Cultural Competency

Cultural competency is defined as a set of academic and interpersonal skills that allow individuals to increase their understanding and appreciation of cultural differences and similarities within, among, and between groups. There has been a great push for increasing cultural competency in many areas of life, especially in medical training. As physicians we interact with a wide range of people from varying cultures. How we deal with the differences and similarities of our cultures impacts patient care.

Introduction and Question
I sometimes wonder if a course in cultural competency is really effective enough to combat the prejudices we all have to some extent that have been collected throughout our twenty plus years of existence. It's almost like those courses in compassion and empathy. Can it really be taught and if it can does that not in and of itself negate the sincerity of empathy/compassion?

I bring this up since the Miguel case deals with both aspects: culture and compassion.

An article that is brief (only 9 pages) and speaks to this and other interesting factors that determine how we treat our patients is found at: http://gsbs.utmb.edu/policy/Distributive%20Justice%20in%20American%20Healthcare.pdf

An excerpt follows in which interesting questions are asked:


 * Is some bias acquired during training? Does exposure to healthcare process magnify preexisting forms of bias and prejudice? The answer to these questions may be emerging. Referencing earlier “studies103 [that] have documented race- and sex-based differences, including race-discordant perceptions of patients,” Rathore et al have produced evidence suggesting that bias is present in the earliest years of clinical training.104 They studied the response of first- and second-year medical students to videos in which professional actors played out the role of an African American woman and a white man with symptoms of angina. The students rated the quality of life of these patients quite differently, although the differences were less when white female students did the analysis.104 Programs in medical education have begun to address these issues,105-109 even framing a patient-centered approach in the context of cultural humility as opposed to cultural competence.

As healthcare professional up and comers we are taught to compartmentalize and with that categorize. It is often tempting and sometimes necessary to apply that to the patient populations we see daily in order to cope with the multitude of responsibilities surmounted upon us. Let's use this case and or article as an opportunity to reflect upon our own experiences/frustrations with cultural challenges in healthcare.

Discussion
I think it is helpful to learn empathy in medical school. Even if it's almost impossible for us to feel the same way as the patients, something as simple as saying "I'm sorry to hear that" can go a long way. Patients do appreciate your acknowledging their pain or tough times they go through. It's definitely better than the alternative like saying nothing at all. I think we can extend that logic to cultural competency.

It's interesting because I think that I agree in principle with most of what has been said... but I think that the difficulty is in putting "cultural competency" into actual practice. It's tricky because these are issues that need to be considered from not only a principled perspective, but a practical one as well. Much like someone was saying, how many people carry inherent biases that they may or may not be aware of? In addition, it's a fine line between respecting another person's cultural beliefs while at the same time doing what's best for the patient.

When I used to work on the Peds Hem/Onc Floor, we had a transplant patient who was in the hospital for 3 months straight. She was a 14 year old girl from a Vietnamese American family that had only immigrated to the United States 6 months prior to her transplant. During the course of her stay, she became fairly depressed and so a psych consult was brought in. Standard procedure during a psych workup of a depressed adolescent female apparently includes questions regarding possible sexual abuse. This infuriated the patient. It infuriated the family. And it took a good 4 hours of intense discussion to convince the family not to leave.

Granted... this certainly could have happened with many other families, their Asian-American background notwithstanding... but the majority of the American patient population has I think a certain acceptance of these types of questions as part of a screening. From my own background, I certainly can say that this is not the case in the Korean-American community.

But there was certainly no malice or poor intent on the part of the Psychiatrist. And would it have been in the patient's best interest not to have that question asked? What about future patients? Yet, in doing so, she risked alienating the family to an extent that they were no longer willing to accept treatment.

Culture competence... easier said than done?

Regarding the patient on the Peds Hem/Onc floor, why wasn't the patient questioned alone? Even if this girl was being sexually abused, I don’t believe she would have admitted it in front of her family.

I think the psychiatrist was doing the right thing by asking the patient about sexual abuse, because you can never be too careful. But, no matter what the cultural background, you have to approach this issue in a way that does not single the patient out. Like we learned in FCM, you could say "I ask all my patients this question..."

Great discussion points. Cultural competency is a tough thing to teach because sometimes it can promote stereotyping. Being aware of personal biases, interviewing in a respectful way, and asking appropriate questions goes a long way. What ideas you have about how best to teach these things?

I guess I should have clarified. The parents were not in the room when questioned. The daughter told the parents immediately afterwards. She was just as bothered by the question as the parents were.

I wasn't in the room, so I don't know exactly what was said or how it was said. The end of the story with her family was actually a happy one. She was started on some anti-depressants, and the child-life specialist was much more active with her and actually used an approach more akin to working with an older elementary school girl.

One of the cultural issues that came out of the discussion regarding how to best care for her was that being a recent immigrant to this country, her own social comfort level with certain issues was not comparable to a teenager girl who had grown up in the US.

My point with bringing up this particular experience I had was just to address the fact that as physicians, if we are to do best for our patients, sometimes we have to be savvy about how we approach our patients. And even the default techniques that we are taught may still be lacking when faced with a dramatic difference in cultural perspective.

