Going Global – A Guide on International Protocols

We live and work in a global economy.  Thanks to the conveniences of modern technology, geographic distance is not a barrier for conducting business worldwide.  It is likely that you have already encountered various forms of cultural diversity in your career as a physician. 

Whether it is through teachers, peers, colleagues, advisors, or patients, you will continuously find yourself interacting and doing business with individuals from diverse cultures and different parts of the world.  In addition to working with and treating patients from varying cultural backgrounds, it is possible that you will either make an international business trip or be responsible for hosting and assisting international colleagues who come to the US on business.

America is the most culturally diverse country in the world, but it is also one of the most culturally inept.  Consequently, most Americans are extremely unfamiliar with the customs and cultures of their international colleagues.  Because international customs often drastically differ from those observed in the US business world, Americans are ill prepared for interacting with individuals from other countries.

This article will explore some general guidelines that should be considered when working with people from other countries.  Additionally, it will explore two specific areas in which customs are markedly different from those of the United States.

General Advice when Doing Business with People from Other Countries

Whether you are doing business with international colleagues in the United States, visiting international counterparts in their home country, or generally interacting with patients who come from varying ethnic backgrounds, there are some things you can do to show your understanding of and appreciation of their culture.

•    Learn a few phrases in the country’s language.  For example, “hello”, “goodbye”, “please”, “nice to meet you”, etc.
•    Learn some facts about the specific countries of your colleagues.  It is important to know a little about the government, social structure, role of women and the role of the family from varying cultures in order to be able to converse with different individuals.  For example, in several parts of the world, you should never talk about your family or ask about another person’s family.
•    Gift giving is a very common practice in other parts of the world, but the etiquette associated with giving gifts varies greatly among countries.  When traveling internationally, you generally can’t go wrong when you purchase gifts that are uniquely American.  However, in some parts of the world, such as Japan, elaborate and expensive gifts are given to foreign visitors and equally elaborate gifts should be given in return.
•    Make an effort to know the religion of international colleagues as this may affect how you interact with them.  For example, there are some religious cultures that do not allow casual touching or handshaking and some religions have strict food restrictions.
•    Familiarize yourself with the standard greetings for specific countries.  For example, in some countries, you only shake hands with persons of a certain rank or standing and other countries frown on shaking hands with a member of the opposite sex.  Further, some countries do not embrace hand shaking at all and replace the traditional handshake with a bow of some sort.
•    Be aware of varying communication styles.  While Americans are very direct and get right to the point, such a straightforward way of communicating is considered unrefined by some cultures.  In other group-oriented cultures such as Japan, singling out a person and giving them a compliment may be considered an insult.
•    Realize that comfort is not as valued in other countries as it is in the United States.  When visiting other countries or when dining in the home of an international colleague, understand what kind of dress is expected, as it will often be dressier than what would be expected in the United States.
•    When visiting other countries, make sure you know the local currency and understand tipping etiquette.  Tipping etiquette varies greatly among countries and there are even a few countries where tipping is not allowed.
•    Communicating internationally via email requires some additional considerations.  Consider the time zone of the person who will be receiving your email and allow an appropriate amount of time for a response.  It is also important to remember that other countries observe different business hours, holidays, and vacations than those that are customary in the United States.  It is not uncommon in some countries for businesses to close for an entire month.  Given these time differences, it is always appropriate to include the date and time appropriate to the country when you send your email.
•    Adhere strictly to the country’s business card etiquette.  Business cards are highly valued in other parts of the world and failure to give them proper respect is insulting to foreign colleagues.
•    Never criticize the regime in power of a specific country.
•    If you are hosting an international colleague, have some local treats, such as coffee, teas, crackers, cheeses, and chocolates, awaiting them in their hotel room.

