Transcript CCC Workshop

Thinking Outside the Box
A Framework for Cross-Cultural Care
Alexander R. Green, MD, MPH
Joseph R. Betancourt, MD, MPH
The Disparities Solutions Center
Massachusetts General Hospital
Co-Chairs, Cross-Cultural Care Committee
Harvard Medical School
Goals of the session
• Increase awareness of common crosscultural issues and challenges
• Discuss some effective approaches for
dealing with these issues and challenges
• Integrate cross-cultural communication skills
into care of all patients, especially across
cultures
• Prepare to teach students about this
Agenda
Part 1
• A framework for cross-cultural care
• Practical tips to integrating this into patient interactions
Part 2
• Short (12 minute) documentary-style video
• Discussion: cross-cultural communication and teaching
• Wrap-up
What is “cultural competence”?
A.
Treating every patient with equal respect and dignity
regardless of culture, ethnicity, race or social status
B.
Having a working knowledge of the important customs,
values, and health beliefs, for a wide range of cultural
groups
C.
Having the skills to communicate well with any patient
you see to explore customs, values, and health beliefs
Questions to think about:
What is Culture?
• A shared system of beliefs, values, and learned
patterns of behavior.
• An individual has many cultural influences
• Nationality, religion, age, education, work,
acculturation, etc…
The character of the cross-cultural interview
Respect
Curiosity
Empathy
51% of Americans have limited
functional health literacy*
• Health literacy is the ability to:
– understand basic medical terms about symptoms
and illness
– follow directions for diagnostic procedures and
therapies
– Engage in a dialogue about medical issues
*Health Literacy: A Prescription to End Confusion. Institute of Medicine.
The National Academies Press. Washington, D.C. 2004.
A Patient-Based Approach to
Cross-Cultural Care
Awareness
of Cultural
and Social
Factors
Elicit
Factors
Negotiate
Models
Implement
Management
Strategies
Tools and skills necessary to provide quality care to
any patient we see, regardless of race, ethnicity,
culture, class or language proficiency
Sociocultural barriers to effective care
• Language barriers
• Health literacy and educational barriers
• Lack of trust in the medical system
• Alternative beliefs about illness
• Alternative forms of treatment
• Customs and religious beliefs
• Socioeconomic barriers
• Physicians’ unconscious biases and decisions
The Patient-Based Approach
to Cross-Cultural Care
Language and interpretation
Core cross-cultural issues
Exploring the meaning of the illness
Determining the social context
Cross-cultural negotiation
With language barriers patients are:
• Less satisfied with with provider communication (Morales,
et.al. JGIM 1999)
• Less likely to have regular source of care and to receive
timely eye, dental, and physical exams (Hu, et.al. WJM
1986)
• Less likely to receive preventive services (Pap, mammo,
BE) (Woloshin, et.al. JGIM 1997)
• More likely to report med complications (Gandhi, et.al. JGIM
2000)
• Professional interpreter services are essential
– Trained interpreters, staff, or telephone based systems
– Family or other untrained interpreters can introduce biases or
may misinterpret
• Effective use of interpreters involves
– Patient and provider facing each other with interpreter to one
side
– Speaking clearly and succinctly with pauses for interpretation
– Avoiding medical jargon, colloquial expressions, and run-ons
The Patient-Based Approach
to Cross-Cultural Care
Language and interpretation
Core cross-cultural issues
Exploring the meaning of the illness
Determining the social context
Cross-cultural negotiation
Core Cross-Cultural Issues
• Communication styles
• Mistrust and Prejudice
• Autonomy, Authority, and the Family
• Traditions and Customs
• Sexual and Gender Issues
Communication styles:
• Eye contact and personal space
• Deferent vs. confrontational
• Expressive versus stoic
• Key Point: understand the importance of
good communication and be flexible to
different communication styles
Mistrust:
• Build trust and reassure patient of your intentions
• Keep in perspective what’s important for patient
• Show respect for patient’s wishes and concerns
• Focus negotiation on medically crucial issues first
• Key point: recognize mistrust and do things
intentionally to build trust with the patient
Autonomy, Authority, and the Family:
• Role of family vs. individual in decision making
• Role of authority figure within family or social group
• Consider involving community leaders or spiritual
leaders in very important decisions
• Key Point: Determine whether the patient makes
medical decisions independently or whether
others should be directly involved
Traditions and Customs
• Clothing
• Religious customs, prayer
• Touch
• Diet
• Key Point: Look for any customs that
may affect health and medical care
Sexual and gender issues:
• Shame / embarrassment in discussion of sexual
issues
• Birth control
• Gender concordance / discordance
• Gynecologic, breast, genital, rectal exams
• Key Point: Be careful when discussing these
issues with patients of different cultures--explain
first why you’re asking
The Patient-Based Approach
to Cross-Cultural Care
Language and interpretation
Core cross-cultural issues
Exploring the meaning of the illness
Determining the social context
Cross-cultural negotiation
What are explanatory models?
• Patient’s conceptualizations of illness
• A spectrum between biomedical and nonbiomedical
• Common sense, folk beliefs, medical
knowledge, personal meaning
Explanatory Model Questions
1. What do you think caused your problem? How?
2. Why do you think it started when it did?
3. How does it affect you?
4. What worries you most?
5. What kind of treatment do you think you should
receive? Results expected?
