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

                        

                        

                       

                                         

                                        

           

                                   

                

                                         

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.

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.

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)

Myths and the Misuse of the Concept of Culture

1. 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

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

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)

Components of Culture

• Environment• Economy• Technology• Religion/world view• Language• Social structure• Beliefs and values

(Hammond P, 1978)

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.)

Components of Medical Culture

• Environment• Economy• Technology• Religion/world view• Language• Social structure• Beliefs and values

Components of Medical Culture

• Environment

Components of Medical Culture

• EnvironmentHospitals, clinicsHygiene, sterilityWork indoors, controlled climatesDiet and eating habitsSleeping quarters

Components of Medical Culture

•Economy

Components of Medical Culture

• EconomyFrom “rags” to “riches”Heavy borrowing, debt for somePromise of future earnings

Components of Medical Culture

•Technology

Components of Medical Culture

• Technology Heavily dependent in all aspects Communication with each other, patients Diagnostic testing Treatment Research Education

Components of Medical Culture

•Religion/world view

Components of Medical Culture

• Religion/world view “House of God” Time is money Importance of speed, efficiency

Components of Medical Culture

•Language

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…

Components of Medical Culture

•Social structure

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".

Components of Medical Culture

• Beliefs and values

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

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 careLack of proportional representation of minorities in the health

professionsLow levels of cultural competence among health care

professionals

Models of Effective Cross-Cultural Communication and Negotiation:

LEARN Model

• Listen• Elicit• Assess• Recommend• Negotiate

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?

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)

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?

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?

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?

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?

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.

• 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.

Executive Order in 2000

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.

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.

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).

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.

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.

Effectively Communicating Through Interpreters

Terminology

Interpretation

vs.

Translation

- oral or sign-language communication (real-time, spoken word)

- written materials

Barriers to Good Interpretation

• Patient’s perspective

• Physician’s perspective

• Interpreter’s perspective

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

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

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

Guidelines for Working with an Interpreter

1. Introduce yourself to patient & interpreter

2. Instruct both parties on the role of interpreter

3. Reassure confidentiality

4. Position interpreter next to or behind patient

Guidelines

5. Use short phrases & speak in normal tone6. Address patients directly, maintain eye

contact7. Encourage interpreters to ask questions

when they don’t understand8. Encourage patient to ask questions, to

repeat your instructions back to you

Guidelines

9. Maintain eye contact with patient & speak directly with the patient

10. You can ask the interpreter for clarification (let the patient know)

11. 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.

Practice

Questions or Comments?