Confessions of a

Culturally Challenged Physician

Shirley Schlessinger, MD, FACPAssociate Dean, Graduate Medical Education

Medical Director Mississippi Renal Transplant Program

Medical Director, Mississippi Organ Recovery Agency

Chief of Staff, University Hospitals and Clinics, 2003-2004

Associate Professor, Division of Nephrology

University of Mississippi Medical Center

Are YOU a “culturally competent”

physician?

•How do you know?

•How is cultural competence evident in your practice?

•What pitfalls must you avoid in the future to maintain cultural competency?

Why Does Cultural Competence Matter?

• Need to eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds

• Improve the quality of services and health outcomes

• A response to current and projected demographic changes in the US

• Meet legislative, regulatory, and accreditation mandates

• Gain a competitive edge in the marketplace• Decrease likelihood of liability / malpractice claims

Ms. BP

• 53 yo BF; ESRD/HTN/ h/o Mental Illness, marginally literate from rural MS

• s/p Renal Tx 9/03

• Concrete thought processes

• Perseveration of delusions

• “My son works for the President”

What IS Cultural Competence?

The ability to function effectively in the context of

cultural differences…

“Culture”

• Beliefs• Traditions• Lifestyles• Age• Education• Profession• Religion• Sexual Orientation

• Values• Socioeconomic

status• Hobbies • Political Affiliation• Geographic origin• Race• Gender• Family position

Adjective AssociationsWhat’s your first thought?

Black maleAlzheimer’s

victimAsian manWelfare recipientDeaf / MuteHomosexualTeenager

Adjective AssociationsWhat’s your first thought?

• Denzel Washington

• Ronald Reagan• Jackie Chan• JK Rowling• Helen Keller• Ellen Degeneres• Hillary Duff

Recognize Stereotyping!!!

• A learned behavior• Applies information and mis-information

about “groups” to an individual• Re-enforced by media and everyday

surroundings• Results in automatic assumptions which can

result in poor patient care

For optimal patient care, we must:

• Recognize and avoid stereotypic mentality

• Know our own biases and value systems

• Respect our patients value systems• Recognize the many cultural influences

that impact decision-making in health care

Ms. SH

• 29 y/o BF deaf/mute since birth• ESRD / HTN referred for Tx

Evaluation• Marginal literacy• ??? Need for interpreter at

evaluation screening clinic appointment????

• Opportunities for education…

Mr. JP

• 44 y/o BM with DM / HTN presented with flank pain / hematuria

• US/CT abd with LARGE renal mass• No evidence of metastasis, likely

curable RCCa• Pt absolutely refused surgery• “I don’t want to go to Hell”

The Grandpa

• Tragic MVA, both parents dead on scene

• Only grandchild brain dead on vent• One set of grandparents want to

donate organs• Other set of grandparents poorly

educated, virtually homeless, in poor health, dirty, and angry…

• Will they halt donation?

Enhancing Your Cultural Competence...

• Be aware of YOUR mental filters• Avoid “labeling” people• Educate yourself!

– Learn a language!– Listen to new music!– Eat sushi!– Read foreign authors!

• Learn to appreciate the individual in every patient you see!

Be Aware of Recognized Cultural Inequities in US

Health CareRacial & Ethnic Minorities are less likely to receive or undergo:

• Routine cardiac eval / CABG• Transplantation• Mammography• Referral for Chemotherapy• Hormone replacement therapy

1. Cross-cultural misunderstandings between providers and patients can

lead to mistrust and frustration, but are unlikely to have an impact on objectively measured clinical

outcomes.

True?

False?

2. When a provider expects that a patient will understand a condition and

follow a regimen, the patient is more likely to do so than if the provider has

doubts about the patient.

True?

False?

3. A really conscientious health provider can eliminate his or her own prejudices or negative assumptions

about certain types of patients.

True?

False?

4. If a family member speaks English as well as the patient’s native

language, and is willing to act as interpreter, this is the best possible

solution to the problem of interpreting.

True?

False?

5. Some symbols - a positive nod of the head, a pointing finger, the “thumb-s up” sign - are universal and can help

bridge the language gap.

True?

False?

6. Out of respect for a patient’s privacy, the provider should always begin a

relationship by seeing an adult patient alone and drawing the family in as

needed.

True?

False?

7. In some cultures, it may be appropriate for female relatives to ask the husband of a pregnant woman to

sign consent forms, if the patient agrees and this is legally permissible.

True?

False?

8. When a patient is not adhering to a prescribed treatment after several

visits, which does NOT help?:

A. Involving family members

B. Repeating instructions loudly to emphasize importance

C. Agreeing to a compromise in timing or amount

D. Listening to folk or alternative remedy suggestions

9. Correct methods to communicate with a patient though an interpreter

include:

A. Making eye contact with the interpreter when you are speaking, then looking at the

patient while the interpreter is telling the patient what you said.

B. Speaking slowly, pausing between words

C. Asking the interpreter to further explain the patient’s statement

D. None of the above

10. In a medical interview with a patient from a different cultural background,

which is the LEAST useful technique? A. Ask questions about what the patient

believes about his illness, what caused the illness, how severe it is, and what type of treatment is needed?

B. Gently explain which beliefs about the illness are not correct

C. Explain the “Western” or “American” beliefs about the patient’s illness

D. Discuss the differences in beliefs without being judgmental