Challenges in Cultural Diversity: Protect Your Patients and Yourself
by Susan Shepard, MSN, MA, RN, Director, Patient Safety Education
Physicians are often faced with providing care to a multicultural society complicated by literacy issues. Assuring safe and quality health care for all persons requires physicians to understand how each patient’s sociocultural background affects his or her health beliefs and behaviors.
Consider the following scenarios: A 32-year-old Middle Eastern married female with uterine fibroids presented at the office of a gynecologist. After years of infertility and pain, a hysterectomy was recommended. She spoke English moderately well but with a heavy accent. Offers for an interpreter were declined, including translation of the surgical consent form. Eight weeks post-hysterectomy, the patient asked the physician how soon she could expect to become pregnant.
An elderly female Asian patient was noncommunicative with the physicians and staff during the first three days of her hospitalization. She would not maintain eye contact or talk, even when an interpreter was provided. Communication regarding the patient’s care or concerns would occur only when a male family member was present. The staff and physicians—concerned with privacy issues—generally spoke with the patient when family members were not present. After several days of delayed treatment because consent for a necessary but nonemergent surgery could not be obtained from the patient, a visiting chaplain of the patient’s same nationality explained the cultural requirement that a male be present for a female’s care.
Addressing the Problem
A link has been shown to exist between provider-patient communication and patient satisfaction, compliance, and improved outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of linguistic, contextual, and cultural barriers that preclude effective patient-provider communication. Research has shown that services for minorities can be improved by removing language and cultural barriers.
When cultures and languages clash, physicians are unable to deliver the care they have been trained to provide. Culturally competent care revolves around both systemic and individual cultural differences that can create conflicts and misunderstandings. If the provider is unable to elicit patient information and negotiate appropriate care, negative health consequences may occur.
How can physicians easily acquire and maintain the skills to provide culturally responsive and appropriate care to the increasingly diverse population of patients in the United States? Traditionally, training in cross-cultural medicine has focused on providing a list of common health beliefs, behaviors, and key “do”s and “don’t”s. This approach does not take into account acculturation and socioeconomic status and can lead to stereotyping. We recommend using an approach proposed by Drs. Carrillo, Green, and Betancourt that helps the physician elicit the patient’s beliefs and preferences in order to identify and deal with his or her concepts, concerns, and expectations. This model is called ESFT (explanatory model, social risk, fears and concerns, and therapeutic contracting).
Shielding Yourself and Protecting Your Patient
Consider this scenario: A 62-year-old Dominican patient presented with hypertension. In the past two years, she had been seen by several physicians, had multiple tests to rule out any underlying etiology, and tried a variety of medications to control her blood pressure. Despite these efforts, her blood pressure remained poorly controlled. The patient, whose primary language was Spanish, had limited English skills but refused an interpreter at all clinic appointments. It appeared that the patient was noncompliant with taking the antihypertension medicine, taking it only periodically when she felt tense or stressed. Further inquiry by the physician revealed that the patient was illiterate and did not understand the complex medication regimen she had been given.
In this scenario, the physician used the ESFT approach. He was able to explore the patient’s explanatory model for hypertension. The patient strongly believed that her hypertension was episodic and related to stress. Because of this, she didn’t take her daily antihypertension medication since this didn’t fit her explanatory model. The physician was able to reach a compromise utilizing this model by explaining that, although her blood pressure goes up during stressful times, her arteries are under stress all the time, even though she didn’t feel it. Taking medications daily would relieve this stress but not help with her stressful episodes. The physician was able to negotiate with the patient to add relaxation techniques to her daily routine.
Health Literacy
The Doctors Company supports the American Medical Association’s (AMA’s) policy on health literacy, which recognizes that limited patient literacy affects medical diagnosis and treatment.
Studies have shown that people from all age, race, income, and education levels are challenged by the inability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment. The AMA has cited a recent government study estimating that over 89 million American adults have limited health literacy skills. Of interest is that, in this group, 22 percent cannot understand the typical patient education handout; 26 percent did not understand when their next appointment was; 42 percent did not understand medication instructions; and up to 78 percent misinterpret warnings on prescription labels.
Even more concerning is that 22 percent do not understand common medical terms, such as bowel, colon, screening test, or blood in the stool. Individuals with limited health literacy incur medical expenses that are up to four times greater than patients with adequate literacy skills. We strive to help every physician to improve patient safety. We encourage you to explore these resources through the AMA Foundation:
- Health literacy toolkit: www.ama-assn.org/ama/pub/category/9913.html
- Health literacy patient safety tip cards: https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod810004?checkXwho=done
- Health literacy partnerships: www.ama-assn.org/ama/pub/category/11128.html
- Streaming video: www.ama-assn.org/ama/pub/category/8115.html
Steps You Can Take
- Check your own pulse and become aware of personal attitudes, beliefs, biases, and behaviors that may influence your care of patients.
- Use the ESFT model and the LEARN model (a mnemonic that outlines ESFT):
— Listen to the patient’s perception of the problem.
— Explain your perception of the problem.
— Acknowledge and discuss differences and similarities.
— Recommend treatment.
— Negotiate treatment.
- Ask the patient or interpreter to “repeat back” what you said during the informed-consent process, during the discussion of the treatment plan, or after any patient educational session with you or your staff. The repeat-back process is a very effective way to determine the extent of the patient’s understanding.
- Use the “Ask Me 3” approach, a tool that identifies three simple questions all physicians should be ready to answer—regardless of whether the patient asks. More information is available at http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/CON_ID_000669 and www.askmethree.org.
- Use language services for your limited English proficiency (LEP) patients.
- If the patient refuses interpreter services, explain to the patient/family member that it is very important to the patient’s care and safety that you and the patient/family understand each other. Suggest a referral to a physician who speaks the patient’s primary language. Be sure to document all of the facts in the medical record.
—Partner with your health plans and hospitals to identify written and oral language services.
—Find out your state requirements. For example, in California, both MediCal Managed Care and Healthy Families health plans are responsible for providing language access (unless it is contractually passed on to the physician). In “fee-for-service” MediCal, the physician is responsible. - Get more information from these useful Web sites:
— www.hrsa.gov/culturalcompetence
— www.diversityrx.org
— www.thinkculturalhealth.org
About the Author
This article, published in 2007, was written by Susan Shepard, MSN, MA, RN, director, patient safety education.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
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