Transcript Cultural Competence in Healthcare

What Culture Does Your Patient
Hurt In?
Cultural Competency in Caring
for Diverse Populations
Fern R. Hauck, MD, MS
Department of Family Medicine
University of Virginia Health System
POM-1, September 10, 2007
Goals of This Talk

Define cultural competency
(culturally responsive healthcare,
cultural humility)

Describe differences in cultural
norms between dominant U.S.
culture and other cultures

Discuss ways to provide high
quality, culturally competent care

Describe what UVA is doing to
address patient care and training
Patient KI:
40 year old female, Somali refugee, who
has been in Charlottesville 4 years.
Developed gestational diabetes with last
pregnancy (here) and continues to have
diabetes mellitus. Most recent hemoglobin
A1C 18. On maximum therapy orally,
refuses insulin. Frequently “noncompliant”
with oral medications and other treatment
advice.
What is your reaction?
• How does this patient make you feel?
• What kinds of issues are involved in her
care?
• How would you approach her in trying to
reach the best outcome for her health?
What is culture?
•
The function of culture is to ensure the survival and
well-being of its members.
• Cultures are dynamic, responsive, coherent
systems of beliefs, values and lifestyles that
have developed within particular geographic
locations; they evolve and are passed on from
generation to generation.
• The resulting lifestyle (cultural) patterns of each group
-such as diet, marriage rules, and means of livelihoodinfluence gene expression, health status and disease
prevalence.
Components of Culture
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Environment
Economy
Technology
Religion/world view
Language
Social structure
Beliefs and values
(Hammond P, 1978)
Definition of Cultural Competence
Having the capacity to function effectively as an
individual or an organization within the context of
the cultural beliefs, practices, and needs presented,
by patients and their communities.
Why is this important???
• Ever-increasing diversity of the population of the United States
• Strong evidence of racial and ethnic disparities in health care
 Barriers in access to care
 Lack of proportional representation of minorities in the health
professions
 Low levels of cultural competence among health care
professionals
Liaison Committee on Medical Education
(LCME): Setting the Standard
“The faculty and students must demonstrate an
understanding of the manner in which people of
diverse cultures and belief systems perceive health
and illness and respond to various symptoms,
diseases and treatments. Medical students should
learn to recognize and appropriately address
gender and cultural biases in health care delivery,
while considering first the health of the patient.”
(LCME, 2000)
States are Following
New Jersey will be the first state to require that
physicians have education and training in cultural
competence for medical licensure (to take effect in
2008). Other states are considering similar
legislation.
Myths and the Misuse of the Concept of Culture
1.
Culture is not race
• 6 racial/ethnic categories by OMB intended
to monitor political allocation of resources,
not as scientific evidence of genetic differences
• Greater genetic within-group variation than between
• Each category contains multiple national groups &
multiple ethnic groups within each national group,
each with its own culture or subculture
Myths and the Misuse of the Concept of Culture
2. Cultures are not homogeneous
• Various levels of acculturation, assimilation,
age, education, family structure, gender, wealth,
refugee or immigrant status all modify the degree
to which one’s cultural group membership may
influence health practices and health status
• Each cultural group is continually undergoing
change
Myths and the Misuse of the Concept of Culture
3. The Western biomedical model and European-American
lifestyle are not the only ways to ensure health
• Research indicates that prevalence of some illnesses
much lower in immigrants’ countries of origin than
after settling in the U.S. (e.g., diabetes, breast cancer)
Comparisons of Cultural Norms and Values
Aspects of Culture
Mainstream
American Culture
Other Cultures
Communication and
language
Explicit, direct
communication.
Emphasis on content -meaning found in
words.
Implicit, indirect
communication.
Emphasis on context –
meaning found around
words.
Time and time
consciousness
Linear and exact time
consciousness. Value
on promptness –
time=money.
Elastic and relative
time consciousness.
Time spent on
enjoyment of
relationships.
Comparisons of Cultural Norms and Values
( continued)
Aspects of Culture
Mainstream American
Culture
Other Cultures
Relationships,
family, friends
Focus on nuclear family.
Responsibility for self.
Value on youth, age seen as
handicap.
Focus on extended family.
Loyalty and responsibility
to family. Age given status
and respect.
Values and norms
Individual orientation.
Independence. Preference
for direct confrontation of
conflict.
Group orientation.
Conformity. Preference for
harmony.
Beliefs and attitudes
Egalitarian. Challenging of
authority. Individuals
control their destiny.
Gender equity.
