Cross-cultural Communication: Know Your Audience

by Mamta Karani, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

In 2008, I had the life-changing opportunity to volunteer at a medical mission camp in Bidada, Kutchh, India. The Kutchhi people lived in a rural, desert area and travelled over 100 kilometers to get medical care at the Bidada Sarvodaya Trust Hospital. Health care practitioners and volunteers flew in from all over the world to provide care for these patients. For some volunteers, this was their fifth trip. For others, like me, this was our first.

During our trip, we had multiple opportunities to educate and provide medical services to the Kutchhi people, a population with a different language and culture than ours. This experience sparked my interest in teaching because I was assigned to teach these patients about how to properly use the medicines that we were dispensing. Patients would quietly wait in line while I read a piece of paper and filled medications in a little plastic bag. I learned how to say “take it once a day” in Kutchhi and give other simple instructions on the proper administration of the medications. However when patients were prescribed over five medications to take on a daily basis, I really had to reassess my methods to make sure they understood what I was saying.  In an attempt to help patients remember, I learned how to write the directions.  After I’d given written instructions, I would ask the patient to teach me regarding the proper administration. However, when checking the patient’s understanding of the regimen, I'd often get a blank stare. I had explained the directions and wrote them out, why hadn’t the patient understood?  I learned the language, collaborated with the local people, and provide both verbal and written instructions.  What went wrong?

When addressing cultural differences and learning how best to effectively communicate, knowledge is key and understanding the audience is vital.¹  As in any teaching plan, we need to:

• prepare by performing strong background research
• actively teach, learn to adapt, keep an open mind, and be patient
• evaluate and make changes when necessary

To effectively address cultural differences, what research is required? First, self-knowledge and self-awareness are needed.  Before we can try to understand someone else’s culture, we have to be aware of our own. Next we should learn about our patients through observation and collaborating with a local team member. Some questions to consider in your research include:

What is the preferred style of the communication for the audience? Are the communication preferences similar or different from our own? In the United States we tend to be low-context communicators — meaning we speak directly. In some cultures, people prefer high-context communication which involves speaking in conceptual terms to get a point across. In general, high-context communicators find nonverbal messages and gestures equally if not more important than what’s verbally stated.  Building a good relationship contributes to the effectiveness of communication over time; and indirect routes and creative thinking are important. In the Navajo culture, for example, if I told a patient that his/her poor blood sugar control might one day lead to a limb amputation if he/she doesn’t take the prescribed medications, the patient may feel insulted and disrespected.  Rather, if I created a story of how a person with high blood sugar required an amputation after not receiving treatment, the patient would be more motivated to learn and intuit the importance of adherence with treatment.

Does the audience believe in individualism or in communitarianism? Do members feel like they each are entitled to make their own decisions or are decisions driven by society and/or family.  Understanding this concept is vital to gaining the respect and trust from the individual and community.

What is the audience’s baseline knowledge?  Are they well educated regarding health issues?  Have they ever attended school?  What is their level of literacy? Can they read? Learning the answers to these questions up front is really important to making certain the audience can understand our take home messages.  As I learned, this was one step I neglected to research.

After having the baseline research, how can we overcome language and cultural barriers? Intercultural trainer, Kate Berardo, states we should:²

1. Speak slowly and clearly.  Even if the patient speaks some English, its hard to digest complex instructions.   If using a translator, simplify your statements and questions — discuss one issue at a time.
2. Ask for clarification. If someone asks questions, assess if you have answered the question and do not make assumptions.
3. Frequently check for understanding. Engage the learner by asking open-ended questions to see if your message is coming across as intended.
4. Avoid idioms. Idiomatic phrases and slang terms that are well understood in one culture, may not translate or make sense to someone in another culture.  Avoid them. Provide examples of things they might be familiar instead. For example, when educating someone about diet, talk about foods that are commonly eaten in that culture. Teaching vegetarians to increase their protein intake by eating meat would be insensitive. Rather teaching vegetarians to increase their protein source by consuming more legumes and beans would be more effective.
5. Be careful of medical jargon. Use simple terms.  Although as practitioners we may be comfortable talking about hypertension, diabetes, condoms, etc, using these terms may confuse or even insult some patients. Consider using simple terms like high blood pressure, high blood sugar, and safe sex practices to get your message across.
6. Be patient and attentive. They are trying to understand us as much as we are them.

