Cultural Differences & Professional Liability Implications

1. Cultural Differences &Professional Liability Implications Panel Members: Lauren M. Kwak, JD Arthur F. Roeca, JD, Roeca Luria Hiraoka LLP Victoria H. Rollins, MHA, RN, CPHRM

2. Objectives • Identify how cultural issues affect patient care & satisfaction, which may have legal ramifications • Observe case presentations where differences in cultures and misperceptions of patient encounters impacted patient safety • Identify and recognize patient safety recommendations to promote safe care Cultural Differences & Professional Liability Implications - 2

3. Case #1 • Patient background: • Joshua Tree is a 67-year old resident of Lancaster, PA • History of Type II diabetes and moderate hypertension • Not taking prescribed medications for HTN • Visiting daughter and son-in-law in Hawaii • Sustained laceration to left foot while walking on the beach • Patient treated by Dr. Kwak • Complications ensued, and patient is suing Dr. Kwak Cultural Differences & Professional Liability Implications - 3

4. Cultural Differences Augment Typical Communication Barriers • Communication is essential to quality of care and patient safety • Direct communication can be inhibited by cultural barriers • Persons whose care is inhibited by lack of sensitivity to a cultural belief may be at risk for poorer outcome • Communication is the most common underlying root cause of sentinel event1 • 1Used with permission: Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E. One Size Does Not Fit All: Meeting The Health Care Needs of Diverse Populations. Oakbrook Terrace, IL: The Joint Commission; 2008:10. Cultural Differences & Professional Liability Implications - 4

5. Communication Is the Foundation • Communication–vital to building relationships and gaining trust • If cannot communicate effectively with patient • Unable to obtain or identify why patient presentedfor treatment • Without understanding the facts • Cannot arrive at correct diagnosis • May lead to incorrect clinical decision • May result in under or over ordering of tests/treatments2 • 2Physician Toolkit: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners:21 Cultural Differences & Professional Liability Implications - 5

6. Verbal Communication • Physicians’ training • Use close-ended questions to obtain medical history • Can be counter-productive • Does not address cultural issues • Can lead to patient perception that physician not listening Cultural Differences & Professional Liability Implications - 6

7. Non-Verbal Communication • Mannerisms and styles of non-verbal communication • Facial expressions–eye contact • Personal space orientation • Gestures • Touching • Body posture Cultural Differences & Professional Liability Implications - 7

8. Case #2 • 32 year-old Middle Eastern married female with history of uterine fibroids, treated for infertility and pain • Spoke broken English with heavy accent but refused an interpreter • Seen by female APRN • Husband did not attend any appointments or preoperative education • Hysterectomy recommended • Consent not translated but offered Cultural Differences & Professional Liability Implications - 8

9. Heightened Legal Duty • A physician should not assume that communication with a patient with limited English proficiency was successful as this misplaced assumption can lead to the false sense that legal duties were met • Despite doing everything according to “textbook,” cultural & language barriers present another layer of responsibility that the physician must overcome to deliver safe medicine Cultural Differences & Professional Liability Implications - 9

10. Meeting Needs of Specific Populations • Staff training • Traditions and rituals • Role of traditional healers • Impact of faith in the health/healing process • Adapt environment to meet specific needs • Awareness of “unlucky numbers” • Interaction of the genders • Culturally sensitive jewelry • Physical set up of the room Cultural Differences & Professional Liability Implications - 10

11. Specific Patient Safety Considerations • Informed consent process • Address cultural and linguistic needs • Translated into appropriate language and terms • Take into consideration • Religious beliefs • Cultural beliefs • Past experiences–can impact trust for consent3 • Cultural (even American subcultures) tendencies (e.g., to underreport pain) 4 • 3Used with permission: Wilson-Stronks A, Galvez E. Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings. Oakbrook Terrace, IL: The Joint Commission; 2008:45. • 4“Learning to Speak Iowan: Corn, Pigs, Cyclones and Hawkeyes,” The Wall Street Journal, September 9, 2011. Cultural Differences & Professional Liability Implications - 11

