Patient Culture I believe we are destined to meet the people who will support, guide, and nurture us...

Patient CulturePatient CultureI believe we are destined to meet the I believe we are destined to meet the people who will support, guide, and people who will support, guide, and nurture us on our life’s journey, each of nurture us on our life’s journey, each of them appearing at the appropriate time, them appearing at the appropriate time, accompanying us at least part of the accompanying us at least part of the way. -- Alice Walkerway. -- Alice Walker

© 2002 Sayantani DasGupta

Last WorkshopLast Workshop Name gameName game Definitions of Race, Ethnicity, Culture Definitions of Race, Ethnicity, Culture

and cultural competenceand cultural competence Mandates and rational for learning Mandates and rational for learning

about these issuesabout these issues Individual health beliefsIndividual health beliefs Medical culture: Illness Vs DiseaseMedical culture: Illness Vs Disease AngerAnger Hidden CurriculumHidden Curriculum

Workshop GoalWorkshop Goal To define and explore the variety of To define and explore the variety of

cultural issues that might impact cultural issues that might impact patient carepatient care

To develop knowledge and skills to To develop knowledge and skills to address these issuesaddress these issues

To develop a long term plan to To develop a long term plan to improve awareness, knowledge and improve awareness, knowledge and skills around cultural competencyskills around cultural competency


AgendaAgenda Patient characteristics Patient characteristics Issues in patient cultureIssues in patient culture Case studiesCase studies Culturally sensitive history takingCulturally sensitive history taking Action Planning Action Planning


NormsNorms One person at a timeOne person at a time Respect the opinions of others - all Respect the opinions of others - all

opinions are validopinions are valid Share depending on your level of Share depending on your level of

comfortcomfort Confidentiality - don’t share information Confidentiality - don’t share information

you may have learned about othersyou may have learned about others Have fun!Have fun!


COMMUNITY PEDIATRICSCOMMUNITY PEDIATRICS COLUMBIA UNIVERSITY

D escribe how health insurance,en titlem ent p rog ram s and the healthcare system affect access to care for

patients in the com m unity

A pp ly basic ep idem io log ica l concep tsand p rinc ip les to hea lth re la ted

issues in the com m unity

P erform a com m unity needs and asses tsanalysis and d iscuss the ir in fluence

on health care p rob lem s and outcom es

D escrib e the W ashing ton H eights andH arlem com m unities and how the ir

resources affect ch ild health

Exp lain m ajor env ironm enta l,soc ia l, econom ic, and po litica l fac tors

affecting ch ildren 's hea lth

COMMUNITY HEALTH

D ev elop skills to com m unicate andelic it in form ation from the p atient andfam ily about the ir health b e lie f system

and soc io -cu ltura l b ackg round

R ecog nize and m anag e the cu ltura lattr ib utes and b iases that the

p rov ider b rings into any c lin ica lencounter

D em onstrate an ab ility to formtherapeutic alliances w ithp atien ts from a v ariety of

soc io-cu ltura l b ackg rounds

Exp la in how belie fs , cu ltures, and e thnicp rac tices can in f luence health s ta tus

and care for ch ild ren of the com m unity

CULTURAL COMPETENCY

H elp p atients w ith com p lex m edica lp rob lem s neg otia te the health care system

U se advocacy skills to developa p lan of ac tion regard ing re levant

com m unity health issues

A rticu la te the im portance of thepediatric ian 's role as an advocate at

every leve l ( ind iv idual, com m unity, national)

ADVOCACY

COMMUNITY PEDIATRICS

Iceberg ExerciseIceberg Exercise Which characteristics of Which characteristics of

patients/people are visible?patients/people are visible? Which characteristics of Which characteristics of

patients/people are patients/people are assumed/invisible?assumed/invisible?


Patient CulturePatient Culture Take 5 minutes to write down a past Take 5 minutes to write down a past

encounter with a patient in which encounter with a patient in which issues of culture/cultural competence issues of culture/cultural competence were important.were important.

