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

Cultural Competence in Medical Practice

Leah Karliner, MD MAS

UCSF

August 2006

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

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

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”

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:1. Culturally competent care2. Language access services3. Organizational supports for cultural competence

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; 2002. Institute of Medicine. http://www.iom.edu/?id=16740

Multiple Factors

Social factors: poverty, education/literacy, housing, diet

Health insurance systems Healthcare systems (organizational cultural

competence) Doctor-patient relationship / communication

Doctor-Patient Communication

The Cultural Formulation, a useful tool in clinical practice

Working with interpreters in clinical practice

The Cultural Formulation(adapted from DSM-IV, Appendix I: “Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes”)

I. Cultural Identity

II. Explanatory Models of Illness

III. Cultural Stressors and Supports

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

V. Clinician Self Assessment

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

Cultural Formulation

I. 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?

I. I: Cultural Identity Individual versus Collective

The family (video: Annie Hall)

Confidentiality: unit patient? family?

I. I: Cultural Identity: Acculturation

Degree to which an individual conforms to majority cultural values and norms

Helps avoid stereotyping

I. Cultural Identity Communication style

Direct vs. indirect

Verbal vs. non-verbal emphasis

(taking the history)

video: The Joy Luck Club

Outline: Cultural Formulation

II. Explanatory Models of Illness

What do you think caused or triggered this problem?

How does your culture (of origin) explain these

symptoms?

II. Explanatory Models of Illness

Idioms of distress; Somatization: expression of individual distress in the metaphor of the body

Culture-bound syndromes

Outline: Cultural Formulation

III. 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?

III. Cultural Stressors and Supports

Family support/stress

Immigration history (and acculturation)

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

Outline: Cultural Formulation

IV. 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?

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)

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

Putting It All Together

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

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 OriginWhere 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)

EXPLANATIONSymptom/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?

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. 2000 Census:

47 million non-English primary language at home Half report speaking English less than very well

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; 2003. The California Endowment. http://www.calendow.org/reference/publications/cultural_competence.stm

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

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

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

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

Definitions

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

Do Interpreters Make a Difference?

Systematic review of literature 1966-9/2005 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

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

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

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

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

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)

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

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

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

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

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

Selected Online Resources

CLAS standards: http://www.omhrc.gov/assets/pdf/checked/Executive%20Summary.pdf

JCAHO:http://www.jointcommission.org/HLC/Resources_Standards.htm

Unequal Treatment: http://www.iom.edu/?id=16740

Lewin Report:http://www.hrsa.gov/culturalcompetence/measures/default.htm

The Cultural Formulation

http://www.med.uiuc.edu/m34/xcultopps/PDF/clinical%20cultural%20assessment.pdf

Selected Online Resources

U.S. DHHS on-line/DVD CME:

https://cccm.thinkculturalhealth.org/

The Network for Multicultural Health Resource Page:

http://futurehealth.ucsf.edu/TheNetwork/Default.aspx?tabid=387

Diversity Rx: Models and Practices (cultural and linguistic access):http://www.diversityrx.org/HTML/models.htm