Culture and Communication: What Do You Need To Know? Lisa Hark , PhD, RD Wills Eye Institute and Jefferson Medical Colle

1. Culture and Communication:What Do You Need To Know?Lisa Hark, PhD, RDWills Eye Institute and Jefferson Medical College

2. Objectives • Increase your awareness of the major shifts in the US. population. • Recognize factors that contribute to building a strong doctor/patient relationship. • Appreciate that patients’ ethnicity and cultural background has a strong influence on their willingness to adhere to your medical advice.

3. The Art of Communication • Your patient is unique with his/her distinctive history containing personal and often intimate information. • What and how you ask questions will set the stage for your ongoing relationship. • A patients’ perception that their physician ‘‘knows them as a person’’ is more highly correlated with patient adherence to medical treatment than any other dimension of care measured.

4. What Does This Mean To You? • You can’t assume your patient will: • Get your Rx filled and take the medication (adherence) • Make an appt and see the specialist you recommend • Get the test or lab work you ordered • Adhere to Preventive Guidelines you suggest • Have the procedure you recommended • Consent for surgery or experimental therapy • Agree to receive chemotherapy or radiation therapy • Show up for your f/u appt

5. The U.S. population is rapidly changing

6. U.S. Census Data (2000-2007) By 2015, minorities are expected to represent 1/3 of U.S. populationBy 2050 minorities are expected to represent 1/2 U.S. population Source: US Census 2000, 2003, 2007. Factfinder.uscensus.gov

7. U.S. Census Data by City (2007) Source: US Census 2007. Factfinder.uscensus.gov

8. Hispanic Population Trends • Hispanics are the largest ethnic minority group. • 1 in 5 Americans predicted to be Hispanic by 2020. • Hispanic population expected to grow by 1.4 million/yr. • U.S. now 3rd largest Spanish-speaking country. • Hispanic youth: • By 2020, Hispanic teens will increase by 62% compared to 10% in overall teens group.

9. U.S. Hispanic/Latino Population (US Census 2007: 14.7% or 44 million) Source: US Census 2007. Factfinder.census.gov

10. Get to Know Your Patient’s Immigration Story • Where are you from? • When did you come to the United States? • Tell me about your journey to come here? • Who did you come here with? • Who did you leave behind? • What contributed to your decision to leave?

11. Irma Matos is a 66-y/o Hispanic woman from Ecuador who immigrated to the U.S. 15 years ago to join her husband who has been in the U.S. for several years. She is a legal U.S resident but continues to enjoy frequent visits to Ecuador to spend time with her two children and five grandchildren. She has a history of well-controlled type 2 diabetes and hypertension, managed with an oral hypoglycemic and an ACE inhibitor. Mrs. Matos comes to see her primary care physician, Dr. Bowman, for a routine visit. She explains that she just returned from Ecuador last week but ran out of her diabetes and hypertension medications during the last 2 weeks of her trip. At this visit, she presents with polydypsia, polyuria, blurred vision, and fatigue, and her prescriptions are renewed. Her blood pressure is also noted to be elevated. Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

12. African-American(U.S. Census 2007: 12.4% or 37 million) Source: US Census 2007. Factfinder.census.gov

13. African American (AA) Population Trends • AA projected to reach over 40 million by 2010. • AA possess the highest level of purchasing power among ethnic groups. • ½ of all households headed by females. • Family composition may be different from yours

14. Potential Questions about Family • Don’t assume a female with a child is married? • Are you with someone? • Don’t assume the baby’s father is involved? • Is your baby’s father involved in your life? • Don’t assume the mother receives child support or insurance coverage for the child? • How involved is the baby’s father?

15. Remnants of Racism • Research shows that physicians may exhibit the following towards African-American patients, compared to white patients: • Less non-verbal attention • Less empathy, courtesy and information giving • More “narrowly biomedical communication” style • Provide less time providing health education • Spend less time chatting and answering questions • Exhibit more negative emotional tone • Be more verbally dominant Source: Cooper LA. J Gen Intern Med. 2006;21:S21-27.

