Module 9: Competent Care
Upon completion of this module, the resident should be able to:
- Define and describe the significance of cultural competence.
- Identify the demographic and other factors that generate and underscore the need for cultural competence in medicine and health care.
- Identify and utilize practical approaches to the provision of culturally competent treatment and care, especially in taking the patient's history.
- Describe and critique the ethical justification for cultural competence.
- Identify the ways in which culturally sensitive and competent care may require different approaches to such ethically significant issues as valid decision making and informed consent or refusal, withholding and withdrawing treatment, etc.
- Identify and utilize practical tips for being culturally sensitive and competent.
Module: 9 / Providing Ethically - and Culturally - Competent Care
- Framing the Challenges: Clinical Scenarios
- Historial, Legal, and Ethical Background
- Techniques and Practices for Culturally Competent Care
- Cultural Competence: The Spiritual Dimension
- Cultural Competence and Clinical Ethics
- Cultural Competence: Some Closing Practical Considerations and Rules of Thumb
- Questions for Discussion, Analysis and Reflection
Mohammed Al-Katani is a 64-year old exile from Iran. Although he has resided in the United States for more 30 years, he has lived within a small community of other exiles from his native country. His working knowledge of English is slight and he relies on his adult son and adult daughter to help him communicate in grocery stores and other places. He has been referred to you for work-up for suspected renal carcinoma. To this, his first appointment with you, he has brought along a family friend to act as translator/interpreter.
John Michael is a 35-year old male Jehovah’s Witness. He has been a victim of gun violence and has sustained gunshot wounds to his abdomen and groin. During emergency treatment, he was transfused due to blood loss and it is likely that he will need additional transfusions during the surgery that he needs for optimal treatment of his wounds. The transfusion he received during emergency treatment is already a matter of grave spiritual concern to him; he believes he has been defiled.
Mai Lee is a Hmong woman, 20-years of age, who has hematuria and has been referred to your practice for evaluation, diagnosis, and treatment. She arrives in your office with her father, her mother, and her brother—all of whom proceed to enter the examining room with Mai.
In the late 18th century, in the newly independent United States of America, the population was approximately four-fifths white and one fifth black. In the mid-19th century, however, the distribution of different races and ethnicities in the American population began to change with the influx of first European, and later Asian immigrants. In the 20th century, around World War II, the growth rate of the Hispanic population began to reach levels of 4 to 6 percent per year. As of the year 2000, according to the U.S. Census Bureau, whites made up 75.1 percent of the population, blacks 12.3 percent, American Indians .9 percent, Asians 3.6 percent, Pacific Islanders .1 percent, Other 5.5 percent, and Multirace 2.4 percent. Also according to Bureau, in the decade of the 1990s, the diversity of the U.S. population increased at an annual rate of 1.65 percent; in one year alone, 1999, 1.7 million people moved into the United States from abroad. It is not only interesting but crucial to note, as well, that the composition of the health care professional workforce does not reflect that of the population at large: for example, in the year 2000, when African-Americans and Hispanics made up 25 percent of the American population, only 6 percent of physicians (and 9 percent of nurses) were African-American or Hispanic.
These demographic trends are salient features of the broader context for this module on culturally competent care—but they are not the only ones. The increased emphasis on cultural competence, in medical education and medical practice, has also been fueled by mounting evidence of racial and ethnic disparities in health care, that is, of bias and prejudice in the clinical judgment of physicians and in the provision of health care services by institutions and systems. Disparities in the treatment of African Americans and Hispanics are especially significant and persistent. Although such disparities are well documented (in the treatment of coronary artery disease and the use of high tech procedures), they pervade other more basic aspects of medical care, from the practice of physical examination and the use of laboratory and other diagnostic tests to the management of pain. The experience of bias and prejudice—along with revelations of such debacles as the Tuskeegee syphilis studies—has engendered widespread mistrust of health professionals and of health care institutions and systems. The multiracial cast of American society, with its diversity index climbing and climbing, and the harms that have been done to patients by prejudiced physicians, health professionals, and/or systems all demand an effective response by the profession. Cultural competence is this response.
