Teaching Culture and Community in Primary Care: Teaching Culturally Appropriate Communication Skills

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Teaching Culture and Community in Primary Care
Teaching Culturally Appropriate Communication
Skills
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OBJECTIVES
By the end of this module, trainees will be able
to

1. Understand the middle stages of the cultural
   sensitivity ladder
2. Explain concept of patient-centered interviewing
   and the LEARN communication tool
3. Facilitate skill building as students move beyond
   minimization

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Where have we been?
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Cultural Sensitivity Scale
CULTURALLY SENSITIVE (Empathy, Integration,
Celebration)
CULTURALLY EGOCENTRIC (Fear, Overgeneralization,
Superiority)
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Needs Assessment

• Focus your teaching on learners cultural
  sensitivity level
• At egocentric stages, attempt to explore values
  and raise awareness

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Where do we go from here?
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Cultural Sensitivity Scale
CULTURALLY SENSITIVE (Empathy, Integration,
Celebration)
MINIMIZATION
CULTURALLY EGOCENTRIC (Fear, Overgeneralization,
Superiority)
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MINIMIZATION
I dont see this culture stuff as important.
Its simple, just treat people with respect and
there wont be any problems.
MINIMIZATION Learner acknowledges that cultural
difference exists, but views it as unimportant
against a backdrop of basic human similarity.
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POTENTIAL EGOCENTRIC REACTION

• I tried to help these people and they ended up
  walking out on me.

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Minimization
CULTURALLY SENSITIVE
CULTURALLY EGOCENTRIC
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Objectives for minimization stage

• Debunk that common sense is common
• Discuss that respect may be different in other
  cultures
• Help move them forward and prevent sliding back
  after tripping up.

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Cultural Sensitivity Scale
CULTURALLY SENSITIVE (Empathy, Integration,
Celebration)
ACCEPTANCE
The learner respects that being attentive to
cultural issues is an important component of a
satisfactory provider-patient encounter.
MINIMIZATION
CULTURALLY EGOCENTRIC (Fear, Overgeneralization,
Superiority)
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Student needs at acceptance stage
Im having a difficult enough time learning
medicine, how can you expect me to learn this
culture stuff too?

• Learners can be overwhelmed by the immense scope
  of information with a variety of cultures

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Objective to meet this need

• Attend to the need of feeling overwhelmed with
  empathy
• Frame the opportunity to learn about other
  cultures
• Teach a framework for obtaining cultural
  information generically

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Student needs at acceptance stage
I bet that mother thought her child was
suffering from empacho and didnt bring him in
for evaluation because of this.

• WARNING! DANGEROUS STAGE
• Focus on knowledge can foster stereotyping and
  assumption of causation

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Objective to meet need

• Teach the difference between generalizing and
  stereotyping
• The patient should be the source for learning
  about their cultural identities

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How do you spell success?
CULTURALLY SENSITIVE
EMPATHY
ACCEPTANCE
MINIMIZATION
CULTURALLY EGOCENTRIC (Fear, Overgeneralizing,
Superiority)
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Patient Centered Interviewing

• Patients as experts about themselves and their
  own culture
• Patient as a partner with the caregiver
• Growing evidence
• Better satisfaction
• Better outcomes

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The LEARN Mnemonic

• LISTEN actively with respect
• ELICIT the health beliefs of the patient
• ASSESS priorities, values and supports
• RECOMMEND a plan of action with adequate
  explanation and understanding
• NEGOTIATE by involving the patient in next steps
  and decisions

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LISTENING

• Appropriate greetings
• Interpreter?
• Open ended questions
• Avoid interruption
• Could you please tell me your reason for the
  visit today?
• How can I help you today?

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ELICITING Patients Perspective

• What worries you the most?
• Are you afraid that you might have something
  serious?
• What do you think has caused your problem?
• Why do you think it started when it did?
• How can I be most helpful to you?

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ASSESSING Values, supports, needs and priorities

• Medicine in the US may be foreign.
• Decision maker may be family or elder.
• Deference to the professional
• Id like to get to know you more today. Could
  you tell me about yourself?
• What brought you here to this country?

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Social Context Review of Systems

• Ask about
• Control over the environment
• Change in the environment
• Social stressors and support network
• Literacy and language

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RECOMMEND a plan of action

• Physicians tend to
• Underestimate the desire for information
• Use language that patients do not understand
• To make sure that we understand one another, can
  you tell me what it is that I explained to you?

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NEGOTIATE Involve your patient in decisions

• What are your ideas about what should happen
  next?
• Involving the patient in care is shown to
  improve
• Satisfaction
• Compliance
• Improved clinical outcomes

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Teaching LEARNUse all of the teaching styles

• Assertive Have you heard about the LEARN
  interview? Let me give a 3 minute summary of the
  technique.
• Suggestive Would it be helpful to
  understanding Mr. Saqs non-adherence to know
  what he thinks about Western medicine?
• Collaborative She wont consent to the lumbar
  puncture? What do we know about her thinking on
  that?
• Facilitative How do you think her culture is
  playing into her decision to forego further
  treatment?

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Teaching LEARNModeling with the POSE

• Be specific in POSEing the question
• Im going to try to get at her health beliefs
  with some questions about her background. Let me
  know what you think worked in the process.

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Teaching LEARNAcknowledge risk

• There is a chance of misunderstanding
• Empathize with the difficulty, highlight the
  benefit.
• I think that this is a very challenging
  situation. Sometimes, I really feel like I dont
  understand what the patients are thinking.