Number of Citations: 1

Submitted: 11 March 2022
Accepted: 28 June 2022
Published online: 4 April, TAPS 2023, 8(2), 14-35
https://doi.org/10.29060/TAPS.2023-8-2/OA2762

Sayaka Oikawa¹, Ruri Ashida² & Satoshi Takeda³

¹Center for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan; ²Center for International Education and Research, Tokyo Medical University, Tokyo, Japan; ³Department of Emergency Medicine, The Jikei University School of Medicine, Tokyo, Japan

Abstract

Introduction: There are various difficulties in treating foreign patients; however, the existing educational programs are still insufficient for addressing this issue. The purpose of this study is to investigate what difficulties are encountered in the treatment of foreigners in emergency departments, and to create scenarios for simulation-based education using real-life cases.

Methods: A cross-sectional anonymous survey to 457 emergency departments was conducted in 2018. Additionally, we conducted a survey of 46 foreign residents who had visited hospitals for treatment in Japan. The data was analysed quantitatively, and the narrative responses were thematically analysed.

Results: Of the 141 hospitals that responded (response rate: 30.9%), 136 (96.5%) answered that they had treated foreign patients. There were 51 and 66 cases with cultural and linguistic difficulties, respectively. In the qualitative analysis, different ideas/beliefs towards treatments or examinations (51.0%) and communication with non-English speaking patients (65.2%) were most common categories in the cases with cultural and linguistic difficulties, respectively. The survey of 46 foreign residents on the surprising aspects of Japanese healthcare showed, 14% mentioned difference in treatment plans between own country and Japan, 12% each mentioned a lack of explanation by medical staff, and a lack of privacy in the examination room. Based on the survey results, we created 2 scenarios of simulation.

Conclusions: Scenarios of simulation-based education using real-life cases may be effective materials for cultivating cultural awareness of medical staff.

Keywords:           Cultural Awareness, Cultural Humility, Emergency Department, Foreign Patients, Simulation-based Education

Based on the survey results, we decided the main topic of the scenarios based on the contents overlapped in multiple cases. “Gender restriction of doctors who treated patients” and “communication difficulty in languages other than Japanese or English” were the most frequent topics in cultural and linguistic difficulties respectively. Following the selection of topics, we synthesised the similar responses to create a scenario that could occur in any size of ED setting. We developed the settings including patient age, sex, language, and backgrounds, regarding that the patient characteristics can be demonstrated by simulated patients. As a result, we developed two scenarios: a scenario of abdominal pain in a Muslim female patient and a scenario of forearm fracture in a Chinese male patient (Appendices 5 and 6).  In the abdominal pain scenario, no female doctor was available, and a learner, a male doctor, had to examine and treat a simulated patient who refused to be seen by a male doctor. In the forearm fracture scenario, no interpreter was available, and a learner had to communicate with a simulated patient who spoke Chinese only. The learning objective for the learners was to communicate appropriately with patients with different cultural and linguistic backgrounds. Based on the results of the survey for foreign residents, we indicated the importance of listening to the patient’s concerns carefully as a teaching point. Also, we reflected the survey results of how each hospital handled the cases on the information for instructors and teaching points.

IV. DISCUSSION

At the time of writing this paper, 96.5% of the EDs had accepted foreign patients; and 82.3% had English-speaking staff. However, only 32.6% of the EDs had multilingual signs for patients, which is listed as actions to be taken in the manual for treating foreign patients (Japan Ministry of Health, Labour and Welfare, 2021).

In the present study, most of the EDs used translation tools when treating foreign patients. Various types of translation methods were found to be used in the EDs, the use of which is consistent with the manual for treating foreign patients (Japan Ministry of Health, Labour and Welfare, 2021). However, we found that the EDs still encountered a significant number of cases with linguistic difficulties. This suggests that even though the EDs own the translation tools, medical staff are not able to utilise them in communicating with foreign patients. According to our survey result, it was revealed that more than half of the cases with linguistic difficulties were of non-English speaking patients. To overcome the linguistic difficulties, medical staff need to be capable of using them enough to communicate with patients of various native languages. In addition to the use of translation tools, multilingual medical explanation/consent forms or signs in hospitals may be effectively used in the aim of communication with foreign patients.

Regarding culturally difficult cases, our survey showed the various issues caused by differences of religious background, lifestyles, and ideas and beliefs on treatment and testing between medical staff and patients. This result is consistent with the reports which elaborated difficulties in treating foreign patients in Japan (Tatsumi et al., 2016). Our study showed that different ideas/beliefs towards treatments or examinations was most common theme in the cases with cultural difficulties in EDs. Knowing beliefs of other culture is one of individual’s capabilities to manage effectively in culturally diverse settings (Ang et al., 2007), and a report on psychiatric hospitals showed that medical staff adapted to hospitalised foreign patients’ culture and religion as they built the relationships with the patients over a long period of time (Kobayashi et al., 2014). Whereas, it is difficult to build relationships with foreign patients in the acute ED setting. Thus, we realised that practical training of communication with foreign patients provide knowledge about their cultures and religions in limited time and is critically important for medical staff in EDs.