16. Mrs. Franklin is a 40-y/o African American woman who came to see Dr. Cox, a cardiologist, for management of congestive heart failure. She had seen another cardiologist in the group (Dr. Moore) 3 months earlier who had told her, “There is nothing wrong with you that losing 50 pounds won’t cure.” [She is 5’4” and weighs 235 lbs (BMI = 40) and she has been overweight for all of her life.] This comment greatly angered Mrs. Franklin and so she did not follow-up with Dr. Moore. Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

17. Potential Responses: Apologize • I’m really sorry. It’s clear that what was said was very upsetting to you. Why did this make you so angry? • What do you think motivated him to make this kind of comment? • Given this experience, what concerns do you have about how I might treat (or take care) of you?

18. Asian Population Trends • Asians include: • Chinese, Japanese, Korean, Vietnamese, Laotian, Pilipino, Thai, Cambodian, Hmong. • Asians are the fastest growing ethnic group and have increased 5X greater than the usual growth rate. • Asians possess the highest income and highest educational levels of all groups, including whites.

19. South Asian Population Trends • South Asians are from: • India, Pakistan, Bangladesh, Nepal, Sri Lanka • Religious practices may influence health beliefs. • Hindu, Muslim, Buddhist • 73% speaking English.

20. U.S. Asian Population (US Census 2007: 4.3% or 13 million) Source: US Census 2000, 2003, 2007. Factfinder.census.gov

21. Identifying a Patient’s Ethnicity Which of the following questions is most effective in identifying a patient’s ethnicity? a. Do you consider yourself Asian? b. Are you Chinese? c. When did you first come to the U.S.? d. What ethnic identity best describes you?

22. Maya Mohammed is a 15-year-old Arab American woman who comes in with her mother, Mrs. Ali, because she has not been feeling well. Maya’s family immigrated from Jordan 1 year ago. Maya and her mother are both Muslims and wearing hijabs. Maya states that she is too tired to talk and Mrs. Ali explains that Maya has lost weight, has had abdominal pain, is tired, and feels achy all the time. After getting more history from the mother, Dr. Brown asks to speak with Maya alone for a few minutes. After Mrs. Ali leaves the room, Dr. Brown asks Maya if she is sexually active and if she could be pregnant. At this point, Maya denies this in an angry tone and states that she wants her mom. When Mrs. Ali returns and asks Maya why she is upset, Maya tells her mother that the doctor is asking if she is pregnant. Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

23. Priya Krishnamurthy is a 73-y/o South Asian Indian woman with a history of HTN who presents to the ED with her family because she has been bumping into objects on her right side since this morning. An urgent CT scan is performed, demonstrating an evolving stroke and she is admitted to the hospital. She does not speak English, so her family speaks for her. Her extended family is quite large and very involved. Numerous relatives are constantly at her bedside. Family members often approach the nurses’ station to ask questions or make requests, and family members do not restrict their time to the hospital’s visitation hours. Furthermore, although the patient’s son is the legal surrogate decision-maker, the family prefers to arrive at all decisions by consensus. Several nurses and physicians are frustrated and feel that the family’s approach to decision making are preventing Mrs. Krishnamurthy from being treated appropriately or in a timely manner.

24. Commonwealth Fund’s Healthcare Quality Survey • African-Americans and Hispanics were the most likely to feel that they had been treated with disrespect by their health care providers. • Asian Americans were the most likely to feel that they had been looked down on by health professionals. • Asian Americans were most likely to feel that their doctor did not understand their background and values.Source: Collins KS. The Commonwealth Fund. 2002.

25. Mr. Le is a 48-year-old Korean American engineer who has been a U.S.resident for the last 20 years. His wife died 10 years ago and he has one daughter, age 26. He develops a sudden headache and left-sided facial drooping with left arm weakness while having lunch with his daughter. His daughter insists (to the point of tears) that he should go immediately to the hospital, but he insists on first seeking treatment from a practitioner of Chinese medicine for “moxibustion” heat therapy. Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

26. According to Traditional Chinese Medicine, Moxibustion, is the treatment of disease by applying gentle heat to acupuncture points. Smouldering herbs are held near the needle to create a warm sensation. Acupuncture and moxibustion are considered complimentary forms of treatment and are commonly used together. Moxibustion is particularly effective for ailments such as bronchial asthma, bronchitis, certain types of paralysis, and arthritic disorders. Source: Google images.

