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© 2023 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

SIUJ  •  Volume 4, Number 4  •  July 2023 SIUJ.ORG

For instance, the NICE (UK) and AUA (US) guide-
lines endorse prostate therapy with Rezūm as an alter-
native treatment option for patients with moderate to 
severe LUTS and a prostate volume of 30 to 80 mL[5,6]. 
However, the European Association of Urology guide-
lines consider the current evidence to support the efficacy 
of Rezūm to be weak [7]. These discrepancies between 
guidelines, as confusing as they may be, must be part of 
patient counseling and consenting, and resulting patient 
anxiety must be addressed in an emphatic and appropri-
ate manner [8]. In the UAE, there is a recent trend towards 
Rezūm for patients with mild LUTS and large prostates 
>  80 mL, in which the evidence base given the above 
seems at least doubtful.

These are just two examples, and it goes without  
saying that this ongoing dilemma has unduly strained the 

References

1. World Health Organization. World Health Organization Country 
Cooperation Strategy at a Glance: United Arab Emirates. Available 
at: Accessed September 16, 2022.

2. Smedley BD, Butler AS, Bristow LR (eds). In the nation’s compelling 
interest: ensuring diversit y in the health- care work force. 
2004;Washington, DC: Institute of Medicine. doi: 10.17226/10885.

3. Bedoll D, van Zanten M, McKinley D. Global trends in medical education 
accreditation. Hum Resour Health.2021;19(70): (2021). https://doi.
org/10.1186/s12960-021-00588-x

4. Dordoni P, Remmers S, Valdagni R, Bellardita L, De Luca L, Badenchini F, 
et al. Cross-cultural differences in men on active surveillance anxiety: 
a longitudinal comparison between Italian and Dutch patients from 
the Prostate Cancer Research International Active Surveillance study. 
BMC Urol.2022 Jul 18;22(1):110. doi: 10.1186/s12894-022-01062-z.

5. Burnett AL, Nehra A, Breau RH, Culkin DJ, Faraday MM, Hakim LS, et 
al. Erectile dysfunction: AUA guideline. J Urol.2018 Sep;200(3):633-
641. doi: 10.1016/j.juro.2018.05.004.

6. National Institute for Health Care and Excellence. Steam treatment 
recommended for men with an enlarged prostate.2020 June 24. 
Available at: https://www.nice.org.uk/news/article/steam-treatment-
recommended-for-men-with-an-enlarged-prostate. Accessed June 
29, 2023.

7. Malde S, Umbach R, Wheeler JR, Lytvyn L, Cornu JN, Gacci M, et al.  
A systematic review of patients’ values, preferences, and expectations 
for the diagnosis and treatment of male lower urinary tract symptoms. 
Eur Urol.2021 Jun 1;79(6):796-809. doi: 10.1016/j.eururo.2020.12.019.

8. Avins AL. When clinical practice guidelines meet the black box. 
Arch Intern Med.2010 Jun 28;170(12):1013-1014. doi: 10.1001/
archinternmed.2010.185.

trust of patients in the medical profession. Consequently, 
“doctor shopping” where patients see several specialists 
for the same problem within a short time is not unusual. 
Similarly, health insurers tend not to trust the judge-
ment of doctors and require that the providers answer 
questions—generally indicating lack of understand-
ing--before approving a treatment. It is not unusual that 
the insurance requests and pays for an abdominal X-ray 
to prove the presence of a JJ stent before approving JJ 
removal.

On a more positive note, the above factors are being 
addressed. The local regulatory bodies are aware of the 
problem and are adopting time-tested models from 
Europe and the US, and the system will eventually 
incentivize and support good medical practice and clin-
ical governance.

245SIUJ.ORG SIUJ  •  Volume 4, Number 4  •  July 2023244

The Dilemma of Multiculturalism and Multinationalism in Medical PracticeUROLOGY AROUND THE WORLD

The Dilemma of Multiculturalism and 
Multinationalism in Medical Practice

Noor Buchholz,1,2 Mohammed Shahait2

1 U-merge Scientific Office, Athens, Greece 2 Consultant Urological Surgeon, Dubai, United Arab Emirates

DOI: 10.48083/GAHF2202 
Soc Int Urol J. 2023;4(4):244–245

The United Arab Emirates (UAE) has made significant progress in expanding health insurance coverage to its 
population in recent years. The government has implemented various policies to ensure all residents have access to 
health care. A report by the Dubai Health Authority (DHA) in 2020 estimated that around 98% of the population in 
Dubai had some form of at least basic health insurance coverage. Depending on the insurance policy, access to specific 
health care providers may be limited and there may be some out-of-pocket expenses for the individual, such as co-
pays or deductibles. For Emirati citizens, however, quality health care is completely free of charge[1].

The UAE is a very diverse country with a population consisting of a minority of Emirati citizens and a majority of 
expatriates from all over the world and from all walks of life. The country’s health care system reflects this diversity, 
with doctors from many different cultural and educational backgrounds and nationalities practicing in the UAE in all 
medical specialties[1]. On one hand, this diversity of medical practitioners in the UAE certainly reflects the country’s 
commitment to providing world-class health care services to its residents and visitors. With a highly skilled diverse 
and well-equipped workforce, the UAE’s health care system can offer a wide range of state-of-the-art medical services 
and treatments[1].

On the other hand, however, although this diversity of doctors undoubtedly enriches health care, bringing a vari-
ety of perspectives and experiences to patient care, there is less positive side[2]. Unfortunately, medical education 
and regulation of medical practice is not universally standardized with respect to the doctor–patient relationship 
and communication, ethics, clinical governance, best practice, regulatory control, and continued medical education 
throughout a doctor’s career[3].

In a multicultural, multi-ethnic, and multinational society like the one in the UAE, physicians may have varying 
approaches to patient care based on their sociocultural background, medico-social education, and communication 
and ethical training. All physicians in the UAE will be faced with a multitude of patients from different sociocultural 
backgrounds with varying expectations and communication skills that will not necessarily match those the doctors 
were trained in and are used to[1]. Therefore, they must develop a set of skills and bedside manners to deal with a vari-
ety of patients, and to understand and address their unique needs and concerns.

In our specialty, this diversity in patients’ backgrounds, cultures, and treatment expectations plays an important 
role in shaping the practices of urologists in the UAE.

Sociocultural factors have been demonstrated to affect the anxiety level among patients on active surveillance 
(AS) for low grade prostate cancer, which is directly linked to patients opting for radical treatment options where AS 
could be indicated [4]. These factors must be taken into account and sensitive counseling must be offered with a view 
to obtaining informed consent for the best course of treatment. Patients can give fully informed consent only if they 
understand the doctor and the doctor understands them and their concerns. This might partially explain the large 
number of prostate cancer patients in the UAE who are eligible for AS but opt instead for surgical treatment. In addi-
tion to a financial aspect that might favor surgical treatments, unaddressed patient anxiety may be a factor here.

National availability of medical devices has to be approved by both the Emirates Authority for Standardization 
and Metrology (ESMA) and the Ministry of Health Authority Prevention (MOHAP). However, their local availability 
is widely market-driven and dependent on the expertise of the providing health care professional. Apart from these 
factors, it also depends on which internationally recognized guidelines the provider chooses to follow.

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