CULTURE AND INTERCULTURAL COMMUNICATION: AN OVERVIEW FOR MEDICAL STUDENTS

7 CULTURE AND INTERCULTURAL COMMUNICATION: AN OVERVIEW FOR MEDICAL STUDENTS Stela Spînu „Nicolae Testemițanu” State University of Medicine and Pharmacy, Chișinău, Moldova Abstract. Culture is defining for any nation, ethnic group, or individual, playing a decisive role in shaping the personality of each generation. In today’s globalized context, we are shaped not only by the values, traditions, and norms of our own culture but also by those we come into contact with. From this perspective, knowledge in the field of interculturality becomes essential, contributing to the development of communication skills, the understanding of diversity, and the adoption of appropriate behavior in multicultural environments. Keywords: Culture, multiculturalism, interculturalism, transculturalism, behavior, communication Published by Teacher Training Department, “1 Decembrie 1918” University of Alba Iulia 1. Introduction Culture is a defining element for every nation, ethnic group, or individual. It shapes a person’s perception of life and death, as well as the way they express and experience suffering and joy. Throughout life, individuals are influenced not only by the values, traditions, and norms of their own culture but also by those with which they come into contact. In this context, it is essential to develop intercultural communication skills and adopt appropriate behaviors when interacting with people from different cultural backgrounds. In line with these ideas, this article aims to define the concept of culture, interpret the forms of interaction between cultural systems, analyze the behavioral and structural dimensions of intercultural communication, and offer recommendations for young people who wish to engage in effective dialogue with representatives of other ethnicities. 2. Culture and Diversity. Theoretical framework 2.1. About culture in a diachronic perspective The word culture is of Latin origin, initially designating the process of caring for land or livestock. Later, through semantic extension, it acquired the meaning of “cultivation of the mind” [Spînu, 2018, p. 7]. In academic discourse, the term culture 8 entered during the Enlightenment, referring to the accumulated knowledge throughout history, the sphere of creative ideas and artistic values, as well as the traditions, ways of thinking, and customs characteristic of various human communities [Georgiu, 2008, p. 18]. Over time, the term culture has been defined from various perspectives due to its extremely broad nature. According to A. Kroeber and C. Kluckhohn, between 1920 and 1950 alone, at least 157 definitions were formulated. After carefully analyzing these, the American anthropologists concluded that “culture represents a set of ideas, values, and symbolic systems created and transmitted by humans, playing an essential role in shaping human behavior” [Minkov, p. 10]. Later, Edward B. Tylor introduced the term culture into the scientific field of cultural anthropology. According to the British culturologist, “culture represents the complex whole of knowledge, beliefs, artistic expressions, moral norms, laws, customs, and any other abilities acquired by humans as members of society” [Rohmah, p. 27]. Today, we can state that culture is “a complex set of values, traditions, norms, symbols, and beliefs, as well as behavioral attitudes, together with the totality of material supports that sustain, preserve, and transmit them from generation to generation. Culture is supported by the multitude of individuals involved and by institutions pursuing spiritual, moral, artistic, and other purposes” [Spînu, 2018, p. 9]. 2.2. Forms of interaction between cultures In the specialized literature, the interaction between cultures is conceptualized through the terms multiculturality, interculturality, and transculturality, each referring to distinct levels of coexistence, communication, and integration between different cultural groups. The term multiculturality was adopted into American academic discourse starting in 1941, reflecting society’s concerns about recognizing cultural diversity and preventing intercultural conflicts. Multiculturalism is a defining characteristic of countries hosting multiethnic communities, such as the United States, Canada, Australia, the United Kingdom, India, and Israel. Through cultural policies, these countries promote respect for diversity, cultivate tolerance, support individual autonomy, encourage equality, and ensure peaceful coexistence. Therefore, when engaging in dialogue with people from these countries, it is important to take into account their values and norms, particularly their emphasis on preserving freedom and the right to personal opinion in interpersonal relationships. A multicultural society may evolve into an intercultural one if greater emphasis is placed on inclusion, exchange, and intercultural dialogue. Intercultural communities share the same territory, respect the values, traditions, and lifestyles of others, and place importance on fostering inclusion and intercultural dialogue. From the perspective of the Council of Europe, “the universal values on which interculturalism is based are respect for human rights, democracy, the rule of law, and recognition of the fact that all people have equal dignity and are entitled to equal 9 respect” [Barrett, p. 26]. Interculturality is valued in countries of the European Union, Switzerland, Russia, Moldova, and others. In the current context of globalization, there is increasing discussion of transculturality—a