Transcript Meeting The Health Care Needs of Diverse Populations.

Cultural Differences &
Professional Liability Implications
Panel Members:
Lauren M. Kwak, JD
Arthur F. Roeca, JD, Roeca Luria Hiraoka LLP
Victoria H. Rollins, MHA, RN, CPHRM
Objectives
• Identify how cultural issues affect patient care &
satisfaction, which may have legal ramifications
• Observe case presentations where differences in
cultures and misperceptions of patient encounters
impacted patient safety
• Identify and recognize patient safety recommendations
to promote safe care
Cultural Differences & Professional Liability
Implications - 2
Case #1
Patient background:
• Joshua Tree is a 67-year old resident of Lancaster, PA
 History of Type II diabetes and moderate hypertension
 Not taking prescribed medications for HTN
• Visiting daughter and son-in-law in Hawaii
• Sustained laceration to left foot while walking on the
beach
• Patient treated by Dr. Kwak
• Complications ensued, and patient is suing Dr. Kwak
Cultural Differences & Professional Liability
Implications - 3
Cultural Differences Augment Typical
Communication Barriers
• Communication is essential to quality of care and
patient safety
• Direct communication can be inhibited by
cultural barriers
• Persons whose care is inhibited by lack of sensitivity to
a cultural belief may be at risk for poorer outcome
• Communication is the most common underlying root
cause of sentinel event1
1Used
with permission: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One Size
Does Not Fit All: Meeting The Health Care Needs of Diverse Populations. Oakbrook Terrace,
IL: The Joint Commission; 2008:10.
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Implications - 4
Communication Is the Foundation
• Communication–vital to building relationships and
gaining trust
• If cannot communicate effectively with patient
 Unable to obtain or identify why patient presented
for treatment
• Without understanding the facts
 Cannot arrive at correct diagnosis
 May lead to incorrect clinical decision
 May result in under or over ordering of tests/treatments2
2Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid
Practitioners:21
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Implications - 5
Verbal Communication
• Physicians’ training
 Use close-ended questions to obtain medical history
• Can be counter-productive
 Does not address cultural issues
 Can lead to patient perception that physician not listening
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Implications - 6
Non-Verbal Communication
• Mannerisms and styles of non-verbal communication
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Facial expressions–eye contact
Personal space orientation
Gestures
Touching
Body posture
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Implications - 7
Case #2
• 32 year-old Middle Eastern married female with
history of uterine fibroids, treated for infertility and
pain
• Spoke broken English with heavy accent but refused an
interpreter
• Seen by female APRN
• Husband did not attend any appointments or
preoperative education
• Hysterectomy recommended
• Consent not translated but offered
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Implications - 8
Heightened Legal Duty
• A physician should not assume that communication
with a patient with limited English proficiency was
successful as this misplaced assumption can lead to the
false sense that legal duties were met
• Despite doing everything according to “textbook,”
cultural & language barriers present another layer of
responsibility that the physician must overcome to
deliver safe medicine
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Implications - 9
Meeting Needs of Specific Populations
• Staff training
 Traditions and rituals
 Role of traditional healers
 Impact of faith in the health/healing process
• Adapt environment to meet specific needs
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Awareness of “unlucky numbers”
Interaction of the genders
Culturally sensitive jewelry
Physical set up of the room
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Specific Patient Safety Considerations
• Informed consent process
 Address cultural and linguistic needs
 Translated into appropriate language and terms
• Take into consideration
 Religious beliefs
 Cultural beliefs
 Past experiences–can impact trust for consent3
 Cultural (even American subcultures) tendencies (e.g., to
underreport pain) 4
3Used with permission: Wilson-Stronks A, Galvez E. Exploring Cultural and Linguistic Services in the Nation’s
Hospitals: A Report of Findings. Oakbrook Terrace, IL: The Joint Commission; 2008:45.
