Cultural Competence in Medical Care

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Cultural Competence in Medical Care

• Geri-Ann Galanti, Ph.D.

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• Culture is best used to understand behavior,
  rather than to predict it, since variation within
  a culture is usually greater than that between
  cultures.

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Stereotype vs. Generalization
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Stereotype vs. Generalization
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Cultures Vary Along Several Dimensions

• Nonverbal communication
• Desire for information
• Decision making
• Emotional expressiveness
• Doctor-Patient relationship

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Communication Gestures
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Communication Gestures
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Communication Gestures
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Communication Gestures
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Communication (Lack of) Eye Contact

• Anglo/African American
• Asian
• Middle Eastern
• Native American

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Desire for Information

• Some, like many Anglo Americans, want a lot of
  information and will research their conditions.
• Others find information a burden and will prefer
  to know very little.

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• Some families, often Hispanic, Asian, or Middle
  Eastern,
• will want information withheld from the patient,
  particularly if it involves a negative prognosis.

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Culturally Competent Approach

• Ask patients if they want information about their
  condition to be given directly to them or to some
  other designated family member.

• Ask in advance of
• need and reconfirm at
• the time of need.

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Decision-making

• Those from egalitarian cultures (like the
  U.S.), may prefer shared decision-making.
• Those from hierarchical cultures (most Asian
  cultures) may prefer a more directive approach.

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Decision-making and Consent

• Men woman are equal.
• Independence valued.

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Decision-making and Consent

• Men woman are equal.
• Independence valued.

Males are dominant. Interdependence valued.
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Making Decisions at Home

• Although the husband may be the decision-maker
  outside the home, other family members may play
  an important role within the home.
• Involve those individuals in follow-up care.

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Emotional Expressiveness
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Doctor-Patient Relationship
Some expect a formal, professional relationship
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Doctor-Patient Relationship
Some expect a formal, professional relationship
Others expect a warm, personal relationship
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Racial Disparities

• Disparities do exist
• Those who have experienced racism often have
  their radar up
• Be sensitive to their perceptions
• Explain things clearly, but dont be
  condescending
• If you have limited time constraints, be sure to
  explain and apologize

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Adherence Issues

• Some patients may agree to your
  recommendations, but not follow through

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Reasons for Non-adherence

• They dont understand your instructions, but are
  too embarrassed to let you know.

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Solution Better Patient Teaching

• Be directive, active
• Focus on short term goals
• Ask questions and ask for demonstrations to
  assess understanding
• Ask, What questions do you have?
• Have them write down their questions before they
  come in
• Involve relevant family members

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Reasons for Non-adherence

• They dont trust you or biomedicine.

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Solution Increase Their Trust

• Show some interest in and knowledge of their
  culture.
• Be open to their beliefs and practices. Be
  willing to compromise.

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Personalismo

• Formal, yet warm
• Use formal terms of address (Mr., Mrs., Ms.)
• Close personal space
• Non-intimate touch

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Reasons for Non-adherence

• They may have fears/concerns based on the
  experience of others

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Solution Ask About Their Concerns

• Do you know anyone else who has been on this
  medication/had this condition? What was their
  experience with it?
• What problems do you think you might have in
  following my recommendations?

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Reasons for Non-adherence

• It may conflict with their world view
• Different disease etiology
• Fatalism its in Gods hands

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Solution Understand Their World View

• Ask questions
• What do you think is wrong?
• What do you think caused the problem?
• Try to incorporate their beliefs in your treatment

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Reasons for Non-adherence

• They may have a present time orientation, so long
  term preventive approaches may not make as much
  sense to them.

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Solution More Time Spent Teaching

• Try to hook it in to something they value. E.g.,
  
• If you want to be healthy for your daughters
  wedding

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Solution Better explanations

• Explain why medications need to be taken until
  they are finished.
• Prescribe medication around activities (e.g.,
  meals) rather than time.

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A present time orientation can also result in
patients arriving late for appointments.

• Try for more flexible scheduling
• Give them the last appointment of the day
• Explain the system carefully its different in
  other countries
• Call the day before with a reminder

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The 4 Cs of Culture

• A mnemonic for asking the right questions to
  elicit the patients perspective.
• These are appropriate for all patients, not just
  those from other ethnic groups.

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1. What do you Call your problem?

• This is one way of asking What do you think
  is wrong? Its getting at the patients
  perception of the problem.

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2. What do you think Caused your problem?

• This gets at the patients beliefs regarding
  the source of the problem.

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3. How have you Coped with the problem?

• This can also be asked in terms of What have
  you done to try to make it better? Who else have
  you been to for treatment?

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Most will try a variety of home remedies before
seeing a physician

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Many Use Multiple Sources of Healthcare

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Examples

• Many of my patients from ___ visit___. Do you?"
• Most patients treat their illness using home
  remedies before they come see me. What have you
  tried?

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Remember

• Your attitude is important. Patients will not
  share this information if they sense your
  disapproval.

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4. What are your Concerns?

• Regarding the condition
• This is really asking, How does it interfere
  with your life, or your ability to function?
• Regarding the recommended treatment

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Bottom Line

• Better communication leads to better medical care

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Bottom Line

• Better communication leads to better medical care
• You need to understand the patients perspective
  (so ask the right questions)

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Bottom Line

• Better communication leads to better medical care
• You need to understand the patients perspective
  (so ask the right questions)
• Know a bit about the range of variation

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Bottom Line

• Better communication leads to better medical care
• You need to understand the patients perspective
  (so ask the right questions)
• Know a bit about the range of variation
• Know where to access more information

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Questions? Contact me

• Geri-Ann Galanti, Ph.D.
• www.ggalanti.com
• Info_at_ggalanti.com