In my case, I could have prepared better by asking the organizers more information about the patients and their literacy levels.  Fortunately, I checked for understanding and asked the patient to teach me about the medications.  In doing so, I realized that many patients were not able to read.  I was able to make changes in how I communicated to get the point across.  I drew a sun and a moon and explained that the sun meant morning and the moon meant evening.  It was like a light bulb turning on and the patient’s eyes gleamed with happiness. When asked again, the patient was able to explain how to appropriately take the medications.  I now realized the importance of doing an analysis and truly understanding your audience before delivering instruction. Without preparation before and evaluation after, we can’t overcome cultural barriers and educate patients.  But, the same is true for any teaching assignment.

References

1.   Cross-cultural communication strategies.  International Online Training Program on Intractable Conflict.   Conflict Research Consortium, University of Colorado.  Accessed on: December 15, 2012

2.  Berardo K.  10 Strategies for Overcoming Language Barriers.  The Culturosity Group, LLC.  Accessed on:  December 15, 2012

3.  LeBaron M.  Communication Tools for Understanding Cultural Differences.  Beyond Intractability.  Accessed on:  December 15, 2012

4.  HubPages.  Identifying and Overcomign Communcation Barriers.  Accessed on:  December 15, 2012

Did Video Kill the Classroom?

by Jess Chasler, Pharm.D., PGY1 Pharmacy Practice Resident, the Johns Hopkins Hospital

When used appropriately, technology can enhance learning by transmitting information and improving active engagement with the material to be learned.  One technology that has become increasingly popular among institutions of higher learning, including pharmacy schools, is video-recorded lectures.  These videos are made available online for students to watch. Video-recordings allow students to re-watch parts of lectures they may have found confusing.  Some schools have used this technology to asynchronously transmit lectures to a satellite campus. Although such recordings may be beneficial in terms of improving students’ understanding of the material, their routine use often leads to reduce classroom attendance.  Does this technology have a net benefit when it comes to learning in professional schools? Do teachers need to change their approach in order to attract more student to attend class?   Should professors change how they teach in order to accommodate a world where most lectures are viewed online?

Classroom Attendance.  What motivates students to attend class in the first place?   And for that matter, does attendance even matter at all?  Studies in the field of education have revealed a positive relationship between classroom attendance and academic performance.¹ Focus groups and surveys have identified various reasons for attendance and absenteeism. Commonly cited reasons for absence include longer breaks between classes, class scheduled before or after a test, availability of course content outside of class, a belief that the class is easy, or the perception that not much is learned when attending class.^2,3   Reasons students cite for attending class relate to the classroom environment and the relationship between the professor and students.  Student are more likely to attend when they perceive the faculty has a high level expertise and credibility.  Students also indicate that they are more likely to attend when they get to apply the information being taught to solving real problems.²  There is also a propensity to attend class when students perceive that the instructors notice and care that they are present or when they feel obligated to attend.³ Reasons for attendance and absence vary from class to class and but, surprisingly, class size does not influence attendance.^2,3

Beyond Learning.  Although absenteeism may impact academic performance, there is also evidence suggesting that there are other important aspects of professional development that may suffer. Presence in class helps to foster relationships between students and faculty, and these types of relationships have been shown to impact professional behavior, attitudes, and occupational values.²   Professional socialization involves the transformation of students into professionals.⁴ This transformation relies on the interaction between students and exemplary pharmacists, which includes faculty members.  By coming to class and forging relationships with faculty, students are able to identify and emulate these professional role models, and even transform relationships from that of professor and student to one of mentor and mentee. Additionally, being present on campus for class helps to encourage participation in professional organizations. If students do not come to campus for class, it is unlikely they will come to campus for an organizational meeting.

