Physician and patient perceptions of cultural competency and medical compliance

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1 HEALTH EDUCATION RESEARCH Vol.30 no Pages Physician and patient perceptions of cultural competency and medical compliance S. Ohana 1,* and R. Mash 2 1 Interdisciplinary Studies, Program on Conflict, Management and Negotiation, Bar Ilan University, Ramat Gan , Israel and 2 Department of Sociology, Ariel University, Ariel 40700, Israel *Correspondence to: S. Ohana. ohanashula@gmail.com Received on December 6, 2014; accepted on October 17, 2015 Abstract To examine the relationship between the different perceptions of medical teams and their patients of the cultural competence of physicians, and the influence of this relationship on the conflict between them. Physicians cultural competence (Noble A. Linguistic and cultural mediation of social services. Cultural competence of health care. Echo New Studio 2007; 91:18 28) might reduce this phenomenon. Structured questionnaires were distributed to 90 physicians working in outpatient clinics in a central hospital in Israel, and to 417 of their patients. Each physician had four to six sampled patients. The findings showed a significant negative correlation (r ¼ 0.50, P < 0.05) between the physicians perception of their cultural competence and the patients perception of physician competence. The more patients perceive the physician as culturally competent, the more they comply with their medical recommendations. In addition, the findings show that ethnicity significantly affects patients perception of the cultural competence of physicians, and their satisfaction with the medical care they receive. Introduction Prior research demonstrates that cultural diversity can create conflicts such as that between Christians and Muslims in the Arab sector, and between secular and ultra-orthodox communities in the Jewish sector [1]. These conflicts are also expressed within the framework of health services. Medical personnel and patients are experiencing differences that are part of the process of social and cultural developments in the world. Cultural diversity, differences in customs and language barriers are factors that may cause conflict. These factors influence the relationships between medical staff and patients, and the degree of patients satisfaction with the patient physician encounter [2]. Farther more, sometimes the cultural gap between medical staff and patients exists because of prejudices and stereotypes of the medical staff, e.g. Blairet al. [3] find in their research that black patients rated less than white patients, their satisfaction among patient-centered care from clinicians with greater implicit race bias. Cooper et al. [4] although find in their special method of research (verbal communication) that among black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness and poorer ratings of interpersonal care comparing to white patients. Patients can have beliefs and perceptions about the nature of their illness and the ways it should be treated that differ from the physician s; this may also create conflict due to the patients poor understanding of the medical instructions. The relationship between the medical staff s and the patients different perceptions of physicians cultural competence background, and the impact of these differences on the conflict between them, has been tested in Israel in a qualitative study [5]. In addition, Gallagher and ß The Author Published by Oxford University Press. All rights reserved. For permissions, please journals.permissions@oup.com doi: /her/cyv060

2 S. Ohana and R. Mash Polanin [6] in their meta-analysis study found varied effectiveness of intervention to increase cultural competence among medical staff. Even Truong et al. [7] found that objective evidence of intervention effectiveness was rare. Both researches claim that it is essential to make future deep and coherent studies for assessing intervention that ought to increase cultural competence among medical staff. The term culture is used to define ethnic groups that share the same background [8]. The term organizational culture refers to the beliefs, assumptions, values and norms, behavior patterns and symbols which are shared by the members of an organization. Organizational culture reflects the core values of the organization [9] and the level of solidarity in the organization [10, 11]. A conflict may rise between the interests and beliefs that groups aspire to, which cannot coexist [12]. Culture dictates how symptoms of illness are perceived [12]. Different cultures relate differently to doctor s instructions. Some cultures view disease and health as Part of a person s fate, and thus do not believe that medical treatment may influence the outcome of a Patient s Disease [13]. This may cause noncompliance with recommended treatment. For example: a 13-year-old girl of Ethiopian Origin Suffered from a life Threatening cancer of her hand. Her physicians decided to amputate her hand, but her parents refused amputation because of their religious belief that a child without a limb brings bad luck. This case is one example of many cases occurring during intercultural encounters between medical personnel failed