What is cultural competence? Medical educators and other scholars of cultural competence have formulated multiple definitions. Three will be considered here:
- One of the most complete, but succinct definitions says this: “Cultural and linguistic competence is a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professions that enables effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, actions, customs, beliefs, and institutions of racial, ethnic, social, or religious groups. ‘Competence’ implies having the capacity to function effectively as an individual or an organization within the context of the cultural beliefs, practices, and needs presented by patients and their communities.” (Cross TL et al. Towards a culturally competent system of care: a monograph on effective services for minority children. National Center for Cultural Competence. Washington, D.C.: Georgetown University Press, 1989.)
- Another definition states that cultural competence “refers to the ability to honor and respect the beliefs, language, interpersonal styles and behaviors of individuals and families receiving services, as well as staff who are providing such services.” (Denboba, MCHB, 1993).
- Finally, according to a third, “cultural humility is best defined not by a discrete endpoint but as a commitment and active engagement in a lifelong process that individuals enter into on an ongoing basis with patients, communities, colleagues, and with themselves .. a process that requires humility in how physicians bring into check the power imbalances that exist in the dynamics of the physician-patient communication by using patient-focused interviewing and care.” (Tervalon, M. & Murray-Garcia, J. (1998). "Cultural humility versus cultural competence: a Critical discussion in defining physician training outcomes in multicultural education." Journal of Health Care for the Poor and Underserved, 9 (2) 117-125.)
The first definition is comprehensive and applicable to individuals as well as organizations or institutions. The second and third definitions go beyond the aim of effective functioning in cross cultural situations and speak directly to the question,What it is that physicians must be or do to provide culturally competent care? According to these definitions, (A) they must respect and honor the patient in his or her difference; (B) they should be skilled in the methods of patient-centered care, especially in the science and art of clinical communication; and (C) they need to exhibit in their behaviors the clinical virtue of humility—both as (perhaps) the only appropriate response to the human dignity of the patient and as a means of promoting authentically shared decision making.
As with every other dimension of professional competence, cultural competence demands much of the physician, including knowledge, skill, affect, and virtue. The knowledge important to cultural competence includes knowledge (especially, experiential knowledge) of other cultures, their customs, worldviews, and languages; of systems of religious belief and practice; of how illness and disease are “refracted,” as it were, through the prisms of age, race, ethnicity, gender, sexual orientation, and spiritual belief. The essential skills of cultural competence include those critical to forming and sustaining interpersonal relationships, including the ability to communicate effectively in the spoken and the written word, to engage the patient and gain his trust, and to shape the processes of history taking and physical examination to the individuating features of this patient. As for affect, cultural competence is reflected in the physician’s positive regard—that is, respect—for the patient, in the desire to feel something of the patient’s plight, and in an emphasis on listening to the patient and fostering the patient’s understanding of the diagnosis and of the options for therapy. With respect to the clinical virtues, cultural competence demands a commitment to excellence and ongoing self-education and improvement, the compassion and empathy that enable physicians to surmount cultural boundaries, and the practical wisdom or prudence to discern what should be done for the particular patient in the particular circumstances of the clinical encounter.
In medicine and health care, there is another dimension to cultural competence that has not been addressed and that is the critical awareness—the critical self-awareness—that there is a distinct culture of medicine. The practice of contemporary medicine entails a specialized language, a body of custom and belief (tacit and otherwise), rites of passage, criteria of achievement—and all the other features of a culture. In and through their very identities, physicians are the bearers of this culture. Thus, the patient-physician relationship is always a cross-cultural experience to the extent that it brings together a patient from one culture and a physician—from the culture of medicine. The challenge for the physician is to come to critical self-awareness of how the culture of medicine can advance as well as impede the aims and ends of healing. Within this culture, the culture of medicine, there are strong tendencies to focus, selectively, on disease (as distinguished from illness), on cure (as distinguished from other possible goals of medicine), and on technology-driven modalities of diagnosis and treatment.
There is an ever-expanding literature addressing the knowledge base that is fundamental to cultural competence. It includes, for example, descriptions of the health beliefs and practices that tend to be characteristic of different cultures—defined in terms of race, ethnicity, or systems of religious belief. Even a sampling of these descriptions is beyond the scope of this module but the additional resources described below include several relevant references. Thus, the emphasis of this module is on practical suggestions for culturally competent communication in the patient-physician relationship. Many of these suggestions have the same template, so to speak: they are all variations on or additions to a patient-centered clinical method. Below is a graphic illustration of this method (from Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA: Sage Publications, 1995, p. 37.)