4“Learning to Speak Iowan: Corn, Pigs, Cyclones and Hawkeyes,” The Wall Street Journal, September 9, 2011.
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Implications - 11
Patient Safety Considerations (continued)
• Other beliefs, needs and values
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Traditions or rituals
Impact and importance of family
Folk remedies
Complementary or alternative medicines
• Check your own pulse and become aware of personal
attitudes, beliefs, biases, and behaviors that may
influence your care of patients
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Physicians also bring cultural biases & notions into
the exam room
The physician/healthcare provider must become aware of his/her own
value system that could influence patient care just as much as the
physician should be aware of his/her patient’s own values.
“A whole body of literature has been published in recent decades
concerning the need for physicians and other providers to be
culturally competent, mindful of the beliefs and prejudices that
patients bring with them to the exam room. But the doctor-patient
interface is a two-way street, and the biases and myths that
doctors themselves carry to the bedside likewise may hinder
understanding.”
H. Lee Kagan. “Vital Signs: Education All Around. A patient’s Misconceptions, and a Medical
Student’s Naiveté, Mask a Critical Diagnosis.” January 29, 2011.
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Unconscious Bias
• Unconscious (implicit) bias among healthcare
professionals contributes to health disparities
• Unrecognized bias against a social group may
affect communication or care offered to those
patients
• Existing evidence does suggest that implicit
bias may affect clinical judgment and decision
making
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Implications - 14
What can an individual do?
• Consider “gut” reactions to specific individuals or
groups as a potential indicator of implicit bias
• Acknowledge and reappraise rather than suppress
uncomfortable feelings and thoughts
• Consider the situation from the patient’s perspective
• Partner with researchers and participate in research to
advance understanding of implicit bias and to develop
evidence-based interventions
“Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from
Here?” The Permanente Journal, Spring 2011; Vol. 15, No. 2.
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Conclusion
• Be alert for less prominent cultural differences
• Monitor your own beliefs, conceptions & biases
• Involve the patient–ask about cultural considerations of
health and care
• Involve others–internal and external resources
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Website Resources
1.www.jointcommission.org/PatientSafety/HLC/HLC_De
velop_Culturally_Competent_Pt_Centered_Stds.htm
2.www.jointcommission.org/PatientSafety?HLC/HLC_Re
sources_and_Links.htm
3.http://minorityhealth.hhs.gov/templates/browse.aspx?lvl
=2&lvlID=15.
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Implications - 17
Resources
Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E, “One Size
Does Not Fit All: Meeting the Health Care Needs of Diverse
Populations,” Oakbrook Terrace, IL; The Joint Commission; 2008.
Wilson-Stronks A, Galvez E, “Exploring Cultural and Linguistic Services in
the Nation’s Hospitals: A Report of Findings,” Oakbrook Terrace: The
Joint Commission; 2007.
American Institutes for Research. (2002). Teaching cultural competence in
health care: A review of current concepts, policies and practices. Report
prepared for the Office Minority Health. Washington, DC: Author.
Physician Toolkit and Curriculum: To Implement Cross-Cultural Clinical
Practice Guidelines for Medicaid Practitioners, March 2004.
H. Lee Kagan. “Vital Signs: Education All Around. A patient’s
Misconceptions, and a Medical Student’s Naiveté, Mask a Critical
Diagnosis.” January 29, 2011.
“Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from
Here?” The Permanente Journal, Spring 2011; Vol. 15, No. 2.
“Learning to Speak Iowan: Corn, Pigs, Cyclones and Hawkeyes,” The Wall
Street Journal, September 9, 2011.
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Implications - 18
Handouts
• 10 Guiding Principles
• Kathleen D. Pagana, RN, PhD, “Mind Your
Manners…Multiculturally,” Gannett Education, (used
with permission).
Mission
[email protected]
1-800-421-2368, ext. 1477
Our Mission is to advance, protect, and
reward the practice of good medicine.
For additional information, go to www.thedoctors.com and click on
Patient Safety
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