in hospitals and patients on the Ethiopian community, for example. These meetings demonstrate the difficulty of the cultural differences between doctors and patients. These cases point to the importance of organizational culture in shaping perceptions, beliefs and behaviors related to health. These and other situations illustrate the need for the doctor to be cultural fit, to understand the information about the patient s culture and to integrate it into the process of health care. Appropriate care across cultures can occur only when patient, family and community. Expectations are aligned with physician knowledge, attitude and behavior [14]. A conflict between a physician and a patient, arising out of cultural diversity, has been defined [15] as a collision between the perceptions, goals or values of the participants in the interaction. The concept of cultural competence in health care is described as the ability of the system to provide effective medical services to patients with different values, beliefs and behaviors, and to meet the social, cultural and linguistic needs of these patients [8]. The field of cultural competence has been developing in recent years as part of the strategy to overcome cultural differences in health services [14, 16, 17]. The signs of a difference in cultural perceptions between patients and medical staff may be difficult to detect [18]. One of the most significant methodological challenges of cultural competence research is the lack of standard metric evaluations [14]. The importance of the research on patients perceptions of their physicians cultural competence lies in identifying the mechanisms through which cultural competence affects health and medical treatment [19]. Cultural competence, from the perspective of patients, is critical to the quality of their care and their satisfaction with the medical treatment received [20]. The patient s perception of the cultural competence of their physician is defined as the ability of the physician to establish an effective physician patient relationship, overcoming any cultural differences. In studies on the issue of the perception of physicians cultural competence by Ethiopian and former Soviet Union (FSU) populations, e.g. there were found to be cultural differences affecting the interaction between the physicians and their patients [21 26]. It has been observed that physicians who receive training in cultural competence communicate better with their patients [27]. Teal and Street [28] suggested four elements model of skills acquisition for improve medical staffs cultural competence. The elements are: communication repertoire, situational awareness, adaptability and knowledge about core cultural issues. The model emphasizes the incremental development of communication skills for managing the cross cultural nature of the clinical encounter. 924

3 Physician and patient perceptions The main purpose of this study is to investigate whether there is a correlation between the different perceptions of physicians and patients of the former s cultural competence, and the existence of conflicts between them. It will also evaluate these differences in relation to how satisfied patients are with their medical treatment. The study dealt with a number of variables in an attempt to focus on the existence of a correlation between them: Our research questions were as follows: (1) Does the difference between the cultural background of the physicians and the patients affect the conflict between them? (2) Is there a relationship between the physicians perceptions of their own cultural competence and the patients perceptions of the physicians cultural competence? (3) Is there a relationship between the physicians perceptions of their own cultural competence and the patients satisfaction with their medical care? (4) Is there a relationship between the background variables of the physicians, the difference between the patients and the physicians perceptions of the latter s cultural competence, and the patients satisfaction with their medical treatment? Methods The research tools were structured questionnaires translated from English to Hebrew, the native language of Israel. The study population included two groups: 90 physicians working in a hospital s outpatient clinics in central Israel and 417 adult Hebrew-speaking patients of those physicians (e.g. Table I about here) (e.g. Table II about here). Four to six patients were sampled per physician. Participants completed the questionnaire voluntarily Table I. Patients socio-demographic features (n ¼ 417) Variables N % Gender Women Men Unknown Total Marital status Single Married Divorced Widower Unknown Total religiosity Secular Traditional Religious Orthodox Unknown Total Patient s birth country Israel North Africa FSU Europe USA/South Africa Ethiopia Yemen Asia Unknown Total Mother s country of birth Israel North Africa FSU Europe USA/South Africa Ethiopia Yemen Asia Unknown Total and with consent. This study used two different questionnaires to gather information on the main study variables: (i) the physicians perception of their own cultural competence and (ii) the patients perception of the physicians cultural competence. The patients questionnaire was based on the one used by Michalopoulou et al. [19] and included: reference to background variables, how the patient perceives the cultural competence of their physician, and the patient s degree of satisfaction with their medical treatment. The patients questionnaire 925

