Family Physician, Odi District, North West Province
South Africa/Senior Lecturer, Department of Family Medicine and Primary Health Care, MEDUNSA
Many doctors from developed countries such as the UK, Ireland, Australia and New Zealand choose to work for a period in a developing country in Africa, Asia or Latin America. Doctors who choose to work in another country will usually experience some form of culture shock. There are additional pitfalls for doctors from developed countries moving to developing countries. Based on the author’s experience of employing doctors from developed countries in a South African context, this editorial examines the components of culture shock, and highlights other important issues related to attitudes and expectations that should to be considered by doctors choosing to work abroad.
The motivation for doctors working abroad can range from a desire for adventure to missionary zeal; from scientific curiosity to a desire for greater practical experience. Monetary gain is not usually a factor. Whatever the reasons, these doctors seldom plan a career in the country they go to, but are ready to make a contribution ranging in duration from months to years.
There is no doubt that the rural health services in these countries, usually district or community hospitals, need the services of such volunteers and are likely to continue to rely on them for some time to come. Yet along with the benefits they bring, doctors from abroad can create negative feelings amongst local health workers and even patients. Often this is simply because of inadequate preparation. Unless the practitioner is recruited through an established service or missionary organisation, little or nothing is done to equip the individual for his/her task. Even large organisations underestimate the preparation necessary to equip those they send out.
I have reflected on my own personal experience of nine years working in a rural area of my own country, South Africa. Dozens of overseas doctors, mainly from the UK, have come to work with us for periods ranging from 2 months to 2 years. Based on this experience, as well as informal research on the issue (1), I wish to offer some suggestions for consideration by any doctors planning a working visit to a developing country.
Most doctors, except those on a very short-term experience, will undergo “culture shock”, which has been well described in the non-medical literature (2,3). There are 4 distinct phases of this ongoing response to a new cultural milieu. Like the process of grieving, people do not necessarily experience these in the same sequence and may move in and out of the different steps. Whilst they are usually more easily noticed by those on the outside, an awareness of them helps the new arrival to deal with them as they arise.
1. Fascination. The visitor is excited by the novelty of the experience. The differences in the host culture arouse interest, fascination or amusement. These are often remarked on at length and repeatedly, to the irritation of the hosts. In any new situation, we adapt by comparing what we are experiencing to what we know in order to assimilate it. This stage is simply part of that process.
2. Irritation. The differences that initially inspire wide-eyed excitement become repetitive experiences. They wear the visitor down because they are so consistently unfamiliar. This leads to negative comparisons with “home”. Nothing in the host culture is seen to be as good as it would be in the country of origin. On a simple level, this might mean longing for the food that one is used to and distaste for what one has to eat. In the health care context, this usually means that practices and procedures are compared to the standards of the home country and found wanting.
Hosts have to exercise much patience to cope with constant comments starting, “back home we would ...give this drug/do this operation/offer this specialist intervention/take this blood test, etc”. Doctors who become stuck in this stage often leave. They cannot cope with the way things are done locally, and will forever remember that health service for its “inferior standards” and “incompetent staff”. These judgements are, however, made on the basis of difference, not appropriateness.
3. Depression. At some stage, the irritation becomes focussed inwards. The visitor feels there something wrong with him that he cannot cope in the situation and becomes depressed. The previous stage can have negative repercussions for the host health service if the doctor returns home without moving out of it. This stage, if not dealt with, can leave the doctor with permanent negative feelings about himself, of inadequacy and incompetence. In this stage the new doctor struggles to make a contribution to the work and needs much care and support. This can drain the energy and resources of the hosts. The doctor may also constantly talk of leaving, which creates unwelcome uncertainty. Good emotional preparation, understanding colleagues, and outside support from home can make a big difference at this stage.
4. Adaptation. Ultimately, most people are able to come to a symbiotic relationship with the host culture so that, while they are not assimilated, they can function effectively and sensitively in the new situation. Despite reaching this level of functioning, they may at times revert to a previous stage. The problems often occur on returning home, when a very similar process of re-entry culture shock may occur. This is exacerbated by relating to people who, having continued in their normal routines do not understand the life-changing experience the returnee has had.
