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Cultural Competence in Medical Practice

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Presentation on theme: "Cultural Competence in Medical Practice"— Presentation transcript:

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?

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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

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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: https://cccm.thinkculturalhealth.org/ The Network for Multicultural Health Resource Page: Diversity Rx: Models and Practices (cultural and linguistic access):


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