Teaching Culture and Community in Primary Care: Teaching Culturally Appropriate Communication Skills

1. Teaching Culture and Community in Primary Care: Teaching Culturally Appropriate Communication Skills

2. OBJECTIVES By the end of this module, trainees will be able to: • Understand the middle stages of the cultural sensitivity ladder • Explain concept of patient-centered interviewing and the LEARN communication tool • Facilitate skill building as students move beyond minimization

3. Where have we been?

4. Cultural Sensitivity Scale CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority)

5. Needs Assessment • Focus your teaching on learner’s cultural sensitivity level • At egocentric stages, attempt to explore values and raise awareness

6. Where do we go from here?

7. Cultural Sensitivity Scale CULTURALLY SENSITIVE (Empathy, Integration, Celebration) MINIMIZATION CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority)

8. MINIMIZATION “I don’t see this culture stuff as important. It’s simple, just treat people with respect and there won’t be any problems.” MINIMIZATION Learner acknowledges that cultural difference exists, but views it as unimportant against a backdrop of basic human similarity.

9. POTENTIAL EGOCENTRIC REACTION “I tried to help these people and they ended up walking out on me.”

10. Minimization CULTURALLY SENSITIVE CULTURALLY EGOCENTRIC

11. Objectives for minimization stage • Debunk that “common sense” is common • Discuss that “respect” may be different in other cultures • Help move them forward and prevent sliding back after “tripping up”.

12. Cultural Sensitivity Scale CULTURALLY SENSITIVE (Empathy, Integration, Celebration) ACCEPTANCE “The learner respects that being attentive to cultural issues is an important component of a satisfactory provider-patient encounter.” MINIMIZATION CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority)

13. Student needs at acceptance stage • Learners can be overwhelmed by the immense scope of information with a variety of cultures “I’m having a difficult enough time learning medicine, how can you expect me to learn this culture stuff too?”

14. Objective to meet this need • Attend to the need of feeling overwhelmed with empathy • Frame the opportunity to learn about other cultures • Teach a framework for obtaining cultural information generically

15. Student needs at acceptance stage • WARNING! DANGEROUS STAGE • Focus on knowledge can foster stereotyping and assumption of causation “I bet that mother thought her child was suffering from empacho and didn’t bring him in for evaluation because of this.”

16. Objective to meet need • Teach the difference between generalizing and stereotyping • The patient should be the source for learning about their cultural identities

17. How do you spell success? CULTURALLY SENSITIVE EMPATHY ACCEPTANCE MINIMIZATION CULTURALLY EGOCENTRIC (Fear, Overgeneralizing, Superiority)

18. Patient Centered Interviewing • Patients as experts about themselves and their own culture • Patient as a partner with the caregiver • Growing evidence: • Better satisfaction • Better outcomes

19. The LEARN Mnemonic • LISTEN actively with respect • ELICIT the health beliefs of the patient • ASSESS priorities, values and supports • RECOMMEND a plan of action with adequate explanation and understanding • NEGOTIATE by involving the patient in next steps and decisions

20. LISTENING • Appropriate greetings • Interpreter? • Open ended questions • Avoid interruption Could you please tell me your reason for the visit today? How can I help you today?

21. ELICITING Patient’s Perspective • What worries you the most? • Are you afraid that you might have something serious? • What do you think has caused your problem? • Why do you think it started when it did? • How can I be most helpful to you?

22. ASSESSING: Values, supports, needs and priorities • Medicine in the US may be foreign. • Decision maker may be family or elder. • Deference to the professional I’d like to get to know you more today. Could you tell me about yourself? What brought you here to this country?

23. Social Context Review of Systems Ask about: • Control over the environment • Change in the environment • Social stressors and support network • Literacy and language

24. RECOMMEND a plan of action • Physicians tend to: • Underestimate the desire for information • Use language that patients do not understand To make sure that we understand one another, can you tell me what it is that I explained to you?

25. NEGOTIATE: Involve your patient in decisions • What are your ideas about what should happen next? • Involving the patient in care is shown to improve: • Satisfaction • Compliance • Improved clinical outcomes

26. Teaching LEARN:Use all of the teaching styles • Assertive: “Have you heard about the LEARN interview? Let me give a 3 minute summary of the technique….” • Suggestive: “Would it be helpful to understanding Mr. Saq’s non-adherence to know what he thinks about Western medicine?” • Collaborative: “She won’t consent to the lumbar puncture? What do we know about her thinking on that?” • Facilitative: “How do you think her culture is playing into her decision to forego further treatment?”

27. Teaching LEARN:Modeling with the POSE • Be specific in POSEing the question: “I’m going to try to get at her health beliefs with some questions about her background. Let me know what you think worked in the process”.

28. Teaching LEARN:Acknowledge risk • There is a chance of misunderstanding • Empathize with the difficulty, highlight the benefit. “I think that this is a very challenging situation. Sometimes, I really feel like I don’t understand what the patients are thinking.”