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Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 14: Navigating Cross­Cultural Communication JudyAnn Bigby; Alicia Fernandez OBJECTIVES Objectives Define cross­cultural communication. Review...

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 14: Navigating Cross­Cultural Communication JudyAnn Bigby; Alicia Fernandez OBJECTIVES Objectives Define cross­cultural communication. Review evidence for the need to improve cross­cultural communication. Describe challenges to effective cross­cultural communication and how they have an impact on clinical care. Describe strategies for effective cross­cultural communication. Ms. Jones is a 56­year­old African­American classroom assistant who was hospitalized with a stroke. Her course rapidly deteriorated and her physicians determined that aggressive treatment would be futile. They approached her family with the recommendation that life support be removed. The doctors explained that Ms. Jones had multiorgan failure and little hope of recovery. Her family, a daughter and two sisters, were shocked by this recommendation and accused the physicians, all of whom were white, of substandard care. INTRODUCTION When patients and physicians interact, cross­cultural communication is a common occurrence as patients and clinicians differ in many important ways. Patients from vulnerable populations (including persons from racial and ethnic minority populations, immigrants, low­income persons, and persons with low educational attainment) and health­care providers face unique challenges to effective communication. These challenges are borne of the differences in life experiences, cultural norms, assumptions, expectations, and barriers inherent in a health­care system in which the biomedical model of health predominates. While this chapter takes an example of an African­American family interacting within the US health­care system, cross­ cultural communication is observed in every country, and, to a certain extent, in every clinical encounter. Patients and physicians may share a common background and have similar expectations of the clinical encounter, yet still differ radically in their level of knowledge or in their personal values. Navigating cross­cultural communication is the norm in most medical encounters. Culture is a coherent system of beliefs, values, and lifestyles held by individuals, their communities, and the larger sociopolitical structure in which they live. Culture is a dynamic entity and is responsive to changes such as socioeconomic position, immigration, and other factors (Figure 14­1). Figure 14­1. Culture is a coherent system of beliefs, values, and lifestyles. Individuals' culture is influenced not only by their personal circumstances but also of their families and extended families' cultures, the culture of their communities, and the culture of the larger social political environment. Individuals, families, communities, and societal cultural systems are dynamic and responsive to multiple forces such as socioeconomic conditions. Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 1 / 16 Figure 14­1. Mount Saint Vincent College Culture is a coherent system of beliefs, values, and lifestyles. Individuals' culture is influenced not only by their personal circumstances but also of their Access Provided by: families and extended families' cultures, the culture of their communities, and the culture of the larger social political environment. Individuals, families, communities, and societal cultural systems are dynamic and responsive to multiple forces such as socioeconomic conditions. Cross­cultural communication in the context of health care is both complicated and complex because of these multiple determinants of culture and the inherent complexities of medical care. Effective cross­cultural communication acknowledges the interplay of multiple factors, including race, ethnicity, cultural norms, religion, socioeconomic position, and education to achieve a common understanding or aim. Effective cross­cultural clinical communication also results in sharing of key information and demonstration of caring. This chapter discusses common barriers to effective cross­ cultural communication and how to overcome them. (For a discussion of the effective use of interpreters, see Chapter 31). EXTENT OF THE PROBLEM There is abundant evidence that patients are concerned about the lack of effective communication with their physicians and other health­care providers. Patients perceive communication problems with their physicians regardless of background—including English­speaking, white, educated patients. That said, communication problems are more common for minority patients and for patients with limited English proficiency. The Commonwealth Fund reported results of a national survey in which 39% of Latinos, 27% of Asian Americans, 23% of African Americans, and 16% of whites reported problems with communication, specifically that their doctor did not listen to everything they had to say, they were not able to understand their doctors, and they were not able to ask questions during their visits.1 Similar reports of poor doctor–patient communication exist in surveys of patients across many different countries with very different health­care systems.2,3 Physicians give more information and offer more support and encouragement to patients who ask questions and express concerns. Creating an obvious feedback loop, patients ask more questions when physicians engage in partnership­building behaviors, but physicians engage in more partnership­building behaviors when the patient is more educated.3,4,5 Latinos and Asian Americans commonly report that physicians do not adequately involve them in decision making.6,7 African Americans are also less likely than whites to report that their doctors include them in decision making, especially when the patient and doctor are of different races.8 Physicians tend to be more verbally dominant and engage in less patient­ centered communication with African­American patients than with white patients, less likely to explain test results, medical conditions, and treatments.9 Ineffective cross­cultural communication is of particular concern in the management of chronic diseases, in high stakes decision making in acute care, and in the context of end­of­life care. African Americans report that they would like to discuss preferences for resuscitation in the event of a cardiopulmonary arrest, but they are more likely than whites not to have done so.10 African Americans are more likely to want family members to make decisions for them at the end of life compared with others, but believe that physicians