concept deeply explored by Wolfgang Welsch in his work Transculturality: The Puzzling Form of Cultures Today. According to the German philosopher, “transculturality demonstrates that lifestyles transcend national borders, taking on a European or global character. At the individual level, transculturality is expressed in the formation of multiple identities, reflecting an era of cultural hybridization in which individuals are influenced by various cultures” [Welsch]. Countries tending toward transculturality are generally characterized by a high degree of globalization, international mobility, and cultural collaboration. Among them are Germany, France, Canada, the United States, Switzerland, and others. People with a transcultural orientation often choose to migrate rather than remain in places that do not offer them stability or satisfaction. They frequently let go of places and things once dear to them, adapting easily to new environments. Thus, the forms of cultural interaction vary depending on each country’s specifics and how it manages cultural diversity. We can distinguish between states with multicultural, intercultural, or transcultural orientations. Naturally, values, norms, beliefs, and behaviors differ not only from country to country but also from one individual to another. In this context, it becomes essential to recognize these forms of cultural interaction and adopt appropriate forms of communication and behavior when navigating cultural environments different from our own. 2.3. Intercultural communication – expression of cultural diversity 2.3.1. Conceptual framework In recent decades, numerous researchers have emphasized that culture is not an independent, autonomous entity but has a dynamic and unstable nature. Dutch psychologists Hubert J. M. Hermans and Harry J. G. Kempen, in their book The Movement of Cultures: The Perilous Problems of Cultural Dichotomies in a Globalized Society (1998), state: “The phenomenon of globalization is responsible for extensive interaction between different cultures, leading to the exchange of economic, political, social, technological, cultural, and ecological elements” [Fernández, p. 20]. This phenomenon causes cultural convergence, which in turn fosters the development of intercultural communication. At present, there is no universally accepted definition of the concept of intercultural communication. Some American researchers, such as William B. Gudykunst, limit this term solely to “dialogue between individuals of different ethnicities.” Other theorists, such as Judith N. Martin and Thomas K. Nakayama, broaden its semantic scope, using it to refer to interethnic, interreligious, interregional communication, as well as communication between individuals with different sexual orientations [Rohmah, p. 76]. In this study, by using the term intercultural communication, we refer to dialogue between individuals with different cultural affiliations, interpreting the specific features of these types of interactions. 10 The first studies in the field of intercultural communication were conducted by American researchers. Initially, the U.S. government identified diplomatic difficulties in interactions with host cultures, attributing them to a lack of understanding of their cultural characteristics and communication norms. In response, in 1946, the government established the Foreign Service Institute, dedicated to training officers for collaboration with people from other cultures. Edward T. Hall, together with Ray Birdwhistell and George Trager, contributed to the development of this institute, laying the foundations of the discipline Intercultural Communication [Spînu]. 2.3.2. Contributions of Edward T. Hall Edward T. Hall’s contributions to the development of the field are significant. He transformed the way individuals from other cultural backgrounds had previously been perceived, emphasizing distinctive traits rather than common ones. He introduced the concepts of high-context (HC) and low-context (LC) cultures, which revolutionized the understanding and analysis of interactions among people belonging to different ethnic communities. According to Hall, in low-context cultures (such as those of the United States, the United Kingdom, Canada, Germanspeaking and Scandinavian countries, etc.), communication is primarily direct and denotative; the expression of thoughts, intentions, or needs is clear and explicit; questions are asked whenever clarification is needed; and a message is considered understood in the absence of further inquiries [Lim]. In high-context cultures—such as those in Latin, South American, Asian, Arab countries, and the post-Soviet region—communication tends to be indirect and connotative; responses are often ambiguous, aiming to preserve harmony or display politeness; nonverbal cues are highly significant; public confrontation is avoided; and issues are preferably resolved in private [Lim, p. 158]. Over time, Hall’s views have been widely adopted and applied across various fields. Following this logic, individuals from low-context cultures (LC) favor informal communication styles, fairness, the use of first names, enthusiastic and confident expression of opinions, acceptance of open confrontation (when it serves the common good), avoidance of sarcasm or irony, unconditional respect for others’ autonomy, and a commitment to equality and impartiality. When communicating with representatives of high-context cultures (HC), however, indirect and subtle communication should be employed; their status and social roles should be respected; and the involvement of close family