Keri Holmes-Maybank, MD
March, 2013
Medical University of South Carolina
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Residents will learn the definition of cultural
competency.
Residents will learn the importance of cultural
competency.
Residents will learn questions to use to
facilitate interviews in culturally diverse
populations.
Residents will identify pitfalls to avoid when
practicing cultural competency.
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Minority populations receive a lower level of
health care.
Successful care of minority populations
requires cultural competency.
By recognizing cultural differences a
respectful relationship between the provider
and patient may begin.
It is important to avoid stereotyping when
practicing cultural competency.
Culturally competent care leads to greater
patient satisfaction and less errors.
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Different languages
Different explanatory models of the cause
and treatment of illness
Religious beliefs
Ways of understanding the experience of
suffering and dying
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Misperceptions secondary to lack of cultural
competence lead to
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Poor interactions
Mistrust
Anger with patients and their families
Unwanted clinical outcomes
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Ethnic minorities ~30% of the population
>329 languages
32 million do not speak English at home
Foreign-born: 50% Latin America, 25% Asia,
25% Europe, Canada, etc.
By 2050 ethnic minorities will be the majority
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Multi-factorial
Minority communities
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More socioeconomically disadvantaged
Lower levels of education
Higher rates of occupational hazards
Greater environmental hazards
Overrepresented among underinsured
Higher rates of disease, disability, death
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Quality of Care - even when adjusted for access
(insurance and income)
◦ Utilization of cardiac diagnostic and therapeutic
procedures
◦ Analgesia for pain control
◦ Surgical treatment of lung cancer
◦ Referral for renal transplant
◦ Treatment of pneumonia and congestive heart
failure
◦ Immunizations
◦ Mammograms
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Cardiac procedures
Analgesic prescriptions
Cancer treatment
Depression anxiety treatment
HIV treatment
Renal disease
Asthma
Pharmacies in Black neighborhoods are less
like to stock and fill narcotics
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Lack of diversity in health care providers
Systems of care poorly designed to meet
needs of diverse patient populations
Poor communication between providers and
patients of different racial, ethnic or cultural
backgrounds
Lack of cultural competency
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Department of Health and Human Services’
Office of Minority health
◦ Culturally and Linguistically Appropriate Standards of
Services(CLAS)
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Healthy People 2010
Task Force on Community Preventative Services
Accreditation Council for Graduation Medical
Education - “Tool for the Assessment of
Cultural Competence Training” TACCT
Liaison Committee for Medical Education
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“Faculty and students must demonstrate an
understanding of the manner in which people
of diverse cultures and belief systems
perceive health and illness and respond to
various symptoms, diseases, and treatment.”
Cultural competence is a complex, life-long
process.
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Describes the ability of systems to provide
care to patients with diverse values, beliefs,
and behaviors, including delivery to meet pts
social, cultural, and linguistic needs.
Cultural competence refers to knowledge,
skills(communication, interpreters, attention
to nonverbal communication), and cultural
sensitivity.
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Capacity to identify, understand, and respect
values and beliefs of others
Consider how these factors interact at
multiple levels of the health care delivery
system
Devise interventions that take these issues
into account
Expansion of cultural knowledge
Disease prevalence, incidence, and treatment
outcomes
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Be aware of how culture shapes patient
values, beliefs, and world views
Acknowledge that differences exist
Respect the differences
Maintain a non-judgmental attitude toward
unfamiliar beliefs and practices
Be willing to negotiate and compromise when
world views conflict
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Differences are not accepted, appreciated,
explored, or understood = disagreements,
difficult interactions, or decisions the
physician does not understand
Creates barriers to accessing health care
Patients may delay or refuse care
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Mistrust
Perceived discrimination
Negative experiences with health care system
Historical events (slavery and abuses in research
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Comprehensive and compassionate care
Reduces unnecessary test
Reduces inappropriate use of services
Reduces the incidence of medical errors
Assures the provision of appropriate services
Improves health outcomes
Increases efficiency staff
Increases adherence
Greater patient satisfaction
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Trust is critical to cross-cultural cooperation
Addressing and respecting cultural
differences will likely increase trust
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Integrated pattern of learned beliefs and
behaviors
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Language
Thoughts
Communication
Ways of interacting
Views on roles and relationships
Actions
Practices/Customs
Values
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Race
Ethnicity
Nationality
Language
Gender
Sexual orientation
Socioeconomic status
Physical and mental ability
Occupation
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Influenced by religious or spiritual concerns
Religious and medial perspectives are
different and could come into conflict though
they do not need to be contradictory
Religious beliefs and practices vary from
individual within same religion or
denomination
Only God has knowledge about and power
over life and death
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Fundamentally shapes the way people make
meaning out of illness, suffering and dying
◦ How symptoms are identified and communicated
◦ Beliefs about causality, prognosis, prevention,
treatment options
◦ Threshold for seeking care
◦ Expectations of care
◦ Adherence
◦ Ability to understand the treatment strategy
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Family, social, and cultural networks reinforce
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Cultural system with specific language,
values, and practices that must be translated,
interpreted and negotiated with patient and
families.
