In our practice patients often must give a urine sample. We then tell them to go to the patients’ toilet and when they are finished, place the sample in one corner of the toilet where there is an extra shelf to collect these samples. One time, a patient, a Hungarian man, came up to my counter and told me that he was supposed to give a urine sample.
I handed him the box for the urine and showed him the toilet. He asked me: “Shall I give the sample right away?” I said, “Yes, please.”. I pointed to the toilet again but he just started to open his pants and give the urine sample right in front of me. I was really baffled so asked him what he was doing and he said, “You told me to do it right away.” I replied, “Yes, but not here, I told you about the toilet.” He really did not seem to understand what the commotion was about. When I asked him again why he was urinating right in front of me, he told me that in his doctor’s office in the small town in Hungary, it was customary to just urinate in the waiting room. Since the doctor’s office is so small, there is nothing unusual about urinating in a urine probe just in one corner of the office.
Usually, I take such events with a good sense of humour, but still I was still quite shocked that it seemed so normal to him and he thought nothing about it.
1. Identities of the actors in the situation
The narrator works as receptionist at a doctor’s office, welcoming patients, storing their information and taking care of insurance matters. She also instructs patients, i.e. where they need to wait and how the procedures will be etc.
The narrator is a 49 year old woman born in Mexico, who has been living in Austria for over ten years, speaking multiple languages including them Spanish, German, English and a little Hungarian. She is very highly educated, holds a PhD, is married and a mother of six children. Her husband, the general practitioner in the office, was born in Vienna and is of Hungarian ancestry.
The patient is a working man from Hungary, who has been in Austria for no longer than 6 months. He is about 58 years old and not highly educated with very little formal education. He works as a stonemason on construction sites. He came to the doctor’s office to give a urine sample which will need to be analysed. He is in quite good spirits and engages in a friendly way with the receptionist.
What draws the actors together is that both have an experience of migration, yet the narrator has been in Austria for a considerably longer time than the patient. The narrator has a connection to Hungary, which is the home country of the patient, since her husband has Hungarian ancestors and she even speaks a little Hungarian. The two protagonists are very different in regards to their educational background and the professional role in which they meet: the narrator being at her place of work as a doctor’s assistant, the patient being in a place little known to him, in a situation of need.
2. Context of the situation
The doctor’s practice located in an inner-city district in Vienna in the heart of Jewish Vienna is inhabited by residents from very diverse national backgrounds. It is also near a subway line stop that passes by the United Nations headquarter in Vienna. The clientele of the practice are very diverse with patients from over 100 countries. The idea behind opening the practice was to create an international doctor’s office where people could feel welcome regardless of their origins. There is an advertisement outside the practice which spells out the languages which are spoken by the staff in the practice, so that potential patients know they will be attended to in English, Spanish, Arabic etc. Many patients cannot speak German. The people working in the practice try to accommodate the cultural specialities of their patients. For example, there is no problem for entire families go into the examination room together, which is very unusual for Austrian medical practices. The general practitioner has learnt how to do an ECG without having patients completely undress. This is a service which is very much appreciated by some of the female Muslim patients.
3. Emotional reaction
The narrator was not offended, but only shocked because it seemed so normal for the patient to urinate in front of her. She took the situation with good humour.
4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock
Taboo of urinating in front of other people:
- Urinating usually happens in specific facilities and is not something commonly done in public. If it is done in public, it only happens on the outside and people try to hide and avoid being seen by others. Thus, the taboo covers urinating in front of someone present, but also watching somebody urinate. (This taboo is specific to a European form of dealing with excrements. In other geographical contexts, it is common to relieve oneself on the outside, in areas dedicated to this purpose, with other people present.)
- Urinating is considered private, something necessary but potentially disgusting to other people. There is a distaste for the sound and smell of urine. Urinating is combined with certain rituals which are done in a hygienic way: Urine must be put into the specific containers dedicated to hold it, these containers are closed or flushed and hands are washed afterwards etc. To follow these rituals is considered an issue of hygiene. This is especially relevant since the incident happened in a doctor’s office, a place where hygiene is considered important, so germs do not spread or sick patients do not infect staff or other patients.