members or spiritual leaders in difficult life situations should be acknowledged and accepted. Significant differences are also evident in managerial behavior. In a conflict, a manager from a low-context culture (LC) may address the situation empathetically, expressing concern for the employee’s feelings with phrases like “I’m concerned about your performance” or “I believe you can do more,” thereby encouraging selfimprovement. Conversely, a manager from a high-context culture (HC) might adopt a more direct and critical approach, saying “Your performance is unsatisfactory” or 11 “I’m unhappy with your work,” emphasizing dissatisfaction without explicitly providing a framework for improvement [Usman, p. 72]. For effective dialogue, it is also crucial to understand the temporal orientation of each cultural environment. Edward T. Hall distinguishes between cultures focused on the past (e.g., Greece, France, the United Kingdom, India, China, Japan, the postSoviet region, etc.), cultures oriented toward the present (e.g., Spain, Italy, Australia, and some Latin American countries), and cultures oriented toward the future (e.g., the United States, Germany, South Korea, Singapore, etc.) [Hurn, p. 27]. According to the anthropologist, when interacting with individuals from cultures focused on the past, it is essential to show respect for their ethnicity, native language, history, traditions, and etiquette norms. Communication with representatives of presentoriented cultures should be direct and denotative, avoiding abstract or overly theoretical discourse. In conversations with individuals from future-oriented cultures, emphasis should be placed on innovation, modern solutions, and long-term strategic planning. Thus, Edward T. Hall’s model remains both effective and highly relevant to contemporary realities. The validity of his ideas is undeniable, and their understanding and application would greatly facilitate authentic and effective dialogue with people from other cultures. 2.3.3. Geert Hofstede's perspective Initially, intercultural communication was a field explored predominantly by American researchers; however, in recent decades, it has also attracted significant academic interest in Europe. Notable contributions include those of Georges Michaud, J. R. Ladmiral, E. M. Lipinski, Geert Hofstede, and others. The most widely discussed achievements in the field of intercultural communication are those of Dutch psychologist Geert Hofstede, renowned for developing a conceptual framework for analyzing and comparing cultures worldwide (Culture’s Consequences, 1980). The elements of Hofstede’s cultural dimensions theory are: „(1) the power distance index (focuses on the degree of equality between people in the country’s society); (2) individualism vs. collectivism (individualistic societies have loose ties that often only relates an individual to his/her immediate family; collectivism describes a society in which relationship ties spread to extended families); (3) masculinity vs. femininity (masculinity is defined as „a preference in society for achievement, heroism, assertiveness and material rewards for success”; femininity stands for a preference for cooperation, modesty, caring for the weak and quality of life); (4) uncertainty avoidance index (societies with a high degree in this index opt for stiff codes of behavior, laws, and generally rely on absolute truth); (5) long-term orientation vs. short-term orientation (this dimension associates the connection of the past with current and future actions/challenges); (5) indulgence vs. restraint (countries with a high individualism rating are more likely to allow or encourage simple pleasures; they are focused on enjoying life and having fun” (Spinu, 2012, p. 192-193). Awareness of these dimensions enables healthcare professionals to better 12 understand international patients, provide them with appropriate advice and treatment, and obtain the desired feedback. Currently, the results of Geert Hofstede’s research are available on The Culture Factor Group platform, managed by an international company specializing in global cultural analysis and consultancy. This platform is highly beneficial for healthcare providers who work with international patients or plan to emigrate. 2.3.4. Intercultural communication related to the structure of cultures In interculturality research, scholars have raised the issue of determining the categories by which one culture can be distinguished from another. Gerhard Maletzke identified and named these as structural characteristics of cultures. These include: the national character of a people, its worldview, time management, spatial perception, thinking style, language, value systems, behavioral models, and interpersonal relationships [Maletzke, p. 72]. According to the author, by delving into these structural characteristics, we can decipher the ethnonym and ethnotype of any people, group, or individual. Below, we will examine the most relevant characteristics that should be considered when seeking to communicate with representatives of other cultures: (1) The national character of a people. The present and future of a nation depend on its character. According to Henri H. Stahl, “the entirety of our Romanian character derives from the Dacians, thus invoking an antiquity older than that of the Romans; the Dacians, in turn, trace back to an even older antiquity, that of the Thracians, and from there further back into prehistory” [Stahl]. Therefore, understanding the national character of a people - often reflected in its history - is essential for anyone who