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Cultural Competence in Medical Practice

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Title: Cultural Competence in Medical Practice


1
Cultural Competence in Medical Practice
  • Leah Karliner, MD MAS
  • UCSF
  • August 2006

2
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-Websters Medical Dictionary

3
Cross-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

4
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

5
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
  • Culturally competent care
  • Language access services
  • Organizational supports for cultural competence

6
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/?id16740

7
Multiple Factors
  • Social factors poverty, education/literacy,
    housing, diet
  • Health insurance systems
  • Healthcare systems (organizational cultural
    competence)
  • Doctor-patient relationship / communication

8
Doctor-Patient Communication
  • The Cultural Formulation, a useful tool in
    clinical practice
  • Working with interpreters in clinical practice

9
The 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

10
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

11
Cultural 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?

12
I Cultural Identity Individual versus
Collective
  • The family (video Annie Hall)
  • Confidentiality unit patient? family?

13
I Cultural Identity Acculturation
  • Degree to which an individual conforms to
    majority cultural values and norms
  • Helps avoid stereotyping

14
Cultural Identity Communication style
  • Direct vs. indirect
  • Verbal vs. non-verbal emphasis
  • (taking the history)
  • video The Joy Luck Club

15
Outline Cultural Formulation
  • Explanatory Models of Illness
  • What do you think caused or triggered this
    problem?
  • How does your culture (of origin) explain these
    symptoms?

16
II. Explanatory Models of Illness
  • Idioms of distress Somatization expression of
    individual distress in the metaphor of the body
  • Culture-bound syndromes

17
Outline 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?

18
III. Cultural Stressors and Supports
  • Family support/stress
  • Immigration history (and acculturation)

19
IV. Cultural elements of the Relationship with
clinician(s)
20
Outline 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?

21
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)

22
Cultural 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

23
Putting It All Together
24
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

25
Cultural Formulation Worksheet Patient
Name___________________ Date_________
26
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27
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

28
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/cul
tural_competence.stm
29
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

30
Language 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

31
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 (gt5 of
    patient population), then
  • Must offer linguistic assistance

32
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

33
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

34
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35
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

36
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

37
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

38
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
    farlet me know if I missed something...

Interpreter
Clinician
Patient
39
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

40
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)

41
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

42
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

43
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

44
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

45
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

46
Selected 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

47
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.a
    spx?tabid387
  • Diversity Rx Models and Practices (cultural and
    linguistic access)
  • http//www.diversityrx.org/HTML/models.htm
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