Doctors and patients relate to each other differently in different cultures. Here seven medical students from around the globe share their insights

Competition time

Scattered on these two pages are seven words for "patient." On the next two pages are seven languages. Match up the right words to the right languages and you could win £50 ($80; ¤70) of amazon.com vouchers. Web readers: it's not easy to scatter words on the web so they are collected here in a box.

1. mareese
2. pacient
3. paciente
4. rogi
5. bolnavi
6. pacijent
7. onye oya

1. Hindi, the national language of India
2. Bengali, a language of eastern india
3. Romanian
4. less commonly used Romanian, literally "ill men"
5. Bosnian
6. Igbo, one of 250 languages used in Nigeria, literally "sick person"
7. Spanish

Email studenteditor@bmj.com with your answers (such as paciente is Spanish, so the answer would be C7), and your name, year of study, University and country by 24 July. We'll pick three winners at random from all those with the right answers and let you know who has won in September's journal.

NASA

Mexico is a country full of differences. In Mexico, we think of three different health groups--the wealthy, the worker with just enough money to live on, and the deprived. Differences between these groups are huge, in terms of how they communicate and the treatment they receive. Recently, litigation has changed things, and doctors feel a lot of pressure dealing with information and probabilities.

Communication between doctors and patients depends entirely on what the doctor thinks patients want. How doctors inform their patients about their illnesses varies between doctors and families; education, religion, and traditions affect the way people communicate. Patients' relatives often want to keep things secret, and ask the doctor not to reveal the truth. This is common in elderly people and people with terminal diseases. People that speak ancient dialects, such as Raramuri, face language barriers which affect their health services.

Treatment depends on what kind of health service you have. People in employment have access to the national health system (Sistema Nacional de Salud), and they have free treatment and prescriptions. They can have available treatments, meaning that maybe the newest and best chemotherapy treatment is not available. Conversely, wealthy people who go to private health services have more choice, because they have the money to pay. People who do not have a job and cannot afford private health care are often treated in charity hospitals. These people are the most deprived--the least protected, informed, and educated part of Mexican society. They often receive bad treatment, poor health service, and sometimes no information at all is given to these patients or their relatives. This is the worst aspect of health care in Mexico, and despite this in these hospitals there are great practitioners that make a big effort to make things different.

You cannot make simple assumptions about Mexico. I live in a country full of differences. Change in Mexico happens slowly; access to education and participation and commitment of government is needed to ensure that people get the best not only for their health but for their life. Adrián González Aguirre BMJ, Clegg scholar, final year medical student, Juarez, Mexico
Email: agonzales@bmj.com

Nigeria

The average Nigerian patient is a victim of circumstance. They are vulnerable to exploitation and sometimes unethical "handling." They find themselves in this situation thanks to poverty, ignorance, and disease. Moreover, they are still badly protected by state and social security structures.

Nigerian doctors, seen by most patients as a bastion of hope, are faced with the task of providing care and support. The relationship that exists between the patient and the doctor or medical student is cordial. Most patients take their doctor into their confidence, even though they may be meeting each other for the first time. The doctor is told the truth or, in some difficult circumstances, the half truth, the patient hoping he finds out the other half by some divine means. The patient may deify the doctor, hold him or her in awe, or give the doctor utmost respect. The doctor on the other hand reciprocates with respect, patience, and humility. As a matter of fact, ethical standards are seldom compromised irrespective of social class and educational attainment on the part of the patient.

BORIS HEGER/AP

A patient receives AIDS drugs in southern Nigeria,donated by US AIDS patients who have become resistant

As much as this is true, however, poverty and ignorance still have a role in defining the eventual course of the doctor-patient relationship. Poverty forces patients into drug trials where they are unhappy giving away so much private information. You do not exactly have the patient's consent, but he or she needs the free drugs. Tightly held beliefs about health can also strain the relationship. Imagine explaining to a Nigerian market woman with AIDS that she does not have eight diseases. Or explaining to an illiterate couple whose child has a heart condition that some village witches are not at work. On the other hand, the relationship could be strengthened by the patient's interest and motivation with regards to helping the doctor either cure or gain greater control over the illness. This sometimes brings in a great degree of empathy and comradeship into the relationship.

Nigerian patients are underprotected by the state, which reduces the possibility of legal redress if the patient feels infringed. This sometimes keeps the doctor and student doctor less defensive and is not in the patients' best interest. The situation of Nigerian patients can be improved by having better protection by the state and social security, vigorous public health education, and economic relief. Chibuzo Odigwe third year medical student, University of Calabar, Nigeria
Email: chibuzo2k2@yahoo.com

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United States

In the United States, debate has been brewing about the basic rights of patients. As part of the larger unresolved debate about the national healthcare system, no consensus has been reached as to whether each person has the right to health care regardless of their ability to pay. The idea of a patient's rights and responsibilities within the existing healthcare system has been agreed.