wishes to establish authentic and constructive dialogue with its representatives. (2) Worldview (perception of reality). In communication, it is important to recognize that people from different cultural backgrounds may perceive reality in distinct ways, and that these differences must be understood, accepted, and respected. For example, the lotus flower is a sacred symbol of purity and spiritual enlightenment in India and Southeast Asia, while in the West it is merely an ornamental plant; mărțișor is a symbol of spring and rebirth in Romanian culture but is unknown elsewhere; in Asian cultures, rice symbolizes prosperity, while in the West it is simply a staple food. Color symbolism also differs: red represents love in Western cultures but prosperity in Chinese culture; white symbolizes purity and happiness in the West, whereas in many Asian cultures it signifies mourning. (3) Time management. Philosophers view time as a formal category, constant for everyone. However, in daily life, its meaning and management vary across cultures. These differences are evident both in different conceptions of time and in diverse approaches to managing it. Maletzke highlights that cultures tend to be predominantly oriented toward the past, present, or future: (a) In China, time orientation is primarily toward the past, evident in ancestor worship and the importance of family tradition; (b) Arabs take pride in a six-thousand-year-old culture, often accompanied by sorrow over the passing of that era; (c) for many Europeans, the past continues to hold significance, particularly for the English; (5) 13 for Americans, the future takes precedence. According to Maletzke, Calvinistinfluenced cultures are strongly future-oriented, emphasizing hard work, business success, and a modest lifestyle [Maletzke, p. 56]. Time management has always been a significant challenge for every nation, ethnic group, or individual. When abroad, one must be aware that attitudes toward time can significantly shape people’s behavior. (4) Value systems. All thoughts, experiences, and actions are rooted in value orientations, which are passed down from generation to generation through socialization but may evolve as societies change [Maletzke, p. 81]. For example: (a) Core Christian values include love, forgiveness, humility, compassion, honesty, and truth; (b) Hindu values emphasize dharma (duty), karma (action and consequence), ahimsa (non-violence), satya (truth), respect for diversity, and bhakti (devotion); (c) Islamic values emphasize iman (faith), adl (justice), compassion, haya (modesty), respect, and honesty.As a result, individuals from these religions display different behaviors because character is built on distinct value foundations. (5) Thinking style and behavioral models. Since ancient philosophy, coherent thinking guided by logic has been emphasized. Today, most Westerners perceive the world as transparent and governed by “laws,” meaning that if initial premises and conditions are known, situations become predictable and controllable. By contrast, in many developing countries, magical thinking prevails, encompassing beliefs in magic, witchcraft, and superstition, which hinder logical reasoning [Maletzke, p. 57]. Thinking style directly shapes behavioral models. Most Europeans and Americans are inclined to engage actively, especially when circumstances demand it. In many other cultures, however, physical labor is considered a sign of low social status, and elites might lose respect if they perform such tasks themselves. In Asia, refraining from physical labor was historically a sign of privilege, with work delegated to lower social classes or even slaves, as was common in Theravada Buddhist, Lamaist, and Islamic regions. Thus, individuals who wish to establish genuine dialogue with members of other ethnic groups must understand and acknowledge the structural characteristics of their culture and adopt communication models and strategies that are suited to their interlocutor’s cultural context. 3. Barriers in intercultural medical communication. Theoretical analysis In intercultural medical communication, numerous challenges may arise. In this study, we will focus exclusively on the most common ones, namely: (1) ethnocentrism, (2) stereotypes, (3) culture shock, and (4) nonverbal communication. 3.1. Etnocentrism The term ethnocentrism was introduced into academic discourse by William Graham Sumner. In his 1906 work Folkways, the American sociologist and philosopher defined ethnocentrists as “individuals or particular groups who consider themselves superior to others, disregarding other cultural forms, and being convinced of the uniqueness of their own culture.” The consequences of ethnocentric attitudes and 14 behaviors in the contemporary world are assessed in different ways. On the positive side, ethnocentric ideas bring together individuals who share the same values, traditions, lifestyles, and beliefs. These individuals often avoid or neglect dialogue with people from other cultural backgrounds and do not seek cultural exchange. In certain situations, however, ethnocentrists may become supporters of radical ideas that can lead to discrimination. The negative role of ethnocentric attitudes in medicine has been analyzed by American researchers Hendry Ton and Russell F. Lim in Clinical Manual of Cultural Psychiatry. According to them, “Psychiatry has advanced from the ethnocentric interpretations of mental disorders prevalent a century ago to a modern approach that values cultural diversity. Contributions from sociologists and anthropologists facilitated the adoption of the biopsychosocial model in 1980, significantly improving both diagnosis and culturally sensitive treatment” (Lim, p. 3). Today, ethnocentric attitudes generally persist in high-context (HC) cultures, representing a major obstacle in doctor–patient relationships and sometimes leading to the neglect of bioethical principles and the core values of the Hippocratic Oath. Healthcare professionals are required to provide care with passion and empathy to all individuals in need, regardless of race, ethnicity, religion, language, or other factors, and ethnocentrism must be overcome. 