You couldn’t write how Dr En-Ming Tham and I met. During a locum session in North London, I came across a patient that I needed to discuss with a regular doctor. The details escape me but I remember browsing through the instant messaging system and pinging a message to the only other doctor on site, Dr Tham. It turns out that En-Ming was also locuming and we had that moment when we both realised that the blind was going to have to lead the blind!

The positive was that En-Ming recognised my name and we got chatting about international work and his involvement with China-UK collaborations. We bumped into each other again at the RCGP annual conference when he was showing round delegates from China. I have to say I really enjoyed this interview because there is so much that is similar between the work that we do but also I have to respect En-Ming for calling me out on a few of my assumptions (see text boxes)!

En-Ming, born to Chinese parents, grew up in the UK and, like myself, grew up with the East at home and the West outside. Having just finished his GP training and with a keen interest in international work, he started fishing around for some opportunities. “It started with, like most of these things, just lucky, completely serendipitous. I think I saw an email from the RCGP international team that they had doing something with China – some memorandum or notice – I just started emailing people and put myself forward because I don’t think there’s many fluent Mandarin-speaking UK-trained GPs”

The RCGP International (to whom the JIC report) run several collaborations worldwide including China, Brazil, and the Middle East amongst others. Some of this includes empowering nations to put in place a culturally adapted MRCGP and ensuring quality control but, for China, they provide a “Training the Trainers” course for Chinese  doctors. “They advertised for a Training Needs Advisor who go out to foreign countries and check their training systems and see what standard they are at and give advice. I asked about that but I wasn’t experienced enough – I had just qualified. Though they suggested I come along to this other thing because of my language. The College were really good actually, very welcoming, they got me involved in one of the courses. They already had people to teach and I was there as a cultural bridge, helping a little bit translating – like a teaching assistant.”

En-Ming and I inhabit a twilight zone between two cultures. Since spending more time in Japan, I am aware that the traits of my personality that, whilst growing up in the UK I had put down to being individual, were actually cultural. For me, I feel comfortable in both countries but neither feels like a complete fit and there’s always an internal yearning for the other country. What that does leave people like us, however, is the unique ability to be cross-cultural and cross-linguistic – perfect for becoming bridges between two networks.

So I ask him whether he has experienced any cultural clashes: “I find that hard to pinpoint. What is cultural and what is linguistic and different educational background in medicine? I find it really hard to separate those things sometimes. There’s all these things that you have to think about when you’re doing all this cross-cultural education – it’s way more difficult and complex than delivering it to a UK audience.”

I push him for an example. “The Chinese doctors have a habit of eating early and then having a nap – that’s cultural – so across China, schools, universities, they will eat lunch at 11:30 in the morning or midday and then have a nap at work. They will just put their head down on the table and you have all these Chinese doctors completely comatosed in their chairs and you’re wondering why. So with the later courses, lunch has been a bit earlier and the lunch has been a bit longer so that people can have a nap on their tables. Another one I’ve done in Essex, they’ve done it all in the same hotel that the Chinese are staying so that they can go to their rooms to sleep and it makes such a big difference because they can come back to the course wide awake, ready to learn.”

I should mention here that En-Ming works with an RCGP collaboration with a Chinese province but also for Essex County Council. “They [Essex county council and a province in China] have a long relationship – about a decade long – with a province for various reasons. So all their schools are twinned. They run their own professional courses for lawyers, judges, firemen that come over from China or they do exchanges including healthcare ones. The roles [for the RCGP and Essex County Council] are about the same. I teach but I’m also course lead. I got involved with the Council through the JIC indirectly. I think, with Essex, someone in the committee was approached. Maybe Sinan [the previous Chair of the JIC]? They just needed someone for a day but then there were more courses after that.”

“So there usually will be a pre-course discussion between the College or Essex and the Health Bureau over there and they discuss what they are looking for. Sometimes you find that what they think they wanted to know when they start talking to you about things are too different across the two systems and may not be applicable to China. For example, going very deeply about referral theory – what influences a referral what is a good referral – that has very little bearing on their day-to-day work because they don’t have to do one as there is no gatekeeper role to a secondary hospital. And you end up moulding it [the teaching] to what they find more useful for their day-to-day work and whatever ideas they had.”