27. Knowing Your PatientsTrusting Your Physician • Many studies show that racial and ethnic minorities have less trust in physicians, researchers, and in the health care system compared to whites. • “Knowing your patient as a person” was more highly correlated with patient adherence to medical treatment than any other dimension of care measured. Source: Cooper LA. J Gen Int Med. 2006;21:S21-27.

28. What Does This Mean To You? • You can’t assume your patient will: • Get your Rx filled and take the medication (adherence) • Make an appt and see the specialist you recommend • Get the test or lab work you ordered • Adhere to Preventive Guidelines you suggest • Have the procedure you recommended • Consent for surgery or experimental therapy • Agree to receive chemotherapy or radiation therapy • Show up for your f/u appt

29. Mr. Carlos Cruz is a 34-y/o Mexican immigrant who went to the ED because of a severe cough. A chest x-ray revealed a small lung nodule of unknown significance. He was felt to have a viral syndrome and given a f/u appt in the pulmonary clinic to evaluate the nodule. After missing his initial and two rescheduled appointments in pulmonary, the nurse calls his home. As she speaks with him, she is not confident that her message is understood. After completing the call, the nurse discusses the patient with Dr. Ross, a staff physician, and expresses frustration over communicating with patients who can’t speak English. She states, “These people never keep their appointments. I don’t know why we waste our time tracking them down.” Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

30. Potential Responses • Mr. Cruz, I’d like to be sure I explained everything well enough. Can you please repeat back to me what I just said. • Why use a trained medical interpreter for all patients including children, teenagers, adults and seniors? • Ensures accurate interpretation • Reduces cultural bias • Improves communication • Fosters “getting to know your patient” and building trust

31. Working with a Trained Medical Interpreter • Step 1: Have a pre-interview with the interpreter and tell them what you hope to accomplish with this interview. Give a brief description of how the patient came to the current situation. • Step 2: Position the interpreter to the side and slightly behind the patient/parent. • Step 3: Make eye contact with the patient/parent and not at the interpreter. • Speak in short sentences • Avoid jargon and phrases that may not translate well from English into another language, such as “the ball is your court.”

32. Positioning the Interpreter Interpreter Position the interpreter behind and slightly next to the patient. Patient Make eye contact with the patient not the interpreter. Physician

33. Considerations • Remember, while this patient may look different from you, you look very different from them. • Recognize that you have an explanatory model that is different from your patient and therefore, you need to investigate their system of healing as well. • Can you help me understand what this condition means to you? • How is this kind of condition treated in your family? • Who makes the medical decisions in your family? • What do you fear most about your sickness?

34. Health Literacy Issues • 25% of U.S. population cannot understand basic written material. • The Institute of Medicine found that 40 million Americans have trouble linking dosage information on a medication bottle with instructions from their physician. • Patients with low literacy are more susceptible to hospitalizations, many due to medication errors. • 500,000 people in Philadelphia have low literacy levels. Source: Carroll N. Health Literacy: A Prescription to End Confusion. Institute of Medicine, National Academies Press. Washington, DC. 2004.

35. Indicators of Low Literacy • Registration forms filled out incorrectly or are illegible • Health questionnaires not completed • Appointments frequently missed • Frequent medication errors • Lack of f/u with referrals, imaging and lab tests • Patients may respond: “I forgot my glasses” Weiss B.D., Mays M.Z., Martz W., et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005;3(6):514-22. Williams M.V., Davis T., Parker R.M., Weiss B.D. The role of health literacy in patient-physician communication. Fam Med 2002;34(5):383-9. Wilson J.F. The crucial link between literacy and health. Ann Intern Med 2003;139:1.

