Table 2. The participants’ perceptions regarding physician–patient communication after watching a video in an Iranian context
Theme Main concept Concept Code Meaning Unit (A sample of quotation)
Cultural diversity   Trust   Belief*     Religious statement Religious statement now in Iran vs. in Sweden Quote: Difference, Amen – religious statements during    conversation Quote: Religious statement, like 60 years ago in Sweden. Participants 1,2,6,10.
Ø Patient value* Ø Patient respect Ø Religious* Importance of considering patient value Exaggeratedly Doctor Respect   Wearing hijab and religious manner Quote: Patients are not convenient during history taking due to exaggerated respect to doctor that might be related to prestige and value. Participants: 2,3,5,6,8,10 Quote: Patient appearance and wearing hijab cloth may be related to mistrust for the doctor. Participants: 2,7,8,9
Interpersonal interaction Ø Insufficient communication   Verbal: Lack of greeting   Nonverbal: Lack of eye contact and physical touch   Lack of physical movement   Quote: Doctor doesn’t look at his patient. He speaks with insufficient tone and pitch to his patient. It is interesting that he doesn’t move when his patient came in. Participants: 1,2,6,8,10 Quote: Doctor did not listen to patient and it seems that he is just asking the list of prepared questions. Participants: 2,4,5,7,8 Quote: when the patient feels nervous and told to doctor that she was worried the doctor did not explain complete why endoscopy is not necessary. Participants: 3,4,5,8,9,10
Context Ø Sociocultural situation Ø Doctor ascendency   Keeping distance between doctor and the patient   Doctors look at the patient from up to down Quote: Patient and doctor sit beside each other in Swedish setting, but in this video, they sit in front of each other and table was in between. Participants: 1,2,4,6,8   Quote: In the video showed that doctor looked at the patient from up to down and did not consider her at the same level of himself. Participants: 10, 12
Doctor centeredness   Doctor authority   Doctors confidence Could not convince patient   No final agreement between doctor and patients Quote: It seems that the patient feels inconvenience during the visit. p Participants: 1,2,3,8, 11   Quote: Doctor couldn’t understand her problem as she explained.  Participants:3,5,9,10
Doctor paternalistic view Doctor pseudo confidence   Patient not convinced   Quote: But he did not consider share decision making so patient was not convinced. Participants 1,2,5,6,10   Quote: If the physicians have weak communication skill to convince the Patient. She will go to another DR to do the endoscopy.  Participants: 1,3,4,5,9,12   Quote: Doctor doesn’t justify patient about the decision made about his problem Participants: 3,4,5,7,9
Doctors socio- cultural class High status of doctor in social hierarchy effect on doctor’s behavior Quote: Doctor authority seems to be based on doctor’s position and social class instead of scientific knowledge or clinical skill.  Participants: 1,3,5,6   Quote: I think there is no need to self-presentation or show power to patients. Participants: 1,2,5,7,8,10
Feedback and attention Doctor does not pay an attention and give feedback Quote: Doctor either does listen to patient carefully or give them feedback. Participants: 4,5,8,9   Quote: I think he doesn’t pay attention to his patient at all.  Participants: 1,2,4,7,8
Cultural diversity                                                 Doctor Dominancy   Ø Patient convinced   Patient not convinced Quote: I believe if patient who is from another culture do not trust to doctor he or she will not use the doctor's prescription and it will threaten patient safety. Participants: 2,4,5,6,8   When patient does not believe the doctor based on their own culture and mind map then they regret to accept the physician opinion and prescription. Participants: 1,3,4,5,10
Ø Historical background Doctor centeredness considered as a dominant strategy Quote: Doctor centeredness was common in Sweden 60 years ago and among older physicians than current doctors in Sweden.  Participants: 8,1
Interpersonal interaction Ø Insufficient communication Verbal: ·   Shortage of interpreter ·   Language barrier ·   Translation Problem   Non-verbal: ·   Body language Quote: " I remember the Iranian patient who was suffering from femur fracture in ER. I had many difficulties to communicate with her then one of the staff (Iranian) who was around by chance helped me to translate and convenience for having surgery. helped us to save patient life Participants: 1,2,5,10 Quote: Communication with body language, nonverbal and Google translator. Participants: 3,4,5,9,10
Trust Ø Believes* Ø Professionalism Ø Patient rights* Ø Preserve patient dignity Delivering bad news and considering patient rights   Lack of breaking bad news to patient, not telling the truth regarding sickness Quote: We believe that it is normal to give any news related to health problem, first to the patient, but in some cultures, doctors prefer to give especially bad news to others instead to the patient. Participants: 2,4,7,9,10
Ø Ethics and values Ø Patient appearance Ø Religious* Ø Gender Considering human being in different culture Quote: All patients sh­­­ould be treated in the same way because they are given equal right to live, ­­­­­­diagnose and treat.  Participants: 1,4,5   Quote: Iranian doctor and patient have some barriers in communication skills such as different gender and they do not have eye contact, these are important barriers – in the Swedish culture it means the one does not pay attention to patient.  Participants: 1,2

Note: concept verification marked with*; Participants expressed similar perceptions as the quotes indicate are noted by their participant number below the quotes.

Int J Med Educ. 2020; 11:158-168; doi: 10.5116/ijme.5f19.5749