Title: Cultural Competence in Medical Practice
1Cultural Competence in Medical Practice
- Leah Karliner, MD MAS
- UCSF
- August 2006
2Culture
- 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-Websters Medical Dictionary
3Cross-cultural
- Dealing with or offering comparison between two
or more different cultures or cultural areas - Merriam-Websters Medical Dictionary
- ?All doctor-patient encounters are cross-cultural
- ?All doctor-patient encounters are human
encounters
4Cultural 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
5CLAS 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
- Culturally competent care
- Language access services
- Organizational supports for cultural competence
6How 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/?id16740
7Multiple Factors
- Social factors poverty, education/literacy,
housing, diet - Health insurance systems
- Healthcare systems (organizational cultural
competence) - Doctor-patient relationship / communication
8Doctor-Patient Communication
- The Cultural Formulation, a useful tool in
clinical practice - Working with interpreters in clinical practice
9The Cultural Formulation(adapted from DSM-IV,
Appendix I Outline for Cultural Formulation and
Glossary of Culture-Bound Syndromes)
- Cultural Identity
- Explanatory Models of Illness
- Cultural Stressors and Supports
- Cultural elements of the Relationship with
clinician(s) - Clinician Self Assessment
10When 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
11Cultural Formulation
- 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?
12I Cultural Identity Individual versus
Collective
- The family (video Annie Hall)
- Confidentiality unit patient? family?
13I Cultural Identity Acculturation
- Degree to which an individual conforms to
majority cultural values and norms - Helps avoid stereotyping
14Cultural Identity Communication style
- Direct vs. indirect
-
- Verbal vs. non-verbal emphasis
- (taking the history)
- video The Joy Luck Club
15Outline Cultural Formulation
- Explanatory Models of Illness
- What do you think caused or triggered this
problem? -
- How does your culture (of origin) explain these
symptoms?
16II. Explanatory Models of Illness
- Idioms of distress Somatization expression of
individual distress in the metaphor of the body - Culture-bound syndromes
17Outline Cultural Formulation
- 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?
18III. Cultural Stressors and Supports
- Family support/stress
- Immigration history (and acculturation)
19IV. Cultural elements of the Relationship with
clinician(s)
20Outline Cultural Formulation
- 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?
21IV. 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)
22Cultural Formulation Outline
- V. Clinician Self Assessment
- For the clinician to ask of him/herself
- Do I have any preconceived ideas about this
patients 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
23Putting It All Together
24Putting 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
25Cultural Formulation Worksheet Patient
Name___________________ Date_________
26(No Transcript)
27Limited 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
28Language 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/cul
tural_competence.stm
29Language Concordance
- Patient and physician speak the same language
- Associated with increased
- Patient satisfaction
- Patient-reported health status
- Adherence with medication
- Adherence with follow-up
30Language Concordance
- Why we cannot rely on language concordance alone
- gt100 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
31What does the law say?
- Civil Rights Act of 1964 Title VI
- If providers receive Federal financial
assistance, and - If language is a threshold language (gt5 of
patient population), then - Must offer linguistic assistance
32What 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
33Definitions
- 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
34(No Transcript)
35Do 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
36Do 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
37How 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
38How 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
farlet me know if I missed something...
Interpreter
Clinician
Patient
39How 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
40How 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)
41How 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
42How 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
43How 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
44Steps 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
45Steps 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
46Selected Online Resources
- CLAS standards http//www.omhrc.gov/assets/pdf/ch
ecked/Executive20Summary.pdf - JCAHO
- http//www.jointcommission.org/HLC/Resources_Stan
dards.htm - Unequal Treatment
- http//www.iom.edu/?id16740
- Lewin Report
- http//www.hrsa.gov/culturalcompetence/measures/d
efault.htm - The Cultural Formulation
- http//www.med.uiuc.edu/m34/xcultopps/PDF/clinica
l20cultural20assessment.pdf
47Selected 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.a
spx?tabid387 - Diversity Rx Models and Practices (cultural and
linguistic access) - http//www.diversityrx.org/HTML/models.htm