American Habits that are Displeasing to People from other Countries

It is important to understand that international individuals working in the United States will have strong cultural differences and will not always understand the customs adhered to in the United States.  There are certain American practices that can be very unfamiliar, and sometimes offensive to your international colleagues.  Understanding these cultural differences will aid you in working with these individuals.  Specific differences you may encounter are:

•    Importance of punctuality.   With the exception of the Arab and Latin worlds, most countries prize punctuality and are extremely insulted by the American habit of arriving late for meetings or appointments.
•    Evening activities that detract from family time.  In most other cultures, primary importance is given to family, and work matters are secondary to family matters.  Therefore, it is not uncommon for colleagues from other cultures to not want to attend work-related activities that occur in the evening and that would take them away from their families.
•    Long cocktail hours before dinner.  Spending several hours “having drinks” before dinner is not common in other countries.  If an international colleague invites you to an 8:00 pm dinner, you should expect that dinner will begin promptly at 8:00 pm.  Understanding this difference may explain why your international colleagues are often not enthusiastic about “having drinks” prior to dinner.
•    Criticizing foreign food.  While Americans have a habit of commenting on or criticizing the taste, preparation, or selection of foreign foods, people from other countries would never think of criticizing our food.  In fact, in other cultures, food is simply not a subject for discussion in negative terms.
•    Constantly correcting other people’s English.  It is discouraging to an international person when his American colleagues continuously point out every grammatical error he makes with his English.  Americans need to appreciate how difficult it is to speak a second language and be gracious and patient with colleagues whose English is not perfect.
•    Not knowing about essential political changes of a country.  Americans should, at a minimum, know about significant political changes that have taken place in the home countries of their colleagues so as not to appear naive or uninformed.  For example, it would be embarrassing to talk about Czechoslovakia instead of the Czech Republic.
•    Joking about religions or sacred traditions.  In America, some of the best jokes have religious or ethnic themes and Americans are often not offended by such jokes.  However, this kind of humor is misunderstood in other cultures and is best avoided.

Specific Protocols for Interacting with Individuals from The Arab World

Business Protocols:
•    Arab individuals are easily offended, so be very cautious in using humor with your Arab colleagues.
•    Punctuality is not expected, nor valued, in this part of the world; therefore, do not be surprised if an Arab colleague traditionally runs late for meetings or appointments.
•    Arabs generally do like to jump straight into business talk.  It is appropriate to engage in small talk before beginning a meeting or “talking shop”.
•    Arab professionals are extremely impressed and appreciative of thoughtful American thank you notes.  If you are the dinner or party guest of an Arab person, or you have received a special favor from an Arab person, writing a short informal thank you note will be very well received.
•    Arab businessmen always shake hands with every man present in a room or at a meeting, but they avoid shaking hands with women.
•    In the Arab world, Ramadan, an annual month of fasting and prayer, usually occurs in March or April.  This time is a very holy time for Arabs, so scheduling a business meeting during Ramadan is never appropriate.  You should also be sensitive to your colleagues and their observance of this holiday.  Often, Arab colleagues will take vacation during this time period.

Social Protocols:
•    Never use swear words or mention God.
•    When sitting, do not expose the soles of your shoes to Arab colleagues.  Doing so is considered extremely offensive.  A recent example that illustrates this custom occurred when the statue of Sadaam Hussein fell in Iraq and we saw television images of Iraqi’s hitting the statue with the soles of their shoes as an act of disgust towards their fallen leader.
•    Arabs do everything with their right hands, so when you offer something, hold something, or receive something; do so with your right hand.  Left hands are used for handling toilet paper.
•    Do not point or signal towards an Arab.  Arabs use such gestures themselves when calling their dogs.
•    Kissing on both cheeks is the customary greeting for Arabs, even when they are of the same sex.
•    It is not uncommon for Arab men to hold hands with male acquaintances in public places.  Doing so has no sexual implication whatsoever.
•    Most Muslim women wear a traditional garment known as the chador, a dark colored cloth that covers the entire body, including the majority of the face.  American women should never comment on this native garb or express an opinion as to how uncomfortable the dress appears.  Making such comments are very offensive to Muslim women.

Conversation Protocols:
•    Most Arabs speak English, but if you can learn a few Arabic phrases or words, your Arab colleagues will be very flattered.
•    Arabs are big soccer fans and they enjoy discussing the sport at length.
•    Avoid the subject of Israel when conversing with Arab colleagues.
•    In many parts of the Arab world, specifically in Saudi Arabia, families are considered a personal matter.  You should avoid asking prying or direct questions about the families of your Arab colleagues.
•    Arabs are generally very interested in the American political system and enjoy hearing Americans discuss local politics.
•    An American woman should never voice her opinion on the lack of liberty of Arab woman, especially in front of her Arab colleagues.  This is true even if she believes that her Arab colleague shares her viewpoint.

