1. Cultural Competence in Medical Practice
Leah Karliner, MD MAS
UCSF
August 2006

2. Culture
1 a : the integrated pattern of human behavior that includes thought, speech, action, and artifacts and depends upon the human capacity for learning and transmitting knowledge to succeeding generations
b : the customary beliefs, social forms, and material traits of a racial, religious, or social group
Merriam-Webster’s Medical Dictionary

3. Cross-cultural
“Dealing with or offering comparison between two or more different cultures or cultural areas”
Merriam-Webster’s Medical Dictionary
►All doctor-patient encounters are cross-cultural
►All doctor-patient encounters are human encounters

4. Cultural Competence Synonyms Cultural humility Cultural awareness
Culturally responsive care
JCAHO: “The delivery of health care services in a manner that is respectful and appropriate to an individual's language and culture”

5. CLAS Standards
National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care
Issued by the U.S. Department of Health and Human Services’ Office of Minority Health (2001)
3 types of standards:
Culturally competent care
Language access services
Organizational supports for cultural competence

6. How are we doing?
Disparities in health and healthcare exist for U.S. ethnic minorities in almost every area that has been studied:
Access to care
Asthma care
Cancer survival
Cardiac care
Diabetes
Pain management
Preventive care
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care; Institute of Medicine.

7. Multiple Factors
Social factors: poverty, education/literacy, housing, diet
Health insurance systems
Healthcare systems (organizational cultural competence)
Doctor-patient relationship / communication

8. Doctor-Patient Communication
The Cultural Formulation, a useful tool in clinical practice
Working with interpreters in clinical practice

9. The Cultural Formulation (adapted from DSM-IV, Appendix I: “Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes”)
Cultural Identity
Explanatory Models of Illness
Cultural Stressors and Supports
Cultural elements of the Relationship with clinician(s)
Clinician Self Assessment

10. When to Use the Cultural Formulation
Clinician suspects that difficulties in communication, evaluation or treatment may be based in cultural differences.
For example, in a cross-cultural encounter, clinician perplexed by:
Medication non-adherence
Lack of follow-up for diagnostic tests
Refusal to consent to procedures

11. Cultural Formulation Cultural Identity Where are you from?
What language would you like to use during our visits?
Do you ever have difficulty understanding what I say in English?
Do you ever have difficulty expressing your concerns to me in English?

12. I: Cultural Identity Individual versus Collective
The family (video: Annie Hall)
Confidentiality: unit patient? family?

13. I: Cultural Identity: Acculturation
Degree to which an individual conforms to majority cultural values and norms
Helps avoid stereotyping

14. Cultural Identity Communication style
Direct vs. indirect
Verbal vs. non-verbal emphasis
(taking the history)
video: The Joy Luck Club
Primacy of the spoken or written word/ directness (vs. non-verbal communication) “It doesn’t matter what they say, but how they say it.” We prize directness, honesty, being straight-forward. We mean what we say. Relate experience of cousin in Taiwan. How do corporate people in Japan do things? In many non-Western societies, subtlety is highly prized. Being confrontative and direct conveys crudeness and disrespect.

15. Outline: Cultural Formulation
Explanatory Models of Illness
What do you think caused or triggered this problem?
How does your culture (of origin) explain these symptoms?

16. II. Explanatory Models of Illness
Idioms of distress; Somatization: expression of individual distress in the metaphor of the body
Culture-bound syndromes

17. Outline: Cultural Formulation
Cultural Stressors and Supports
Who lives at home with you?
When someone is sick in your family, to whom do you turn for help?
How much do your family or friends know about this illness?

18. III. Cultural Stressors and Supports
Family support/stress
Immigration history (and acculturation)

19. IV. Cultural elements of the Relationship with clinician(s)

20. Outline: Cultural Formulation
Cultural elements of the Relationship with clinician(s)
What kinds of experiences have you had in working with doctors? What was helpful? What was not?

21. IV. Cultural elements of the Relationship with clinician(s)
Relationship to Authority, Conflict avoidance
History of medical treatment: “treatment pathway”
Experiences of racism/disparities in care
Informed consent (not abdicating responsibility for outcome)

22. Cultural Formulation Outline
V. Clinician Self Assessment
For the clinician to ask of him/herself:
Do I have any preconceived ideas about this patient’s race/ethnicity?
What are my prior experiences with patients from this culture?
How are these affecting my communication with this patient? The care I give him/her?
Know your own culture

23. Putting It All Together

24. Putting It All Together
Systematic review of five main topic areas
Can spend single visit on review, or cover areas over several visits;
Use worksheet as you go

25. CULTURAL FORMULATION SECTION (what I would like to know/what I learn)
Cultural Formulation Worksheet Patient Name:___________________ Date:_________
CULTURAL FORMULATION SECTION
ASSESSMENT
(what I already know)
PLAN
(what I would like to know/what I learn)
IDENTITY
Country/Region of Origin
Where are you from?
English proficiency / primary language
How hard is it to speak in English?
Do you ever have difficulty understanding what I say?
Level of acculturation (fully/somewhat/little/none)
EXPLANATION
Symptom/diagnosis
What do you think caused or triggered this problem?
How does your culture (of origin) explain these symptoms?
STRESSORS & SUPPORTS
Who lives at home with you?
When someone is sick in your family, who do you ask for help?
How much do your family or friends know about this illness?
RELATIONSHIP
Prior Experiences with Doctors or Healers
What kinds of experiences have you had in working with doctors? With other healers?
What was helpful? What was not?
Clinician Self-Assessment
What are my preconceived ideas about this patient’s race/ethnicity or country of origin?
What are my prior experiences with patients from this culture?

