Cross-Cultural Communication: Interacting Effectively with Patients from Diverse Backgrounds

1. Cross-Cultural Communication: Interacting Effectively with Patients from Diverse Backgrounds Fern R. Hauck, MD, MS Department of Family Medicine University of Virginia EFM1 – February 2011

2. Objectives • Define culture and cultural competence. • Learn how to effectively collaborate and care for patients whose cultural experiences and beliefs differ from those of “mainstream” US medical culture. • Identify laws and standards related to caring for LEP patients • Learn different methods of effective communication and interaction. • Learn how to effectively communicate through interpreters.

3. What is culture? • Cultures are dynamic, responsive, coherent systems of beliefs, values and lifestyles that have developed within particular geographic locations; they evolve and are passed on from generation to generation. • The resulting lifestyle (cultural) patterns of each group -such as diet, marriage rules, and means of livelihood- influence gene expression, health status and disease prevalence. • The function of culture is to ensure the survival and • well-being of its members.

4. Cultural Values • Give an individual a sense of direction and meaning to life. • These values are held on an unconscious level. • Of the many factors known to determine health beliefs and behaviors, culture is the most influential. (Harwood, 1981)

5. Myths and the Misuse of the Concept of Culture • Culture is not race • 6 racial/ethnic categories by OMB intended to monitor political allocation of resources, not as scientific evidence of genetic differences • Greater genetic within-group variation than between • Each category contains multiple national groups & multiple ethnic groups within each national group, each with its own culture or subculture

6. Myths and the Misuse of the Concept of Culture 2. Cultures are not homogeneous • Various levels of acculturation, assimilation, age, education, family structure, gender, wealth, refugee or immigrant status all modify the degree to which one’s cultural group membership may influence health practices and health status • Each cultural group is continually undergoing change

7. Myths and the Misuse of the Concept of Culture 3. The Western biomedical model and European-American lifestyle are not the only ways to ensure health • Research indicates that prevalence of some illnesses much lower in immigrants’ countries of origin than after settling in the U.S. (e.g., diabetes, breast cancer)

8. Components of Culture • Environment • Economy • Technology • Religion/world view • Language • Social structure • Beliefs and values (Hammond P, 1978)

9. Take a Moment Think about your own culture, especially your beliefs and values. Describe your cultural “profile” keeping in mind the preceding components. How do they influence your attitudes, and experiences with health and health care? (You may need to think about the time before you entered medical school.)

10. Components of Medical Culture • Environment • Economy • Technology • Religion/world view • Language • Social structure • Beliefs and values

11. Components of Medical Culture • Environment

12. Components of Medical Culture • Environment • Hospitals, clinics • Hygiene, sterility • Work indoors, controlled climates • Diet and eating habits • Sleeping quarters

13. Components of Medical Culture • Economy

14. Components of Medical Culture • Economy • From “rags” to “riches” • Heavy borrowing, debt for some • Promise of future earnings

15. Components of Medical Culture • Technology

16. Components of Medical Culture • Technology • Heavily dependent in all aspects • Communication with each other, patients • Diagnostic testing • Treatment • Research • Education

17. Components of Medical Culture • Religion/world view

18. Components of Medical Culture • Religion/world view • “House of God” • Time is money • Importance of speed, efficiency

19. Components of Medical Culture • Language

20. Components of Medical Culture • Language • Abbreviations, eponyms, acronyms • Language that “mystifies” – a whole different vocabulary • Medical professionals (and • patients) from diverse cultures, • speaking many languages AIDS, SIDS, MRI, DNR…

21. Components of Medical Culture • Social structure

22. Components of Medical Culture • Social structure • Hierarchical • Students….attendings • Staff….doctors • Patients….doctors • Shared experiences • Member of an exclusive club • Clothing (white coats, scrubs) Doctor (title), a title of respect. It comes to English from Old French and is the agent form of the Latin verb docere, "to teach".

23. Components of Medical Culture • Beliefs and values

24. Components of Medical Culture • Beliefs and values • Biologic/scientific basis of disease and evidence-based medicine • Hard work is rewarded • “Can-do” attitude – we can fix anything

25. Definition of Cultural Competence Having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented, by patients and their communities. Why is this important??? • Ever-increasing diversity of the population of the United States • Strong evidence of racial and ethnic disparities in health care • Barriers in access to care • Lack of proportional representation of minorities in the health professions • Low levels of cultural competence among health care professionals

26. Models of Effective Cross-Cultural Communication and Negotiation:LEARN Model • Listen • Elicit • Assess • Recommend • Negotiate

27. LEARN Model • Listen • Identify and greet family/friends of patient • Provide an interpreter • Listen with sympathy and understanding to the patient’s presentation/perception of the problem • Use open-ended questions to start: How can I help you today? Could you please tell me the reason for your visit today?