SBE is an effective educational format which makes learners’ unconscious incompetence to conscious incompetence (Morell et al., 2002), in other words, medical staff may be able to recognise their unconscious biases towards foreign patients by participating in SBE. As consistent with the previous survey by the MHLW (2021), the culturally difficult cases included complicated issues that require the cooperation of administrative staff and full-time English interpreters in the hospital. In the present study, we created the two scenarios targeting medical staff as learners based on the real-life cases with the many responses in the survey. However, we need to create more varieties of scenarios that can involve other professions than health care professionals. Furthermore, the acquisition and retention of learners’ skills in a single training session of SBE is limited (Legoux et al., 2021). SBE aimed at cultivating cultural awareness cannot be completed in a single session but in continuous sessions with multiple scenarios.

The results of our survey of foreign residents showed that they had been surprised at the differences in treatment plans between their country and Japan, a lack of explanation by medical staff, and a lack of privacy in the examination room. We found that it is important to investigate the opinions of those who receive medical care in a country different from their home because their perspectives allow us to recognise the things taken for granted among medical staff.  Medical staff’s unconscious biases about patients of different cultural backgrounds or national origins influence their decision-making (Tervalon & Murray-Garcia, 1998), and implicit bias can contribute to miscommunication (Bartlett et al., 2019). Therefore, listening to the concerns of foreign patients is important in order to avoid providing treatment based solely on medical staff’s biases. Furthermore, in creating scenarios, referring to the survey results of multiple stakeholders made the contents more multi-dimensional and relevant. This study was conducted in the contexts of EDs in Japan, however, scenarios created with perspectives of both medical staff and patients who have various cultural backgrounds may effectively address to the real-life problems triggered by unconscious biases, even in other contexts. 

In Emergency situations, we often focus on the patients’ cultural backgrounds, national origins, languages, and religious background in order to provide effective treatments. However, recognising our own bias is not achieved by only focusing on the patients’ culture. Self-reflection is necessary to recognise one’s own cultural biases. The process of self-reflection of our own culture is important for cultivating cultural awareness. Furthermore, the importance of cultural humility – discovering one’s own values toward other cultures through continuous self-reflection and becoming aware of one’s own relationship to the world – has been recently noted in medical education (Chang et al., 2012). As a further research, the development of scenarios that include the study guide which ensure the learners’ self-reflection is required for SBE in emergency settings.

There are several limitations in this study. The response rate of a survey for EDs was 30.9%, which is unable to deny sampling bias. We conducted a survey for EDs with a focus on English, however, it is necessary to conduct surveys on languages other than English. In addition, the survey was only for the EDs of training hospitals in the top 10 prefectures with the most foreign tourists. We may consider expanding the number of hospitals to collect more information about difficulties they encounter in treating foreign patients. For the sub study, the snowball sampling had a methodological limitation in calculating total number the survey sent. As a further research, impacts of SBE using these scenarios on the treatment of foreign patients is less clear. To assess whether foreign patients’ satisfaction of medical care will change, and whether unconscious bias towards foreign patients among medical staff will decrease by conducting these scenarios are necessary.

V. CONCLUSION

In the current study, we were able to clarify linguistic and cultural difficulties in treating foreign patients in the EDs. We developed the scenarios for SBE using the real-life difficult cases of foreign patients with linguistic or cultural differences in medical care in Japan. The simulation training using these scenarios may be useful for promoting cultural awareness of medical staff in EDs. In future, more varieties of scenarios of SBE need to be created and shared in order to treat foreign patients safely and adequately.

Notes on Contributors

SO contributed to the design of the study and conducted data collection and analysis. RA devised the project, the main conceptual ideas, and conducted data collection and analysis. ST contributed to the design of the study and the interpretation of the data.

Ethical Approval

This study was approved by the Institutional Review Board of The Jikei University School of Medicine Japan (Approval No. 28-211(8454), 28-276(8519)). An informed consent was obtained from all the participants responded to the survey.

Data Availability

The data that support the findings of this study are not openly available due to privacy. The materials are available from the corresponding author on reasonable request.

Acknowledgement

The authors would like to acknowledge the respondents at the EDs of training hospitals, the foreigners living in Japan, and the young clinicians at The Jikei University School of Medicine for their cooperation in the study. 

Funding

This work has been supported by JSPS KAKENHI, grant number 16K08883.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content of the article.

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*Sayaka Oikawa
Center for Medical Education and Career Development,
Fukushima Medical University,
1 Hikarigaoka, Fukushima, 960-1295, Japan
Email: sayaka9@fmu.ac.jp