Present the case in 1-2 sentences. Present the case in 1-2 sentences. Also, what was the cultural issue? Also, what was the cultural issue? What were the interpersonal/ What were the interpersonal/ institutional barriers? What might have institutional barriers? What might have made the situation easier for you?made the situation easier for you?


Issues in Patient CultureIssues in Patient Culture LanguageLanguage Meanings of IllnessMeanings of Illness Help Seeking BehaviorHelp Seeking Behavior Social and Historical ContextSocial and Historical Context Core Cultural Issues (gender, Core Cultural Issues (gender,

authority, physical contact, decision authority, physical contact, decision making, religion/spirituality)making, religion/spirituality)


Case StudiesCase Studies Case 1: You are seeing a Dominican American girl Case 1: You are seeing a Dominican American girl

for her one-year-old physical. She has a dried and for her one-year-old physical. She has a dried and crusted lesions on her skin that her father says is crusted lesions on her skin that her father says is “varicella”that she had 2 weeks ago. The parents “varicella”that she had 2 weeks ago. The parents did not seek medical care at that time because they did not seek medical care at that time because they knew they had this appointment coming up knew they had this appointment coming up anyway. Although you try to focus on the nature of anyway. Although you try to focus on the nature of the rash (was it a dewdrop on a rosepetal?) the the rash (was it a dewdrop on a rosepetal?) the parents continue to ask you many questions about parents continue to ask you many questions about their daughter’s milk intake. You ultimately realize their daughter’s milk intake. You ultimately realize that that they have stopped her milk intake that that they have stopped her milk intake altogether. altogether.


Questions for Case Study Questions for Case Study #1#1

What is this family’s primary concern?What is this family’s primary concern? What is your primary concern?What is your primary concern? How do you reconcile these two How do you reconcile these two

agendas?agendas? What are your primary educational What are your primary educational

goals with this family?goals with this family? How will you communicate these How will you communicate these

goals?goals?© 2002 Sayantani DasGupta

Case StudiesCase Studies Case #2: You are seeing an Arabic American Case #2: You are seeing an Arabic American

family you have seen multiple times in the family you have seen multiple times in the past. On previous appointments, the mother past. On previous appointments, the mother would bring her 3 children. On this visit, the would bring her 3 children. On this visit, the father is present as well. Although he speaks father is present as well. Although he speaks better English than his wife, he cuts her off better English than his wife, he cuts her off repeatedly and undermines your pleasant repeatedly and undermines your pleasant relationship with the mother. He frequently relationship with the mother. He frequently erupts into Arabic, and appears to be yelling erupts into Arabic, and appears to be yelling at the mother.at the mother.


Questions for Case #2Questions for Case #2 What is the family dynamic here?What is the family dynamic here? What issues should you be What issues should you be

concerned about?concerned about? How do you re-establish a How do you re-establish a

relationship with this family?relationship with this family? How might your age and gender be How might your age and gender be

an issue here?an issue here?© 2002 Sayantani DasGupta

Case StudiesCase Studies Case Study #3: You are seeing the son of a Case Study #3: You are seeing the son of a

recently immigrated Cambodian family who has recently immigrated Cambodian family who has transferred to your clinic after leaving another transferred to your clinic after leaving another major medical center in the city. On examining the major medical center in the city. On examining the child, you realize the child has a dramatic murmur. child, you realize the child has a dramatic murmur. The parents tell you that the child has “a bad The parents tell you that the child has “a bad heart” for which he has received treatments. You heart” for which he has received treatments. You assume the child has been receiving penicillin for assume the child has been receiving penicillin for rheumatic heart disease. However, the parents rheumatic heart disease. However, the parents grow agitated when you suggest that this regimen grow agitated when you suggest that this regimen be continued, and the child receive an be continued, and the child receive an echocardiogram.echocardiogram.


Questions for Case #3Questions for Case #3 What are your assumptions in this case?What are your assumptions in this case? How can you clarify if they are correct?How can you clarify if they are correct? How might this child’s cultural or How might this child’s cultural or

political heritage impact the experience political heritage impact the experience of illness?of illness?