Working in London with its diverse population, we have evolved by using translators to facilitate consultations, whether that is in person or through Language Line. I’m fascinated by the power shift that arises in the consultation room just by having this third party in the room and find myself searching for strategies to feel less disempowered by it. It reminds me of the famous scene in the film “Lost in Translation” where the translator turns to Bill Murray’s character and sums up a very long spiel by the director in three words. It appears that this happens in education as well. “I’ve noticed that with the people who come to talk sometimes go the other way. They might see the translator and the people in the room are losing interest and they get more tight and tense up and go on even longer or start reading off the slide. They give up trying to engage with the room.”

So being able to speak both languages puts En-Ming in a unique place where he has access-all-areas in the language department. “It’s quite interesting witnessing how much harder it is to deliver a course through a translator because everything depends on how much energy they have and how well they are translating the subtler things like the humour and the turns of phrases of the lecturers. On one course, during the first week there was an excellent translator and the second week there was a different person translating and it completely shifted the way the course happened.”

“That’s the other subtle thing, in the cross-cultural classroom, is giving feedback to the translator which is hard because the translator is not a medic, they’re not trained in education, they’re just doing word-for-word stuff. You have to feedback to them without undermining their authority because its important that the learners trust the translator. That’s something I found very interesting – the role of the translator and how I interact with them.”

“A bad translator would translate word-for-word without trying to interpret the way in which something is said and I think it can kill of the vibe in a classroom very quickly – although you can argue that it is good translating because it is accurate. The best translation I’ve seen is when the translator understands the sentence and knows where it is leading, maybe understanding the cultural context or the turns of phrases used and also translating that. This draws laughs from a crowd in the same way that would have been drawn from an English crowd which is just magical and very hard to do and that is amazing translation.”

There is actually a term for this. We are all accustomed to the “language barrier” which is where we might not be able to communicate due to not knowing the appropriate vocabulary but there is also a “semantic barrier”. This refers to the obstacles faced by not understanding the meaning or the context of the words. A crude example would be words like ‘wicked’ in English which has a negative and positive connotation.

“I just went to a conference at the Oxford union about modern China and there was a very famous literary translator there, Nicky Harman. She was talking about literary translations – about translating the essence and being true to the author. You don’t always think of doing that in the classroom because it’s not as complex. It’s just a lecture. But it’s just as important. That’s the role that people like us who are cross-cultural, cross-linguistic should have. So often there is no one else in the room who is a medic and speaks both language fluently. And I don’t think it’s an intuitive skill.”

For the record, the Japanese that I work with prefer to battle through in English with varying results. Speaking a second language is hard and I know all too well the frustrations of not being able to express yourself as eloquently as you could do in your native tongue. My Japanese is not bad but it’s not native, having grown up in the UK, and I’ve had to endure some pretty patronising moments. But whatever I go through, I know it’s nothing compared to those who have to present at conferences, write abstracts and network in a second language. I am one of the fortunate ones where English, the international language, is my strongest tongue just through the accident of where I grew up. I really wish to remind everyone who is a native English-speaker involved in international work of this privilege. Keep your sentences short and don’t let your sentences merge into the next (this is an incredibly British thing to do – especially when flustered!)

So what is En-Ming’s favourite aspect of his work? “I’ve definitely been surprised at how receptive the Chinese have been to role-playing and practising the different communication skills and different sections of the consultation. Those have often been the highlights because they’re dynamic and interesting and that’s where you feel like you’re challenging them the most. Some of the other bits of the course it feels like you’re delivering fairly didactically because you’re going through a translator. When you break things down and get into small groups and everyone lets their hair down, you get the feeling that it’s potentially something more worth-their-while, because they’re experiencing something well out of their own learning environment and their culture which is hopefully something that they come here for.”

“Role-plays are such a cheap tool and there is good evidence that getting good at facilitating role-plays improves outcomes. It’s so cheap. Having well-skilled communication experts as your primary care physician adds so much value and it’s so underdone.”

