1. Patient-Centered Communications & Cultural Competency Michael Bednarski, PhD mbednarski@aol.com 800-856-7219med-coach.com

2. Being a Resident (How It Sometimes Feels) There is something I don’t know that I am supposed to know. I don’t know what it is I don’t know, and yet am supposed to know. And I feel I look stupid if I seem both not to know it and not know what it is I don’t know. Therefore I pretend I know it. This is nerve-wracking since I don’t know what I must pretend to know. Therefore I pretend to know everything. I feel you know what I am suppose to know but you can’t tell me what it is because you don’t know that I don’t know what it is. You may know what I don’t know, but not that I don’t know it, and I can’t tell you. So you will have to tell me everything. But I can’t even let you know that R.D. LANG KNOTS (1970) Being a Resident (How It Sometimes Feels) There is something I don’t know that I am supposed to know. I don’t know what it is I don’t know, and yet am supposed to know. And I feel I look stupid if I seem both not to know it and not know what it is I don’t know. Therefore I pretend I know it. This is nerve-wracking since I don’t know what I must pretend to know. Therefore I pretend to know everything. I feel you know what I am suppose to know but you can’t tell me what it is because you don’t know that I don’t know what it is. You may know what I don’t know, but not that I don’t know it, and I can’t tell you. So you will have to tell me everything. But I can’t even let you know that R.D. LANG KNOTS (1970)

3. What is “Patient-Centered” Communications? 1.A biopsychosocial approach that integrates Cultural Sensitivity, Psychosocial Awareness, Socioeconomics, and Behavioral Interventions in the doctor-patient interaction 2.Care that seeks to understand patient illness and capacity for health by embracing the unique history, life circumstances, values, and perspective of each patient – as told by each patient 3.Care that uniformly meets the needs of different and diverse patient populations 4.Care that requires an understanding of ourr own personal, cultural/ethnic, and scientific preferences and “blind spots” 5.Care that utilizes constructs from psychology – treatment-effect size and outcomes We can no longer just ask: “What illness does this patient have?” Need to also ask: “Who is the person that has this illness? And how does that knowledge shape our intervention?” Does it take longer?

4. Non-Biological Factors that Moderate Health and Health Outcomes Therapeutic Alliance (“Joining”) – Foundation of Patient-Centered CareTherapeutic Alliance (“Joining”) – Foundation of Patient-Centered Care –Active listening skills, rapport, perspective-taking, individual differences Cultural/Ethnic AwarenessCultural/Ethnic Awareness –Sensitivity to cultural differences in social structure, beliefs, and health practices – Recognizing cultural “blind spots” Social Determinants of Health (SDH)Social Determinants of Health (SDH) –The role social and economic conditions play as determinants of health and attitudes towards the health care system. –Economic disparities that lead to chronic stress, morbidity mortality, and inhibit access to care Psychosocial FactorsPsychosocial Factors –The role nonphysical factors such as, emotions, behavior, values, and social stressors play in the etiology, diagnosis and treatment of physical illness

5. Why Focus on Communications (At the heart of every medical decision you make) Facts: Diversified Patient PopulationDiversified Patient Population 100,000 + interviews in typical career100,000 + interviews in typical career An ACGME requirement – inter-correlates with allAn ACGME requirement – inter-correlates with allChallenges: Treatment Adherence (47%)Treatment Adherence (47%) Forget 50% w/in 5 minutesForget 50% w/in 5 minutes Health Literacy –Institute of MedicineHealth Literacy –Institute of Medicine Sentinel Events (JCAHO) –situational awarenessSentinel Events (JCAHO) –situational awareness Busier Schedules - Drain on resourcesBusier Schedules - Drain on resources LitigationLitigationBenefits: Better OutcomesBetter Outcomes Efficiency of Care – fewer Dx tests - fewer referralsEfficiency of Care – fewer Dx tests - fewer referrals Patient SatisfactionPatient Satisfaction Perceived CompetencePerceived Competence Increased Tx AdherenceIncreased Tx Adherence Reduced LitigationReduced Litigation

6. Why is Knowing Your Communication Style Important Psychological habits that relate to doctor-patient differences in: Too much Vs too little communicationToo much Vs too little communication The information that gets (or doesn’t get) our attentionThe information that gets (or doesn’t get) our attention How we make treatment decisionsHow we make treatment decisions Need for closureNeed for closure Patient-Centered Care Starts with awareness of your own assumptions and how they are communicated to patientsStarts with awareness of your own assumptions and how they are communicated to patients

