Confessions of a Culturally Challenged Physician

1. Confessions of a Culturally Challenged Physician Shirley Schlessinger, MD, FACP Associate Dean, Graduate Medical Education Medical Director Mississippi Renal Transplant Program Medical Director, Mississippi Organ Recovery Agency Chief of Staff, University Hospitals and Clinics, 2003-2004 Associate Professor, Division of Nephrology University of Mississippi Medical Center

2. Are YOU a “culturally competent” physician? How do you know? How is cultural competence evident in your practice? What pitfalls must you avoid in the future to maintain cultural competency?

3. Why Does Cultural Competence Matter? • Need to eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds • Improve the quality of services and health outcomes • A response to current and projected demographic changes in the US • Meet legislative, regulatory, and accreditation mandates • Gain a competitive edge in the marketplace • Decrease likelihood of liability / malpractice claims

4. Ms. BP • 53 yo BF; ESRD/HTN/ h/o Mental Illness, marginally literate from rural MS • s/p Renal Tx 9/03 • Concrete thought processes • Perseveration of delusions • “My son works for the President”

7. What IS Cultural Competence? The ability to function effectively in the context of cultural differences…

8. Beliefs Traditions Lifestyles Age Education Profession Religion Sexual Orientation Values Socioeconomic status Hobbies Political Affiliation Geographic origin Race Gender Family position “Culture”

9. Adjective AssociationsWhat’s your first thought? Black male Alzheimer’s victim Asian man Welfare recipient Deaf / Mute Homosexual Teenager

10. Adjective AssociationsWhat’s your first thought? • Denzel Washington • Ronald Reagan • Jackie Chan • JK Rowling • Helen Keller • Ellen Degeneres • Hillary Duff

11. Recognize Stereotyping!!! • A learned behavior • Applies information and mis-information about “groups” to an individual • Re-enforced by media and everyday surroundings • Results in automatic assumptions which can result in poor patient care

12. For optimal patient care, we must: • Recognize and avoid stereotypic mentality • Know our own biases and value systems • Respect our patients value systems • Recognize the many cultural influences that impact decision-making in health care

13. Ms. SH • 29 y/o BF deaf/mute since birth • ESRD / HTN referred for Tx Evaluation • Marginal literacy • ??? Need for interpreter at evaluation screening clinic appointment???? • Opportunities for education…

14. Mr. JP • 44 y/o BM with DM / HTN presented with flank pain / hematuria • US/CT abd with LARGE renal mass • No evidence of metastasis, likely curable RCCa • Pt absolutely refused surgery • “I don’t want to go to Hell”

15. The Grandpa • Tragic MVA, both parents dead on scene • Only grandchild brain dead on vent • One set of grandparents want to donate organs • Other set of grandparents poorly educated, virtually homeless, in poor health, dirty, and angry… • Will they halt donation?

16. Enhancing Your Cultural Competence... • Be aware of YOUR mental filters • Avoid “labeling” people • Educate yourself! • Learn a language! • Listen to new music! • Eat sushi! • Read foreign authors! • Learn to appreciate the individual in every patient you see!

17. Be Aware of Recognized Cultural Inequities in US Health Care Racial & Ethnic Minorities are less likely to receive or undergo: • Routine cardiac eval / CABG • Transplantation • Mammography • Referral for Chemotherapy • Hormone replacement therapy

18. 1. Cross-cultural misunderstandings between providers and patients can lead to mistrust and frustration, but are unlikely to have an impact on objectively measured clinical outcomes. True? False?

19. 2. When a provider expects that a patient will understand a condition and follow a regimen, the patient is more likely to do so than if the provider has doubts about the patient. True? False?

20. 3. A really conscientious health provider can eliminate his or her own prejudices or negative assumptions about certain types of patients. True? False?

21. 4. If a family member speaks English as well as the patient’s native language, and is willing to act as interpreter, this is the best possible solution to the problem of interpreting. True? False?

22. 5. Some symbols - a positive nod of the head, a pointing finger, the “thumb-s up” sign - are universal and can help bridge the language gap. True? False?

23. 6. Out of respect for a patient’s privacy, the provider should always begin a relationship by seeing an adult patient alone and drawing the family in as needed. True? False?

24. 7. In some cultures, it may be appropriate for female relatives to ask the husband of a pregnant woman to sign consent forms, if the patient agrees and this is legally permissible. True? False?

25. 8. When a patient is not adhering to a prescribed treatment after several visits, which does NOT help?: A. Involving family members B. Repeating instructions loudly to emphasize importance C. Agreeing to a compromise in timing or amount D. Listening to folk or alternative remedy suggestions

26. 9. Correct methods to communicate with a patient though an interpreter include: A. Making eye contact with the interpreter when you are speaking, then looking at the patient while the interpreter is telling the patient what you said. B. Speaking slowly, pausing between words C. Asking the interpreter to further explain the patient’s statement D. None of the above

27. 10. In a medical interview with a patient from a different cultural background, which is the LEAST useful technique? A. Ask questions about what the patient believes about his illness, what caused the illness, how severe it is, and what type of treatment is needed? B. Gently explain which beliefs about the illness are not correct C. Explain the “Western” or “American” beliefs about the patient’s illness D. Discuss the differences in beliefs without being judgmental