The patient-centered clinical method begins with the fact that culture shapes a patient’s understanding of health, illness, and healing—and with the assumption that the physician is obligated to elicit this understanding as an essential step in culturally sensitive and clinically effective diagnosis, treatment, and care. The mnemonic acronyms described below are useful tools for this purpose.
Background: What is going on in your life?
Affect: How do you feel about what is going on?
Trouble: What troubles you most?
Handling: How are you handling that?
Empathy: This must be very difficult for you.
(Source: Stuart MR and Leiberman JR. The fifteen-minute hour: applied psychotherapy for the primary care physician. New York: Praeger, 1993)
Beliefs about health What caused your illness/problem?
Explanation Why did it happen at this time?
Learn Help me to understand your belief/opinion.
Impact How is this illness/problem impacting your
Empathy This must be very difficult for you.
Feelings How are you feeling about it?
(Dobbie AE, Medrano M, Tysinger I, Olney C. The BELIEF instrument: a preclinical teaching tool to elicit patients’ health beliefs. Family Medicine. 35:316-319.)
Explanation How do you explain your illness?
Treatment What treatment have you tried?
Healers Have you sought any advice from
Negotiate Mutually acceptable options.
Intervention Agreed on.
Collaboration With patients, families, healers.
(Levin SJ, Like RC, Gottlieb JE. ETHNIC: A framework for culturally competent ethical practice. Patient Care. 34(9), 188-189.)
Just as ethnicity can be a powerful influence on an individual’s beliefs and practices concerning health and illness, so, too, can his or her faith or spiritual orientation. The question is how should a physician approach and tend to a patient’s spiritual beliefs and practices in the context of caring for that patient? What is the scope and what are the limits of that approach? From an ethical point of view, respect for a patient’s spirituality—for his embrace of a faith commitment or for his utter rejection of the same—is required by the physician’s obligation to achieve the patient’s good and to respect his values and preferences in the process. Sound, effective clinical judgment, which is also demanded by beneficence, requires the physician to explore the connection between a patient’s spiritual commitments and his understanding of his condition and preferences with respect to diagnosis and treatment. For this express purpose, another mnemonic acronym is useful for addressing the spiritual dimensions of a patient history:
F—Faith and Belief: "Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs that help you cope with stress?" IF the patient responds "No," the physician might ask, "What gives your life meaning?" Sometimes patients respond with answers such as family, career, or nature.
I—Importance: "What importance does your faith or belief have in our life? Have your beliefs influenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?"
C—Community: "Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?" Communities such as churches, temples, and mosques, or a group of like-minded friends can serve as strong support systems for some patients.
A—Address in Care: "How would you like me, your healthcare provider, to address these issues in your healthcare?"
(Source: Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine 2000;3:129-37.)
The Anglo-American tradition in clinical ethics (and broadly speaking, bioethics) tends to emphasize the individual, her rights to self-determination, and the respect she is owed as an autonomous being; the individual is the source and arbiter of values determinative for that individual’s life (within certain state-imposed constraints). This tradition tends to stress, as well, procedural ethics rather than substantive ethics, focusing on who has the power or authority to decide and how decisions are to be made.
