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Medical Student Perspectives: Cultural Differences in Patient Care

In 2006, the United States spent over $2 trillion, or 16% of its GDP, on healthcare expenditures, the world’s highest. Despite this, minorities tend to have less access to healthcare; and when they do, their health outcomes are worse when compared to whites with similar diseases, age, socioeconomic status, and other potential confounding factors (Smedley, Stith, & Nelson, 2002) (see Figure 1). Cultural and linguistic barriers in the health care setting are thought to be among the top causes for these disparities. The American College of Physicians (ACP) has outlined cultural competency as one of the major methods of addressing these barriers.

Cultural competence is defined as “the ability of health care providers and institutions to deliver effective services to racially, ethnically and culturally diverse patient populations.” But how do we as a medical community, and specifically as medical students, even begin to approach this?

As we begin our clinical years, we are already faced with many challenges as we transition our knowledge into practice. An additional layer of complexity is added when we consider the extremely diverse backgrounds from which our patients come. It may be easier in these instances to focus on “the medicine” and disregard the psychosocial aspects of a patient’s life. However, these may be some of the most important factors that contribute to how your patients view health and healthcare and can therefore influence their adherence to treatment/lifestyle changes, satisfaction with their healthcare, and ultimately, their overall well-being (see Figure 1). Addressing these psychosocial aspects moves us toward becoming culturally competent and, therefore, more effective physicians.

Figure 1. Factors that Seem to Independently Contribute to Health Behaviors (Bigby, 2003)

1.) Exposure to biomedical and popular standards of care as determined by:
    a. Level of formal education
    b. Generational status
    c. Level of encapsulation within ethnic and family social network
    d. Experience of medical treatment
    e. Previous experience with particular diseases
    f. Age at immigration (if applicable)
    g. Degree of migration back and forth to country of origin (if applicable)
2.) Income
3.) Occupation
4.) Area of origin in native country (if applicable)
5.) Religion

It is reasonable to assume that most providers would find it morally and professionally objectionable to be prejudiced or biased against certain minority groups. However, whether conscious or not, and despite best intentions, “healthcare providers’ diagnostic and treatment decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity” (Smedley, Stith, & Nelson, 2002).

An excellent starting point to untangle and understand the origins of these biases is to consciously analyze what makes up your own culture and beliefs. Only after a thorough analysis of your own biases and prejudices can you begin to deconstruct them. These values are what make up your relative assessment of others. Careful self-assessment and critique are the first steps towards cultural competence (Bigby, 2003).

Several models and strategies have been developed to improve patient interactions and can be applied in the setting of cultural differences (see Figures 2 and 3).

Figure 2. Models for Improving Patient Interactions

LEARN Model 1
Listen to the patient’s perspective.
Explain and share one’s own perspective.
Acknowledge differences and similarities between two perspectives.
Recommend treatment.
Negotiate mutually agreed upon plan.

RESPECT Model 2

    Respect
  • A demonstrable attitude involving both verbal and nonverbal communications
    Explanatory model
  • What is the patients’ point of view about his or her illness? How does it relate to the physician’s point of view? All points of view must be elicited and reconciled.
    Sociocultural context
  • How class, race, ethnicity, gender, education, sexual orientation, immigrant status, and family and gender roles, for example, affect care
    Power
  • Acknowledging the power differential between patients and physicians
    Empathy
  • Putting into words the significance of the patient’s concerns so that he or she feels understood by the physician
    Concerns and fears
  • Eliciting the patient’s emotions and concerns
    Therapeutic alliance/Trust
  • A measurable outcome that enhances adherence to, and engagement in, health care

1 (Berlin & Fowkes, 1983)
2 (developed by Boston University Residency Training Program in Internal Medicine, Diversity Curriculum Taskforce)


Figure 3. Some Additional Strategies for Clinical Cultural Assessments
(Adapted from Diversity Rx Website; Bigby, 2003)

1.) Patients should be considered as individuals first.
2.) Do not assume that ethnic identity indicates specific cultural values or behavior.
3.) Most people from racial and ethnic minority groups are bicultural in American society; however, the degree of acclimatization varies.
4.) Some aspects of a patient’s cultural history, values, and beliefs are relevant to clinical situations and some are not. Do not prejudge which are relevant; let the patient tell you.
5.) Identify strategies taken from the patient’s cultural orientation that you both can use to enhance the therapeutic alliance. Acknowledge those that seem counter-productive.