Gift Giving Protocols:
•    Never praise any personal possession of an Arab too exuberantly, as he may feel inclined to give it to you.
•    When doing business with Arabs, wait until you have received a gift before returning a gift.  This is because Arabs are known for giving expensive, elaborate business gifts and you will want to ensure that your return gift is equally elaborate.
•    Never give alcohol to anyone in a strict Muslim country such as Saudi Arabia.
•    Be cautious about giving a gift of food to an Arab as he may interpret the gesture as a criticism on the quality of his food that he will be serving you.

Specific Protocols for Interacting with Individuals from India

Business Protocols:
•    Almost all Indians speak English, even if Hindi is the national language, but it is always appreciated when an American tries to learn a few Hindi phrases.
•    Indian women appreciate and are pleased by a man’s chivalrous behavior in the workplace.  Therefore, men should not be afraid to help a female Indian colleague by opening the door for her, helping her with her coat, or even rising when she enters or leaves a room.
•    Indians appreciate punctuality, but are known for canceling and rescheduling appointments.
•    Before beginning a business meeting with an Indian colleague, engage in “small talk”.  Doing so is the traditional way of building rapport and trust.

Social Protocols:
•    The traditional social greeting, the namaste, is made by putting your fingertips together in a prayer position and slightly bowing your head at the same time.
•    Indians are very familiar and comfortable with hand shaking.  However, be aware that some Indian women remain uncomfortable shaking hands with men.
•    In general, Indian society is conservative about physical contact, and public displays of affection are not accepted.
•    Indian food is often extremely spicy.  Your Indian colleagues will not be offended if you decline to eat the very spicy food.
•    Do not point to someone with your finger.  Doing so is seen as an accusatory gesture.  To get the attention of someone, hold out your hand with the palm down and make a swooping motion with your fingers.
•    Folding your hands or keeping them in your pockets may be interpreted as arrogant gestures.
•    Many Indians do not wear shoes inside a home.  If you are invited to the home of an Indian friend or colleague, you should make sure that your socks are clean and do not have holes as you will likely be asked to remove your shoes.

Conversation Protocols:
•    Indians are very proud of their history, art, palaces and gardens.  It will please your Indian colleagues if you are able to converse on such matters.
•    It is never appropriate to bring up the topic of religion or comment on the country’s poverty.
•    India is a very family-oriented country and they enjoy discussing their own families as well as learning about others’ families.  Asking about your family is a sign of genuine friendliness.

Gift Giving Protocols:
•    Give a gift to an Indian colleague with both hands.  Gifts are not normally opened in the presence of the giver.
•    Never give a Hindu anything made of cowhide or pigskin.  The cow is sacred in the official state religion and anything made with pigskin is an insult to the religion.
•    It is appropriate to give liquor to Hindus, but not to Muslims.
•    When you meet an Indian colleague for the first time, it is traditional to bring him a small, inexpensive gift.  A box of American chocolates or some other type of gourmet sweet is a good suggestion.
•    When an Indian colleague invites you to dinner, take fresh cut flowers for the host and always bring presents for the children.
•    Indian women appreciate American cosmetics and perfume, so these always make good gift choices

What once was a large world is now quite small.  Our workplaces as well as our educational institutions are global entities populated by individuals with very diverse backgrounds.  In your medical career, you will experience this diversity in a number of ways; through teachers, colleagues, patients, and peers.  Making the effort to understand global protocols will not only show respect for individuals of differing ethnicities, but also enhance your professionalism and your reputation as a well rounded, respected physician.

About the Author:

Wesley D. Millican, MBA, CEO and Physician Talent Officer of CareerPhysician Advisors, LP, and CareerPhysician, LLC, provides comprehensive talent solutions for academic children’s hospitals, colleges of medicine and academic medical centers across the nation. He possesses a longstanding passion for career development of all young physicians and serves as a go to career resource for training program directors and their residents and fellows. In continuing his commitment to the “future of medicine”, Mr. Millican speaks nationally at residency and fellowship programs. His Launch Your Career® Series is a proven resource for today’s residents and fellows and has served as a go to resource for program directors over the last 15 years.