Thinking Outside the BoxA 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 cross-cultural 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.

Elicit Factors

Negotiate Models

Awarenessof Culturaland Social

Factors

ImplementManagement

Strategies

A Patient-Based Approach to Cross-Cultural Care

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

Language and interpretation

Core cross-cultural issues

Exploring the meaning of the illness

Determining the social context

Cross-cultural negotiation

The Patient-Based Approach to Cross-Cultural Care

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

Language and interpretation

Core cross-cultural issues

Exploring the meaning of the illness

Determining the social context

Cross-cultural negotiation

The Patient-Based Approach to Cross-Cultural Care

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

Language and interpretation

Core cross-cultural issues

Exploring the meaning of the illness

Determining the social context

Cross-cultural negotiation

The Patient-Based Approach to Cross-Cultural Care

What are explanatory models?

• Patient’s conceptualizations of illness

• A spectrum between biomedical and non-biomedical

• 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?

Language and interpretation

Core cross-cultural issues

Exploring the meaning of the illness

Determining the social context

Cross-cultural negotiation

The Patient-Based Approach to Cross-Cultural Care

Determining Social Context

• Financial barriers

• Literacy

• Environment change

• Social stressors / support systems

Language and interpretation

Core cross-cultural issues

Exploring the meaning of the illness

Determining the social context

Cross-cultural negotiation

The Patient-Based Approach to Cross-Cultural Care

Negotiation Across Cultures

• All medical encounters are a negotiation between the

healthcare provider and the patient across cultures

Cross-Cultural Negotiation:Striving for Cooperation

Mutual understanding

Patient’s perspective Provider’s perspective

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

Mutual understanding

Patient’s model Biomedical model

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