While the need for professionalism at work seems obvious, students and sometimes faculty may behave in ways that can have serious negative consequences for their work and ultimately, for the impressions that foreign hosts develop of those who come to learn and help.
“Who, me?!” you may be asking. After all, what got you interested in medicine and in Child Family Health International’s (CFHI) programs were most likely motives of the highest integrity: an altruistic desire to assist and be of service to others, and to make a difference in a world sharply divided by need. Of course, these motives are commendable. But don’t be offended that we bring this topic up. You may be surprised to learn that, despite CFHI’s thorough screening of participants and its service-oriented mission, unprofessional behavior is the most common problem CFHI experiences with participants in overseas electives. It can include ignoring rules set by host families, non-attendance at (or lateness for) clinic, or making unreasonable demands of host-country staff. Some problems may be extreme (e.g., becoming frustrated and leaving the program without notice) but usually they are much less so (e.g., wearing that wrinkled, un-ironed lab coat you stuffed unceremoniously into your backpack the day before or showing up late, thinking no one will notice). We mention this subject now, before you even set forth on your elective, because we believe in most cases the unprofessional behavior is not intended as such, and in many cases it is subtle and unconscious and an unrecognized reaction to complex emotions… . We hope that by discussing this topic ahead of time, we can warn you about what to watch out for, both in yourself and in other participants.
For you, this month will pass rapidly and become one of hopefully many, enlightening and challenging experiences. You may think that, given your fleeting, transient presence overseas with CFHI, whatever you do, positive or negative, will be a mere ‘drop in the bucket’, quickly forgotten as successive cohorts of CFHI participants come and go throughout the year. But however short your stay, we urge you to consider carefully the impact of your particular drop in the bucket. People in developing nations, including healthcare professionals and students, are much less mobile and more isolated than those in developed nations, for whom global travel, the internet, up-to-date information and advanced communications technology are daily realities. The isolation is especially severe in remote, rural areas. So your presence, characteristics and acts may continue to be remembered and remarked upon in your host country, for better or for worse, long after you leave, whereas in your home country, the same incident might have been quickly brushed aside. More important is the far-reaching effect your actions can have on long-term local healthcare. Unprofessional conduct in the healthcare setting such as insisting that local staff allow you to observe a procedure although the patient feels this is intrusive, will only create mistrust in or reinforce stereotypes about people from our wealthy developed nations. By association such behavior can also harm the longer-term trust between local physicians and their patients, a bond vital to continued, sustainable healthcare in your host country.
Let’s say you arrive one day at clinic to find your preceptor not there… you wait for 20, 30 and finally after 45 minutes, the doctors arrives. You feel discouraged and frustrated with this lack of respect for your presence and have an awkward day with the doctor, feeling hardly noticed. You decide the next day not to bother going to your rotation, opting instead to spend time emailing home and doing some site-seeing. Despite your experience waiting for the doctor, this would be seen as very unprofessional behavior. There are several reasons why unprofessional behavior happens in CFHI electives. A major contributor is ‘culture shock’. That is, individuals suddenly immersed in a foreign culture tend to react to the differences and stresses with a predictable set of responses: initial elation, later impatience, irritability or resistance to the host country’s ‘alien’ norms, and feelings of loneliness, tiredness, or social withdrawal. (CFHI participations receive more complete information on Culture Shock in the orientation package provided to them on site). These can occur even if you have traveled frequently in the past. Eventually, most people adapt to the new culture and become comfortable, but the road to that point can be bumpy, winding and unpredictable. The most important thing to realize about this process is that although you will to some degree experience culture shock, you may not even know you are feeling its effects. For example, you might ascribe feelings of irritability and impatience with some aspect of a rotation (potentially sparking an unprofessional incident) to either your own failings (e.g., your failure to be more flexible, adaptable or understanding) or to those of the host country’s culture (i.e., its failure to conform to your ‘Western’ standards, though possibly for its own good reasons). In reality, your feelings are a side-effect of stress – neither entirely your fault, nor that of the culture. And, when recognized as such, steps can be taken to alleviate the symptoms of culture shock by, for example, informing CFHI local coordinators that you need to take a day off to rest, without causing offence to your hosts.
A second major reason for unprofessionalism is more subtle, involving the built-in, invisible biases of our cultural perceptions of what’s normal and right. ‘Ethnocentrism’ is the unconscious tendency people have to assume that there is a set of views or behaviors that are ‘normal’, and that this ‘right’ set of behaviors or norms is that belonging to their particular culture. The example above of what is acceptable behavior for a doctor versus a student’s attendance at clinic illustrates how we might have different standards at home than those in our host country. CFHI’s approach is one of partnership. We partner with local individuals, trusting that they understand better and more wholly what their community may need, accept and tolerate. Even though you are a smart, dynamic and probably flexible person, please do not assume you “know better” than the local people you meet.