would not involve families in collaborative decision making.11,12 Despite the recent attention to cultural competence in medical school curricula, several studies document persistent deficits in cross­cultural communication among medical students and physicians.13 CHALLENGES IN CROSS­CULTURAL COMMUNICATION Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Ms. Jones’ does not care that theCommunication, medical evidence suggestsBigby; that further treatment is futile. Their life experience has taught them that life2is/ 16 Page Chapter 14:family Navigating Cross­Cultural JudyAnn Alicia Fernandez ©2024 McGraw Hill. All Rights Reserved. of Use PrivacyAmericans Policy Notice Accessibility precious, withstanding suffering is a sign ofTerms faith, and that African have often beaten the odds and defied death. They do not completely trust the health­care system to do the best for Ms. Jones. Despite the recent attention to cultural competence in medical school curricula, several studies document persistent deficits in cross­cultural Mount Saint Vincent College communication among medical students and physicians.13 Access Provided by: CHALLENGES IN CROSS­CULTURAL COMMUNICATION Ms. Jones’ family does not care that the medical evidence suggests that further treatment is futile. Their life experience has taught them that life is precious, withstanding suffering is a sign of faith, and that African Americans have often beaten the odds and defied death. They do not completely trust the health­care system to do the best for Ms. Jones. Multiple barriers at the patient, provider, and health system levels contribute to the communication difficulties in this scenario. Clear disagreement has arisen between Ms. Jones’ family and her medical team about appropriate care. Interactions between the family and the health­care providers are strained. The health­care providers do not understand the family’s reaction; they believe the family does not understand the limits of medical technology in this clinical situation. The family believes the physicians are acting out of prejudice or bias and are not offering Ms. Jones the same care she would receive were she white or young. The physicians did not involve the family in their decision making, but simply presented them with their recommendation about withdrawing life support. They have failed to consider potential differences that may have led to this communication breakdown, including racial discordance between the treatment team and the Jones family, religion, spirituality, and the relevant broader social context. PATIENT­LEVEL BARRIERS Acceptance of Inadequate Communication In some cultures, it is considered inappropriate for patients to ask questions of the health­care provider.14 In dominant US culture, patients with lower socioeconomic status or low health literacy are often intimidated in the clinical interaction and do not solicit additional information or express their wishes.3 Researchers have demonstrated that patients can learn assertiveness skills that result in more participatory clinical interactions.15 The Ask Me Three campaign (http://www.npsf.org/?page=askme3) is an example of a large­scale patient education campaign aimed at activating patients to ask more questions. Health coaches, who meet with the patient before the clinical interaction, can be very helpful in empowering patients to ask questions and express their own values. For issues as diverse as pain control in cancer patients in the United States16 to reproductive care in poor Indonesian women,17 coaches or navigators can play a key role in improving patient–doctor communication. Trust Lack of trust of the health­care provider may be a significant barrier to effective communication. One strategy that some patients may use to protect against stereotyping by clinicians is to withhold information that they perceive would be viewed negatively. Trust is particularly relevant for groups that have historically experienced bias in the health­care system, as reflected in denial of service, segregated service, or blatantly inferior service.18 The legacy of past abuses such as the US Public Health Service Syphilis Experiment continues to influence some African Americans’ ability to trust the system.19 In 2010, revelation about a related Guatemala syphilis experiment has caused widespread distress among Latinos.20 Health Literacy Health­care clinicians often overestimate patient understanding of key concepts in care, including prevention, self­management, and chronic disease processes. This can result in significant discordance in visit goals and expectations. It is important for providers to develop skills that permit them to ascertain the extent of patients’ understanding of their clinical condition, and to work with them to establish appropriate, mutually acceptable goals and strategies for addressing clinical concerns (see Chapter 15). CLINICIAN­LEVEL BARRIERS Lack of Cultural Competence Clinician deficiencies are the most frequently described contributors to poor cross­cultural communication, likely because they have been the most thoroughly researched. Physicians are less satisfied with their interactions with patients who are racially, ethnically, and linguistically diverse. They perceive that patients from these groups are less interested in prevention, managing their illnesses, and engaging in healthy behaviors.21,22 Downloaded 2024­2­18 9:29 Your IP is 63.247.225.21 Frustration may stem from theAclinicians’ lack of awareness regarding the influence of their own cultural norms. Clinicians are often unaware that they Page 3 / 16 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez reveal negative attitudes to patients, particularly when addressing the health beliefs and behaviors of unfamiliar cultures. Physicians and patients ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility often do not discuss the “cultural rules” that underlie their interactions until there is a problem. Perhaps, most importantly, physician attitudes and lack of communication skills can lead to decreased patient trust.23 Lack of Cultural Competence Mount Saint Vincent College Clinician deficiencies are the most frequently described contributors to poor cross­cultural communication, likely becauseAccess theyProvided have been the most by: thoroughly researched. Physicians are less satisfied with their interactions with patients who are racially, ethnically, and linguistically diverse. They perceive that patients from these groups are less interested in prevention, managing their illnesses, and engaging in healthy behaviors.21,22 Frustration may stem from the clinicians’ lack of awareness regarding the influence of their own cultural