Biomedical world view of professional training
creates values, perspectives, and biases.
Traditional H&P does not facilitate learning
how patients make decisions
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Right of patient to be informed about
condition, possible treatments, ability to
choose or refuse life –prolonging medical
care, advance directives
Truth-telling is not the norm in much of the
world
Can be seen as cruel and potentially harmful
May lose hope and suffer unnecessary
physical and emotional distress
Some believe hastens death
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Disease is the objective, measurable
pathophysiology that creates the illness
Illness includes the assumed etiology—be it
natural (fall that breaks a bone), supernatural
(God’s will, witches, or malevolent spirits), or
metaphysical (bad airs or seasonal changes
for which one is unprepared)
The assumed etiology establishes the
groundwork for negotiating objectives of care
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Develop communication skills
Aware of the specific beliefs and practices
Be sensitive cultural differences
Accept the patient values and world views as
starting points for the MD-PT relationship
Humility and genuine concern
Friendly and helpful
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Avoid medical jargon
Checking for understanding
Use translator
Ask specific questions - Inquire about values
Self-reflection to address own bias = barriers
Respect = trust = confide
Respectful emotionally supportive dialogue
can overcome racial barriers
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Disregarding importance of culture to
patient’s view and beliefs
“Cultural imperialism” - giving greater
meaning to values and disregard patient’s
MD’s may misinterpret non-verbal cues
without knowing cultural context
Family/untrained interpreters may
misinterpret medical phrases, censor
sensitive or taboo topics, or filter/summarize
discussion
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Interrupting
Failing to maintain appropriate physical
distance
Failing to listen
Assuming words mean the same to patient
Stereotyping
Appearing disrespectful
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Great diversity with in ethnic and cultural
groups
Individuals w differ socio-cultural factors:
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Gender
Socioeconomic class
Education
Immigrant status
Acculturation
Religion
Personal psychology
Life experience
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Elicit patient perspectives on illness and their
expectations
Ask patient if they have a certain belief
Open-ended questions
Empathic comments
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Increase awareness of racial and ethnic
disparities in health and the importance of
socio-cultural factors on health beliefs and
behaviors
Identify the impact of race, ethnicity, culture
and class on clinical decision-making
Develop tools to assess the community
members’ health beliefs and behaviors
Develop human resource skills for crosscultural assessment, communication and
negotiation
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Excellent evidence - improves knowledge of
health care professionals
Good evidence – improves attitudes and skills
of health professionals
Good evidence –impacts pt satisfaction
Poor evidence training impacts pt adherence
Poor evidence - training cost
No studies - health outcomes
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What do you think caused your sickness?
Why do you think it started when it did?
What do you think your sickness does to you?
How severe is your sickness?
What are the biggest problems your sickness
has caused for you?
What do you fear most about your sickness?
What are the most important results you hope
to get from treatment?
Kleinman
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What do you think might be going on?
Would you like me to tell you the full details of
your condition?
Is there someone else you would like me to talk
to?
What language are you most comfortable
speaking?
What are your greatest concerns now that you
have this illness?
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Who can help you with physical care,
emotional support, transportation?
Where do you go for religious or spiritual
strength, or solace?
What kind of assistance is available to you in
your community that might be helpful during
this time?
Where were you born and raised?
When did you emigrate to the U.S.?
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Understanding patients as individuals in
context of culture does not prevent conflicts
over differing beliefs, values, or practices
Does serve to identify areas of negotiation
and create atmosphere of mutual respect
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Ventilation and cardiopulmonary resuscitation
hasten death
Nodding indicates politeness and respect not
agreement
May seek aggressive treatment bc value
sanctity of life not bc misunderstand limits of
technology
History of poor access to care may feel
palliative care = giving up or poor care
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American Islamics expect broader issues of
faith and belief to be addressed in clinical
encounter
Black women who think God is controlling
health less likely to get mammograms
Some black communities believe suffering is
redemptive, must be endured, stopping life
support to avoid pain and suffering may be
seen as failing a test of faith
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Family is decision maker - responsibility to
protect the sick from burden
Hospice is failure of the caretaker
Filial piety – expectation children will care for
their parents
How well fulfill their filial duties is open to
community scrutiny and judgment
Reflect poorly on parenting abilities
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“Face” – indirect communication
◦ never put pt in a position of embarrassment or loss
of honor by directly asking a sensitive questions
◦ preservation or family and community honor
(Chinese American)
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Allows ambiguity and allows to save face and
possibility of hope
Can offer patient opportunity to know
“informed refusal”
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Statements of family are indirect questions –
acknowledges families fears, respects need
for indirect discussion, invites further
questions
Feel western MD seems to be giving negative
info through informed consent, truth telling,
advance care planning
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Home or natural remedies
Religion is a source of enormous emotional
support
More likely to want aggressive care at end of life
Less likely to have DNR and advance care plans
Less likely to trust the motives of md
Mistrust is a barrier to organ donation
Mistrust is barrier to participating in medical
research
More blacks fear inadequate medical care
Feel many unmet needs for communication
Want to be informed of dx and prognosis to
make informed decisions
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Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J, the Task Force on Community
Preventative Services. Culturally competent healthcare systems. A systematic review. Am J Prev Med
2003;24(3S):368-379.