People from the developed world may be particularly prone to variations of ethnocentrism, presuming that because things are done a certain way in their own country, not only is this the way things are done everywhere, but this is the way things should be done everywhere. Of course, not even developed nations that speak the same language (e.g., Australia and the United States) share identical cultural norms, so it is unreasonable to expect that developing nations with divergent languages, histories and economies will either. In medicine, we are used to making judgment calls as to what is or is not medically ‘normal’ and healthy, upon which most cultures may agree. However, although diagnoses may be similar in your host country, this does not mean that there will be cross-cultural agreement on how to treat or respond to a particular medical diagnosis. In the developing world, a treatment decision may be dictated not only by medical knowledge but also by different cultural norms, economic realities and local belief systems. On a CFHI rotation in Oaxaca, Mexico, one alumna noticed that many patients insisted on injections instead of oral medications, regardless of the illness. The rationale, she later observed, was the perception that an injection would have a more immediate effect than medicine taken orally. She also made the following observation:
One young woman had come in with melasma [facial pigmentation around the cheeks]. The doctor had ordered lab tests to check her liver and kidneys, but not because she thought that was the cause of her illness. Apparently, it is community wisdom that facial spots mean liver or kidney abnormality. Sun exposure is the real cause, but the woman wouldn’t have really accepted that explanation without some backup.
…So, declaring that local practitioners are ‘wrong’ to use or not use a particular technique, and should do things the way you are used to back home, may fail to take into account local realities (e.g., cost, lack of supplies, patients’ belief systems) of which local practitioners are well aware but of which you are not.
Another potential area of conflict involves differing views on the value of individuality. In the developed world, people mostly take the view that individuality, personal initiative, ability to question authority and think for oneself are valuable traits, worth celebrating, protecting and rewarding. Yet in many cultures of the developing world, conformity with authority, and with community norms, is more valuable because this supports community cohesion. Thus, some self-appointed task you may see as a commendable exercise of personal initiative on your part might cause you to seem selfish or threatening (and thus unprofessional) to local staff because your were not asked to do it, or because you did not consult with them before commencing the activity.
Finally, it is important for you to know the privilege of visiting the people and sites that will host you while you are abroad. Traveling abroad is seldom a part of the medical or higher education experiences of people from developing countries. In contrast to the developed world, healthcare workers in poorer countries cannot expect student loans, scholarships, or even a single, well-paying job upon graduation. Moreover, for students from developed nations, overseas medical electives serve important and valuable functions, such as teaching about conditions that while unusual in the developed world, are important in ‘travel medicine’. However, in developing countries misuse has led to a derisive view of medical electives as ‘medical tourism’, where unqualified students seek impoverished, needy patients for the purpose of practicing their rudimentary skills upon people having little choice but to accept this or no care. This reinforces harmful stereotypes about people from the developed world as merely seeking to profit from people in developing countries, seeing them only as sources of natural resources, cheap labor, or as guinea pigs for foreign medical students to hone their skills. Clearly, this view does not accurately describe all people of the developed world, but equally obviously, it is unfair to expect indigent patients (of any country) to accept unqualified or incompetent care simply because they are so desperately need medical care of some kind.
A corollary to the entitlement argument is that CFHI participants, having paid their placement fees, may feel they are then entitled to ‘do as they please’ with their elective. Presumably, they feel that, like buying any other parcel of goods, once you have forked over your hard-earned cash, what you do with your ‘purchase’ is entirely your business, including skipping the clinic to spend the day surfing or enjoying some ‘retail therapy’ when you are feeling a bit down. We beg to differ. Money from CFHI electives simply reimburses physicians and onsite coordinators for their time and effort, similar to your college tuition. You will receive more than your hosts for this experience. Relationships such as those you will forge during your CFHI experience simply cannot be bought, and while it may be true that short-changing yourself may in the end be your own private concern, short-changing local healthcare providers and patients by damaging their trust in, or respect for, local healthcare staff is a serious matter and should be everyone’s concern, for the reasons discussed above.
In the end, professionalism is courtesy, communication and consideration of others’ viewpoints. So, while on your CFHI elective, realize that people see you as not just an ambassador for your country, but for the developed world in general. Consider your reasons and motivations for choosing this elective, and think about ethical issues (e.g., privacy, informed consent) that may confront you there. Consider how you will alleviate the inevitable culture shock—writing letters/ e-mail to those back home, enjoying favorite pastimes or music, or bringing a private stash of a favorite food, perhaps. Gain as much knowledge as you can of the local culture and language before arrival—not only will you understand and enjoy more, but you will be better understood as well. Language and communication are keys to overcoming misunderstanding, relieving culture shock and building trust vital to the doctor-patient relationship. If you are not fluent and need help, a local CFHI coordinator can help. To help overcome the isolation that many students and practitioners of developing nations feel, you can research local medical needs before you arrive and volunteer some effort towards meeting that need, to whatever extent your skills allow. This could include volunteering in peer education, collaboration in research, helping out at an orphanage or hospice, or some other project of your choosing. Finally, as you embark upon your elective and go about your activities in the host country, try to step into the shoes of local staff and patients, consider their perspectives and ask yourself whether you are obeying the Golden Rule, that is, are you treating others the way you would want to be treated if the roles were reversed?  |