norms. Clinicians are often unaware that they reveal negative attitudes to patients, particularly when addressing the health beliefs and behaviors of unfamiliar cultures. Physicians and patients often do not discuss the “cultural rules” that underlie their interactions until there is a problem. Perhaps, most importantly, physician attitudes and lack of communication skills can lead to decreased patient trust.23 Stereotyping Stereotyping is a particularly important challenge when caring for vulnerable patients. Clinicians often wish to learn about the specific health beliefs of distinct cultural groups, which can be quite helpful. However, knowledge about general cultural beliefs in specific populations is insufficient for effective cross­cultural communication. Persons from racial and ethnic minority groups represent a wide range of cultures, beliefs, and attitudes depending on place of birth, educational attainment, socioeconomic position, acculturation, and other factors. So, knowledge of general health beliefs and attitudes of a group of people can be used only to generate hypotheses that can be tested with individual patients. The unconscious (and certainly the conscious) use of appearance or some other personal characteristic to stereotype patients is a routine occurrence. The 2003 Institute of Medicine report, Unequal Treatment, documented a long list of studies documenting bias in diverse clinical fields from cardiac care to HIV/AIDS diagnosis and treatment, and the treatment of pain.24 In another example of stereotyping, studies have shown African Americans were judged more likely to be substance abusers and were rated as less intelligent and less educated when compared to whites.25 INTERSECTION OF PATIENT AND CLINICIAN BARRIERS Patients and clinicians each enter interactions with assumptions about the other party, and cultural factors influence their predetermined expectations about how the encounter will proceed (Figure 14­2).17 Clinicians need to be conscious of how these assumptions are developed and then negotiate expectations and goals based on input from the individual patient (Box 14­1). Figure 14­2. Both the doctor (D) and patient (P) use filters that influence assumptions made about each other and each understanding of the interaction. These assumptions influence the interpretation of what happened in the interaction and subsequent behavior. When the doctor and/or patient are aware of how they use their filters, they may reexamine their assumptions and thus influence the interaction and interpretation of the interaction. Box 14­1. Common Pitfalls Failing to appreciate cultural differences, rendering one’s own values dominant, and dismissing the value systems held by others Making the medical model the only or dominant paradigm Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez as a shortcut to understanding how the individual patient values cultural norms ©2024Stereotyping McGraw Hill.groups All Rights Reserved. Terms of Use whether Privacyand Policy Notice Accessibility Bias and lack of personal awareness of bias Page 4 / 16 Mount Saint Vincent College Access Provided by: Box 14­1. Common Pitfalls Failing to appreciate cultural differences, rendering one’s own values dominant, and dismissing the value systems held by others Making the medical model the only or dominant paradigm Stereotyping groups as a shortcut to understanding whether and how the individual patient values cultural norms Bias and lack of personal awareness of bias Using medical jargon and technical language that impede communication Failing to check for meaning and understanding with the patient Failing to inquire about patient preferences for decision making Failing to express empathy in cross­cultural communication clinical encounters Failing to express empathy in communication mediated via an interpreter Lack of awareness of historical events that may shape patient illness and beliefs SYSTEMS­LEVEL BARRIERS Historically, health­care professionals have received little or no training in cross­cultural communication. In addition, many system­level forces obstruct improvements in effective communication (Box 14­2). Furthermore, the physical limitations of clinical sites often do not facilitate the unique decision­making styles of some groups. In cultures in which family decision making is valued above individual one­on­one interactions, examination rooms may be too small, yet conference rooms to hold family meetings are frequently nonexistent, and the hours of operation often do not accommodate work and care­​taking schedules of extended families. Box 14­2. Systems­Level Challenges to Effective Cross­Cultural Communication Growing diversity of the US population without concurrent diversification of health­care professional staffs Increasing emphasis on technology and use of electronic medical records, which may undermine and underemphasize the need to talk to patients face to face Pressure on health­care clinicians to care for more and sicker patients in shorter clinical encounters The “inverse care law” whereby the sickest and most vulnerable patients often have access to the least amount of care Reimbursement systems that reward procedural interventions and care of healthy patients over care for complex patients or socially vulnerable people SOLUTIONS TO EFFECTIVE CROSS­​ C ULTURAL COMMUNICATION Ms. Jones’ family asks permission to include their pastor in the next discussion about her care. They want reassurance from the clinical team that she will be treated with dignity and that her needs will not be ignored. They also want to make sure that a family member who is arriving from out of town has an opportunity to see her before she dies. The clinicians are able to accommodate this request. Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Effective cross­cultural the health­care clinician integrate awareness of her own cultural beliefs and attitudes with her5 / 16 Page Chapter 14: Navigatingcommunication Cross­Cultural requires Communication, JudyAnn Bigby;toAlicia Fernandez clinical McGraw expertise,Hill. andAll useRights knowledge of the patient’s values and cultural social context, to accomplish mutually determined goals of ©2024 Reserved. Terms of individual Use Privacy Policy Noticeand Accessibility care. Table 14­1 shows a model developed by the Boston University Residency Program in Internal Medicine Diversity Curriculum Taskforce for caring for patients from diverse racial, ethnic, and cultural groups.26 Mount Vincent College Ms. Jones’ family asks permission to include their pastor in the next discussion about her care. They want reassurance from the Saint clinical team that by: from out of she will be treated with dignity and that her needs will not be ignored. They also want to make sure that a family memberAccess who Provided is arriving town has an opportunity to see her before she dies. The clinicians are able to accommodate this request. Effective cross­cultural communication requires the health­care clinician to integrate awareness of her own cultural beliefs and attitudes with her clinical expertise, and use knowledge of the patient’s individual values and cultural and social context, to accomplish mutually determined goals of care. Table 14­1 shows a model developed by the Boston University Residency Program in Internal Medicine Diversity Curriculum Taskforce for caring for patients from diverse racial, ethnic, and cultural groups.26 Table 14­1. Respect Model Action Comment Respect Show a demonstrable attitude involving both verbal and nonverbal communications. Explanatory model What is the patient's point of view about his or her illness? How does it compare to the provider's point of view? Both points of view should be elicited and reconciled. Sociocultural How do class, race, ethnicity, gender, education, sexual orientation, immigrant status, and family and gender roles impact care? context Power Acknowledge the power differential between patients and physicians. Empathy Put into words the significance of the patient's concerns so that the patient feels understood. Concerns and fears Elicit the patient's emotions and underlying concerns. Therapeutic Provide a measurable outcome that enhances adherence and engagement in health care. alliance/trust Source: Model developed by the Boston University Residency Program in Internal Medicine Diversity Curriculum Taskforce and adapted from Bigby J. Beyond culture. Strategies for caring for patients from diverse racial, ethnic, and cultural groups. In Bigby J, ed. Cross­Cultural Medicine. Philadelphia, PA: American College of Physicians, 2003. PERSONAL AWARENESS For the clinician, exploring personal identity is an important first step in developing effective cross­cultural communication. Understanding how personal race, ethnicity, culture, socioeconomic position, and other characteristics influence one’s practice as a physician can be enormously helpful (Figure 14­1). Assessing personal awareness is an ongoing process of self­reflection throughout a career. Individual clinicians may become more aware of the assumptions they make about patients through critical reflection on their own background and clinical practice. A set of questions designed to assess and enhance personal awareness is shown in Table 14­2. Table 14­2. Assessing Personal Self­Awareness 1. How do you define your own racial or ethnic identity? 2. What did you learn to value while you were growing up? 3. Which features of your own racial or ethnic group do you view positively? 4. Which features of your own racial or ethnic group do you view negatively? 5. What are some characteristics that are important to your identity? Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 While you were growing up, were Communication, the schools and neighborhoods homogenous, or racially and/or ethnically mixed? What about socioeconomically? PageAt6 / 16 Chapter6.14: Navigating Cross­Cultural JudyAnn Bigby; Alicia Fernandez ©2024 McGraw Hill.inAll Rights Reserved. of Useto interact Privacywith Policy Notice Accessibility what point your life did you have theTerms opportunity people who were different from you? 7. Are there culturally distinct groups with which you feel comfortable? 8. Are there culturally distinct groups with which you feel uncomfortable? (Figure 14­1). Mount Saint Vincent College Assessing personal awareness is an ongoing process of self­reflection throughout a career. Individual clinicians may become more aware of the Access Provided by: assumptions they make about patients through critical reflection on their own background and clinical practice. A set of questions designed to assess and enhance personal awareness is shown in Table 14­2. Table 14­2. Assessing Personal Self­Awareness 1. How do you define your own racial or ethnic identity? 2. What did you learn to value while you were growing up? 3. Which features of your own racial or ethnic group do you view positively? 4. Which features of your own racial or ethnic group do you view negatively? 5. What are some characteristics that are important to your identity? 6. While you were growing up, were the schools and neighborhoods homogenous, or racially and/or ethnically mixed? What about socioeconomically? At what point in your life did you have the opportunity to interact with people who were different from you? 7. Are there culturally distinct groups with which you feel comfortable? 8. Are there culturally distinct groups with which you feel uncomfortable? 9. What is the racial/ethnic or sociocultural characteristic of the patients with whom you feel most competent in establishing rapport and a treatment plan? 10. What is the racial/ethnic or sociocultural characteristic of patients with whom you have the most difficulty establishing rapport and establishing a treatment plan? 11. How do factors related to your racial or ethnic identity and/or from your life experience affect how you interact with patients from backgrounds that are different from your own? Source: Adapted from Goldman R, Monroe AD, Dube C. Cultural self­awareness: a component of culturally responsive patient care. Ann Behav Sci Med Educ 1996;3:37­46. INDIVIDUALIZED CULTURAL ASSESSMENT “You’ve got to find out the identity of a person to even get to know them.” (Patient, as quoted in Kagawa­Singer)8 Discovering a patient’s identity is enormously rewarding, and is the first step toward effective cross­cultural communication. Prior to the clinical encounter, clinicians may collect general information about specific cultural groups with whom they are unfamiliar, recognizing that they risk unhelpful stereotyping by applying these to individual patients without confirmation. General cultural information should be considered a foundation for understanding cultural norms. This information can be used to generate hypotheses about the potential health beliefs of a particular patient. These hypotheses then can be directly tested with an individual patient or family. For example, persons of Chinese origin commonly do not want to be directly informed about grave diagnoses. To test whether a particular patient’s beliefs are congruent with this hypothesis, a clinician might say, “In general, I give patients as much information as possible about their medical conditions. How do you feel about me sharing more detail with you now, or would you prefer that I speak with someone in your family, or all