Cultural Competence in Medical Practice Leah Karliner, MD MAS UCSF August 2006
Mar 27, 2015
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