4 S. Ohana and R. Mash demonstrated high reliability with a Cronbach s alpha reliability coefficient of The questionnaire included three parts: Part A consisted of nine background questions on sociodemographic variables such as age, gender, country of birth, religion (see Table I) etc. Part B included 28 items. The first 10 items assessed the patients perception of the cultural competence of the physicians and the next set of statements related to the patients satisfaction with their medical treatment as they perceived it. The questionnaire answers were based on a Likert scale from 1 to 7, with 1 representing never, and 7 representing always. The score for each patient s perception of their physician s cultural competence, quality of care and satisfaction with the health care provided was calculated as the average of all 28 items. Part C consisted of five questions which examined the extent to which the patient followed the medical recommendations, and possible reasons for not following these recommendations. Likert scale of 5 1 was used in this section: 1 representing never, and 5 representing always. The second questionnaire, which was distributed to the physicians, included the physicians background variables and how the physician perceived his/her own cultural competence. The questionnaire for the physicians was based on the questionnaire developed by Doorenbos et al. [14], and included three parts. Part A consisted of 11 background questions with a demographic nature, such as gender, age, marital status, etc. (see Table II). Part B included statements related to how physicians perceived their own cultural competence. This part consisted of 28 statements and demonstrated good reliability (Cronbach s alpha reliability coefficient was 0.89), including the 2D of cultural competence: behavior, awareness and cultural sensitivity. The questionnaire answers were originally based on a scale from 1 to 5, but to make them comparable with the answers on the patients questionnaire, they were changed to a different scale range of 1 7, with 1 representing never and 7 representing always. The physicians perception of their cultural competence was calculated as the mean of 28 items. Calculating the difference between the physicians perception of their own cultural competence and the patients perception of Table II. Physicians socio-demographic and background features (N ¼ 90) Variable Frequency % Gender Women Men Unknown Marital status Single Married Divorced Widower Unknown Religiosity Secular Traditional Religious Orthodox Unknown Country of birth Israel Russia USA/South America Other Mother s birth country Israel Europe FSU South America Other Main language Hebrew English Hebrew/English Russian Hebrew/Russian Arabic/Russian Physician medical school graduate country Professional experience (years) Israel FSU USA/South America Europe (years) Unknown their cultural competence was done by averaging the differences between these two sets of perceptions. Part C of the physicians questionnaire included 926

5 Physician and patient perceptions three questions which examined the physicians estimation of the extent to which the patient was following medical recommendations. The research procedures were approved by the local Helsinki Committee. The study was performed in the outpatient clinics of the hospital during 8 months in The questionnaire was given to all the patients who visited the clinics, and who gave their verbal consent to participate in the study. It was handed to patients after their visit to the physician s clinic. The physician s questionnaire was given personally to the physicians of these patients. The physicians filled in these questionnaires immediately after each patient visit. Each questionnaire was given a numerical code that identified the clinic unit, the physician and the patient, so that the patients of each physician were identified anonymously. The study variables included dependent variables: the difference between the physicians perception of their own cultural competence and the patients perception of their cultural competence. The research variables of the physicians dealt with the question: How culturally competent do physicians perceive themselves to be? The research variables of the patients dealt with the question: How do the patients perceive the cultural competence of their physicians and how satisfied are they with their medical care? Cultural competence includes both the competence of the physicians and the patients perception of the cultural competence of the physicians. The difference between the physicians perceptions of their cultural competence and the patient s perception of the physicians competence was calculated by averaging the gap between cultural competence perceptions over 417 patients (each patient group versus individual physician). A gap between the two averages supposed to indicate gap of perception between patients and physicians regarding physicians cultural competence. The gap direction