical language they have gleaned from books. This is often emphasized in stressful situations such as the CSA exam. They mentioned that they might appreciate some explicit guidance on local turns of phrase or colloquialisms, which would smooth their everyday consulting, if not the more generic language used in the CSA itself. Also mentioned was the use of humour, or cultural references which IMG trainees are not aware of, and it could be useful to specifically touch on these.

IMG trainees may need extra help to integrate into the culture of the practice. For example to ensure they feel comfortable joining in the chat in reception or at coffee time. Encourage social chat using newspapers or TV programmes for example and suggest correcting language errors with advice by all PHCT. Help them identify that although they may feel more secure and comfortable working with IMG colleagues, during educational release for example, they will benefit most from working with a mixed group. (And that group will benefit from their perspectives)

Many need to practice explanation. I had a large list of conditions to explain, risk to explore and bad news to break in a hat and these were drawn out and the trainee had 5 minutes to think about this and then explain the issue in clear terms. Most would struggle not to use medical language or would follow a rigid model (E.g. Breaking bad news) that was inappropriate. At the next session they would have an opportunity to try again having explored Patient.co.uk for example and we kept doing this time after time. Then this was built up into scenarios using a strict time line – 3 minutes at the start to include ICE (lots of listening), 4 minutes to data gather (open then closed including red flags and keep focused) and 3 minutes to share understanding and explanations. (Using the patient’s ICE to underpin the sharing). And for those who keep struggling repetition, repetition and repetition of cases is important and in particular to make use of clarification, reflecting back not just words but meaning and feelings, summarizing and signposting.

6. Accents

In a similar vein, strong accents can become even stronger in stressful situations such as the exam. The IMG trainees felt it might be useful for the trainer to make clear that it is OK to acknowledge their accent with the patient and explain that they are happy to repeat anything that is not understood.

And that they are encouraged to ask the patient or trainer to repeat things they have not understood. I have learnt that in a hierarchical model IMGs often will feel reluctant to ask me to explain things again even if they have not understood.

7. Joint surgeries

Although time-consuming, the IMG trainees felt that joint surgeries, and getting direct feedback at the time, were invaluable for highlighting a multitude of small issues which they perhaps would not include in videos etc.

Increasing use of joint surgeries has helped. And trainees want direct feedback. “Just tell me what I need to improve” I suggest Agenda Led Outcome Based Analysis might help since the outcome wish is clearly to pass the CSA and the agenda is to look at improving skills observed either directly or during video analysis.

And remember the importance of role modelling for trainees

8. Emphasise the benefits

Cultural diversity in the practice team can obviously be a huge advantage, and the trainees felt that their strengths in terms of dealing with consultations in different languages and culturally diverse patients should be acknowledged.

Mairi Jamieson and Katie Browne September 09 -Working with W of Scotland trainees

Additional suggestions Iain Lamb December 09 Working with SE Scotland trainees

Using Edward De Bono’s Six Thinking Hats (12)

Have you been in situations where difficulties occurred because you were on a different wavelength either with learners or colleagues. For example you come up with an idea and it is immediately criticized as being impossible to implement. Has someone else suggested an idea that has made you so anxious it has been impossible for you to discuss it effectively? Have you been in a situation where you are expected to provide solutions but everything becomes chaotic and wooly since there are not enough facts or evidence to underpin informed discussion?

Six hats encourage parallel proactive and collaborative thinking by metaphorically asking everyone to wear the same hat so that for example everyone tries to create ideas at the same time. Later it will be possible and necessary for everyone to judge the ideas again with everyone focusing on this at the same time

When you think of blue, think of the sky. The blue hat is the hardest one to understand. It deals with controlling the thinking process. The blue hat is often "given" to one person, who controls what hat will be "worn", hence controlling the type of thinking being used.

De Bono’s hats are indicative of both emotional states as well as frames of mind (i.e., perspective from which an issue is viewed). He noted: "Emotions are an essential part of our thinking ability and not just something extra that mucks up our thinking" One thinking style (or hat) is not inherently "better" than another. A full, balanced team recognizes the need for all hats in order for the team to consider all aspects of whatever issues they are facing.


Main benefits of Six Thinking Hats method:

  1. Allow to say things without risk

  2. Create awareness that there are multiple perspectives on the issue at hand

  3. Convenient mechanism for 'switching gears'

  4. Rules for the game of thinking

  5. Focus thinking

  6. Lead to more creative thinking

  7. Improve communication

  8. Improve decision making
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