Presentation on theme: "Cultural Competence in Medical Practice"— Presentation transcript:
1 Cultural Competence in Medical Practice Leah Karliner, MD MASUCSFAugust 2006
2 Culture1 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 generationsb : the customary beliefs, social forms, and material traits of a racial, religious, or social groupMerriam-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 careJCAHO: “The delivery of health care services in a manner that is respectful and appropriate to an individual's language and culture”
5 CLAS StandardsNational Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health CareIssued by the U.S. Department of Health and Human Services’ Office of Minority Health (2001)3 types of standards:Culturally competent careLanguage access servicesOrganizational 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 careAsthma careCancer survivalCardiac careDiabetesPain managementPreventive careUnequal Treatment: Confronting Racial and Ethnic Disparities in Health Care; Institute of Medicine.
7 Multiple FactorsSocial factors: poverty, education/literacy, housing, dietHealth insurance systemsHealthcare systems (organizational cultural competence)Doctor-patient relationship / communication
8 Doctor-Patient Communication The Cultural Formulation, a useful tool in clinical practiceWorking 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 IdentityExplanatory Models of IllnessCultural Stressors and SupportsCultural 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-adherenceLack of follow-up for diagnostic testsRefusal 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 normsHelps avoid stereotyping
14 Cultural Identity Communication style Direct vs. indirectVerbal vs. non-verbal emphasis(taking the history)video: The Joy Luck ClubPrimacy 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 IllnessWhat 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 bodyCulture-bound syndromes
17 Outline: Cultural Formulation Cultural Stressors and SupportsWho 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/stressImmigration 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 avoidanceHistory of medical treatment: “treatment pathway”Experiences of racism/disparities in careInformed consent (not abdicating responsibility for outcome)
22 Cultural Formulation Outline V. Clinician Self AssessmentFor 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
24 Putting It All Together Systematic review of five main topic areasCan 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 SECTIONASSESSMENT(what I already know)PLAN(what I would like to know/what I learn)IDENTITYCountry/Region of OriginWhere are you from?English proficiency / primary languageHow hard is it to speak in English?Do you ever have difficulty understanding what I say?Level of acculturation (fully/somewhat/little/none)EXPLANATIONSymptom/diagnosisWhat do you think caused or triggered this problem?How does your culture (of origin) explain these symptoms?STRESSORS & SUPPORTSWho 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?RELATIONSHIPPrior Experiences with Doctors or HealersWhat kinds of experiences have you had in working with doctors? With other healers?What was helpful? What was not?Clinician Self-AssessmentWhat 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 providersDifferent from primary language spoken at homeU.S Census:47 million non-English primary language at homeHalf report speaking English less than very well
28 Language Barriers & Health Disparities Less access to usual source of careFewer physician visits & preventive servicesPoorer adherence to treatment & follow-up for chronic illnesses (e.g. asthma)Lower comprehension of dx & treatment after ED visitLess satisfaction with careIncreased medication complicationsIncreased admissions from the EDIncreased length of stay in hospitalLanguage 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 satisfactionPatient-reported health statusAdherence with medicationAdherence 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 reportedPatients maneuver through entire healthcare systemRegistrationLabRadiologyEDHospitalizationCashier
31 What does the law say? Civil Rights Act of 1964 – Title VI If providers receive Federal financial assistance, andIf language is a ‘threshold’ language (>=5% of patient population), thenMust offer linguistic assistance
32 What actually happens? Bilingual clinicians Bilingual staff – clinical and non-clinicalFamily & friendsTelephone – e.g. Language LineVideo conferencing professional interpretersIn-person professional interpreters
33 Definitions Interpreter Ad Hoc Interpreter Professional Interpreter 3rd party present in clinical interaction whose role is to facilitate oral language interpretationAd Hoc InterpreterUntrained person called upon to interprete.g. family member/friend, bilingual staff pulled away from other duties, self-declared bilingual who volunteers (other patients)Professional InterpreterPerson paid & provided by hospital or health system to interpretTraining not standardized
35 Do Interpreters Make a Difference? Systematic review of literature /200528 published papers comparing at least 2 language groups & reported data about medical interpreters in following areas:Communication (errors and comprehension)UtilizationClinical outcomesSatisfaction21 assessed professional interpreters separately from ad hoc interpreters
36 Do Interpreters Make a Difference? In all four areasUse of professional interpreters was associated with improved clinical care approaching or equal to that of English-speakersThis improvement was more than with use of ad hoc interpreterKarliner, 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 triadIntroduce the interpreter to the patient;Address the patient directly;Watch the patient during the interpretationBody languageBehavioral cluesInvite correction: “this is what I understand so far…let me know if I missed something...”InterpreterClinicianPatient
39 How to work with a professional interpreter Speak in short unitsAsk short questionsExplain medical terms in simple languageAsk the patient to repeat back any instructions
40 How to work with an untrained/ad hoc interpreter: Untrained staffLanguage abilities may not be equal in both English and the 2nd languageMay not know medical terms in either English or the 2nd languageAsk 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 guidanceWord for word interpretation (preserving tone & meaning)Avoid answering for the patientPosition 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 friendsAvoid using minors!!!May be uncomfortable interpreting personal/intimate informationMay try to ‘protect’ parent from informationAlters 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 termsSpeak directly to the patientKeep your spoken units and questions short
44 Steps along the road to cultural competence Like any other skills this takes practiceUse the cultural formulation when you find yourself at an impasse with a patient from a culture different from your ownBe 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 possibleIf you must use an ad hoc interpreter, give them guidanceAvoid 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):