- The taboo of urinating in front of others is also connected to the visual dimension of exposing one’s penis or vagina – parts of the body which are thought to be private and prohibited from public exhibition (aside from specific occasions such as in the context of free body culture).
- Exposing a penis does carry a different symbolism to exposing a vagina. It is more often associated with jokes and pranks, especially if it does not involve an erect penis. Men are also more likely, in an Austrian context, to be seen urinating in public. At the same time, being confronted by a naked penis without having consented to it is also considered weird and potentially disturbing.
Urine is regarded as waste product which is not to be made visible. By putting it in a probe and making it available for scientific examination it is transformed and dissociated from the body. This transformation is relevant within a medical context, since it becomes a substance to work with and is no longer considered a disgusting excrement. Yet specific elements need to be put in place for this transformation to happen – among them that the urine is collected in a closed container, is labelled etc. By having the patient be so cavalier about all these requirements, the narrator might have felt afraid for the practice’s reputation. Maybe she was ashamed in case other patients took notice. The incident could have threatened the professional practice and the protocol for dealing with urine samples.
Empathy: other patients could be made uncomfortable sitting in the waiting room, hearing, seeing or smelling someone’s pee.
Implicit rules of conduct in a waiting room:
- Waiting at a doctor’s office happens under specific conditions. It is usually quiet in the room and people keep to themselves and only talk to ask which patient arrived last. Nothing decidedly medical happens in a waiting room and anamnesis, examinations and diagnosis all take place somewhere else. The incident threatened these codes of conduct.
- Safeguarding the rules of conduct falls into the receptionist’s duties and the patient’s action thereby caused the receptionist to react.
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?
Naïve and simple yet friendly; a little dull; backward; pragmatic; non-compliant with norms
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
The patient exhibits a pragmatic orientation:
- He does what seems easiest and quickest.
- He could be challenging the taboo of urinating in front of other people, yet it seems more likely that he is being pragmatic regarding the taboo.
- By his actions he is avoiding anything happening to the probe. It is clear who gave it which eliminates potential mix-ups.
Doctor’s office as a space that falls out of norm:
- Since the patient is not a regular at the doctor’s office, he might be at loss regarding the codes of conduct in the waiting room and what is expected from him. Thus, his actions could be pointing towards an insecurity on how to behave.
- Furthermore, the medical system is often experienced as intimidating, especially by people which a more precarious social position, i.e. people with migrant status or of low social standing.
- Also, the patient might have a different understanding of the norm of urinating in front of others, and was just trying to do his best to fulfil the task given to him in the best possible way.
On the one hand, it might be evidence for a vigorous acceptance of hierarchies:
- He is being asked to pee, so that is what he does without thinking twice about it. The behaviour of the patient might point to different perceptions of hierarchies between the receptionist as representative of the medical profession and the working-class background of the patient.
On the other hand, the interpretation of what happened might not be understood using cultural differences or cultural norms at all, but might be a consequence of social class difference only.
7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?
Codes of conduct within different types of medical spaces
There are certain very specific, context dependent and culturally differing rules of how to act within various medical spaces i.e. there is a difference between the examination room and the waiting room. The health care professionals are in charge of safeguarding these rules, since their professional position depends on it.
- The staff must give the same instructions repetitively, yet this information might by completely new to the patients. Thus, they focus on their delivery and explain in easy words, even if it is for the 100th time in a day.
- Use of icons and pictures to spell out how to act and what to avoid.
Humour as an answer to culture shocks
Using humour as a method for dealing with patients and in situations of shock helps to avoid devaluating the other. At the same time, it also bears the potential that the other person feels laughed at and not taken seriously.
This case shows that you cannot prepare yourself to avoid culture shocks, but it rather depends on how you deal with a shock, when you experience it.