In addition to culture, another major barrier to the reduction of healthcare disparities is linguistic barriers. According to Title VI of the Civil Rights Act of 1964, “no person in the United States shall on ground of race, color or national origin be excluded from participation and be denied the benefits or be subjected to discrimination under any program or activity receiving federal financial assistance.” For patients who have limited English proficiency, it is the responsibility of the physician to find a way to overcome these language barriers in order to provide an equivalent level of care as would be received by an English-speaking patient.

This can be achieved through trained professional interpreters, or an interpretation phone system. It is not acceptable to use patients’ family members or friends for many reasons. The ability of the interpreter is unknown, as are their potential personal agendas. It also may hinder the collection of accurate data, particularly on sensitive topics. Additionally, one should note that physicians often overestimate their fluency in other languages. Research has shown that providers usually overestimate their language proficiency and patients often do not understand what the provider is communicating (Bigby, 2003). This can be dangerous as misunderstandings can easily occur. Therefore, physicians should be certain of their fluency, and err on the side of caution and use a professional interpreter when in doubt.

When using an interpreter, there are some general guidelines that should be followed for effective communication in these settings. In an ideal situation, the physician should meet with the interpreter before the patient encounter to determine whether the interpreter is bicultural as well as bilingual. Those that are bicultural can be used as a resource during the interview. The style of interpretation (phrased, simultaneous or summary) should also be discussed and determined based on the type of interaction taking place. And lastly, it should be stressed that physicians should still make an effort to establish rapport with their patient through the interpreter. Patients who require interpreters should not be treated differently from the patient care or personal perspectives.

I hope that you can begin to see some of the issues and challenges involved in eliminating the disparities in minority healthcare. Articles, books and documentaries abound studying cultures and their beliefs and practices. It was not the goal of this article to familiarize you with all of these or provide a comprehensive manual for how to approach your patients of various backgrounds. However, I hope that it did serve to familiarize you with the concept and importance of cultural competency, provide some general models for approaching patients of different cultures, unearth some of your personal or professional prejudices and serve as a springboard from which to begin your own changes and pursuit of knowledge based on your unique practice and patient population.

For a more detailed discussion and additional information on these topics, I highly recommend the book Cross-Cultural Medicine edited by JudyAnn Bigby, MD. Also, many ACP policy papers abound, and provide interesting discussions on policies and curriculums to reduce disparities in healthcare.

Andrew A. Chang, MA
North Atlantic Representative, Council of Student Members
Health & Public Policy Committee Representative
New York Medical College, MD/MPH in Health Policy & Management
Class of 2008
Co-Founder, La Casita de la Salud,
The NYMC Student-Run Clinic in East Harlem, NY
E-mail: andrew_chang@nymc.edu

References

American College of Physicians. (2004). Racial and ethnic disparities in health care: a position paper of the American college of physicians. Philadelphia: Annals of Internal Medicine, 141, 226-232.

Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care.West J Med. 1983;139:935.

Bigby, JudyAnn, Cross Cultural Medicine. Philadelphia: American College of Physicians, 2003.

Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57 Suppl 1:181-217.

Brach C, Fraser I. Reducing disparities through culturally competent health care: an analysis of the business case. Qual Manag Health Care. 2002;10:15-28.

Harwood A. Guidelines for culturally appropriate health care. In: Harwood A, ed. Ethnicity and Medical Care. Cambridge, MA: Harvard University Press: 1981:483-507.

Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-8.

Smedley BD, Stith AY, Nelson AR, eds. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine. Washington, DC: National Academies Press.

Smith WR, Betancourt JR, Wynia, MK, Bussey-Jones J, Stone VE, Phillips CO, Fernandez A, Jacobs E, Bowles J. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med. 2007; 147:654-665.

Back to March 2008 Issue of IMpact

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