36. Mary, a 2-y/o Caucasian girl, comes with her mother (Ms. Jones) to see Dr. Robinson for a well-child visit. This is her 6th visit with this pediatrician. Ms. Jones seems most concerned about Mary’s fever, runny nose, and ear pain. Physical exam reveals that Mary has an ear infection, and Dr. Robinson prescribes an antibiotic suspension. She instructs Ms. Jones to give Mary 1 teaspoon of the antibiotic, 2 times per day for 10 days. Ms. Jones nods and seems to understand. Ms. Jones is asked to f/u in 1 month and agrees. Ms. Jones returns to the clinic with Mary 1 month later and explains that Mary’s cold and ear pain have resolved. Dr. Robinson asks if Mary took the antibiotic for all 10 days. Ms. Jones responds: “Yes, but it was hard to give the medicine in the ear, because the drops kept rolling out.” When Dr. Robinson asks the mother to read a medicine bottle, Ms. Jones says she doesn’t have her glasses. Dr. Robinson looks at the chart registration form which is incomplete and contains many spelling errors. She then asks Ms. Jones, “Do you feel comfortable reading this medication bottle?” Ms. Jones replies, “No.” Source: Hark L and DeLisser H. Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals. Wiley-Blackwell. Malden, MA. 2009.

37. Stereotyping Patients and Insensitivity Also Leads to Poor Health Outcomes

38. Denise Smith is a 41-year-old Caucasian woman who shares an apartment with another woman. For 5 days she has had a cough and worsening shortness of breath. She visits the local health department clinic for a refill of her asthma inhaler (her last visit was 7 years ago). Ms. Smith has a very short, dark haircut and is wearing black sunglasses, black slacks, a white button-down shirt, and baggy blazer. She walks up to the front desk to check in for her appointment and the clerk responds, “Sir, please write your name down and you’ll be called shortly.” The nurse calls out, “Denise Smith, please come to the door.” On coming to the door, the nurse says to Ms. Smith, “Sir, I was calling for your wife.” Ms. Smith pushes open the door and walks through. She refuses to allow the nurse to take any vitals and asks to see the doctor immediately. On entering the room, the doctor asks, “Sir, has your wife stepped out to the bathroom?” Disgusted by the confusion once again, Ms. Smith angrily responds, “No, I’m Denise. Doesn’t anyone know who I am? Look, I’ve been waiting here for an hour and all I need is a refill for my asthma pump. Can’t you just do that for me?”

39. Mr. Leslie O’Malley is a 66-y/o Irish-born American who presents as a new patient after feeling a lump in his right breast. He has mild hypertension. Mr. O’Malley has not smoked in more than 20 years and reports social alcohol use. Physical exam demonstrates bilateral gynecomastia and confirms the presence of a right breast mass and he is referred for a mammogram. Laboratory studies are all normal except an isolated mild elevation in his plasma bilirubin level. Dr. Beck interprets the combination of gynecomastia and elevated bilirubin as indicating potentially heavy alcohol consumption and asks the patient, “How much alcohol do you really drink?” Mr. O’Malley denies significant use of alcohol, insisting that he drinks no more than two beers a week. Dr. Beck, however, continues to press the issue, asking, “Are you sure? Are you absolutely sure? It’s okay to admit the truth.” Mr. O’Malley responds angrily, “Why do you keep asking me? I already told you the truth: I only drink socially.”

40. Mr. O’Malley reluctantly schedules a mammogram. When he checks in, he is instructed to sit with other female patients. After a wait, the technologist asks, “Is Leslie O’Malley here?” When he stands up, she states, “Not you, sir, just your wife.” Embarrassed, Mr. O’Malley responds, “I am Leslie O’Malley, and I am here for a mammogram.” Mr. O’Malley is escorted to a dressing area and is the only male in this room. Several minutes later, he is greeted by a technician who introduces herself and comments, ”Wow, you’re my first guy.” Later, in the mammogram suite, she jokingly remarks, “Looks like an A cup; hope I can do this right.” The following day Dr. Beck calls Mr. O’Malley to inform him that a suspicious mass has been detected in the right breast. Dr. Beck outlines a diagnostic plan beginning with a needle biopsy of the mass. Mr. O’Malley abruptly hangs up on Dr. Beck, refuses to answer several follow-up calls over the next 3 days, and fails to make the recommended arrangements for a diagnostic needle biopsy.

41. Lisa Hark, PhD, RDDirector, Online Medical Education Wills Eye Institute840 Walnut StreetPhiladelphia, PA. 19104215-928-3045lhark@willseye.org