One particular form of negative adaptation must be guarded against. Arising from comparisons with home, the doctor might mistakenly decide that the differences that exist relate to inferior standards or, worse still, a lack of concern for local people. This can lead to a feeling that “anything goes”. The doctor can practice any sort of medicine or perform any sort of procedure without concern for possible untoward consequences - third-rate medicine for the 'third' world. This is usually the result of mistaking culturally and contextually appropriate responses by health workers to people’s needs and problems for lack of care and concern. Most health workers in developing countries seek to give the best possible care they can, given the skills and resources at their disposal.
Doctors with families are not protected from culture shock. Whilst a partner can be a support in coping with this process, each person in the partnership or family may be in a different stage at the same time, which can lead to great conflict.
An attitude that doctors from richer countries often communicate to their hosts is that they expect gratitude for the "sacrifice" they have made. They could be earning more and living more comfortably “back home”. If things are not as the doctor expects them to be, the hosts are told, directly or indirectly, that they are ungrateful. Such an attitude quickly creates resentment and damages working relationships. This damage can be aggravated when those same overseas doctors, in comparison to local staff, have better salary and support packages organised for them.
A similarly destructive attitude exists amongst visiting doctors who, despite the best intentions want to make a significant contribution to the local work, display the unintended arrogance of the reformer, or expert, who is going to show the “ignorant locals” a better way of doing things. New ideas are always welcomed, but such gifts need to be shared sensitively and humbly if they are to be well received. A wise person will examine the long-term impact of any changes suggested, especially if she is not going to remain in the context for very long. Doctors need to be realistic in matching any changes proposed to the extent of their own commitment, and to their own willingness to see through the changes.
It is wise for a doctor going abroad not to commit himself to stay for longer than he may cope with. In the constant struggle to staff their hospitals, medical superintendents or directors may offer positions to overseas doctors both on the basis of their experience and their expected length of stay. A doctor who indicates she is willing to commit herself for a year and then leaves after 6 months lets the local service down badly – just as one who puts off her arrival at the last minute.
It is better to promise a minimum commitment and mention any doubts at the outset. The stay can then be lengthened by mutual agreement. Similarly, it is not wise to make decisions about departure when in the throes of culture shock. Many doctors, who make fixed plans to move on because they are not coping, later regret these premature decisions as they adapt to their new situation, and either wish they did not leave or long to return.
It is reasonable to expect a commitment from the receiving hospital regarding any position or appointment. The local health service should provide answers to the most commonly asked questions. However, in providing this information, it is difficult for doctors working in the frontline to be objective about their circumstances. In addition, these local doctors may not understand the needs and wants of doctors coming from overseas. This can leave the enquirer feeling there is a lack of interest. Thus it is useful to ask for contact names and addresses of people who have worked there in the past. Most rural hospitals in Africa and Asia will have had expatriate doctors who can be contacted to provide a wealth of useful information. This information should always be checked out with the local contact. Circumstances can change and , as noted above, culture shock will have affected the other person’s memories and perceptions of his experience.
As part of one’s preparation it is worth finding out about local cultural norms and expectations. The area in which this is often most noticeable is dress. Doctors should not assume they can wear what they do at home. Locals may be more or less formal. Even the simple process of greeting can be fraught with difficulties.
When considering working abroad, it is vital to go with a willingness to learn – not only about medicine and healthcare, but also about language and culture; not only from doctors, but also from other health workers and from patients. The doctor who is not open to learn will quickly find she is not suited to a rural hospital in the developing world. Learning the local language is an important ingredient in this. No one can be expected to be fluent in a few months, but the simple ability to greet another person in his or her own language goes a long way to being accepted.
It is helpful to remember that, if their stay is to have any meaning, it is not essential that the visiting doctors accept the locals. Rather, it is more important that their local colleagues and patients accept the expatriates! Working abroad can be a highlight of a doctor’s career, but success should not be taken for granted. Preparation, patience and preparedness to learn are the keys to success.
(Acknowledgements: I am grateful to the Director and Staff of the Monash University Centre for Rural Health for support and for the space to do the reading and reflection which underlies this article.)
(1) Couper, Ian. Culture Shock among New Doctors (Column) SA Fam Pract 2002; 25(1): 17-18
(2) Furnham A, Bochner S. "Social difficulty in a foreign culture: an empirical analysis of culture shock." In Bochner, S. Cultures in Contact: Studies in Cross Cultural Interaction. Oxford: Pergamon Press, 1982.
(3) Hodge, Alan. Communicating across cultures: An ABC of cultural awareness. Willoughby, NSW: Janus Resources. 1987.