3.2. Stereotypes Relations between different cultural communities are closely tied to how these communities perceive and value their own identity. In this context, stereotypes are often used. The term stereotype, derived from the Greek stereo (“rigid”) and typos (“impression”), was introduced into academic discourse by Walter Lippmann. In his 1922 work Public Opinion, the American political scientist argued that “people need a simplified version of reality, and this is what stereotypes provide” (Macovei, p. 56). The causes of stereotype formation are varied. When individuals from different cultural backgrounds meet, they tend to interpret others’ behavior, ways of thinking, and actions through the lens of their own culture, generalizing and simplifying them (positively, negatively, or neutrally) in order to describe them more easily later. This approach is subjective, highlighting similarities while ignoring significant differences. In this way, stereotypes are created and perpetuated. Stereotypes are not necessarily negative or harmful, though the term often carries negative connotations due to its association with prejudice, as stereotypes invariably involve feelings toward a cultural group and expectations about its behavior (Thomas, p. 120). Below are several internationally recognized stereotypes, often considered by medical professionals: Americans, Canadians, and Australians are perceived as friendly, easygoing, natureand sports-loving, direct in communication, assertive, materialistic, and ambitious; they have high standards, show perseverance in following proposed treatments, and prefer cutting-edge medical technologies; The British, Germans, Swiss, and Scandinavians are viewed as calm, discreet, pragmatic, 15 reserved in communication, and formal in their interactions with doctors; the Chinese, Koreans, and Japanese are seen as ambitious and materialistic, widely using traditional medicine and being reserved in discussions about mental health; Romanians, Italians, French, and Greeks are perceived as sociable, friendly, open in communication, respectful, and cautious; they place particular emphasis on interpersonal relationships and are considered resilient to pain. It is important to note that these stereotypes are generalizations and do not accurately reflect the diversity and complexity of these cultures. When stereotypes are taken at face value, they may lead to discrimination or misguided assumptions. 3.3. Culture shock The term culture shock was introduced into academic discourse in 1950 by Kalervo Oberg. According to the Canadian anthropologist, the concept describes the anxiety caused by the loss of familiar signs and symbols of social interaction. People are not born with a predefined culture but only with the ability to understand and use it. As we grow up in a particular cultural context and learn to interact socially, culture shapes our mindset and lifestyle [Georgiu, 2004, p. 13]. Culture shock affects the way people perceive information related to a new culture, representing a challenging experience that can either transform them or motivate them to grow. Kalervo Oberg described the process of overcoming culture shock through four stages: (1) Honeymoon phase – an initial period of fascination and enthusiasm; (2) Frustration stage – when cultural realities become foreign, confusing, and exhausting; (3) Adjustment – the stage of awareness and acceptance of cultural differences; (4) Reverse culture shock – when values once embraced begin to feel unfamiliar. As Michael Paige emphasized, “Culture shock is the expected confrontation with the unknown; reverse culture shock is the unexpected confrontation with the familiar.” Culture shock can pose a significant challenge in the context of medical tourism, as patients face linguistic, psychological, and emotional barriers, as well as differences in treatment and care practices. Therefore, medical staff must be aware of the diversity of cultural patterns, demonstrate behavior appropriate to patients’ expectations, ensure effective communication, and avoid value-based conflicts. 3.4. Impediments to nonverbal communication Nonverbal communication can be defined as the totality of conscious and unconscious movements and postures through which attitudes and emotions are conveyed. It includes the following components: (a) body language (kinesics), (b) eye contact (oculesics), (c) physical posture and personal space (proxemics), (d) paralanguage, (e) physical contact (haptics), and (f) the use of time (chronemics). (a) Body language (kinesics) encompasses body posture, facial expressions, and gestures. Facial expressions are a key source of information, particularly about underlying emotional states. Early research indicated that the same facial expressions are associated with certain emotions across all cultures. The three main parts of the face (the forehead and eyebrows, the eyes, and the mouth) convey happiness, surprise, disgust, fear, anger, and sadness [Maletzke, p. 187]. In medical