Hierarchical. Respect for
authority and social order.
Individuals accept their
destiny. Different roles for
men and women.
Gardenswartz L, Rowe A. Managing Diversity: A Complete Desk Reference and Planning Guide, 1993.
Communicating in a Cross-Cultural Encounter
• The physician could work exclusively
within the biomedical paradigm
• The patient and physician could function
exclusively within each of their native cultures
• The physician could work within the
patient’s cultural framework
• The physician and patient could negotiate between
their concepts of the etiology of disease & the
most appropriate means of treatment to reach
mutually desirable goals
(Kagawa-Singer M, 2003)
“Ethnic Mnemonic”
E:
T:
H:
N:
I:
C:
Explanation
Treatment
Healers
Negotiation
Intervention
Collaboration and Communication
Developed by: Steven J. Levin, MD; Robert C. Like, MD; Jan E. Gottlieb, MD.
Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical
School.
“Ethnic Mnemonic” – “E”
E: Explanation
What do you think may be the reason you have
these symptoms?
What do friends, family, others say about these
symptoms?
Do you know anyone else who has had or who
has this kind of problem?
Have you heard about/read/seen it on
TV/radio/newspaper? (If patient cannot offer
explanation, ask what most concerns them
about their problem).
“Ethnic Mnemonic” – “T”
T: Treatment
What kinds of medicines, home remedies or
other treatments have you tried for this illness?
Is there anything you eat, drink, or do (or
avoid) on a regular basis to stay healthy? Tell
me about it.
What kind of treatment are you seeking from
me?
“Ethnic Mnemonic” – “H”
H: Healers
Have you sought any advice from
alternative/folk healers, friends or other people
(non-doctors) for help with your problems?
Tell me about it.
“Ethnic Mnemonic” – “N”
N: Negotiation
Negotiate options that will be mutually
acceptable to you and your patient and that do
not contradict, but rather incorporate your
patient’s beliefs.
Ask what are the most important results your
patient hopes to achieve from this intervention.
“Ethnic Mnemonic” – “I”
I: Intervention
Determine an intervention with your patient.
May include incorporation of alternative
treatments, spirituality, and healers as well as
other cultural practices (e.g. foods eaten or
avoided in general, and when sick).
“Ethnic Mnemonic” – “C”
C: Collaboration and Communication
Collaborate with the patient, family members,
other health care team members, healers and
community resources.
Effectively use interpreters in encounters with
patients with limited English proficiency.
Additional Tips
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4.
5.
Don’t treat the patient in the same manner as you would
want to be treated.
Begin by being more formal with patients who were
born in another culture.
Don’t be “put off” if a patient fails to look you in the
eye.
Don’t dismiss beliefs that are not held by our Western
biomedical tradition.
Be cautious in relating bad news or in outlining detailed
differential diagnoses.
(Salimbene S, 2005)
Culturally Competent Healthcare Systems
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Interpreters or bilingual providers
Cultural diversity training for staff
Linguistically and culturally appropriate
health education and information materials
Tailored healthcare settings, such as
refugee or immigrant health clinics
(Task Force on Community Preventive Services, 2002)
International Family Medicine Clinic
• Started in October 2002
• Collaboration between IRC, Health Department, and Family
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Medicine
New refugee patients scheduled after Health Department screening
Provide treatment of tropical, acute, chronic illnesses to refugee
families
Refer to specialists as needed, coordinate care
1000 patients from 50+ countries,
speaking 30+ languages:
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Afghanistan
Somalia
Liberia
Sudan
Burma
Uzbekistan
Community Outreach & Collaboration
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ESL program/health literacy presentations and
role plays
Health fairs
UVA Services
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Interpreters: In-house or via contracted
providers; CyraCom phone
Cultural diversity training for staff: culture
fairs, CultureGrams
Linguistically and culturally appropriate
health education and information materials
(Spanish mostly)
Course Offerings
• International, Tropical and Cross-Cultural
Medicine (Elective)
 1415 (Family Medicine and Internal Medicine)
 4 week elective
 Drs. Houpt and Hauck, course directors
Patient KI:
40 year old female, Somali refugee, who
has been in Charlottesville 4 years.
Developed gestational diabetes with last
pregnancy (here) and continues to have
diabetes mellitus. Last hemoglobin A1C
18. On maximum therapy orally, refuses
insulin. Frequently “noncompliant” with
oral medications and other treatment
advice.
What is your reaction?
• How does this patient make you feel?
• What kinds of issues are involved in her
care?
• What else would you like to know about
KI?
• How would you approach her in trying to
reach the best outcome for her health?
Questions or Comments?