Things can stand quite differently when one steps out of the Anglo-American tradition into that of another culture or system of belief. In many other cultures, the hyper-individualism of American culture is countered by a respect for and reliance upon groups, especially the family. Although caring for patients always, arguably, entails caring for their families, this truism of patient care is often a “fact of life” in other, non-Anglo cultures. This simple but profound difference can necessitate culturally attuned and sensitive ways of addressing such issues as confidentiality, truth telling, informed consent and refusal, withdrawing or withholding treatment, and dying and death. For example, communicating the bad news of a terminal diagnosis directly to a patient is now thought to be an ethically valid and, indeed, required practice but both ethical validity and practical necessity can give way in different cultural contexts. It is important, however, to note that although descriptions of the health beliefs and practices that tend to be characteristic of a particular group may be useful, they may—or may not—be relevant to an individual with that group identity. The distinction between a generalization and a stereotype is useful here. Generalizations apply broadly to groups of individuals and tend to frame commonalities—in beliefs, preferences, and values—among the individuals in a given group; they are a point of departure, rather than a destination in the process of understanding the beliefs, preferences, and values of an individual. A stereotype obliterates the difference between a group and an individual; to stereotype is reach premature closure on the question of how closely does a given individual’s beliefs and practices mirror that of the group to which he or she belongs. Physicians and other caregivers should never assume that because patient X is Y (with Y being a particular race, ethnicity, gender, age, sexual orientation, or religious affiliation), he or she will believe this or that or do that or this; that is, they should not stereotype. Generalizations are background information, of real but limited utility in the effort to place individuals in context. The only way to discover how the individual stands vis-Ã -vis that context is to ask open-ended questions—and to listen with care.
Cultural differences in ethical thinking and practice can engender a sort of relativistic perspective on clinical ethics and press home the question of whether there are any universal, transcultural ethical imperatives that hold for physicians, no matter where, when and with whom they find themselves in practice. Indeed, there are such imperatives: the cardinal duty is the physician’s obligation to care for the patient, acting in the service of his or her good. This precept holds no matter what the demographic mapping of the patient: whether the patient is male or female, Western or non-Western, believer or atheist, patient and physician are “bound together” by the former’s need for help and latter’s commitment to provide that help. Thus, the duty or commitment to benefit the patient while avoiding harm to him or her is universal.
In the effort to provide culturally competent care, physicians will often need to seek practical ways to bridge language barriers. Many urban-based hospitals now have translators and interpreters on staff—although friends and family members of patients may also offer their services for this purpose. In light of the often inherent complexity of medical information and data (for example, about diagnostic tests, the risks and benefits of alternative treatments, etc.), it is crucial that translators and interpreters be deployed in ways that optimize communication over language barriers. Some guidelines, developed and promoted by the American Medical Student Association, include:
- Unless you are thoroughly effective and fluent in the target language, always use an interpreter.
- Try to use an interpreter of the same sex as the client but avoid using family members as interpreters.
- Learn basic words and sentences in the target language; emphasize by repetition and speak slowly, not loudly.
- Be patient. Careful interpretation often requires that long explanatory phrases be used.
- Address the patient directly: do not direct commentary to or through the interpreter as if the patient did not exist.
- Return to an issue if you suspect a problem and get a negative response. Be sure the interpreter knows what you want.
- Provide instructions in LIST format and have patients repeat their understanding of the medical therapy.
- Use short questions and comments; avoid technical terminology and professional jargon, like "workup."
- Use language that the interpreter can handle; avoid abstractions, idiomatic expressions, similes and metaphors.
- Plan what to say ahead of time. Do not confuse the interpreter by backing up, rephrasing or hesitating.
Salimbene and Graczykowski offer ten practical “rules of thumb” for providing culturally competent care:
- Do not treat the patient in the same manner you would want to be treated. Culture determines the roles for polite, caring behavior and will formulate the patient's concept of a satisfactory relationship.
- Begin by being more formal with patients who were born in another culture. In most countries, a greater distance between caregiver and patient is maintained through the relationship. Except when treating children or very young adults, it is best to use the patient's last name when addressing him or her.
- Do not be insulted if the patient fails to look you in the eye or ask questions about treatment. In many cultures, it is disrespectful to look directly at another person (especially one in authority) or to make someone "lose face" by asking him or her questions.
- Do not make any assumptions about the patient's ideas about the ways to maintain health, the cause of illness or the means to prevent or cure it. Adopt a line of questioning that will help determine some of the patient's central beliefs about health/illness/illness prevention.
- Allow the patient to be open and honest. Do not discount beliefs that are not held by Western biomedicine. Often, patients are afraid to tell Western caregivers that they are visiting a folk healer or are taking an alternative medicine concurrently with Western treatment because in the past they have experienced ridicule.
- Do not discount the possible effects of beliefs in the supernatural effects on the patient's health. If the patient believes that the illness has been caused by embrujado (bewitchment), the evil eye, or punishment, the patient is not likely to take any responsibility for his or her cure. Belief in the supernatural may result in his or her failure to either follow medical advice or comply with the treatment plan.