supposed to indicate that if physicians perception of their cultural competence is lower or higher than the patients perception of their cultural competence. Results The results obtained show how patients perceive the cultural competence of their physicians, considering the dimensions of competence. Very high correlations were found, which can indicate the multicollinearity between the patients perception of the cultural competence of their physician and their general satisfaction with their medical care (r ¼ 0.87, P <0.01(. (e.g. Table III about here).a significant correlation was found between general satisfaction of the medical care and the following variables: patients perception of the cultural knowledge and cultural ability of their physicians (r ¼0.97, P <0.01 and r ¼0.94, P <0.01, respectively) patients perception of their participation in medical treatment (r ¼0.81, P <0.01( and the patients perception of the communication between them and the physicians (r ¼ 0.80, P <0.01(. A significant high correlation was also found between the patients perception of the cultural competence of physicians and the patients satisfaction with their medical treatment (r ¼ 0.87, P < 0.01). Therefore, the more patients assess their physicians as culturally competent, the more satisfied they are with their medical treatment. No significant correlation was found between the physicians perception of their own cultural competence and the patients perception of their cultural competence. This study examined our four research hypotheses: (i) There is a relationship between the cultural backgrounds of the medical staff and of the patients and the probability of conflict existing between them. This hypothesis was supported by our findings. This relationship is explained through the gaps between the perception of physicians of their own cultural competence and patients perception of the cultural competency of their physicians. These gaps contribute to the conflict between them. A significant negative correlation was found (r ¼ 0.5, P < 0.05) between the gaps of physicians perception of their cultural competence and the patients perception of the cultural competence 927

6 S. Ohana and R. Mash Table III. Pearson correlations between the study variables of doctors and patients Physicians Perception of their own cultural competence Patient satisfaction with medical care physicians Perception of their own cultural competence Patients perception of their sharing with medical care Patients perception of their wait in the doctor s visit Patients perception of the cultural knowledge of doctors ** Patient satisfaction with medical care Physicians perception of their own cultural competence ** 0.81 ** Patients perception of their involvement with medical care ** 0.37 ** 0.63 ** 0.44 ** Patients perception of their wait in the doctor s visit ** 0.78 ** ** 0.97 ** Patients perception of the cultural knowledge of doctors 0.88 ** 0.41 ** 0.80 ** ** 0.94 ** Patients perception of the cultural ability of doctors 0.77 ** 0.57 ** 0.80 ** 0.98 ** 0.92 ** 0.80 ** Patients perception of communication with doctors *P < 0.05 **P <0.01 of the physicians: The greater the gap between a patient s perception of the doctor s cultural competence and the doctor s perception of his own cultural competence, it is less likely that the patient will fulfill medical instructions. (ii) There is a relationship between the physicians perception of their own cultural competence and the patient s perception of the same. There was no significant relationship between these two perceptions (r ¼ 0.02, P > 0.05). The hypothesis was therefore not supported. (iii) There is a relationship between the physicians perception of their own cultural competence and the patients level of satisfaction with their treatment. No significant correlation was found (r ¼ 0.08, P > 0.05). The hypothesis was therefore not supported. (iv) Background variables may predict the difference between patients and physicians perception of the cultural competence of the physicians, and the patients satisfaction with their medical care. (e.g. Table IV about here). Table IV presents the results of multivariate analysis of variance (MANOVA) and indicates that sharing the clinical treatment process with the patient is a variable which explains the difference between the physicians perception of their own cultural competence and the patients perception of the cultural competence of the physicians and the patients satisfaction with their medical care. Shared decision making is a collaborative process that allows patients and their providers to make health care decisions together considering the patient s values and preferences. In addition, when physicians and patients were from the same cultural background, the gaps narrowed and the patients satisfaction increased. When physicians were female, the gaps in perceptions between physicians and patients decreased. This may be explained by better verbal and communicative skills of women. This finding is supported by Laura et al. [30].Their study found that the female physicians adopt more partnership building-style with patients than their male colleagues. The study variables explained 77% of the variance in patients satisfaction. The hypothesis was supported. 928