Back A, Arnold R, Tulsky J. Mastering Communication with Seriously Ill Patients. Balancing Honesty with
Empathy and Hope 2009. Cambridge University Press.
Beach MC, Price EG, Gary TL, et al. Cultural competency: A systematic review of health care provider
educational interventions. Med Care. 2005 April;43(4):356-373.
Betancourt JR, Green AR, Carrillo. Cultural Competence in Health Care: Emerging Frameworks and
Practical Approaches. The Commonwealth Fund, Field Report 2002.
Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Define cultural competence: A practical
framework for addressing racial/ethnic disparities in health and health care. Public Health Reports JulyAugust 2003;118:293-302.
Betancourt JR, Green AR, Carrillo E, Park ER. Cultural competence and health care disparities: Key
perspectives and trends. Health Aff March 2005;24:499-505.
Carrese JA, Rhodes LA. Bridging cultural differences in medical practice. The case of discussing
negative information with Navajo patients. J Gen Intern Med 2000;15:92-96.
Crawley LM, Marshall PA, Lo B, Koenig BA. Strategies for culturally effective end-of-life care. Ann Intern
Med 2002;136:673-679.
Kagawa-Singer M, Blackhall LJ. Negotiating cross-cultural issues at the end of life. “You got to go
where he lives”. JAMA 2001;286(23):2993-3001.
Kleinman A. Patients and Healers in the Context of Culture. Berkeley, California: University of California
Press, 1980.
Levin SJ, Like RC, Gottlieb JE. ETHNIC: A Framework for culturally competent clinical practice. In:
Appendix: Useful Clinical Interviewing Mnemonics. Patient Care 2000;34(9)188-9.
Mull JD. Cross-cultural communication in the physician’s office. West J Med 1993;159:609-613.
Steiner RP, Rubel AJ. Recommended core curriculum guidelines on culturally sensitive and competent
health care. Fam Med 1996;27:291-297.
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R Resources for patients and families
I Individual identity and acculturation
S Skills of patient and family to adapt to
disease
K Knowledge ab health beliefs, values,
practices, and cultural communication
etiquette
Resources for patients
and families
Tangible resources that the family can
draw on, such as:
level of education, socioeconomic
status (including
insurance), social support networks,
in-language
social service agencies, transportation,
grocery
shopping, etc.
What kind of assistance is available to you in your
community that might be helpful during this time?’’
‘‘Do you know others in your community who have faced
similar difficulties?’’
Individual identity and
acculturation/
assimilation
Questions about the patient, the
context of his or her life,
and individual circumstances, including
place of birth,
refugee or immigration status,
languages spoken, and
degree of integration within the ethnic
community.
‘‘Where were you born and raised?’’
‘‘When did you emigrate to the U.S. and how has your
experience been coming to a new country?’’
‘‘What languages do you speak and in which are you most
comfortable talking?’’
What are your most important concerns now that you
have this illness?
Life history assessment: ‘‘What were other important
times in your life and how might these experiences
help us to know you?’’
Skills available to the
patient and family to
adapt to the disease
requirements
The actual ability of the patient and the
family to navigate
the health care system and cope with
the demands of
the disease itself—emotionally,
physically, socially,
and spiritually.
‘‘Who are the people in your support system that are
helpful or harmful?’’
‘‘Who is there to help you with physical care, emotional
support, transportation, and care of loved ones.’’
‘‘Who do you see or talk with, where do you go for
religious or spiritual strength, or solace?
Knowledge about the
ethnic group’s health
beliefs, values,
practices, and Cultural
communication etiquette
Beliefs, values and practices associated
with communication etiquette and
health, including attitudes toward
truth-telling, family-centered vs.
individual-centered decision-making
style, historical, social, and political
issues that might affect relationships
between the patient and elements of
the dominant culture.
Knows the dominant ethnic groups in practice. Reads about
the different cultures. Attends continuing education
programs about each culture—the beliefs, values, and
practices surrounding health, including truth-telling. What is
the symbolic meaning of the disease?
Learns about surrounding death and dying;
Does the patient/family adhere these beliefs and practices?
How are decisions made in this cultural group? Does this
family adhere to traditional cultural guidelines or do they
adhere more to the Western model?
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A
B
C
D
E
Attitudes
Beliefs
Context
Decision making
Environment
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E
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H
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Explanation
Treatment
Healers
Negotiate (mutually acceptable options)
Intervention (mutually acceptable)
Collaboration (patient, family, healers)
Spirituality
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B
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Beliefs
What caused your illness/problem?
Explanation
Why did it happen at this time?
Learn
Help me to understand your belief.
Impact
How is this impacting your life?
Empathy This must be very difficult for you.
Feelings How are you feeling about it?
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L
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Listen to the patient's perspective
Explain and share MD’s perspective
Acknowledge differences
Recommend a treatment plan
Negotiate a mutually agreed upon plan
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Assessment – willing to participate in
discussion
Preparation - disclose potentially upsetting
information
Communication - caring, kind, respectful
manner, do not rush, positive focus
Follow-through