The Patient-Based Approach
to Cross-Cultural Care
Language and interpretation
Core cross-cultural issues
Exploring the meaning of the illness
Determining the social context
Cross-cultural negotiation
Determining Social Context
• Financial barriers
• Literacy
• Environment change
• Social stressors / support systems
The Patient-Based Approach
to Cross-Cultural Care
Language and interpretation
Core cross-cultural issues
Exploring the meaning of the illness
Determining the social context
Cross-cultural negotiation
Negotiation Across Cultures
• All medical encounters are a negotiation
between the healthcare provider and the
patient across cultures
Cross-Cultural Negotiation:
Striving for Cooperation
Patient’s perspective
Provider’s perspective
Mutual understanding
Improved cooperation
Teaching challenges
• Avoid teaching stereotypes
• Avoid pitfall of “us” and “them” - normal
doctor - strange, exotic patient
• Can’t be seen as a marginalized “add-on”
• Avoid preaching - keep practical
• Don’t let them off the hook with generalities
Cross-Cultural Care
Embedding into Practice:
Points of Inquiry and the
Medical History
Core Cross-Cultural Issues
• Styles of Communication
– Empower patient to participate and ask questions
• I need you to help me help you; please let me know if you don’t
understand
• Can embed style of communication into social history
• Autonomy, Authority, and Family Dynamics
– Identify how patients want to hear news; who else should be
involved
• When we get the results, how should I share them with you? Anyone
else?
• Can embed decisionmaking preferences in to advance directives or
social history
Core Cross-Cultural Issues
• Role of Biomedicine
– Determine whether patient sees anyone else; identify use of CAM and folk
remedies
• What do you take for your condition? Do you see anyone else?
• Incorporate into medication history
• Traditions, Customs, Spirituality
– Determine whether there are customs that might interfere with clinical care
(Ramadan, blood transfusions, diet around holidays)
• Are there any traditions, customs (diet, holidays) or spiritual beliefs I should
know about that might impact the care I provide?
• Can embed into social history
Core Cross-Cultural Issues
• Sexual and Gender Issues
– Explore issues related to sexuality, orientation; determine
comfort with clinical of opposite gender
• I may refer you to other physicians or health care providers…are
you comfortable seeing any gender?
• I ask questions about sexual orientation to all my patients…I will
always define what I mean first
• Can embed into social history
• Mistrust and Prejudice
– Identify mistrust (through previous health experience); provide
focused reassurance
• What do you like or not like about your last health care provider or
health care experience?
• Can integrate into social history
Meaning of the Illness:
Identifying Explanatory Models
1. What do you think has caused your problem? How?
2. Why do you think it started when it did?
3. How does it affect you?
4. What worries you most? Severity? Duration?
5.
What kind of treatment do you think you should receive? What
result do you expect?
Can be part of HPI or in A/P
Social Context
1.
Tension:
-What are your major supports and stressors?
2.
Environment Change
-What was medical care like where you come from?
3.
Language/Literacy
-Do you have trouble reading pill bottles?
4.
Life Control
-What are your thoughts about health care? Can you get meds?
Provider-Patient Negotiation
Patient’s model
Biomedical model
Mutual understanding
Improved adherence
Cultural Competence
Addressing Adherence
The ESFT Model
• Explanatory Model
• Social Risk for Noncompliance
• Fears/Concerns about the Medication
• Therapeutic Contracting/Playback
Meaning of the Illness:
Identifying Explanatory Models
1. What do you think has caused your problem? How?
2. Why do you think it started when it did?
3. How does it affect you?
4. What worries you most? Severity? Duration?
5.
What kind of treatment do you think you should receive?
What result do you expect?
Determining Social and Financial
Risk for Noncompliance
1. How do you get your medications?
2. Are they difficult to afford?
3. Do you have the time to pick them up?
4. How quickly do you get them?
5. Do you have help getting them if needed?
Determining Fears and
Concerns about Medications
1. Does this medication sound okay to you?
2. Are you concerned about the:
– Dosage
– Size of pill
– Color of pill
3. Have you heard anything about this
medication?
4. Are you worried about side effects?
Determining Patient Understanding
of the Treatment
Remembering how to take medications can
be difficult...
1. Do you understand how to take the medication?
2. Can you tell me how you will take them?
Summary
• Focus on the individual patient (don’t assume)
• Ask questions and be curious about the patients
perspective (beliefs, customs, fears, reasons)
• Be sensitive and respectful of cultural differences
• Communicate at the patient’s level - interpreter if
necessary
• Be aware of mistrust and try to build trust
• Be aware of social factors, not just cultural
• Be flexible when necessary and negotiate
Discussions based on films
Small Group Conversations
• What were the major cross-cultural challenges?
• How were they addressed in the film and what
would you have done differently?
• What are the take home points to try in your
practice?
Summary
• Sociocultural factors impact provider-patient
communication and non-medical factors
(race, gender, age) influence clinical
decisionmaking
• A patient-based approach can help providers
improve quality of care
• We can make cultural competence real by
embedding into practice