Most states have passed their own bills of rights for patients through their legislatures, and, in August 2001, both the House of Representatives and the Senate passed federal versions of a similar bill. Although the bills in the two chambers were different, they agreed in some fundamental principles about what health plans should provide--that is, access to emergency care and specialists, payment for routine medical care while the patient is involved in a clinical trial, and the ability to obtain a third party medical review when the health plan denies payment for certain treatment.

What caused the discord between the plans was under what conditions a patient can bring a lawsuit against his health plan if denied care or coverage. A Republican party backed amendment to the House's bill limited patients' ability to bring suits on health plans, but the Senate's bill did not. Debate on this topic is strongly partisan. Most Democrats claim that denying patients the ability to bring health plans to court for substandard care is a vote against patients' rights, but most Republicans say that excessive litigiousness will only benefit the trial lawyers while driving the cost of healthcare higher.

How this legislation translates to the hospitals and doctors is doubtless more complicated. As it is, malpractice insurance for surgeons and obstetricians and gynaecologists, for example, is so expensive that it drives some young doctors to avoid these important specialties. Alternatively, medical errors occur relatively frequently and can even be deadly for the patient, so there needs to be some form of recourse for substandard care. What seems most important is balancing these two forces to ensure appropriate care of patients while freeing doctors from fear of frivolous litigation.

Elissa Altin first year medical student, Harvard medical school, Boston, United States
Email: sophia_altin@student.hms.harvard.edu

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Bosnia-Hercegovina

Despite many difficulties, things are looking up for patients in Bosnia-Hercegovina. A complicated puzzle is slowly coming together because of ongoing reconstruction and reform of the old socialist healthcare system. Previously people's rights to health care were unlimited, if they were covered by health insurance--the utopian expectations of a social welfare state. Even then, patients were neglected in some ways. They would get little or no information on their health status, and not much attention was paid to follow up during and after their treatment. Waiting rooms were too small. Without a system for appointments, people sometimes had to wait an hour or more, loosing patience when others would be allowed through immediately on arrival because they knew the nurse or doctor.

The long awaited few moments with the general practitioner would be just enough for writing prescriptions for drugs or filling in referral papers for specialist services. Little or no attention was given to prevention, health education, or promoting health. Communication between the doctor and the patient is not part of medical training at university and is hardly ever mentioned as a specific subject.

With the changes in the health system, patients were probably unaware of what they were going to lose--a broad and expanding range of healthcare rights and growing capacity of healthcare services. Just before the war, the country was almost on the verge of financial collapse. In addition to that, war caused enormous damage to the country.

Now, Bosnian family doctors put emphasis on the doctor-patient relationship, as skilled clinicians based in the community. Newly introduced systems for appointment enable patients to communicate with doctors and to participate in decisions about his or her health care.

Patients in Bosnia-Hercegovina face new problems. The money available for basic health care has decreased and many people do not have insurance, especially the unemployed (currently 40% of the population). Doctors and other healthcare staff, who provided great support to people even during the worst times of war, are trying their best to help patients, even though they are facing many administrative and financial limitations.

Do's and don'ts of working with patients

Do
• Use plain language which all patients are likely to understand
• Establish patients' views on what might be wrong with them
• Ensure understanding by reiterating and summarising what has been said in the interview

Don't



• Patronise
• Dismiss the patient's opinions
• Allow the patient to leave the consultation feeling more confused and dissatisfied than when they arrived

Mirza Muminovic third year medical student, University of Sarajevo, Bosnia
Email: voxmedici@hotmail.com

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India

India is a big country, where 1200 million people live. The population is varied and so the doctor-patient relationship is hard to generalise. The concept of "patient power" only exists in Indian cities. In rural India, most patients are poor and illiterate; they do not have any choice regarding their treatment and so are generally happy with whatever treatment they get. The poor masses have great respect for doctors, and some even believe that rather than the medicines, it is the doctor's godly touch which helps heal a disease.

But in Indian cities, patients are well informed and aware. Even the lower middle socioeconomic group in eastern India has set up an organisation to fight against the professional negligence of doctors. The consequences have become detrimental for medics. In government hospitals, patients often think that they are getting less than proper treatment; every other month, newspapers carry stories regarding assaults on doctors (by patients) in the hospitals. This is pathetic, as not all doctors are bad. In cities, patients have the full opportunity to choose their treatment. Doctors just usually suggest what treatment would be better for a particular case. During treatment, every day, the patient and his or her relatives are kept thoroughly informed.

SAURUBH DS/AP

A patient with dengue fever in New Delhi

In the past, diseases like leprosy, syphilis, and tuberculosis were stigmatised illnesses. Now, after patients' attitudes have improved and the advent of excellent medical treatment against these diseases, stigmatisation because of these conditions is much less. But AIDS is stigmatised, even after thorough health education campaigns--the most educated people in Indian cities still throw AIDS patients into total social isolation; the identities of patient with AIDS are kept confidential in this country.