Video Recording Lectures.  Absenteeism from class has been associated with poorer academic outcomes, however this may not hold true for students who watch lectures from home. Indeed, some studies have shown that when lectures were posted online, students scored higher on exams.^5.6 In one therapeutics course, there was a substantial (25-75%) decrease in attendance but has not be consistently seen in all cases.⁵  A similar study found that attendance was not impacted when lectures went online.  However, students in this study had to wait 72 hours following the live session to gain access to the online video of the lecture.⁶ In both studies, an overwhelming majority of students found the online video to be a useful resource and recommended implementing the technology as a permanent change.^5.6

A Personal Perspective.  In an editorial discussing online lecture capturing, Romanelli and colleagues make the argument that classroom attendance should not be the deciding factor as to whether or not to implement this technology. They argue the focus should be on facilitating student learning.⁷  But beyond achieving the stated learning objectives on exams, it is also important to keep in mind unmeasured, often hidden outcomes, such as the formation social and mentoring bonds that are an important part of professional development.  As a recent graduate of a school that made lectures available online for students, I can say that it was helpful to have access to them. I found it beneficial to pause, rewind, and (occasionally) watch lectures on “double-speed.”  But relying online video-recorded lectures did come at a cost.  I felt less engaged in pharmacy school when compared to my experience as an undergraduate.  Now as I prepare to lecture to pharmacy students at my alma mater this spring, I can’t help but hope that most students will attend. Cues from the class can help guide a lecture, and I worry I may not know until weeks later if a concept I was attempting to convey was not clearly explained.

There is no doubt that in the age of video-recorded lectures, faculty must lead the way by inspiring students to be actively engaged in school.  Relegating purely didactic instruction to the web and implementing active learning strategies for all face-to-face sessions is one potential solution.⁸  Faculty should also be vocal about encouraging their students to come to class and should be adaptable by changing the format and style of their lectures in those circumstances when many will choose to watch the lecture online. Delaying access to online videos may encourage students to attend while also taking advantage of this technology.  Policies that encourage attendance may also help keep students on-track.

So, do video-recorded lectures have a net benefit for students in professional schools?  There are no clear cut answers but one thing is certain: future faculty must work to create a classroom environment that is both engaging and functional for online viewing. Further work in this area is needed so that students can gain the necessary knowledge, skills, and attitudes to become professionals.

References

1.  Hidayat L, Vanal S, Kim E, Sullivan M, Salbu R. Pharmacy Student Absenteeism and Academic Performance. Am J Pharm Educ. 2012; 76(1): Article 8.
2.  Fjortoft N. Students’ Motivations for Class Attendance. Am J Pharm Educ. 2005; 69 (1): Article 15.
3.  Westrick SC, Helms KL, McDonough SK, Breland ML. Factors Influenceing Pharmacy Students’ Attendance Decisions in Large Lectures. Am J Pharm Educ. 2009; 73 (5): Article 83.4.  Hammer DP, Berger BA, Beardsley RS, Easton MR. Student professionalism. Am J Pharm Educ. 2003;67:Article 96.5.  Elsasser GN, Hoie, EB, Destache CJ, Monaghan MS. Availability of Internet Download Lecture Audio Files on Class Attendance and Examination Performance. International Journal of Instructional Technology and Distance Learning. 2009; 6(2); 19-23.6.  Bollmeier SG, Wenger PJ, Forinash AB. Impact of Online Lecture-capture on Student Outcomes in a Therapeutics Course. Am J Pharm Educ. 2010; 74(7): Article 127.7.  Romanelli F, Cain J, Smith KM. To Record or Not to Record? Am J Pharm Educ. 2011; 75(8): Article 149.
8.  Stoner SC, Fincham JE. Faculty Role in Classroom Engagement and Attendance. Am J Pharm Educ. 2012; 76(5) Article 75.

Required Readings: Turn Reluctance into Enthusiasm

by P. Tim Rocafort, Pharm.D., Assistant Professor, University of Maryland School of Pharmacy

I still remember the days when I impatiently waited for the end of the school year. I could hear the summer sun knocking on the windowpane of my 7^th period British Literature class, while I struggled to keep up with my teacher’s ramblings about Rudyard Kipling’s “The Jungle Book.”  All I could think about was escaping from that concrete forest called high school and onto the sandy shores where homework was left far away. But before I bolted out to freedom, I was shackled by the required reading list distributed by the teacher.  All I could think was “so long sweet summer.”  Yet, to my surprise, by the first quarter of the next school year, I was passionately participating in group discussions of the assigned books. What happened to swayed me from being a literary antagonist into a Shakespearean fan?  How has this revelation influenced my perspective on required readings?

From summer readings to manuscript about investigational studies, required readings to most students is often a dreadful task that a learner “must” complete. The fact that reading is labeled as “mandatory” or “assigned” may deter the learner from pursuing it and often induces sleep when attempted.  Even worse, if students are dissuaded by the obligatory nature of the reading, they may eventually develop apathy to reading as a whole. Some may argue that there are three reasons why this happens: 1) learners can’t do it, 2) learners don’t want to do it, and 3) learners just want to get through it. 