8. Communication Styles E..…………………………….0……………………………… I (Interpersonal Orientation) S...……………………………0……………….……………. N (Information-Seeking Habits) T...……………………………0……………………….……. F (Decision-Making Habits) J...……………………………0………………….…………. P (Closure-Seeking Habits) 30------25-----20------15-----10------5------0-----5------10------15------20------25------30

9. Introversion Vs. Extraversion Where we direct our attention Interaction Stimulates Thinking/ReflectionInteraction Stimulates Thinking/Reflection ConciseConcise Stays on one TopicStays on one Topic Interaction Stimulates Action/Expression Expansive Jumps Topics

10. Sensing Vs. iNtuition How we use information Sensing Vs. iNtuition How we use information Communicates Facts, DetailsCommunicates Facts, Details Succinct, Matter-of-FactSuccinct, Matter-of-Fact Realistic – Stays with the DataRealistic – Stays with the Data Communicates Concepts, Possibilities Inquisitive -Asks Questions Hunches, Leaps of logic – Sees Beyond the Data

11. Thinking Vs. Feeling How we “make up our mind” Thinking Vs. Feeling How we “make up our mind” Tells it like it isTells it like it is Candid - BluntCandid - Blunt Communicates LogicCommunicates Logic Tells it with concern Warm/Supportive Communicates Feelings

12. Judging Vs. Perceiving Our approach to getting things done Judging Vs. Perceiving Our approach to getting things done Presents UrgencyPresents Urgency Speaks DecisivelySpeaks Decisively Prefers PlansPrefers Plans Keeps Things Open Presents Looseness Respects Change

14. TIPS FOR USING TYPE WITH PATIENTS

15. Understanding Patients Extraverted Patients Seek interactionSeek interaction Seek energy/enthusiasm.Seek energy/enthusiasm. Openly express their thoughts and feelings,Openly express their thoughts and feelings, Easily distracted by other activities (KISS)Easily distracted by other activities (KISS) Introverted Patients Need time to reflect More self-contained Need thoughts and feelings drawn out Usually waits for others to make the first move.

16. Understanding Patients Sensing Patients Sensing Patients Like precise instructionsLike precise instructions Need info step-by-stepNeed info step-by-step Like facts, not theoriesLike facts, not theories Want details, “next steps”Want details, “next steps” iNtuitive Patients Seek future implications Want the “Big Picture” Naturally skeptical Will tune-out details

17. Understanding Patients Thinking Patients Thinking Patients Need to know why things are doneNeed to know why things are done Dislike small talkDislike small talk Views things logicallyViews things logically DebatesDebates Feeling Patients Needs feelings recognized Needs warmth/support View things emotionally Defers

18. Understanding Patients Judging Patients Strong need for clarity of goals and objectivesStrong need for clarity of goals and objectives Like things settled and finishedLike things settled and finished Need structure and predictabilityNeed structure and predictability Need CLOSURENeed CLOSURE Perceiving Patients Strong need for understanding process Act spontaneously – change minds Need flexibility Avoid CLOSURE

19. Cultural Competence

20. What do we mean by “culture”? An integrated pattern of behaviors, learned beliefs, and assumptions about the world. Passed on from one generation to another.An integrated pattern of behaviors, learned beliefs, and assumptions about the world. Passed on from one generation to another. “All societies are confronted with universally shared problems that emerge from the human requirements of dealing with fellow human beings, time, and nature. One culture can be distinguished from another by the specific solutions it chooses to apply to these problems and dilemmas.”*“All societies are confronted with universally shared problems that emerge from the human requirements of dealing with fellow human beings, time, and nature. One culture can be distinguished from another by the specific solutions it chooses to apply to these problems and dilemmas.”* *From: “Type and Culture”

21. Why is Cultural Competence Essential? American diversity statisticsAmerican diversity statistics –11 ½ % of Population is Foreign Born and Rising –By 2050 white non-Hispanics will decrease from 75% (1996) to 50% of the population. –African American, Hispanic, and Asian American – double digit growth in last 10 yrs. –32 million speak language other than English at home. Culture Influences Treatment & OutcomeCulture Influences Treatment & Outcome –Different Illness Belief Systems & Help-Seeking Behaviors Changing Health Care SystemChanging Health Care System –Shorter stays = Greater emphasis on Tx compliance –Many receive no, or substandard care

22. Why is Knowing About Culture Important? Culture Influences: –How we interpret other people’s intentions and actions –Beliefs about the cause and treatment of illness –Help-seeking behaviors - Who to turn to in times of illness –Symptom recognition & communication –Level of acculturation & compliance to Western Medicine & the health professions

23. Iceberg Analogy language, clothing, foods, etiquette Observable Not Observable Unspoken but known Known traditions, customs, values, perceptions, assumptions, things we always do USS Medicine Unconscious Immediately Apparent Invisible - Unknown deeply internalized – beliefs & worldviews that are difficult to express and understandable only by someone from the same culture Known Thru Questions

24. Iceberg Analogy Learning Points We can only see 10% of a person’s cultural attributesWe can only see 10% of a person’s cultural attributes –We cannot see the most important dimensions of a person’s culture, including values, attitudes, and beliefs. –Most of who we are is below the surface, yet we tend to make assumptions based on the visible portion. Leads to misjudgment and misunderstanding which prevents us from looking deeper into the person –To really get to know someone – look below the surface - How do we do that?

