Transcript Cultural Competence in Medical Practice

Patient-Centered Communications
&
Cultural Competency
Michael Bednarski, PhD
[email protected]
800-856-7219
med-coach.com
Being a Resident
(How It Sometimes Feels)
There is something I don’t know that I am supposed to know.
I don’t know what it is I don’t know, and yet am supposed to know.
And I feel I look stupid if I seem both not to know it and not know
what it is I don’t know. Therefore I pretend I know it.
This is nerve-wracking since I don’t know what I must pretend to
know.
Therefore I pretend to know everything.
I feel you know what I am suppose to know but you can’t tell me what
it is because you don’t know that I don’t know what it is.
You may know what I don’t know, but not that I don’t know it, and I
can’t tell you.
So you will have to tell me everything.
But I can’t even let you know that
R.D. LANG KNOTS (1970)
What is “Patient-Centered” Communications?
1.
A biopsychosocial approach that integrates Cultural Sensitivity,
Psychosocial Awareness, Socioeconomics, and Behavioral Interventions
in the doctor-patient interaction
2.
Care that seeks to understand patient illness and capacity for health by
embracing the unique history, life circumstances, values, and
perspective of each patient – as told by each patient
3.
Care that uniformly meets the needs of different and diverse patient
populations
4.
Care that requires an understanding of ourr own personal,
cultural/ethnic, and scientific preferences and “blind spots”
5.
Care that utilizes constructs from psychology – treatment-effect size and
outcomes
We can no longer just ask: “What illness does this patient have?”
Need to also ask: “Who is the person that has this illness? And how does that
knowledge shape our intervention?”
Does it take longer?
Non-Biological Factors that Moderate Health and Health
Outcomes
•
Therapeutic Alliance (“Joining”) – Foundation of Patient-Centered Care
– Active listening skills, rapport, perspective-taking, individual differences
•
Cultural/Ethnic Awareness
– Sensitivity to cultural differences in social structure, beliefs, and health
practices – Recognizing cultural “blind spots”
•
Social Determinants of Health (SDH)
– The role social and economic conditions play as determinants of health
and attitudes towards the health care system.
– Economic disparities that lead to chronic stress, morbidity mortality, and
inhibit access to care
•
Psychosocial Factors
– The role nonphysical factors such as, emotions, behavior, values, and
social stressors play in the etiology, diagnosis and treatment of physical
illness
Why Focus on Communications
(At the heart of every medical decision you make)
Facts:
• Diversified Patient Population
• 100,000 + interviews in typical career
• An ACGME requirement – inter-correlates with all
Challenges:
• Treatment Adherence (47%)
• Forget 50% w/in 5 minutes
• Health Literacy –Institute of Medicine
• Sentinel Events (JCAHO) –situational awareness
• Busier Schedules - Drain on resources
• Litigation
Benefits:
• Better Outcomes
•
Efficiency of Care – fewer Dx tests - fewer referrals
•
•
•
•
Patient Satisfaction
Perceived Competence
Increased Tx Adherence
Reduced Litigation
Why is Knowing Your Communication
Style Important
Psychological habits that relate to doctor-patient
differences in:
• Too much Vs too little communication
• The information that gets (or doesn’t get) our attention
• How we make treatment decisions
• Need for closure
Patient-Centered Care
• Starts with awareness of your own assumptions and how
they are communicated to patients
Communication Styles
30------25-----20------15-----10------5------0-----5------10------15------20------25------30
E..…………………………….0………………………………I
(Interpersonal Orientation)
S...……………………………0……………….…………….N
(Information-Seeking Habits)
T...……………………………0……………………….…….F
(Decision-Making Habits)
J...……………………………0………………….………….P
(Closure-Seeking Habits)
Introversion Vs. Extraversion
Where we direct our attention
• Interaction Stimulates
Thinking/Reflection
• Concise
• Stays on one Topic
• Interaction Stimulates
Action/Expression
• Expansive
• Jumps Topics
Sensing Vs. iNtuition
How we use information
• Communicates Facts, •
Details
• Succinct, Matter-of-Fact •
• Realistic – Stays with
•
the Data
Communicates Concepts,
Possibilities
Inquisitive -Asks Questions
Hunches, Leaps of logic –
Sees Beyond the Data
Thinking Vs. Feeling
How we “make up our mind”
• Tells it like it is
• Candid - Blunt
• Communicates Logic
• Tells it with concern
• Warm/Supportive
• Communicates Feelings
Judging Vs. Perceiving
Our approach to getting things done
• Presents Urgency
• Speaks Decisively
• Prefers Plans
• Keeps Things Open
• Presents Looseness
• Respects Change
DOMINANT FUNCTONS
ISTJ
ISFJ
INFJ
I N TJ
ISTP
ISFP
INFP
INTP
ESTP
ESFP
ENFP
ENTP
ESTJ
ESFJ
ENFJ
ENTJ
TIPS FOR USING TYPE
WITH PATIENTS
Understanding Patients
Extraverted Patients
Introverted Patients
• Seek interaction
• Need time to reflect
• Seek energy/enthusiasm.
• More self-contained
• Need thoughts and
feelings drawn out
• Usually waits for others
to make the first move.