of us together? All patients are different, and I want to make sure I do what you prefer.” This approach, often termed “cultural humility” rather than cultural competence, is more patient centered.27,28 Using a narrative, open­ended style, as opposed to asking specific questions, may be effective. With the cultural context in place, the specifics of a patient’s life experience gain greater meaning (Box 14­3). Finally, this approach is most useful when combined with an awareness of important historical events that may be germane to the patient’s life history. Knowing that Cambodia endured one of the world’s worst genocides during the late 1970s is as important as knowing common Cambodian attitudes toward Western medications. Box 14­3. Basic Information in the Cultural Assessment Level of formal education Downloaded 9:29 A Your IP is 63.247.225.21 Racial or2024­2­18 ethnic self­identification Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez ©2024Generational McGraw Hill.status All Rights Terms of Use Privacy Policy Notice Accessibility (e.g., Reserved. first­generation immigrant) Page 7 / 16 Level of encapsulation within ethnic and family social network (e.g., living in a community with a large concentration of a cultural group) Using a narrative, open­ended style, as opposed to asking specific questions, may be effective. With the cultural context in place, the specifics of a Mount Saint Vincent College patient’s life experience gain greater meaning (Box 14­3). Finally, this approach is most useful when combined with an awareness of important Access Provided by: historical events that may be germane to the patient’s life history. Knowing that Cambodia endured one of the world’s worst genocides during the late 1970s is as important as knowing common Cambodian attitudes toward Western medications. Box 14­3. Basic Information in the Cultural Assessment Level of formal education Racial or ethnic self­identification Generational status (e.g., first­generation immigrant) Level of encapsulation within ethnic and family social network (e.g., living in a community with a large concentration of a cultural group) Immigration history (if applicable) Degree of migration back and forth to country or region of origin (if applicable) Area of origin in native country Occupation currently (and before migration, if applicable) Sexuality and important sexual and nonsexual relationships Religion and spirituality Personal or family experience in the health­care system or with relevant illness Decision­making preferences: who, when, how Information preference: how much and how delivered CREATE AN ENVIRONMENT THAT BUILDS TRUST Building trust is a key component of effective cross­cultural communication. Patients view trust­building behaviors as a sign that clinicians are invested in them as individuals and that they want to help patients, and articulate behaviors that they would like physicians to exhibit (Table 14­3). Trust­ building behaviors display respect and build rapport. Small actions such as asking a patient how she prefers to be addressed go a long way to demonstrate respect. Clinicians often forget the power differential that exists in their relationships with patients. Demonstrations of empathy are meaningful ways to improve communication with patients. Empathic behavior requires active listening (nodding, encouraging), picking up and restating on patients’ concerns (“Sounds like you found that…”), identifying the factual content of the patient’s statement (What I heard you say…”), asking about and affirming affective responses (“I hear how frightening that was for you”), and requesting clarification of unclear statements.29 Table 14­3. Trust­Building Behaviors Actions Attitudes Introduce yourself by name, title, and role. Do not make assumptions. Ask the patient what she or he prefers to be called. Pay attention to cultural beliefs. Make an effort to make the person comfortable. Acknowledge and respect different perspectives. Do not appear to be rushed. Distinguish the person as an individual. Ask personal questions. (How is your daughter doing now? Is school any better for her?) Display genuine concern. Use plain language. Listen for the patient's style of telling about symptoms. Listen to questions. Be responsive. Hold patient information Downloaded 2024­2­18 9:29asAconfidential. Your IP is 63.247.225.21 Ask14: patient if they are satisfied with the appointment. Chapter Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez ©2024Apologize McGrawwhen Hill. there All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility is a problem. Page 8 / 16 demonstrate respect. Clinicians often forget the power differential that exists in their relationships with patients. Demonstrations of empathy are Mount Saint Vincent College meaningful ways to improve communication with patients. Empathic behavior requires active listening (nodding, encouraging), picking up and Access Provided by: restating on patients’ concerns (“Sounds like you found that…”), identifying the factual content of the patient’s statement (What I heard you say…”), asking about and affirming affective responses (“I hear how frightening that was for you”), and requesting clarification of unclear statements.29 Table 14­3. Trust­Building Behaviors Actions Attitudes Introduce yourself by name, title, and role. Do not make assumptions. Ask the patient what she or he prefers to be called. Pay attention to cultural beliefs. Make an effort to make the person comfortable. Acknowledge and respect different perspectives. Do not appear to be rushed. Distinguish the person as an individual. Ask personal questions. (How is your daughter doing now? Is school any better for her?) Display genuine concern. Use plain language. Listen for the patient's style of telling about symptoms. Listen to questions. Be responsive. Hold patient information as confidential. Ask patient if they are satisfied with the appointment. Apologize when there is a problem. Empathic statements have been shown to increase trust. A recent study found that patients preferred physicians who portrayed difficult facts within an optimistic context.30 While not always possible, this too may help create trust: “let’s hope for the best, while we work on the rest.” Eliciting the patient’s concerns is always an effective partnership­building tool. Finally, a responsive, culturally competent health system can help support the clinician– patient relationship. For example, the use of navigators or health coaches has also been shown to increase patients’ trust in their primary care providers.31 The end result of these behaviors should be a meaningful therapeutic alliance. Some aspects of a patient’s cultural values