Cultural Competence in Medical Practice

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Cultural Competence in Medical Practice

• Leah Karliner, MD MAS
• UCSF
• August 2006

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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

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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

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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

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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

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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

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Multiple Factors

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

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Doctor-Patient Communication

• The Cultural Formulation, a useful tool in
  clinical practice
• Working with interpreters in clinical practice

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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

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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

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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?

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I Cultural Identity Individual versus
Collective

• The family (video Annie Hall)
• Confidentiality unit patient? family?

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I Cultural Identity Acculturation

• Degree to which an individual conforms to
  majority cultural values and norms
• Helps avoid stereotyping

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Cultural Identity Communication style

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

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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?

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II. Explanatory Models of Illness

• Idioms of distress Somatization expression of
  individual distress in the metaphor of the body
• Culture-bound syndromes

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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?

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III. Cultural Stressors and Supports

• Family support/stress
• Immigration history (and acculturation)

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

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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)

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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

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Putting It All Together
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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

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Cultural Formulation Worksheet Patient
Name___________________ Date_________
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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

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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
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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

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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

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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

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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

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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

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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

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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

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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

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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
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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

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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)

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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

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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

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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

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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

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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

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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

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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