- Inquire indirectly about the patient's belief in the supernatural or use of nontraditional cures. Say something like, "Many of my patients from ___ believe, do, or visit___. Do you?"
- Try to ascertain the value of involving the entire family in the treatment. In many cultures, medical decisions are made by the immediate family or the extended family. If the family can be involved in the decision-making process and the treatment plan, there is a greater likelihood of gaining the patient's compliance with the course of treatment.
- Be restrained in relating bad news or explaining in detail complications that may result from a particular course of treatment. "The need to know" is a unique American trait. In many cultures, placing oneself in the doctor's hands represents an act of trust and a desire to transfer the responsibility for treatment to the physician. Watch for and respect signs that the patient has learned as much as he or she is able to deal with.
- Whenever possible, incorporate into the treatment plan the patient's folk medication and folk beliefs that are not specifically contradicted. This will encourage the patient to develop trust in the treatment and will help assure that the treatment plan is followed.
(Source: Salimbene S. Graczykowski JW. Ten Tips for Improving The Caregiver/Patient Relationship Across Cultures. When Two Cultures Meet: American Medicine and the Cultures of Diverse Patient Populations, Book 1, What Language Does Your Patient Hurt In? An 8-Part Series of Practical Guides to the Care and Treatment of Patients from Other Cultures. Inter-Face International. Amherst Educational Publishing. Amherst, MA; 1995: 23-25.)
The patient in the case is Mr. Al-Katani, the 64-year old Iranian exile encountered in the clinical scenarios that framed the challenges of cultural competence at the outset of this module. Imaging studies confirm the suspected diagnosis of renal carcinoma and additional studies and tests reveal a Stage II, locally invasive tumor. Mr. Al-Katani’s son and daughter have been accompanying him on these most recent visits, instead of the family friend, and, in response to your review of the effectiveness, benefits, and risks of the treatment options, they seem to be in conflict. Mr. Al-Katani’s son reports that his father believes that the cancer is simply his fate and that it would be an offense against Allah to resist his fate; the son also seems to endorse and accept his father’s acquiescence. Mr. Al-Katani’s daughter, however, wants her father to undergo the recommended surgery with the hope of achieving a cure, or at least remission of disease.
- Is Mr. Al-Katani’s response to his diagnosis typical of Muslims of his country of origin?
- What are the possible ways in which effective communication in this case may have been compromised or undermined?
- How would you approach the ethical demands of valid decision making/informed consent or refusal in this case?
- What, if anything, should you do about the conflict between Mr. Al-Katani’s son and daughter?
The website for the National Center for Cultural Competence at Georgetown University’s Center for Child and Human Development is an excellent resource for health care professionals. It is located at: http://www11.georgetown.edu/research/gucchd/nccc/.
Although tailored to the needs of health care professionals in the Seattle, Washington area, the Cross Cultural Health Care Program has a resource-rich website, including downloadable profiles of twelve different ethnic communities. To download one or more profiles, go to: http://www.xculture.org/resource/library/index.cfm#downloads.
Brief, useful profiles of dominant ethnic communities (Anglo-American, Middle Eastern, Hispanic/Mexican, Southeast Asian, African-American) can be found in a downloadable pamphlet at: www.vistastaff.com/pdfs/profiles/cultural_sensitivity.pdf.
Issues in Islamic Medical Ethics is a website maintained by the University of Virginia. It can be found at: http://people.virginia.edu/~aas/ismedeth.htm.
The George Washington University Center for Spirituality and Health maintains a website with a wide range of resources on the relationship between faith, health, and medicine; it is located at: http://www.gwish.org. Christina Pulchalsky, MD, M.S., the center’s director, is a nationally recognized leader in spirituality and health; she has authored many articles on the integration of spiritual issues and concerns in medical practice. One that is well worth reading can be found at: http://www.turner-white.com/pdf/hp_mar01_spirit.pdf.
An interesting powerpoint presentation, which addresses the history of the link between spirituality and health, as well as current thinking and practice, can be found at: http://courses.washington.edu/mhe518/SpiritinMedicine.ppt.