and beliefs are relevant to clinical situations and some are not. Let the patient provide advice and guidance. For example, ask about interactional norms (how younger clinicians show respect for elders; how older clinicians allow young patients to ask questions or express an opinion; how gender roles translate to clinical situations). Assess an individual patient’s values and beliefs, and incorporate this information into clinical assessments and decision making. Identify strategies taken from the patient’s cultural orientation that can be used to enhance the therapeutic alliance; acknowledge those that seem counterproductive. These behaviors are consistent with behaviors and attitudes that others have described as being important for improving cross­cultural communication and that exhibit patient­centered approaches.27,32 It is important to remember that, as illustrated in Figure 14­2, the absence of these clinician behaviors may be interpreted as disrespectful and biased, based on the patient’s past experience of racial, ethnic, or cultural biases. IDENTIFY PATIENT’S EXPLANATORY MODEL OF ILLNESS “The patient needs to open up to tell you these things.” (Patient as quoted in Kagawa­Singer)10 Identifying patient’s explanatory model of his or her illness is a fundamental aspect of cross­cultural communication. Kleinman and colleagues33 have developed an anthropologic approach to eliciting a comprehensive understanding (Box 14­4). When asked in a respectful, caring manner, these questions can facilitate an understanding of the patient’s expectations and provide important information that a traditional medical interview would miss. Preface these questions with a respectful introduction, such as “I know that patients and doctors sometimes have different ideas about what causes certain symptoms or illnesses. I’d like to know more about your ideas about your problem.” Box 14­4. Anthropologic Approach to Eliciting a Comprehensive Understanding What do you call your problem? What name do you 9:29 give it? Downloaded 2024­2­18 A Your IP is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez do youHill. think illness started?Terms of Use Privacy Policy Notice Accessibility ©2024Why McGraw All your Rights Reserved. When did it begin? Page 9 / 16 developed an anthropologic approach to eliciting a comprehensive understanding (Box 14­4). When asked in a respectful, caring manner, these Mount Saint Vincent College questions can facilitate an understanding of the patient’s expectations and provide important information that a traditional medical interview would Access Provided by: miss. Preface these questions with a respectful introduction, such as “I know that patients and doctors sometimes have different ideas about what causes certain symptoms or illnesses. I’d like to know more about your ideas about your problem.” Box 14­4. Anthropologic Approach to Eliciting a Comprehensive Understanding What do you call your problem? What name do you give it? Why do you think your illness started? When did it begin? How severe is it? What do you fear most about your illness? What are the major problems your illness has caused? Do you have any ideas about what treatment you should receive or others who would be helpful? From Kleinman A, Eisenberg L, Good B. Culture, illness, and care: Clinical lessons from anthropologic and cross­cultural research. Ann Intern Med 1978;88:251­258. Acknowledge what the patient has shared by summarizing what you have heard. Describe to the patient your assessment of the problem and acknowledge any discrepancies between your interpretation and the patient’s. Avoid medical jargon or technical language. Explain how your assessment addresses the concerns identified by the patient. Check to see if the patient has heard and understood what you said. “What questions do you have about what I have just said? What should I explain in more detail?” It may be useful to summarize the understanding of the patient’s major concerns. From this process, the patient and clinician can develop a problem list that reflects their negotiation. If the patient is hesitant to agree, explore the source of hesitation and begin to negotiate again. NEGOTIATE A PLAN FOR FURTHER EVALUATION AND TREATMENT Once the problem list and possible diagnosis are identified, the clinician can begin to make recommendations for next steps. Ask the patient whom he would like to involve in the process and then accommodate the patient’s request by agreeing to meet with important family members or others. Address patient confidentiality up front and ask for clear guidance about how much information should be shared with the family. The process of developing a diagnostic and treatment plan affords an opportunity to ask about the patient’s use of alternative and complementary therapies and about the patient’s expectations for treatment. As the clinician outlines possible strategies for further diagnostic evaluation or appropriate treatments, the clinician should allow the patient to stop and ask questions. Confirm the patient’s comprehension by asking him or her to describe his or her understanding of the next steps. Provide language and literacy­level–appropriate written instructions for patients who identify the problem, tests, and relevant instructions for undergoing the tests, and any prescribed medications. The information also should outline any self­ management instructions for the patient. Ask the patient how well he thinks he can adhere to the plan. Note possible financial barriers, explaining that some tests or medication may be expensive and that the clinician is willing to seek alternatives. Patients often wait until the end of the encounter to raise concerns and fears. Budget time accordingly, and use empathic statements to build rapport.29 Sometimes, patients rely on nonverbal cues to convey these concerns. They also may use indirect questions to inquire about issues about which they are uncomfortable. They may pose hypothetical situations or talk about what happened to a family member or friend. Clinicians may answer indirectly or if they feel it is appropriate, ask the patient about how the hypothetical applies to her. NEGOTIATING THROUGH DISAGREEMENT When there is a disagreement between the clinician and patient, it is important to acknowledge it. Identify the patient’s most pressing concern and begin to outline what can be done to address it. If the patient rejects the clinician’s concerns or diagnosis, the clinician should return to the principles of cultural humility and ask clarifying questions to identify core areas of agreement and disagreement. Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez IDENTIFY DESIRED OUTCOMES ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 10 / 16 Effective cross­cultural communication can improve clinical outcomes from both the patient and clinician perspective.34,35 Effective communication is NEGOTIATING THROUGH DISAGREEMENT Mount Saint Vincent College Access Provided by: When there is a disagreement between the clinician and patient, it is important to acknowledge it. Identify the patient’s most pressing concern and begin to outline what can be done to address it. If the patient rejects the clinician’s concerns or diagnosis, the clinician should return to the principles of cultural humility and ask clarifying questions to identify core areas of agreement and disagreement. IDENTIFY DESIRED OUTCOMES Effective cross­cultural communication can improve clinical outcomes from both the patient and clinician perspective.34,35 Effective communication is associated with increased satisfaction for the patient and clinician.6 Patient adherence and an enhanced understanding of the disease process and treatment also may improve with effective cross­cultural communication.36,37 CONCLUSION Cross­cultural communication is a critical skill for today’s medical clinicians, irrespective of where they practice. Effective communication in the context of significant cultural differences requires concerted efforts to ensure open exchange. Fortunately, the skills required for effective communication are attainable by most health­care clinicians. KEY CONCEPTS Navigating Cross­Cultural Communication Assess your own cultural beliefs and attitudes. —Acknowledge your major cultural identity. —Identify possible areas of discomfort. —Identify possible areas of bias. —Examine your assumptions when dealing with ​individual patients. Perform a cultural assessment on the patient. —Identify the patient’s major cultural identity by a ​ sking the patient. —Ask the patient about decision­making and information­sharing preferences —Assess level of formal education, employment history, immigration history, role of religion and spirituality, and past experience in the health­care system. —Test hypotheses about health beliefs and attitudes using general information about specific cultural groups but do not apply to patients without individual confirmation. Create an environment that builds trust. —Employ trust­building behaviors in interactions with all patients. —Identify the patient’s explanatory model of illness and the patient’s desired outcomes. —Negotiate a diagnostic and treatment plan that incorporates the patient’s model. —Acknowledge the patient’s concerns with empathy. —Identify patient preferences for family or other key individuals’ involvement. —Use empathic statements with all patients —Encourage the patient to ask questions. —Summarize and IP check for accuracy. Downloaded 2024­2­18 concerns 9:29 A Your is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez that All effective requires ​ongoing relationship building and continuous reassessment. ©2024Recognize McGraw Hill. Rightscommunication Reserved. Terms of Use Privacy Policy Notice Accessibility Recognize that all communication between clinicians and patients shares key elements of cross­cultural communication. Page 11 / 16 Mount Saint Vincent College Cross­cultural communication is a critical skill for today’s medical clinicians, irrespective of where they practice. Effective communication in the context Access Provided by: of significant cultural differences requires concerted efforts to ensure open exchange. Fortunately, the skills required for effective communication are attainable by most health­care clinicians. KEY CONCEPTS Navigating Cross­Cultural Communication Assess your own cultural beliefs and attitudes. —Acknowledge your major cultural identity. —Identify possible areas of discomfort. —Identify possible areas of bias. —Examine your assumptions when dealing with ​individual patients. Perform a cultural assessment on the patient. —Identify the patient’s major cultural identity by a ​ sking the patient. —Ask the patient about decision­making and information­sharing preferences —Assess level of formal education, employment history, immigration history, role of religion and spirituality, and past experience in the health­care system. —Test hypotheses about health beliefs and attitudes using general information about specific cultural groups but do not apply to patients without individual confirmation. Create an environment that builds trust. —Employ trust­building behaviors in interactions with all patients. —Identify the patient’s explanatory model of illness and the patient’s desired outcomes. —Negotiate a diagnostic and treatment plan that incorporates the patient’s model. —Acknowledge the patient’s concerns with empathy. —Identify patient preferences for family or other key individuals’ involvement. —Use empathic statements with all patients —Encourage the patient to ask questions. —Summarize concerns and check for accuracy. Recognize that effective communication requires ​ongoing relationship building and continuous reassessment. Recognize that all communication between clinicians and patients shares key elements of cross­cultural communication. CORE COMPETENCY Negotiating Conflicts Patients and clinicians do not always agree on a plan of action, even when the clinician has tried to be sensitive to the cultural perspective of the patient. When the patient and clinician disagree about the course of action in a clinical situation, it is important for them to recognize that there are effective strategies for resolving the conflict. The conflict rarely should lead to patients seeking care elsewhere, although sometimes that is the solution to the problem. Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Define the Chapter 14:problem. Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Make sure the clinician and patient agree on the conflict. Page 12 / 16 Clinician: “Mr. Smith I think that we have come to a point where we don’t agree on the next course of action. I understand that you want to be Mount Saint Vincent College Patients and clinicians do not always agree on a plan of action, even when the clinician has tried to be sensitive to the cultural perspective of the Access Provided by: patient. When the patient and clinician disagree about the course of action in a clinical situation, it is important for them to recognize that there are effective strategies for resolving the conflict. The conflict rarely should lead to patients seeking care elsewhere, although sometimes that is the solution to the problem. Define the problem. Make sure the clinician and patient agree on the conflict. Clinician: “Mr. Smith I think that we have come to a point where we don’t agree on the next course of action. I understand that you want to be admitted to the hospital, but I believe your problem does not require hospitalization. I think that with appropriate antibiotics your infection will resolve and we can provide close follow­up for you as an outpatient.” Mr. Smith: “Dr. Jones, I know my body and I don’t feel well. The last time a doctor sent me home when I thought I should be admitted I had a heart attack at home.” Examine your own motivations. Have any other factors influenced your decisions? Does the patient have unique social or other circumstances that warrant consideration? If you are not sure, ask. Acknowledge the patient’s concerns. “It must be frightening that I am suggesting sending you home.” Demonstrate trust­building behavior. (Make an effort to make the patient comfortable. Do not appear to be rushed.) Be responsive to the patient’s statement. (“I heard you say you have been sent home inappropriately before.”) Demonstrate empathy. (“That must have been scary for you. I am sorry that you had to go through that experience.”) Ask questions to identify the patient’s specific concerns. (“Sometimes, some people have not been treated fairly in our health care system. Do you think that is a problem in your case?” or “What do you think will happen to you if you go home today?”) Be responsive to patients’ concerns. (“I understand your feelings that you were mistreated in the past.”) Identify opportunities for a compromise. Ask whether the patient thinks there are alternatives. Ask if he or she has other family members or someone else with whom he or she is close and who should be involved in the discussion. Devise a list of possible compromises between the two positions. Ask if patient is comfortable with one of the alternative plans. Restate the compromise you have reached and ask if patient has same understanding. Assess the patient’s satisfaction with the outcome. Acknowledge the patient’s willingness to share his or her thoughts. Apologize about the disagreement. Ask if he or she is satisfied with the resolution. Ask what can be done to avoid conflicts in the future. DISCUSSION QUESTIONS 1. Discuss some of the barriers to effective cross­cultural communication at the patient, clinician, and health systems level. What are some strategies for addressing systems level barriers? Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Page 13 / 16 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez 2. Think back toHill. a time needed health What was your experience like? Did you have a good relationship with your clinician? What ©2024 McGraw All when Rightsyou Reserved. Termscare. of Use Privacy Policy Notice Accessibility made the relationship work? How was it problematic? What role did your education level or race or ethnicity play? Mount Saint Vincent College DISCUSSION QUESTIONS Access Provided by: 1. Discuss some of the barriers to effective cross­cultural communication at the patient, clinician, and health systems level. What are some strategies for addressing systems level barriers? 2. Think back to a time when you needed health care. What was your experience like? Did you have a good relationship with your clinician? What made the relationship work? How was it problematic? What role did your education level or race or ethnicity play? 3. How would you design a program to train clinicians in clinician­effective cross­cultural communication? 4. What other elements of a social history are important to obtain? How do these add to the basic cultural information data? 5. Return to the case of Ms. Jones. Write a role play that illustrates how you think her clinicians could approach her family with news of Ms. Jones’ poor prognosis. How would the clinicians inquire about end­of­life care for Ms. Jones? RESOURCES http://www.diversityrx.org. Provides a summary of the wide spectrum of strategies available to overcome linguistic and cultural barriers to care, and describes their application in model programs around the country. http://www.ethnomed.org. The EthnoMed site contains information about cultural beliefs, medical issues, and other related issues pertinent to the health care of recent immigrants to Seattle or the United States, many of whom are refugees fleeing war­torn parts of the world. http://nccc.georgetown.edu/. The mission of the National Center for Cultural Competence (NCCC) is to increase the capacity of health and mental health programs to design, implement, and evaluate culturally and linguistically competent service delivery systems. http://www2.massgeneral.org/disparitiessolutions/index.html. The Disparities Solution Center groups research, resources, and tools to address health­care disparities at multiple levels. http://xculture.org/resources/general­resource­guides/cultural­competence­resources/. The Cross Cultural Medicine Program provides resources and training to bridge health­care providers and institutions and diverse communities to advance access and quality of health care. Bigby J. 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Thom DH, Hessler D, Willard­Grace R, Bodenheimer T, Najmabadi A, Araujo C, Chen EH. Does health coaching change patients’ trust in their primary care provider? Patient Educ Couns 2014;96(1):135–138. [PubMed: 24776175] 32. Shapiro J, Hollingshead J, Morrison EH. Primary care resident, faculty, and patient views of barriers to cultural competence, and the skills needed to overcome them. Med Educ 2002;36(8):749–759. [PubMed: 12191058] 33. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: Clinical lessons from anthropologic and cross­cultural research. Ann Intern Med 1978;88(2):251–258. [PubMed: 626456] 34. Paez KA, Allen JK, Beach MC, Carson KA, Cooper LA. Physician cultural competence and patient ratings of the patient­physician relationship. J Gen Intern Med 2009;24(4):495–498. [PubMed: 19194767] 35. Fernandez A, Schillinger D, Grumbach K et al. Physician language ability and cultural competence. An exploratory study of communication with Spanish­speaking patients. J Gen Intern Med 2004;19(2):167–174. [PubMed: 15009796] 36. Taylor SL, Lurie N. The role of culturally competent communication in reducing ethnic and racial healthcare disparities. Am J Manag Care 2004;10(Spec No):SP1–SP4. [PubMed: 15481430] 37. Cooper LA. A 41­year­old African American man with poorly controlled hypertension: Review of patient and physician factors related to hypertension treatment adherence. JAMA 2009;301(12):1260–1272. [PubMed: 19258571] Downloaded 2024­2­18 9:29 A Your IP is 63.247.225.21 Chapter 14: Navigating Cross­Cultural Communication, JudyAnn Bigby; Alicia Fernandez ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 16 / 16