After taking charge of a patient's treatment in hospital, doctors have to obtain consent for each and every step. For any intervention, both surgical and non-surgical, doctors nowadays take written permission from the patient's party (relatives or friends). In the past patients and doctors had a cordial relationship. After the advent of the "legal threat," however, this beautiful relationship has been totally destroyed. Now medics are behaving so mechanically with patients in hospitals that sometimes they seem just like robots. This does patients no good because they are not robots.

Sanjit Bagchi fourth year medical student, Calcutta National Medical College, India
Email: sanjitbagchi@yahoo.com

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Romania

Until 1989, during the time of Romania's communist regime, patients were the government's last concern. Faced with acute problems caused by the permanent lack of money for health care, the medical world after 1989 disregarded patient related issues. But things are changing. Recently, Romania released a new law on patients' rights that aligns to European Union standards.

Still, most patients do not know what this law contains. Many people from less advantaged backgrounds or rural areas are not even aware that it exists. This is due to both their own ignorance and insufficient promotion from the government. Besides, most patients could not afford a lawyer to protect their rights if the law had been breached.

In my everyday life as a medical student I see that patients tend to place doctors on a pedestal and consider them all knowing. White coats intimidate them. Patients act humbly, consent easily, and do not have the courage to ask doctors many questions, which affects the relationship between doctor and patient. Patients without medical knowledge often feel vulnerable and helpless. They overlook the fact that doctors are professionals doing their job and can therefore make mistakes and are responsible for their actions.

The situation reflects on doctors. Some doctors respect patients' rights and take time to inform them in detail and provide clear explanations. They ask patients to express their needs and try to communicate with them by reducing the gap between doctor and patient. However, for other doctors patients are of little concern. These doctors exploit the fact that most patients do not ask, do not know, and would not take them to court; they only want their patients' signed consent to cover their backs.

As medical students we have the advantage that almost all patients allow us to perform examinations or procedures on them and are highly communicative in history taking. Patients are grateful that we take time to listen. They ask us to explain more about their disease, the risk of certain procedures, or the results of their investigations. Patients are more open to us because we are less intimidating than doctors. They meet us with trust and respect, and this is reciprocated by most students I know.

Although the country has a long way to go, Romania is taking important steps towards patient oriented medicine. As the generations of doctors and ignorant patients gradually disappear I see the doctor-patient relationship improving.

Do

• Explain the nature of every action, and keep the patient informed; most people do not like to be kept in the dark
• Take the time to listen to the stories and comments of the patient, even if it disturbs the rhythm of taking the history, but do set a limit
• Intersperse your monotonous taking of the history with some moments of humour or amusement; it is a big emotional help to patients and it makes the interview more enjoyable

Don't



• Try to force a patient to give a history when he or she is under temporary physical or psychological distress, even if your tutor has told you to do it. Come back at a more appropriate time
• When taking a long history, do it in two or more separate visits rather than bother the patient with a long and tiring conversation
• Be aware that young women may be uncomfortable with men doing a gynaecological examination on them

Irina Haivas third year medical student, Iasi University of Medicine, Romania

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Peru

There is not a common doctor-patient relationship in Peru. Because Peru is a multicultural country, different types of relationships can be seen comparing the coast with the mountains, the north with the south, urban with rural, and, most controversially, hospitals with clinics. Each situation is influenced in a particular way by economic, educational, religious, and social factors, and sometimes also by the type of disease.

Medicine has always be seen as the most important profession. Doctors are an important element of this magnificent stereotype, where they become or play the role of God, King, or magician.

Due the fact that people are ill, and because the doctor knows a little bit of everything, patients look at doctors as being superior. It is difficult to find a patient that questions more than they need to. Patients just listen to what the doctor orders, whether they understand or not. If you contradict your doctor, he or she will commonly reply, "Excuse me. Are you the doctor?"

As doctors know a little bit of everything, you can rely on them, more so if your health is at stake. You feel like the person in front of you is the only one capable to look after you; any counsel or indication from him is all that matters. You feel protected and if you follow his directions everything will go well.

CHARLES WLAKER/TOPHAM

Doctor-patient relationships in Peru depend on three factors--economy, education, and social condition--influenced by both the doctor and the patient. Economically, the higher you charge, the better treatment you give to your patient, including time, information, and, ironically, free samples of medicines.

The more educated your patient is, the more time you spend with them. Some see it as a waste of time trying to explain a prescription or a condition to an undereducated patient. Explaining 3, 4, or 10 times can be really irritating, so you just give a prescription and wait for a thank you.

In Peru, medicine has special status in society. Doctors are an important part of society's structure. Patients can be afraid when talking to a doctor; but doctors like this fear and respect because it gives them status.

Cèsar Eduardo Wong Alcázar final year medical student, Universidad Peruana Cayetano Heredia, Lima, Peru
Email: wongalcazar@terra.com.pe