7 Physician and patient perceptions Table IV. Multivariate variance analysis comparing physicians perception of their own cultural competence and patients perception of physicians cultural competence by patients satisfaction with medical care F Mean square Df Type III sum of squares Dependent variable Source 3.28* Gap between the perception of the physician Satisfaction with the medical treatment 6.34** Gap between the perception of the physician 7.96* Satisfaction with the medical treatment 5.45* Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment * Gap between the perception of the physician * Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician Satisfaction with the medical treatment Gap between the perception of the physician and the patient of cultural competenc Satisfaction with the medical treatment When patients report a more serious medical problem, they are more likely to follow the physician s recommendations (2 (16) ¼ 40.13, P <0.001). The findings also show that the extent to which the patient follows the clinical recommendations is directly related to their perception of the severity of the medical problem. The findings showed that the extent to which the patient follows the medical recommendations is low in the case of taking drugs and high in the case of hospitalization (2 (16) ¼ 40.02, P <0.001). As the patient perceives the refusal of treatment guidelines as high Clinic The physician and patient- same background Physician gender Level of religiosity of the physician Marital status of the physician Gender of the patient Degree of sharing the physician s decisions with the patient Waiting Duration of Residence Error Total health significance, such as the refusal to analyse the filling level is high medical instructions. The mean and standard deviation gap between the physicians perceptions of their own cultural competence and the patients perceptions of physician cultural competence were calculated: the average of the gaps was 0.24 and the standard deviation was In addition, no correlation between the physicians perceptions of their own cultural competence and the patients perceptions of physician cultural competence was found (r¼ 0.02, P > 0.05). 929

8 S. Ohana and R. Mash Table V. Post hoc test comparison between the ethnic groups in relation to patients perception of the cultural competency of doctors (the table shows only the ethnic groups for which a significant link was found) P Std. Error Mean difference Mother s country of birth Mother s country of birth * North Africa Israel * Former Soviet Union * Ethiopia * Asia North Africa * Israel Former Soviet Union * Yemen ** Asia * Former Soviet Union Yemen * Asia * Israel Israel ** North Africa ** Former Soviet Union ** Ethiopia ** Yemen The table shows only the ethnic groups for which a significant link was found. *P < **P < Table VI. Post hoc test comparison between the ethnic groups in relation to the satisfaction of patients from medical treatment (the table shows only the ethnic groups for which a significant link was found) P Mean Difference Mother s country of birth Mother s country of birth * Former Soviet Union Israel * Ethiopia * Ethiopia North Africa * Israel Former Soviet Union * Ethiopia * Ethiopia Europe * Israel Ethiopia * North Africa * Former Soviet Union * Europe The United States and South America * Yemen Asia * Persian golf countries * Ethiopia Yemen * Ethiopia Persian golf countries *P < **P < The negative difference indicates that the physicians perception of their cultural competence is lower than the patients. This gap indicates that patients perceive the physician s cultural competence as higher than the physicians perceive it themselves. Testing the patients perception of the cultural competence of physicians by ethnicity and overall satisfaction of patients showed that among Ethiopians there is a low degree of satisfaction with medical treatment, as well as a low perception 930

9 Physician and patient perceptions of the cultural competence of physicians, compared with other ethnic groups (e.g. Table V about here) (e.g. Table VI about here). Findings show that ethnicity significantly affected the patients perception of the cultural competence of the physicians and their satisfaction with their medical care. Hence, we see great importance in understanding ethnic differences that exist between various populations. Using a post hoc test showed that there are significant differences between native-born individuals and immigrants from the FSU and Ethiopia. Native-born patients perceive physicians as having a higher cultural competence than immigrants from Ethiopia and the FSU. In addition, there are significant differences between Asia and all other countries, and between people from North Africa and Asia. North African immigrants perceive physicians as having a higher cultural competence than patients from Asia. Using a post hoc test for comparing all the ethnic groups by general medical treatment satisfaction with the medical treatment received showed that satisfaction was the lowest among immigrants from Ethiopia and the FSU. After finding the differences between ethnic groups in relation to the degree of satisfaction with their medical care