“We’ve gone as far as things like learning what small group facilitation means, running a role-play, rules of feedback and it all seems to go down quite well. When you go down far enough – like how a senior doctor might give feedback to a junior doctor – that is where so far I’ve been met with more of a cultural or habitual barrier. This really still tends to be ‘this is where you’ve done wrong’ and ‘this is how I would do it, bang, bang, bang’  rather than a two-way facilitating conversation and that’s been quite hard to explore. It seems quite a deep thing.”

Sonia: ‘Are you managing to break down these barriers?’

En-Ming: ‘One question is ‘is it our role to be breaking down those barriers?’

Hofstede separates cultures into six binary categories. Arguably, this is rather simplistic but is an easy entry-level way to see the variability between cultures. In this example, En-Ming may be referring to the difference in power distance, which is the extent to which less powerful members of a team accept the hierarchy. A junior in a culture of less power distance may feel more empowered to challenge the views of a more senior member.

“We were doing a fish bowl – so someone was playing a GP trainee and someone was playing the patient and someone is playing the trainer – and the purpose of the role play is for the trainer to facilitate the feedback for the GP trainee. What was really fascinating was that we talked about why we use feedback rules and why people feel uncomfortable being challenged too much. We were still finding that when giving feedback, people were just spraying off a list of ‘you did this wrong’, ‘you should have said that faster’ and there was very little two-way conversation. I thought maybe that this was just a culturally significant thing and that this was intractable and how they’re taught. But when we did the feedback of the feedback afterwards, one girl who had played the GP trainee said ‘you know what? it really felt like a list and it felt too much and I felt very defensive’. It was the same stuff that you hear when you run these sessions in GP training in the UK – like Pendleton rules. So exactly the same stuff came out of their mouths. ‘I didn’t feel comfortable receiving that feedback’, ‘I felt very vulnerable’ and ‘she sprayed a list of negatives of what was done wrong’. I’m yet to answer that question [are you breaking down these barriers?] but some of these things may be universal.”

It’s hard to separate all these things out and I often feel guilty about cultural overshadowing like diagnostic overshadowing where you put everything down to whatever condition the patient has.

“The other thing is that if you were running this kind of feedback form with a bunch of UK orthopaedic surgeons it might be the same sort of thing. They may give feedback in their own hierarchal way. It’s hard to separate all these things out and I often feel guilty about cultural overshadowing like diagnostic overshadowing where you put everything down to whatever condition the patient has. It’s very easy when you’re teaching to say ‘this is not working very well maybe it’s a cultural thing’. Sometimes if you look deeper it’s a competency thing with they way you’ve tried to explaining it.”

I like the fact that, throughout the interview, En-Ming focuses on what is similar between the two cultures – the aspects that make us human – rather than focusing on the differences. By giving the Chinese GPs tools in education, they can apply this in their own way to their own problems. This makes me reflect on the work that I do and what can I do differently. I think he’s right about the cultural overshadowing and I am guilty of that. Being aware of differences, for example as delineated by Hofstede’s theory, is useful as a context but, at the end of the day, creating connection by being flexible and on a human level is what can motivate an intercultural team to work together.

So what was En-Ming’s advice to GPs early in their career? “The thing that has made it happen so far for me is having conversations, putting out what you’re interested in.  I did have to be very proactive at the beginning. I had to say ‘I’m really interested in using my Chinese somehow’ even though that was  never my plan early on in medicine. I never realised that this would be my thing. So putting out there that you’re interested in certain aspects of international care. Get conversations going. It was never about China for me until I saw that email.”

And why primary care? “It’s the only way to meet the healthcare needs. It’s the only way with the funds and the aging population. I think everyone recognises that. I think some people find it hard to see it here with the funding but, in China, they see it and they are really pushing to have things in their community.”

Dr En-Ming Tham is a locum doctor in his First 5 working in North London and works for both the RCGP and Essex County Council as Course Leader on their collaborations with … province and … province  in China respectively.