Patients felt that medical residents’ ability to communicate is worse than their expectations. However, medical residents who were taught communication skills using Western guidelines in a problem-based learning (PBL) format during their undergraduate medical curriculum perceived themselves to have the same low scores as the patients’ perceptions. Whereas the medical residents without undergraduate training in communication skills in a non-PBL curriculum perceived themselves to have higher scores than patients’ perceptions. In this regards, there is an urgent need for better and more systematic communication skills training, especially training accommodating local cultural characteristics .
Both doctors and patients indicated they would prefer a more partnership-oriented style of communication; however, the commonly practised style was one-way . A one-way communication style was practised because of a lack of time for consultation related to the poorly structured health care system, patients were not prepared for a dialogical communication because of the culturally hierarchical gap between doctors and patients and also because of doctors’ lack of training in communication skills . To apply the desired partnership style of communication with patients, our findings suggest that doctors need to use more the core communication skills, which turned out to be the key to addressing cultural aspects of Southeast Asian people: (1) When doctors greet their patients they should explore what the patients would like to be called. In Indonesia, the ‘term of address’ may be as close as if they were greeting a member of their own family to provide a warm rapport and to avoid the cultural hierarchical gap; (2) Paying attention to any subtle, Southeast Asian nonverbal cues is important. What the patient says may not represent what they are thinking, because naturally they would maintain harmony by being polite; (3) The strong influence of family members in clinical decision-making within a communal culture requires the doctor to balance the patient’s and family’s opinions, without neglecting patient preferences; (4) Almost everyone uses alternative medicine, so this should be taken into consideration when discussing the care plan [10, 11]. A guideline for communicating with Southeast Asian patients accommodating their cultural characters is called: The Greet-Invite-Discuss guideline .
During the informed consent process, patient autonomy is frequently challenged by the cultural context. Patients are not able to address their concerns to the doctors who are considered to be higher in hierarchy; additionally the strong involvement of family often overrides the patient’s autonomy, rendering it difficult for patients to make independent choices . On the other hand, doctors often use informed consent to protect themselves from a potential legal suit . Although nurses can act as patient advocates, their role during the informed consent process is also influenced by the hierarchical relationship with the doctors and time constraints in the workplace. Nurses are frequently overburdened with tasks delegated by doctors . Doctors and nurses have similar views on the barriers during the informed consent process but they have different perceptions about the potential of the nurse’s role within the process .
To be able to act as advocates in such a challenging context, health professionals should integrate clinical, legal and ethical knowledge with the communication skills . A course to help professionals learn to be patient advocates was piloted for inter-professional participants such as nurses and doctors . Leary’s Rose, a model to map different hierarchical positions in a negotiation process, was used as an educational tool to help participants face hierarchical encounters [17, 18]. The Four-Components Instructional Design model (4C/ID), a model that emphasizes the importance of using whole and authentic learning tasks, was used to design the course [16, 19]. Both models are based on Western educational principles, but their use was tailored to the local situation. Course evaluations showed retention of knowledge and transfer to practice .