Competence in dealing with within-culture issues in doctor-patient consultations: an assessment of Sri Lankan junior doctors
This study developed and validated the 22-item Kelaniya Measure of Cultural Competence (KMCC) for Sri Lankan junior doctors through a two-phase process, revealing that while most practitioners adopt a high-advocacy approach, they generally exhibit low-enquiry levels when addressing cultural issues in clinical practice.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In any society, the way people understand health is shaped by the world they grew up in. Beliefs about what causes illness, what foods are safe, and how to treat a wound are often passed down through generations, forming a deep layer of personal culture. When a doctor meets a patient, they are not just exchanging medical facts; they are navigating a meeting between two different ways of seeing the world. For decades, medical training has focused heavily on the "biomedical" model, a system based on scientific evidence and standardized treatments. This approach works brilliantly for many conditions, but it can sometimes clash with a patient's personal beliefs. If a doctor dismisses those beliefs too quickly, the patient may feel unheard, stop following the treatment plan, or hide their true concerns. The goal of modern medicine is to find a balance where the doctor respects the patient's worldview while still providing effective care. This balance is often called cultural competence, but it becomes a unique challenge when the doctor and the patient share the same background. In this scenario, the doctor is not an outsider looking in; they are a member of the same culture who has been trained to think like a scientist. The tension arises when the doctor's professional training conflicts with the very cultural beliefs they grew up with.
A team of researchers in Sri Lanka set out to understand how junior doctors handle this specific tension. Sri Lanka is a place where traditional beliefs and modern medicine coexist in daily life. A doctor there might have grown up hearing that certain foods are "heating" to the body or that specific rituals are necessary for healing, only to be taught in medical school that these ideas have no scientific basis. The researchers wanted to know: when these doctors face a patient with such beliefs, do they ask questions to understand the patient's view, or do they simply tell the patient what to do? To find out, they developed a new way to measure this skill, called the Kelaniya Measure of Cultural Competence. They started by interviewing thirty experienced doctors to identify forty-one common situations where culture and medicine clashed. These situations ranged from a family refusing a full autopsy due to religious beliefs, to a pregnant woman avoiding prawns because she thinks they are too "hot" for her body, to a patient refusing a blood transfusion based on astrology.
Using these real-life scenarios, the researchers created a survey for junior doctors—those with one to three years of experience after graduating from medical school. The survey asked the doctors to rate two things for each scenario: how much they would ask the patient about their beliefs, and how strongly they would advise for or against those beliefs. They also asked the doctors to explain why they would respond that way. One hundred and seventy-six doctors from four major hospitals in Sri Lanka took part in the study. The results revealed a clear pattern. On average, the doctors were willing to give advice, but they were not very eager to ask questions. They tended to adopt a "low-inquiry, high-advocacy" approach. This means they were quick to tell patients what the medical science said and to push for a specific course of action, but they were less likely to pause and explore why the patient held their beliefs in the first place. The data showed that female doctors were slightly more likely to ask questions and offer advice than their male colleagues, and doctors from one specific medical school were more inquisitive than those from others, but the overall trend was consistent across the group.
The researchers discovered that the doctors' responses were not random; they fell into three distinct categories of belief. The first group involved "beliefs of cautiousness," where patients avoid certain foods or actions out of fear they might make an illness worse, such as a pregnant mother avoiding prawns. The second group, "beliefs of contradiction," included beliefs that directly opposed medical advice, like a patient refusing a life-saving blood transfusion because of a fortune teller's prediction. The third group, "beliefs of alternatives," covered cases where patients sought help from traditional healers instead of, or in addition to, doctors. The study found that most doctors responded to these situations based on what they had been taught in their curriculum, rather than on their own personal cultural beliefs or their attitude toward the specific patient. This suggests that their medical training had effectively overwritten their lay cultural knowledge, leading them to act as strict advocates for biomedical science without fully engaging with the patient's perspective.
The study concludes that this is not a problem of tolerance or a lack of knowledge about "other" cultures, since the doctors and patients share the same background. Instead, it is a training issue. The current medical curriculum seems to teach doctors to prioritize scientific facts over cultural exploration, creating a gap where doctors act first and ask questions later. The researchers argue that this approach can lead to patients silently ignoring medical advice because their concerns were never heard. They propose that medical schools need to teach a specific skill called "intercultural competence," which involves learning how to negotiate between the doctor's scientific view and the patient's cultural view. This means learning to ask questions with genuine curiosity rather than just correcting the patient. The new tool they developed, the Kelaniya Measure of Cultural Competence, offers a way to track whether future training programs actually help doctors change their behavior in the consultation room, ensuring that the bridge between science and culture is built on understanding rather than just instruction.
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