25. Cultural Intelligence in the Practice of Medicine

26. Obstacles to Culturally Intelligent Medicine Personal EthnocentrismPersonal Ethnocentrism Assumption – “My own cultural beliefs are the only reliable or correct ones.” Others are viewed (experienced) as “different” or “similar” to those beliefs. Obstacle – Creates a deficit in rapport and increases personal distance between Dr and Patient – Imposes “Doctor-Patient” role-playing Medical EthnocentrismMedical Ethnocentrism Assumption - Health care providers, educated and socialized within a bio-medical modal have superior knowledge and the correct, most accurate approach to health care. Obstacle – Prohibits the introduction of patient beliefs and behaviors that impact Dx and Tx compliance. Creates distance – Quiets the patient Must shift from biomedical to biopsychosocial framework

27. Three Assumptions to Challenge “People from a particular culture are mostly the same.” Differences in birth region, education, and income level make impact how your patient communicates, perceives illness, and makes health decisions. “If the patient is not suggesting what he/she needs, they must not need anything.” Difficult for people to verbalize their cultural values, belief systems, and world views in ways that are understandable to someone from a different culture. Difficult to step outside one’s culture and see it objectively “More ‘personal’ interaction will take too long.” A little time up front save lots of time over the course of treatment Improves information retention, compliance, patient satisfaction. Tips For Working With all Cultural Groups

28. Tips For Working With all Cultural Groups (The Personal Encounter) Treat Each Person Uniquely - Each individual is different and may not fit the common pattern for his/her ethnic group. Do not assume each individual is bound to communicate in a certain wayTreat Each Person Uniquely - Each individual is different and may not fit the common pattern for his/her ethnic group. Do not assume each individual is bound to communicate in a certain way Determine Level of Acculturation – notice dress, language skills, and mannerismsDetermine Level of Acculturation – notice dress, language skills, and mannerisms Listen to the Patient – focus on explanation of cause of illness w/o rushing, concluding, or judging.Listen to the Patient – focus on explanation of cause of illness w/o rushing, concluding, or judging. Ask Yourself - “Am I aware of assumptions & cultural biases. that impact my understanding?” “Do I prompt and appreciate the belief systems, or health attitudes of this patient?”Ask Yourself - “Am I aware of assumptions & cultural biases. that impact my understanding?” “Do I prompt and appreciate the belief systems, or health attitudes of this patient?” Notice and Use Non-Verbals - smiling, silence, gestures, nodding, eye contact, body language, touch, etc. Follow their lead.Notice and Use Non-Verbals - smiling, silence, gestures, nodding, eye contact, body language, touch, etc. Follow their lead.

29. Tips For Working With all Cultural Groups (The Clinical Encounter) Ask about the pt’s basic health & illness beliefs, medications, and other forms of careAsk about the pt’s basic health & illness beliefs, medications, and other forms of care –“How/why do you think this is happening to you?” “What do you think caused this?” “Other patients from your culture believe….What do you believe?” Practice “Joining”? Consider which beliefs or practices would not interfere with or be contraindicated with Tx, and allowConsider which beliefs or practices would not interfere with or be contraindicated with Tx, and allow –“What things have you or others done to take care (treat) this?” Ask who is involved in decision-making and bring them into the discussionAsk who is involved in decision-making and bring them into the discussion –“Are there family members that we should discuss this with?” When possible avoid a Tx plan that conflicts with pt’s beliefs and lifestyle. Work through with patient.When possible avoid a Tx plan that conflicts with pt’s beliefs and lifestyle. Work through with patient. –“Can you agree with what we have decided, and can you do it?”

30. CONCLUSIONS Much of what we need to know, we don’t know. The patient does.Much of what we need to know, we don’t know. The patient does. Communicating effectively with different patients requires openness about the limits of our own style and culture.Communicating effectively with different patients requires openness about the limits of our own style and culture. Patient-centered communications is a skill that can be learned.Patient-centered communications is a skill that can be learned. “People as objects” assignment