12. Patient Safety Considerations (continued) • Other beliefs, needs and values • Traditions or rituals • Impact and importance of family • Folk remedies • Complementary or alternative medicines • Check your own pulse and become aware of personal attitudes, beliefs, biases, and behaviors that may influence your care of patients Cultural Differences & Professional Liability Implications - 12

13. Physicians also bring cultural biases & notions into the exam room • The physician/healthcare provider must become aware of his/her own value system that could influence patient care just as much as the physician should be aware of his/her patient’s own values. • “A whole body of literature has been published in recent decades concerning the need for physicians and other providers to be culturally competent, mindful of the beliefs and prejudices that patients bring with them to the exam room. But the doctor-patient interface is a two-way street, and the biases and myths that doctors themselves carry to the bedside likewise may hinder understanding.” • H. Lee Kagan. “Vital Signs: Education All Around. A patient’s Misconceptions, and a Medical Student’s Naiveté, Mask a Critical Diagnosis.” January 29, 2011. Cultural Differences & Professional Liability Implications - 13

14. Unconscious Bias • Unconscious (implicit) bias among healthcare professionals contributes to health disparities • Unrecognized bias against a social group may affect communication or care offered to those patients • Existing evidence does suggest that implicit bias may affect clinical judgment and decision making Cultural Differences & Professional Liability Implications - 14

15. What can an individual do? • Consider “gut” reactions to specific individuals or groups as a potential indicator of implicit bias • Acknowledge and reappraise rather than suppress uncomfortable feelings and thoughts • Consider the situation from the patient’s perspective • Partner with researchers and participate in research to advance understanding of implicit bias and to develop evidence-based interventions • “Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here?” The Permanente Journal, Spring 2011; Vol. 15, No. 2. Cultural Differences & Professional Liability Implications - 15

16. Conclusion • Be alert for less prominent cultural differences • Monitor your own beliefs, conceptions & biases • Involve the patient–ask about cultural considerations of health and care • Involve others–internal and external resources Cultural Differences & Professional Liability Implications - 16

17. Website Resources • 1.www.jointcommission.org/PatientSafety/HLC/HLC_Develop_Culturally_Competent_Pt_Centered_Stds.htm • 2.www.jointcommission.org/PatientSafety?HLC/HLC_Resources_and_Links.htm • 3.http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15. Cultural Differences & Professional Liability Implications - 17

18. Resources • Wilson-Stronks A, Lee KK, Cordero CL, Kopp AL, Galvez E, “One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations,” Oakbrook Terrace, IL; The Joint Commission; 2008. • Wilson-Stronks A, Galvez E, “Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings,” Oakbrook Terrace: The Joint Commission; 2007. • American Institutes for Research. (2002). Teaching cultural competence in health care: A review of current concepts, policies and practices. Report prepared for the Office Minority Health. Washington, DC: Author. • Physician Toolkit and Curriculum: To Implement Cross-Cultural Clinical Practice Guidelines for Medicaid Practitioners, March 2004. • H. Lee Kagan. “Vital Signs: Education All Around. A patient’s Misconceptions, and a Medical Student’s Naiveté, Mask a Critical Diagnosis.” January 29, 2011. • “Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here?” The Permanente Journal, Spring 2011; Vol. 15, No. 2. • “Learning to Speak Iowan: Corn, Pigs, Cyclones and Hawkeyes,” The Wall Street Journal, September 9, 2011. Cultural Differences & Professional Liability Implications - 18

19. Handouts • 10 Guiding Principles • Kathleen D. Pagana, RN, PhD, “Mind Your Manners…Multiculturally,” Gannett Education, (used with permission).

20. Mission • vrollins@thedoctors.com • 1-800-421-2368, ext. 1477 • Our Mission is to advance, protect, and reward the practice of good medicine. • For additional information, go to www.thedoctors.com and click on • Patient Safety Cultural Differences & Professional Liability Implications - 19