• Openly express their
thoughts and feelings,
• Easily distracted by other
activities (KISS)
Understanding Patients
iNtuitive Patients
Sensing Patients
•
•
•
•
Like precise instructions
Need info step-by-step
Like facts, not theories
Want details, “next steps”
•
•
•
•
Seek future implications
Want the “Big Picture”
Naturally skeptical
Will tune-out details
Understanding Patients
Thinking Patients
• Need to know why things
are done
• Dislike small talk
• Views things logically
• Debates
Feeling Patients
•
•
•
•
Needs feelings recognized
Needs warmth/support
View things emotionally
Defers
Understanding Patients
Judging Patients
• Strong need for clarity of
goals and objectives
• Like things settled and
finished
• Need structure and
predictability
• Need CLOSURE
Perceiving Patients
• Strong need for
understanding process
• Act spontaneously –
change minds
• Need flexibility
• Avoid CLOSURE
Cultural Competence
What do we mean by “culture”?
• An integrated pattern of behaviors, learned beliefs,
and assumptions about the world. Passed on from
one generation to another.
• “All societies are confronted with universally
shared problems that emerge from the human
requirements of dealing with fellow human beings,
time, and nature. One culture can be distinguished
from another by the specific solutions it chooses to
apply to these problems and dilemmas.”*
*From: “Type and Culture”
Why is Cultural Competence Essential?
• American diversity statistics
– 11 ½ % of Population is Foreign Born and Rising
– By 2050 white non-Hispanics will decrease from 75% (1996) to 50%
of the population.
– African American, Hispanic, and Asian American – double digit
growth in last 10 yrs.
– 32 million speak language other than English at home.
• Culture Influences Treatment & Outcome
– Different Illness Belief Systems & Help-Seeking Behaviors
• Changing Health Care System
– Shorter stays = Greater emphasis on Tx compliance
– Many receive no, or substandard care
Why is Knowing About Culture
Important?
Culture Influences:
– How we interpret other people’s intentions and
actions
– Beliefs about the cause and treatment of illness
– Help-seeking behaviors - Who to turn to in
times of illness
– Symptom recognition & communication
– Level of acculturation & compliance to Western
Medicine & the health professions
Iceberg Analogy
Known
Observable
language,
clothing,
foods,
etiquette
Immediately Apparent
USS Medicine
Not Observable
Unspoken but known
traditions, customs, values, perceptions,
assumptions, things we always do
Known
Thru
Questions
Unconscious
deeply internalized – beliefs & worldviews
that are difficult to express and
understandable only by someone from the
same culture
Invisible - Unknown
Iceberg Analogy
Learning Points
• We can only see 10% of a person’s cultural attributes
– We cannot see the most important dimensions of a person’s culture,
including values, attitudes, and beliefs.
– Most of who we are is below the surface, yet we tend to make
assumptions based on the visible portion. Leads to misjudgment and
misunderstanding which prevents us from looking deeper into the
person
– To really get to know someone – look below the surface - How do we
do that?
Cultural Intelligence in the
Practice of Medicine
Obstacles to Culturally Intelligent
Medicine
•Personal Ethnocentrism
Assumption – “My own cultural beliefs are the only reliable or correct
ones.” Others are viewed (experienced) as “different” or “similar” to
those beliefs.
Obstacle – Creates a deficit in rapport and increases personal distance
between Dr and Patient – Imposes “Doctor-Patient” role-playing
•Medical Ethnocentrism
Assumption - Health care providers, educated and socialized within a
bio-medical modal have superior knowledge and the correct, most
accurate approach to health care.
Obstacle – Prohibits the introduction of patient beliefs and behaviors
that impact Dx and Tx compliance. Creates distance – Quiets the
patient
Must shift from biomedical to biopsychosocial framework
Tips For Working With all Cultural Groups
Three Assumptions to Challenge
“People from a particular culture are mostly the same.”
• Differences in birth region, education, and income level make impact
how your patient communicates, perceives illness, and makes health
decisions.
“If the patient is not suggesting what he/she needs, they must not need
anything.”
• Difficult for people to verbalize their cultural values, belief systems, and
world views in ways that are understandable to someone from a different
culture. Difficult to step outside one’s culture and see it objectively
“More ‘personal’ interaction will take too long.”
• A little time up front save lots of time over the course of treatment
•Improves information retention, compliance, patient satisfaction.
Tips For Working With all Cultural Groups
(The Personal Encounter)
• Treat Each Person Uniquely - Each individual is different and may not fit
the common pattern for his/her ethnic group. Do not assume each
individual is bound to communicate in a certain way
• Determine Level of Acculturation – notice dress, language skills, and
mannerisms
• Listen to the Patient – focus on explanation of cause of illness w/o
rushing, concluding, or judging.
• Ask Yourself - “Am I aware of assumptions & cultural biases. that impact
my understanding?” “Do I prompt and appreciate the belief systems, or
health attitudes of this patient?”
• Notice and Use Non-Verbals - smiling, silence, gestures, nodding, eye
contact, body language, touch, etc. Follow their lead.
Tips For Working With all Cultural Groups
(The Clinical Encounter)
• Ask about the pt’s basic health & illness beliefs, medications, and other
forms of care
– “How/why do you think this is happening to you?” “What do you
think caused this?” “Other patients from your culture
believe….What do you believe?” Practice “Joining”?
• Consider which beliefs or practices would not interfere with or be
contraindicated with Tx, and allow
– “What things have you or others done to take care (treat) this?”
• Ask who is involved in decision-making and bring them into the
discussion
– “Are there family members that we should discuss this with?”
• When possible avoid a Tx plan that conflicts with pt’s beliefs and
lifestyle. Work through with patient.
– “Can you agree with what we have decided, and can you do it?”
CONCLUSIONS
• Much of what we need to know, we don’t know. The
patient does.
• Communicating effectively with different patients
requires openness about the limits of our own style and
culture.
• Patient-centered communications is a skill that can be
learned.
“People as objects” assignment