Are we culturally tone-deaf?
New York, United States
|Hahoe Folk Village Mask Dance. Ian Sewell. July 2008. Accessed via Wikimedia. CC BY-SA 2.5|
The cultural norms of American medicine are speciously like those of traditional Korean culture, but the differences place Korean-American students at a disadvantage. When I began my third year of medical school, a fourth-year student advised, “Just do what you can do be useful.” If there is anything I know how to do, it is how to be useful. The Korean word noonchi signifies emotional intelligence and being acutely aware of surroundings and others’ feelings. It means to listen and gauge moods and needs before they are expressed, and represents a culture in which people are always trying to be considerate and helpful in any social setting.
Third-year medical students step out of the classroom and begin to experience day-to-day work in internal medicine, surgery, pediatrics, and more. We call these glorified shadowing opportunities “clerkships.” When I entered my first clerkship in obstetrics and gynecology (OB/GYN), being useful was much more difficult that I had expected because there was little I could do in the realm of real patient care. It was not difficult to carry out tasks like preparing the ultrasound machine, running down labs, and calling consults. The most frustrating aspect was controlling the impression I made when evaluated individually and in comparison with others. Korean social norms do not help a person to exude confidence in the setting of American medicine.
During the first two weeks of my OB/GYN clerkship, I was on gynecologic surgery. Most of our surgeries were transvaginal hysterectomies, which meant there was limited space for people to be involved. For two entire weeks, I stood on top of a stool watching surgeries from afar. By the third hour of surgery, I was falling asleep standing up—a first and no longer seemingly impossible feat. On the other hand, my Caucasian colleague told me that she had scrubbed in on every surgery without asking—she assumed that she would be involved. Our first two weeks on the same service were drastically different because of what we allowed or did not allow ourselves to do. My keen sense of noonchi made me aware that I was not an asset but rather a burden to my surgical team. I felt I had no right to demand or be part of a surgery that I was not asked to be part of and where it was evident that I was in the way. But the “American” culture of confidence and being proactive had empowered my colleague to claim ownership of the experiences she was entitled to as a third-year student. It was very natural for her and she took these actions without a second thought. She fully reaped the benefits of those two weeks and was well-integrated into the team. I wondered why I was not able to be proactive and most of all, I was frustrated that being polite and considerate, which I once considered to be a strength, was now thought of as being extremely passive and incompetent.
I began to reflect on the roots of my own passiveness and how something that was once taught as manners had now become the source of missed opportunities. In medicine, many things are congruent with what was embedded in me growing up. In Korean culture, hierarchy, age, and experience are all highly valued. Although the American medical system may seem a bit more lenient today, such as residents calling some attending physicians by their first names, medicine is still quite hierarchical. But what is not congruous is the medical student motto—“fake it till you make it”—a notion of feigning confidence until you actually know what you are doing. Many students hear that phrase along with, “It doesn’t matter if you’re wrong, just say it with confidence and people will believe you and trust you.” I soon figured out that confidence and being proactive meant the same thing.
When I asked an attending physician what it looked like to be proactive, she advised me to say to my resident, “I’m going to do xyz, okay?” In essence, do not wait until someone asks you to do something. This felt unnatural and almost disrespectful to me. I could not imagine telling a superior that I was going to do something for a patient, especially in a field like medicine. Gaining a second opinion, a confirmation, permission—these seemed vital to avoiding detrimental mistakes. But to attending physicians and most residents, the formal and cautious questioning so natural to Korean culture sounds needy, unconfident, and incompetent.
In my feedback I was told that I should “speak up more and be confident” because I “knew my stuff.” Many of my Korean colleagues and I shared the same feedback: “Speak up more” or “She should be more proactive.” We did not fail these clerkships because there were other standardized measures for evaluating us. Comments about our perceived incompetence did not result in our downfall. They did, ironically, wear down our confidence. Sometimes my imposter syndrome worsened in the context of cultural clashes. My behavior, or an act of respecting boundaries, may be looked upon by Koreans as being raised well in a good family, but by Americans it was seen as not being prepared or not knowing enough to take action.
Confidence, in Korea, is an internalized word, something we believe is only possessed through years of experience and accomplishment. Confidence is easily perceived as arrogance and so we all plunge into humility. If you watch any Korean TV shows, you will see that when someone is being complimented, the first reaction is to always deny and then to attribute it to some external cause. Exerting yourself with certainty in the face of superiors with more experience—that did not feel like confidence. Moreover, stating your unsolicited wishes or thoughts out loud to others seemed defiant and arrogant.
Are we standardizing the way we express confidence and competence in medicine? I am surprised that most Korean physicians, whether Americanized or not, have adopted a similar manner of conducting themselves in the hospital, a practiced confidence that borders on absolute certainty and arrogance. There is something quite impenetrable in the tone of speech. I found myself adopting the same standardized tone to be able to adjust to the American medical system. I relaxed more, spoke a little louder at baseline, and allowed myself to try certain phrases like, “I’m going to do this for Patient A, okay?” It worked well and I found myself better integrated in all my teams. My feedback became: “Clara was an asset to the team, she will be a great physician in whatever path she will choose,” and “She was always well prepared and used evidence based medicine to support patient care.” But it did not really feel like a win. What is the purpose of making us all the same? After all, we are treating diverse patients who are not all accustomed to American mannerisms. Foreign patients are less confident in exerting their own beliefs or opinions in the face of a new language and new social expectations. The loss of my cultural mannerism was necessary to thrive in my work environment but it made me wary of losing an entire part of myself just to fit in—something immigrants always have to do but resent at the same time.
Cultural norms are quite black and white. Therefore, it is not about finding a balance between two cultures because that balance does not exist. In Korea, you cannot just skip out on using formal language. In America, you cannot start bowing to show respect. This predicament compels the question: Is it true diversity if we negatively reinforce and effectively delete the cultural undertones that allow each person to contribute an important perspective in communicating and connecting with others? What would it look like if we promoted a truly diverse community of physicians rather than just the appearance of diversity? Physicians and medical educators must not only find less subjective and culturally biased means of evaluating competence in students and future physicians, but also promote an environment that is not culturally tone-deaf.
CLARA S. KOO is a medical student at Icahn School of Medicine at Mount Sinai in New York. She attended New York University where she received a BA in Biology. She has been published in Mercer Street, a collection of essays for NYU undergraduate students
Highlighted in Frontispiece Volume 12, Issue 3 – Summer 2020