How should you proceed to ensure the How should you proceed to ensure the best care for this child?best care for this child?


Meanings of IllnessMeanings of Illness Disease: Abnormalities in the Disease: Abnormalities in the

structure and function of body structure and function of body organs and systems.organs and systems.

Illnesses: The human experience of Illnesses: The human experience of sickness - shaped by cultural sickness - shaped by cultural factors governing perception, factors governing perception, labeling, explanation and valuation labeling, explanation and valuation of the discomforting experience. of the discomforting experience.


Culturally Competent Culturally Competent HistoryHistory

What do you think caused your What do you think caused your problem?problem?

Why do you think it started when it Why do you think it started when it did?did?

What do you think your sickness What do you think your sickness does to you? How does it work?does to you? How does it work?

How severe is your sickness? Will it How severe is your sickness? Will it have a short or long course?have a short or long course?


Culturally Competent Culturally Competent HistoryHistory

What kind of treatment do you think you What kind of treatment do you think you should receive?should receive?

What are the most important results you What are the most important results you hope to receive from this treatment?hope to receive from this treatment?

What are the chief problems your What are the chief problems your sickness has caused for you?sickness has caused for you?

What do you fear most about your What do you fear most about your sickness?sickness?--Arthur Kleinman et al.--Arthur Kleinman et al.


Perceptions of Disease Perceptions of Disease and Illnessand Illness

Invasion of microorganismInvasion of microorganism Deterioration of body due to age, Deterioration of body due to age,

accidentaccident Body imbalanceBody imbalance Punishment by GodPunishment by God Result of offending ancestorsResult of offending ancestors


Perceptions of Healing and Perceptions of Healing and CuringCuring

Fighting an intruderFighting an intruder Putting the body back in balancePutting the body back in balance Making an atonement to God for Making an atonement to God for

wrongdoingwrongdoing Making peace with ancestorsMaking peace with ancestors


Perceptions of DoctorsPerceptions of Doctors HealerHealer Expert/miracle workerExpert/miracle worker God’s workerGod’s worker ShamanShaman Confidant or family memberConfidant or family member Authority figure Authority figure Someone who inflicts painSomeone who inflicts pain


Wrap Up: AwarenessWrap Up: Awareness Personal backgroundsPersonal backgrounds Potential biasesPotential biases The need for culturally competent The need for culturally competent

carecare The Anger IssueThe Anger Issue Aspects of medical culture Aspects of medical culture

including the hidden curriculumincluding the hidden curriculum

Wrap-Up: KnowledgeWrap-Up: Knowledge Definitions – race, ethnicity, cultural Definitions – race, ethnicity, cultural

group, cultural competencegroup, cultural competence Mandates for culturally competent Mandates for culturally competent

carecare Definition – the hidden curriculumDefinition – the hidden curriculum Meanings - Disease vs. IllnessMeanings - Disease vs. Illness Perceptions of Disease and Illness, Perceptions of Disease and Illness,

Healing and Curing, Doctors Healing and Curing, Doctors

Wrap-Up: SkillsWrap-Up: Skills Interpreter use trainingInterpreter use training Skills for addressing cross-cultural Skills for addressing cross-cultural

situationssituations ++ Spanish language skills training Spanish language skills training

The LEARN ModelThe LEARN Model L isten to your patient from his/her L isten to your patient from his/her

cultural cultural perspectiveperspective E xplain your concerns and your reasons E xplain your concerns and your reasons

for for asking for personal informationasking for personal information A cknowledge your patient’s concernA cknowledge your patient’s concern R ecommend a course of actionR ecommend a course of action N egotiate a plan with your patient that N egotiate a plan with your patient that

takes takes into consideration his/her into consideration his/her cultural norms cultural norms and personal lifestyleand personal lifestyle

Individual and Group Individual and Group Action PlansAction Plans

What do we as an institution/you What do we as an institution/you as residents do well?as residents do well?

How can you continue doing these How can you continue doing these things?things?

What can be improved upon?What can be improved upon?


Patient Culture I believe we are destined to meet the people who will support, guide, and nurture us...

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