and their perception of physicians cultural competence, we examined whether there were differences between the groups regarding the extent to which patients followed their physicians instructions. In comparison with patients from other countries, Ethiopian patients and the patients FSU did not comply significantly with their physician s instructions (F (8,395) ¼ 19.29, P < 0.01). A post hoc test of the relative differences in the degree of compliance with the physicians orders according to the patients ethnic origin showed that Ethiopian patients and patients from the FSU follow the physician s instructions to a lesser extent with respect to other patients from Israel, North Africa, Europe, Asia Patients, etc. Table VII. Measures multiple regression results predicting the level of compliance with the provisions of health care patients t Beta S. Error B STEP ** Patients perception of their participation in health care F (1,171) ¼ , R 2 ¼ 0.48, P ¼ STEP ** Patients perception of their participation in health care 2.59** Level of religiosity of patients F (2,171) ¼ , R 2 ¼ 0.49, P¼ STEP * Patients perception of their participation in health care 2.80* Level of religiosity of patients 2.68* Gap between the perception of physicians of their own cultural competence and Patients perception of the cultural competency of physicians F (3,171) ¼ , R 2 ¼ 0.51, P ¼ STEP ** Patients perception of their participation in health care 3.40** Level of religiosity of patients 2.72** Gap between the perception of physicians of their own cultural competence and Patients perception of the cultural competency of physicians 2.61** Communication between patients and doctors F (4,171) ¼ 61.43, R 2 ¼ 0.51, P ¼ *P < **P <

10 S. Ohana and R. Mash Stepwise regression (e.g. Table VII about here) shows that a patient s perception of physician competence may impact patient adherence to treatment, which can affect disease progression and health outcomes. The more the gap between physicians perception of their own cultural competence and the patient perception of the physicians cultural competence narrows, the more patients accept the medical treatment (F(4,171) ¼ 61.43, R 2 ¼ 0.51, P < 0.01). Discussion This research examined differences between the ways the physicians perceive their cultural competence and the way their patients perceive it. Our study examined also how these differences contribute to the conflict between them, as well as to patients satisfaction with their treatment. There are a number of issues at the base of the study: the physicians perception of their ability to treat patients of different cultural backgrounds, the patients perception of the cultural competence of the physicians, and the assessment of conflicts in the process of medical care. In addition, these relationships and differences in perceptions of cultural competence may affect the course of the medical treatment and potential health outcomes. The conflict between doctor and patient has a significant meaning in the context of physician patient relationships, and may be the result of cultural differences between them, resulting in patients non-compliance with physicians instruction. The main purpose of this study was to investigate whether there is a connection between patients and physicians perceptions of the cultural competence of physicians. In pursuit of this aim, we examined discrepancies in these perceptions, which indicate the existence of conflicts between them, in order to evaluate the impact of physician and patient perceptions of physician cultural competency on the patients degree of satisfaction with their treatment. The findings indicate a significant positive relationship between the patients perception of the cultural competence of their physicians and their satisfaction (r ¼0.87, P < 0.01). Patients satisfaction with their medical treatment is related to the cultural competence of physicians, as perceived by the patient. When the difference between the cultural backgrounds of the patient and their physician is reduced, the probability of conflict between them is also reduced. The findings showed that Ethiopian patients and patients from FSU (first generation migrants) are significantly less likely to follow their physicians instructions than other populations (see Tables I and II). In addition, Ethiopian and FSU patients expressed the lowest level of satisfaction with their medical treatment, and the perception of the cultural competence of the physicians was lowest among these groups. The findings show that the greater the difference between the patients perception of the cultural competence of the physicians, and the physicians perception of their own cultural competence, the less likely the patient is to follow the physician s recommendations (r ¼ 0.50, P <0.05), and the probability of conflict between them will increase. The results indicate that there is no significant relationships between the physicians perception of their own cultural competence and the patients perception of their cultural competence (r ¼ 0.02, P >0.05). Discrepancy between the physicians perception of their own cultural competence and the patients perception of their cultural competence emphasizes the need to improve the cultural competency of medical staff. These findings are consistent with the results of the study of Star and Wallace [30] which examined the concept of cultural competence among physicians. They showed that most physicians define themselves as culturally competent to a medium to high degree, although they were not perceived as such by their patients. This finding may lead to a wrong bias and overestimation of the cultural perception as compared to the perception of patients in the study of Shapiro and Morrison [30] who studied the perceptions of physicians and patients regarding the need to provide training to improve cultural competence. They found that physicians and educational staff reported appropriate cultural communications in 932