28. LEARN Model • Elicit • Elicit the patient’s health beliefs as they relate to the reason for the visit and his/her health behaviors. • What are some questions that may help with this? (Hint: Kleinman paper)

29. LEARN Model • Elicit the patient’s health beliefs/explanatory model: • What do you think has caused your problem/illness? • Why do you think it started when it did? • What kind of treatment do you think you should receive? • What are the most important results you hope to receive from this treatment? • How can I be of most help to you?

30. LEARN Model • Assess • Assess potential attributes and problems in the patient’s life that may have an impact on his health and health behaviors: • Could you tell me more about yourself? • What brought you to this country? How does medical care differ here? • Are there times that are bad for your appointments? Do you have transportation problems? • Do you have trouble reading medicine bottles or appointment slips?

31. LEARN Model • Recommend • Recommend a plan of action with an explanation of your rationale using language the patient can understand. • Check back: to make sure that we understand one another, can you tell me what it is I just told you? • Is there any part that you don’t understand?

32. LEARN Model • Negotiate • Negotiate a plan of action with your patient after you have made your recommendations. • Examples: • Let’s come up with a plan that works for you. • What do you think should be the next steps?

33. Title VI of the Civil Rights Act of 1964 • “No person in the United States shall on the ground of race, color or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” • This came about to ensure that all Americans would be eligible to receive Medicare benefits.

34. Executive Order in 2000 • Issued by President Clinton • Ensures that Limited English Proficient (LEP) persons who are eligible for Federal programs and services have meaningful access to the health and social service benefits that they provide. (=Interpreters) • Access must be at no additional cost to the LEP person.

35. National Standards for Culturally andLinguistically Appropriate Services (CLAS) Introduced in 2000 by DHHS Office of Minority Health (www.omhrc.gov/CLAS) The CLAS standards are primarily directed at health care organizations; however, individual providers are also encouraged to use the standards to make their practices more culturally and linguistically accessible. The principles and activities of culturally and linguistically appropriate services should be integrated throughout an organization and undertaken in partnership with the communities being served.

36. National Standards for Culturally andLinguistically Appropriate Services (CLAS) • 14 standards are organized by themes: Culturally Competent Care (Standards 1-3) • Language Access Services (Standards 4-7) • Organizational Supports for Cultural Competence (Standards 8-14) • Within this framework, there are three types of standards of varying stringency: mandates, guidelines, and recommendations.

37. National Standards for Culturally andLinguistically Appropriate Services (CLAS) • CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards 4, 5, 6, and 7). • CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13). • CLAS recommendations are suggested by OMH for voluntary adoption by health care organizations (Standard 14).

38. CLAS Mandates • Standard 4Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. • Standard 5Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

39. CLAS Mandates • Standard 6Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). • Standard 7 Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.

40. Effectively Communicating Through Interpreters

41. Interpretation vs. Translation - oral or sign-language communication (real-time, spoken word) - written materials Terminology

42. Barriers to Good Interpretation • Patient’s perspective • Physician’s perspective • Interpreter’s perspective

43. Barriers to Good Interpretation • Patient’s perspective • Not aware they are entitled to free services, often bring in family members (including children) • Confidentiality • Difficulty in developing rapport • Difficult to understand certain concepts, illnesses, terminology • Patients reluctant to ask questions, if interpreter no longer present/phone call ended • Shy, embarrassed to ask for clarification if don’t understand

44. Barriers to Good Interpretation • Physician’s perspective • Too much time and trouble, especially phone • May cut back on dialogue/questions • Inadequate training/experience/competence • Using medical jargon

45. Barriers to Good Interpretation • Interpreter’s perspective • Inadequate training, lack of medical terminology • Confidentiality • Overstepping boundaries • Patient or doctor speaks too fast or long sentences • Directing questions to interpreter • Interpreter controls the visit, rather than the provider

46. Guidelines for Working with an Interpreter • Introduce yourself to patient & interpreter • Instruct both parties on the role of interpreter • Reassure confidentiality • Position interpreter next to or behind patient

47. Guidelines • Use short phrases & speak in normal tone • Address patients directly, maintain eye contact • Encourage interpreters to ask questions when they don’t understand • Encourage patient to ask questions, to repeat your instructions back to you

48. Guidelines • Maintain eye contact with patient & speak directly with the patient • You can ask the interpreter for clarification (let the patient know) • Don’t get frustrated if it seems to take too long to interpret. English is a concise language and many languages don’t have equivalent words for medical conditions.

49. Practice

50. Questions or Comments?