Roma consultation

The incident

“I was a junior doctor and I was called at the hospital emergencies department to receive a young patient, 16 years old, who suffered of stomach-aches. He came from a “travelling community” (Roma). I asked his family to stay away of the examination room but they refused. So four people stayed with him in the very small examination room. Each time I asked him a question it was the father who answered and the mother only moaned. I didn’t know who were the two others people. This ambiance was heavy and so the examination was difficult. I became a bit nervous because I could not perform my examination well and in a normal quiet manner.

I asked the family to get out of the room, and then all the people looked at the father waiting for his decision. So I had to negotiate with him explaining that I understood his anxiety but I had to examine his son in calm way to do my job properly.

He finally accepted and the entire family waited in the hall.”

1. Identities of the actors in the situation

Narrator: Man, 24 year old, French, catholic, finishing medical school and internship in an hospital

The patient: Young teenager (16 y.o), man, from so-called “Traveling Community” or Roma community.

The patient’s family: his mother and father and two extra people of whom the narrator does not know the connexion to the patient. He thinks they are part of a same clan and thinks the father was the chief (and the oldest person as well) of this clan and the only decision maker.

2. Context of the situation

The incident happened in a general hospital in a small town (Paris suburbs) called Val d’Oise. The narrator was the only intern on call for the ER (there was also a surgeon intern only for surgical emergencies). It was the first time that the narrator faced a consultation with Roma people.

3. Emotional reaction

“I felt anxious and nervous. My attention being distracted by the people around the young boy, preventing me of doing a proper examination to measure the degree of urgency of the patient illness.

I first asked them to leave the room without specific look at them but they refused. So I started to become nervous and asked again with a louder voice. But unsuccessful again. So I took the time to understand who the authority was and to explain why I had to be alone during the exam.”

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.
  1. Representation of the hospital space: When we go to a hospital, we keep calm and silence, medical space is for healing and it is peaceful and quiet. This is in particular a condition for a proper medical examination and clinical interviews with patients.
  2. Need to adapt to the culture of the institutions we enter: According to the narrator’s through observation (contextual communication) people should check what is the appropriate behaviour for a given institution.
  3. Intercultural awareness – need to adapt to the other: The professional has to mobilise his resources to adapt to possible cultural differences: Try to understand the situation first and then test a strategy to step in. The adaptation to othersis trying to understand which are the rules or cultural frames of the other.
  4. Mission and responsibility of the medical doctor: The mission of the medical professional is to examine the patient and to evaluate the degree urgency of the illness in order to be able to intervene in the best possible way.
  5. Autonomy, self-determinationand individualism: As the young adult is 16 years old he should be able to answer questions about his health by himself.
  6. Confidentiality: Usually when youngsters come to a consult with their parents the doctor asks the adults in a certain moment to please wait outside so he can have a confidential talk with the patient. Sometimes the patient can entrust the doctor with an important clue for his treatment.
  7. Professional Identity threat:

“I need calm, emotionless examination to make sure to do the right thing, but my calm was threatened by the anxiety of theaccompanying family and friends; I was distracted from my task by the noise of the family expressing their anxiety and filling up the exam room, which was quite narrow, hindering an easy exam of the young patient.”

A big responsibility of the doctor is on the line during an emergency consultation and in order to focus/concentrate he requires calm. The noise and comments of the relatives distracted him from his task.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

Negative and stressing.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

1) Collectivism: “Rom” is a single name, meaning “accomplished man and married within the community”. The traditional Romanies place a high value on the extended family. The identification with the community has precedence over individual self-presentation and autonomy. Social organisation based on the extended family, the nucleus around which social and personal relations develop. That is why when a member becomes ill, the entire family and not just close family members accompany the infirmed or affected individuals – Prevalence of the group over the individuality of each person.The decisions taken by an individual with respect to his health are strongly influenced by his extended family. This makes the relationship with the health-care system more complex because it is no longer a relationship between the health-care system and one individual; it is between the system, the individual and his extended family. This characteristic has very visible and striking effects such as the presence of many family members at doctors’ surgeries, emergency rooms or at hospital, which others can sometimes find very annoying.[i] The extended family usually has a very clear idea of the course family members’s lives should take.

2) Healing / hospital space: hospital space is cold and for healing this does not help. Healing needs life and warmth, and it is the role of the community to provide this warmth with their presence and care.

3) Patriarchy: Traditionally, Roma communities tend to be patriarchal and this could explain the authority of the father as the “authorized” speaker.

4) Exteriorisation of feelings, emotions: in Roma cultures exteriorisation of emotions is accepted to a greater degree than in dominant French culture. It is all right to express anxiety when one is anxious, it is not considered as a loss of face.

[i]Health and the Roma Community: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/promocion/desigualdadSalud/docs/Health_and_the_Roma_Community.pdf

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

The emotional impact of situations in emergency rooms, or in life-threatening conditions can imply substantial stress and anxiety for the people accompanying a patient.  While in many Western (and Eastern) cultures the externalisation of emotions is heavily regulated, in some cultures the manifestation of emotions is accepted, even required.  Many Roma cultures subscribe to this second tendency. Such externalisation of emotions can seem childish or disorderly for the people who have been socialised into moderating emotions. This example illustrates how sensitive zones appear along the return of repressed behaviour – usually bodily actions which we learn to suppress during socialisation and whose appearance makes us very uneasy. For more details see Cohen-Emerique on the origin of “sensitive zones”.

The incident also points to the intersection of communication styles and hierarchy orientations. In the situation the knowledge of more hierarchical communication preferences is a resource for the narrator: once he understood the cultural pattern of the family his strategy was to address the authority figure, taking him as interlocutor ensured proper respect was given.  The word “respect” is often, possibly over-used, but it can be a key to many situations once it acquires a concrete interpretation. In this situation respecting the system of authority was crucial, even if from other point of view it may seem merely a detail.