11 Physician and patient perceptions terms of language and understanding of specific cultural knowledge. The patients reported that the most important aspect of the physicians behavior was to devote time to the patient, be thorough in providing explanations to the patient, answer the patients questions, and monitor patients. Cultural competence may reduce disparities and encourage cooperation between medical staff and patients [30]. Our results demonstrate (by stepwise regression, see step 3 in Table VII) that patient s perception of physician competence may impact patient adherence to treatment, which can affect disease progression and health outcomes. The more the gap between physicians perception of their own cultural competence and patience perception of the physicians cultural competence narrows, the more patients accept the medical treatment (F(4,171) ¼ 61.43, R 2 ¼ 0.51, P < 0.01). The research findings show that the association between patient sharing and medical care doctors difference between the perception of the cultural competency of patients perception of themselves and the cultural competency of physicians and patients satisfaction with medical care. The findings suggest that involving patient in the course of the medical treatment is a variable that may explain the gap between the perception of doctors of their own cultural competence and the patients perception of the cultural competency of the physicians and the patients satisfaction with the medical care. Sharing patient is the most important variable responsible alone for 48% of the level of compliance with medical instructions by the patient (see Table VII). An additional research question addressed the relationship between the physicians perception of their own cultural competence, and patients satisfaction with their medical care. The findings showed no significant correlation between the two (r ¼ 0.08, P> 0.05). However, poor communication between the physician and the patient could lead to distrust, conflict and patients dissatisfaction with their medical care [24]. This finding may be due to the lack of a significant association between physician perception of their own cultural competence and patient perception of physician competence. The findings show that there is a connection between sharing information about the medical procedure with the patient and the difference in the physicians and patients perception of the physicians cultural competence and the patients satisfaction with their medical care. In addition, the findings suggest that when the physician and the patient are from the same cultural background, the differences between them are reduced and patient satisfaction increases. The findings also suggest that the physicians gender influences the difference in perceptions between them; when the physicians are women, the differences between the physicians and the patients perceptions are reduced regardless of the patients gender. Michalopoulou [19] emphasized that patients perceptions of physicians cultural competence is positively associated with their satisfaction with their medical care. Therefore, understanding the mechanisms underlying the reduced differences in perceptions of physician cultural competency could help to improve patient satisfaction. Satisfaction was also found to be related to improved clinical results when the physicians and patients have a common ethnic ancestry. A relationship was also found between the degree to which the patients follow the physicians recommendations and their perception of the severity of the medical problem. The findings also show that the extent to which the patient fulfills the clinical recommendations is directly related to his concept of the severity of the medical problem and patient adherence to medications was low. This study has some limitations: There was not enough cultural heterogeneity in the sample; the distribution of the sampled subjects in relation to ethnicity and age did not necessarily represent the distribution of ethnicity and age in the population as a whole (see Table III). About half of those sampled were born in Israel, 20% were Ethiopian and 14% of them were from the FSU. The average age of the subjects was 48.88, which is the midpoint of the range of subjects, but is suggests that the study focused mainly on an older age group. The use of a relatively homogeneous sample may impair the ability to generalize the findings to other populations. 933

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