Learners can’t do it.  Poor reading comprehension may explain why some students dread required readings. If the selected readings are too difficult and beyond the reader’s level, they will intimidate and deter rather than stimulate and encourage.¹ The learner’s educational background, which included reading exercises that varied in quality and resulted in differences in analytical and critical thinking skills when compared to peers, has a critical role in this problem.¹ Information regarding past educational experiences is vital in analyzing the learner’s baseline reading comprehension; however, this assessment is often never done because educators are much too eager to overload learners with materials that promote “independent learning”.²  Primary source text (like clinical trials) and other forms of academic research, may be too difficult or confusing for learners to grasp if introduced too early in their training.  So they may simply just give up or not try at all, despite their initial yearning to learn.^2,3,4

Learners don’t want to do it.  In today’s world, where technology makes obtaining information easier and quicker, it is challenging to find a “place” for required readings intended to provoke thought and expand perspectives.⁵  In an era when students expecte dynamic discussions, interactive videoconferencing, and activities that promote “doing” or application rather than “passive” undertakings, required readings are often poorly received by students.^{5, 6} Moreover, educators now rely heavily on these new “exciting” tools to replace traditional instructional methods. Changing social-cultural influences and generational perceptions are key contributors to the listless view of required readings by students.⁵

Learners just want to get through it.  Many learners have a “just get through it” attitude when it comes to required readings.⁶  This sentiment may be exacerbated by educators who feel obligated to hand-hold or spoon-feed the students to ensure delivery of the information.  Learners suffer from a lack of effort and fail to achieve deep and long-lasting understanding.  Instead, they settle for rote memorization.

So, how was I converted from being a reluctant follower to an enthusiastic supporter of required readings? I owe much of my personal development to teachers who identified the issues and addressed them with instruction.

From my teachers I learned that required readings are a tool to establish one’s own thoughts regarding the subject.  They are not a be-all and end-all fountain of wisdom.  Using therapeutic guidelines in a patient-centered care approach is a good example of ensuring knowledge is taken beyond the fine print and into day-to-day clinical practice. The educator must take the initiative to point out key facts and pose significant questions that motivate learners to complete the assigned task in an active, evaluative manner.  Simply providing a student a package insert to interpret drug information may not be the best way to educate a student about patient-specific dosing and drug interactions. Including case-based scenarios along with a series of Socratic questions may effectively supplement this approach and allow for students to create more patient-focused judgments about the meaning of the written materials. The educator should also engage students in vibrant learning sessions by encouraging students to share their thoughts and allowing the class to systematically analyze the material. Involving students in journal club discussions, pharmacotherapy rounds sessions, and patient case presentations will help elevate their reading comprehension and understanding of the subject. The educator must also demonstrate proficiency of the subject by being prepared to discuss key issues from the readings. With the educator’s facilitation and expertise, required readings become a more effective exercise that involves active reading that improves the analytical and critical thinking skills of learners.⁷

Instead of leading to a dead end, required readings should direct learners to a more enlightened and enriched path.  At the end of the day, it is up to the learner to take responsibility for completing required readings, but it is up to the educator to set a positive tone and to use them wisely to develop deeper insights.

References:

1. Ryan T.E. Motivating novice students to read their textbooks.

Journal of Instructional Psychology. 2006; 33(2), 135-140.

2.  Linderholm T., Wilde A. College students' beliefs about comprehension when reading for different purposes. Journal of College Reading and Learning. 2010; 40(2), 7-19.

3.  National Endowment for the Art. To read or not to read: A question of national consequence. Washington, D.C.: National Endowment for the Arts. 2007

4.  Concepción D.W. Reading Philosophy with Background Knowledge and Metacognition. Teaching Philosophy. 2004; 27(4): 351-368. 

5.  Oblinger D.S.,  Oblinger J.L. Educating the Net Generation. Educase. 2005.

6.  Paulson E.J. Self-selected reading for enjoyment as a college developmental reading approach. Journal of College Reading and Learning. 2006; 36 (2), Spring, 51-58.

7.  Wade S.E., Moje E.B. The role of text in classroom learning: Beginning an online dialogue. Reading Online, 2011; 5(4).