27. Limited English Proficiency
Unable to speak, read, write or understand English at a level to interact effectively with health care providers
Different from primary language spoken at home
U.S Census:
47 million non-English primary language at home
Half report speaking English less than very well

28. Language Barriers & Health Disparities
Less access to usual source of care
Fewer physician visits & preventive services
Poorer adherence to treatment & follow-up for chronic illnesses (e.g. asthma)
Lower comprehension of dx & treatment after ED visit
Less satisfaction with care
Increased medication complications
Increased admissions from the ED
Increased length of stay in hospital
Language Barriers in Healthcare Settings: An Annotated Bibliography of the Research Literature; The California Endowment.

29. Language Concordance Patient and physician speak the same language
Associated with increased:
Patient satisfaction
Patient-reported health status
Adherence with medication
Adherence with follow-up

30. Language Concordance Why we cannot rely on language concordance alone
>100 languages spoken commonly in U.S.
At UCSF in our survey of primary care clinicians, 20 different languages reported
Patients maneuver through entire healthcare system
Registration
Lab
Radiology ED
Hospitalization
Cashier

31. What does the law say? Civil Rights Act of 1964 – Title VI
If providers receive Federal financial assistance, and
If language is a ‘threshold’ language (>=5% of patient population), then
Must offer linguistic assistance

32. What actually happens? Bilingual clinicians
Bilingual staff – clinical and non-clinical
Family & friends
Telephone – e.g. Language Line
Video conferencing professional interpreters
In-person professional interpreters

33. Definitions Interpreter Ad Hoc Interpreter Professional Interpreter
3rd party present in clinical interaction whose role is to facilitate oral language interpretation
Ad Hoc Interpreter
Untrained person called upon to interpret
e.g. family member/friend, bilingual staff pulled away from other duties, self-declared bilingual who volunteers (other patients)
Professional Interpreter
Person paid & provided by hospital or health system to interpret
Training not standardized

35. Do Interpreters Make a Difference?
Systematic review of literature /2005
28 published papers comparing at least 2 language groups & reported data about medical interpreters in following areas:
Communication (errors and comprehension)
Utilization
Clinical outcomes
Satisfaction
21 assessed professional interpreters separately from ad hoc interpreters

36. Do Interpreters Make a Difference?
In all four areas
Use of professional interpreters was associated with improved clinical care approaching or equal to that of English-speakers
This improvement was more than with use of ad hoc interpreter
Karliner, et al. In press. Health Services Research

37. How to work with a professional interpreter
Allow extra time for an interpreted visit;
Select an interpreter keeping gender and confidentiality in mind;
The interpreter is part of your therapeutic team: hold a brief pre-meeting with the interpreter:
share relevant information about your patient and this visit;
Ask the interpreter to cover everything that is said, conveying the tone and meaning of the message, rather than paraphrasing or rephrasing

38. How to work with a professional interpreter
Introduce yourself directly to the patient;
Position yourself in a therapeutic triad
Introduce the interpreter to the patient;
Address the patient directly;
Watch the patient during the interpretation
Body language
Behavioral clues
Invite correction: “this is what I understand so far…let me know if I missed something...”
Interpreter
Clinician
Patient

39. How to work with a professional interpreter
Speak in short units
Ask short questions
Explain medical terms in simple language
Ask the patient to repeat back any instructions

40. How to work with an untrained/ad hoc interpreter:
Untrained staff
Language abilities may not be equal in both English and the 2nd language
May not know medical terms in either English or the 2nd language
Ask if comfortable interpreting with this particular patient (gender / confidentiality)

41. How to work with an untrained/ad hoc interpreter
Be explicit before they come into the room about what you need / give them guidance
Word for word interpretation (preserving tone & meaning)
Avoid answering for the patient
Position them in triad (show them where)
Give permission to ask you to slow down or rephrase something in easier terms

42. How to work with an untrained/ad hoc interpreter
Family and friends
Avoid using minors!!!
May be uncomfortable interpreting personal/intimate information
May try to ‘protect’ parent from information
Alters relationship between parent and child

43. How to work with an untrained/ad hoc interpreter
Same techniques as with staff, but need to emphasize certain points even more:
Ask them to avoid answering for the patient;
Give them permission to ask you to slow down or rephrase something in easier terms
Speak directly to the patient
Keep your spoken units and questions short

44. Steps along the road to cultural competence
Like any other skills this takes practice
Use the cultural formulation when you find yourself at an impasse with a patient from a culture different from your own
Be open to what you might find out – communication is two-way and so is mis-communication

45. Steps along the road to cultural competence
When you have a language barrier with a patient, use a professional/trained interpreter if possible
If you must use an ad hoc interpreter, give them guidance
Avoid using minors to interpret

46. Selected Online Resources
CLAS standards:
JCAHO:
Unequal Treatment:
Lewin Report:
The Cultural Formulation

47. Selected Online Resources
U.S. DHHS on-line/DVD CME:
The Network for Multicultural Health Resource Page:
Diversity Rx: Models and Practices (cultural and linguistic access):