Empathy and Gwangju’s Migrants

By Maddy Miller

How It All Began

After living in Gwangju for about six years, mostly as a private academy teacher, partly as a language student at Chonnam National University, I returned to the U.S. with the goal of getting into graduate school. Not knowing which program to select, I missed the 2021 application cycle, and so, I got a job in Koreatown, Los Angeles, at a primary care clinic. There I was able to maintain my connection to Korean language and culture through interacting with our patients and healthcare providers (HCP; this includes doctors, nurses, medical assistants, case workers, physician assistants, pharmacists, and so on). Frustrated with my indecisiveness about which academic program to choose and struggling to find community in L.A., in January 2023, I reached out to a friend still living in Gwangju, an international student from Uzbekistan studying for his master’s degree in economics.

We decided to read Anne Fadiman’s The Spirit Catches You and You Fall Down together. The book outlines the difficulties – medical, cultural, linguistic – faced by one family who immigrated to California as they interacted with the American healthcare system on behalf of their young daughter, diagnosed with epilepsy. In our conversation about the book, I said to him, “I want to be able to do that as my research in graduate school, about Gwangju.” He quickly replied, “Why not do it now?” So, that April, we embarked on a research project to do just that. The friend ended up having to tend to other responsibilities, but this project was one of the most formative experiences I have had to date.

Interviews Begin

I conducted nearly 100 hours of interviews between April and June 2023, with 34 migrant families in four different languages (English, Korean, Russian, Chinese, with the help of a Russian native-speaker friend and a Chinese native-speaker friend).

My Uzbek friend and I thought it was possible that some childless migrants living in Gwangju had never visited a Korean hospital or clinic, even if they had been sick, because of constraints of their home country’s health system or simple stubbornness (“I’ll be fine”). Hence, we decided to focus on migrant parents because we assumed that, being concerned for their child’s health more than their own, they would visit Korean clinics or hospitals more often than a childless migrant. We initially set out to discover whether migrants felt that they faced racial and ethnic discrimination when visiting Korean hospitals and clinics.

Within the first few interviews, though, it became clear that most migrants we were talking to did not feel this to be the case. Rather, they felt that Korean HCPs either discriminated on the basis of Korean language ability, were uncomfortable because of a language barrier, or were not discriminatory at all. The beauty of qualitative research is that the topic and questions are emerging and responsive to participants, and the two questions I came to focus on with the remaining interviews were “Why do migrants like the doctors they like, and dislike the doctors they dislike?” and “What makes a migrant stay at a given healthcare facility, and what makes them leave?

Doctor Shopping

“Doctor shopping” is the official term for changing doctors or healthcare facilities when not a result of medical malpractice. In countries like Korea or Singapore, because there is no referral required to change doctors, doctor shopping is quite common. A primary care physician (PCP) in the US or general practitioner (GP) in the UK or Canada typically provides a referral to connect a patient under their own care to another HCP in more specialized care or diagnostic testing. Because the PCP or GP oversees transfer of care, doctor shopping is much less common in those countries – and sometimes is cost prohibitive.

When it does occur, though, most doctor shopping in the US is because of either (a) narcotic seeking (over-use or abusive) behavior or (b) getting a second opinion, either one the HCP has given but the patient disagrees with, or one the patient believes is accurate but the HCP refuses to determine. I was curious to find what prompted Gwangju’s migrant parents to engage in doctor shopping, as some indicated they do so often, while others found a pediatrician or other healthcare provider that they loved, and never wanted to go doctor shopping again.

The answer to my research question (“Why do migrant parents stay or go? What pushes them to engage in doctor shopping?”) boiled down to trust. If people trust their doctor or their child’s doctor, they are more likely to stay there. This has been shown in research to typically result in better health outcomes.

Empathy

In trying to understand the components of this trust, I found that the biggest criteria for trust or distrust in an HCP was the migrant’s perceived empathy from the provider. Providers’ empathy was expressed as being focused on two main topics: empathy about their child’s health condition and/ or the reason the parent has come to clinic this day, and empathy about the difficulties faced by being a foreigner (most predominantly language, but also about biophysical differences, cultural differences, accessing or inability to access resources, etc.).

Empathy can be conceptualized in a number of ways: Semantically, it is related to words like “care,” “sympathize,” “have compassion for,” “try to understand,” or “imagine oneself in another’s shoes.” Some authors, like Leslie Johnson, write that it encompasses recognizing human worth and dignity; others, such as Abraham Verghese, connect it with being present and engaging in active listening. In clinical encounters, between a doctor and patient, though, it is typically incorporated and accounted for more specifically, such as in association with specific nonverbal behaviors.

Scales like the Essential Elements of Communication (EEC) are used in medical and nursing schools to help the faculty score students according to specific behaviors (“made sufficient eye contact,” “sat close enough but not too close”) that are intended to engage the patient, encouraging the patient to be more forthcoming in their retelling of medical histories, eliciting worries that could become barriers to medication schedule adherence, or clarifying any information about upcoming procedures and treatment.

Empathy is perceived by a patient as “the doctor is kind, warm, helpful, supportive,” while a doctor sees it more as “I’m getting the patient to give me the information I need to know.” This works in favor of both patient and doctor: The patient feels more confident in the doctor’s care; the doctor can make or help the patient make decisions that will lead to better health outcomes (read: fewer mistakes that will lead to a patient suing for malpractice). Patient satisfaction also leads to less tension in non-clinical moments at a clinic, such as interacting with the registration desk about check-in or insurance coverage questions. Empathy in clinical care is better for everyone.

Bids for Empathy

This is true around the world. Doctors and patients in the US, Taiwan, and Korea all have these empathy cues, and in many cases the behaviors associated with these cues are the same. Sometimes, unfortunately, across language barriers, these cues are more difficult to pick up on because of the added communicative load of working with and through a medical interpreter. It’s not always possible to convey an “ask” for empathy (typically called “bids” in the academic literature). Usually this is because of time constraints but also because of limitations on other aspects of the encounter, such as having family of the patient also involved in a clinic visit or competing goals (e.g., “I need more blood pressure medication, but also I wanted to ask about my diet’s effect on my weight”).

These bids for empathy might look different in different cultures; some cultures, such as Chinese, are more receptive to interruptions for questions. Others may be less direct in asking for sympathy or empathy; talking about difficulties in their personal lives may be intended to elicit an “I’m so sorry to hear that. How is that impacting your health?” for patients, while others may be more stoic and not want to talk about “personal problems.”

In Gwangju, specifically, it is clear that migrant patients are seeking much the same thing as both (a) migrant patients elsewhere, and (b) Korean patients in Gwangju. Migrant patients want to be seen, heard, and respected by their doctors, whether they are from the same culture or not. And this feeling of being seen, heard, and respected adds to their trust in the doctor, increasing their willingness to continue treatment with the same doctor over an extended period of time.