Games in Healthcare

by Melissa Weaver, Pharm.D., PGY1 Pharmacy Practice Resident, Carroll Hospital Center

I love Angry Birds. Fire the slingshot to send the single-minded birds on their mission!  Victory comes when the evil pigs die! Getting engaged in the game is so easy.  On level 1-1, the player gets three angry birds to kill one evil pig in a wooden and ice structure.  Usually, the player needs only one angry bird to succeed at the mission and feels like a “rock star” after the victory. The story and feelings build with each episode and level.¹

But how do suicidal birds relate to healthcare and education?  Think of the last time you sat in a class and were captivated by the topic.  Compare that to the last time you played a video or computer game and were completely engrossed. In which situation were you more engaged and involved?  I’ll admit, I often feel more involved when I play Angry Birds than when I listen to a lecture.

So what exactly is a game?  The definition seems to be evolving, but Roger Caillois, the French sociologist, said that games have six elements: (1) non-obligatory (2) separate in time and place (3) uncertain course (4) unproductive (5) governed by rules and (6) make-believe.²  Games are designed with multiple ways of keeping the player participating and involved.  Most presentations I have seen lack that level of engagement. The lecture is thought by some to be an inefficient, stifling, and clunky means of delivering instruction; a blunt tool in an age of laser precision.³

Why do games make a difference now?  Games are not new to healthcare education.  In 1995, one of my preceptors played Jeopardy! during her pharmacy residency at the University of Illinois, Chicago.  But technology has improved significantly since 1995.  The proliferation of mobile devices such as tablets and smart phone pave the way for using these devices to teach.  These devices are the first to overcome the limitations of handsets as learning tools.³ The technology also allows the speed and scope of information to be more current than is typically seen in academic courses.⁴ 

How are games being used in healthcare?  Currently, there are more than 300 health-related games on the market aimed at patients in two general themes – physical exercise and brain fitness games.⁵  But disease-specific games are also available such as Re-Mission, a video game for young people with cancer.  The lead characters for Re-Mission include Roxxi, a microscopic robot that fights infections and cancer at the cellular level; Smitty, a retired nanobot who provides holographic guidance to Roxxi; and Dr. West, creator of the self-aware artificial intelligence nanobots and the nanotech chronic illness treatment program.⁶  From a patient education standpoint, the game addresses the importance of taking oral chemotherapy regimens, prompt reporting of symptoms and side effects, proper nutrition, as well as anxiety, nausea, and pain management.⁷ A randomized controlled trial compared adolescents and young adults who played a standard commercial video game versus Re-Mission.  Participants were asked to play the game at least one hour per week for the three-month study period. The conclusion of the trial is that treatment adherence and indicators of cancer-related self-efficacy and knowledge were significantly improved in those who played Re-Mission.⁸

Games are engaging.  They can be used to teach by allowing the learner to apply newfound knowledge to new situations.  Game scenarios can be easily modified to reflect the continuous influx of healthcare information updates.  While playing the game, the learner has the opportunity to make decisions and instantly see the results of those decisions.  The ability to recreate the scenario allows the learner to practice this decision-making skill. Better decisions in healthcare result in better healthcare.

References

1  Angry Birds [Internet]. Finland: Rovio Entertainment Ltd. Accessed 2012 Oct. 16. 

2  Caillois R. Man, Play and Games. University of Illinois Press: 2001. pp. 9-10. Accessed on 2012 Nov 26. 

3  Galagan P. From Pie in the Sky to the Palm of Your Hand: The Proliferation of Devices Spurs More Mobile Learning. T+D [serial online]. March 2012;66(3):29-31. Accessed 2012 Oct 11.

4  Kalman F. Social Media: Learning's New Ecosystem. Chief Learning Officer [serial online]. August 2012;11(8):42-45. Accessed 2012 Oct 11.

5  Gaming in Healthcare. Digitome Corporation. Accessed on 2012 Nov 26.

6  Re-Mission Characters. HopeLab, A Part of the Omidyar Group. Accessed on 2012 Nov 26.

7  Re-Mission For Clinicians. HopeLab, A Part of the Omidyar Group. Accessed on 2012 Nov 26.

8  Kato PM, Cole SW, Bradlyn AS, Pollock BH. A Video Game Improves Behavioral Outcomes in Adolescents and Young Adults WithCancer: A Randomized Trial. Pediatrics 2008; 122:2 e305-e317.