While I certainly understand the need for the questioning of sexual abuse, there's a part of me that can also understand the outrage of the family... not condoning... just understanding where it comes from... because I think my parents would have had the same if not possibly a more inappropriate reaction.

I guess I just want to expand on the short point that was made earlier. It was said that one of the obstacles that makes teaching cultural competency difficult is that it can promote stereotyping. I think this is the fine line that must be walked. We must constantly be aware of the possible beliefs and practices of our patients, and we must think of what these may be before we talk to them for the first time. This leads to an interesting situation; we must simultaneously be prepared for certain twists and turns when interviewing a new patient, yet also not let any pre-conceived notions of what they might say or believe cloud our judgment. No matter what ethnic or religious group a person belongs to it does not define who they are so tightly that they cannot waiver. The one time we go in assuming that we know what the patient believes, or how they will respond to a situation, is the time we will be unforgettably wrong.

Now how should competency without stereotyping be taught? I guess we should all remember the board questions on cultural competency where that answer was always, "Never assume what the patient believes" or something along those lines. I guess the only way that we can be sure is to simply ask the patient.

I think someone made a great point in discussing cultural competency vs. obstacles in teaching cultural competency such as stereotyping. This statement is powerful. Thinking back to my previous volunteer and FCM experiences, too many a time would I assume something. For example, I had volunteered at the Children's Hospital in Seattle while I was in college. The Mexican-American eight year old child had seizures and brain imaging to study his brain. He would spontaneously have seizure episodes as we would play checkers. The mother would give me these saddened looks as he was having these seizures that would last upwards of a minute. I think at the time she might have wanted to talk about it further. But I assumed she did not because I was not of the same background as her, and did not delve further or ask any questions of her as a result. The worst I could have done was offend her, and the best result possible was she would be able to talk about her feelings, where she might not have otherwise had a chance to do so. I took it for granted that even though cultural generalizations are important, individual differences abound. It's like the answer to the question in elementary school: How can you fit more into the jar after you have put as many rocks as you can? Pour in the sand. I think of cultural stereotypes and understanding as the rocks because it sets up the basic framework for you to work from and is a danger trap for stereotypes, and the individual patient preferences and identities as the sand that seeps through the cracks and makes it a complete jar, without overly relying on the rocks, of course. The most important point would be to "just ask the patient." If the patient was mad, its one of those things where you could think to yourself "I came in with a pure heart, and wanted to ask the question not for my own curiosity, but for my understanding of the patient, so that I can better treat them." and to relay it to the patient and his or her family without being overly apologetic. When talking to patients of any culture and cultural beliefs, it’s as important to "say the right things" but it is also equally vital to pay attention to how the words are coming across. Exhaustive research has shown that body language carries up to 90 percent of your communication in everyday life. It is not only how you move your body (fidgety vs. slow controlled movements of speech and hands) but also how you deliver the statement to the patient (inflection, tone, speed) that could make the difference in developing rapport to better treat the patient. Some are not aware of this, while others relate to their patient better and are able to elicit the necessary information to make the all-important diagnosis because of this. I think body language in communication is even more important in cases where one does not share the same culture and language because the language spoken might not be understood as well. It is not necessarily something that is rational to people; this is something that people are aware of on both a subconscious and conscious level of thinking.

I had a Vietnamese college friend who said his mother used to "coin" him when he got sick. This is a Vietnamese practice whereby the adult takes a coin and rubs it vigorously onto the back, leaving a long red mark onto the back. He swears by it and reports no problems with it in the past. My friend's mom had known of one other Vietnamese mom who had gotten reported by the physician because of these marks. Although understandable and unfortunate, I can see how this creates massive ramifications elsewhere. My friend always got better, but what if he had acute sinusitis with CNS complications, and after coining he did not get better? Based on what his mom heard from her friend, I can imagine she would be very reluctant to approach the doctor, thereby putting Mark's health in further danger. How can we balance cultural understanding vs. following the law vs. encouraging patient proactivity in their own health issues? This is something to which I hope to find an answer.

I think of cultural competency as less of an endpoint to be achieved but more like a life-long learning process. To achieve this end I think you have to constantly be open-minded, and you also have to be willing to admit your own deficits in cultural knowledge. In this respect I agree very much with what others were saying: you have to enlist your patients' help in educating you about their culture. I think you can do this without being embarrassed or awkward if you are very honest and up-front with them that you'd like to learn from them so you can be a better doctor. I don't think this undermines your authority at all: for one, you're not admitting any deficit in medical knowledge, and also, who would ever expect you to know everything about every culture? I like the statement that if you come with good intentions and a pure heart, your sincerity and eagerness will be interpreted in a good way by the patient. If you make this attitude clear from the beginning of your interaction I think it will really improve communication and establish rapport.

I like the direction others are going with this discussion. There are certainly little tricks of the trade we can learn in FCM and FM. But being culturally sensitive is a lifelong process of learning. I think every time you meet a patient from another cultural background, assuming you approach the encounter with an open heart and open mind, you may pick up a little more of the "feel" of what works and what doesn't work -- the _intangibles_ of eye contact, body language, and tone of voice vis a vis yourself and the patient. You can almost see a little bit of that learning process in the med student or doctor actor in the sequence of video clips for the case.

In regards to a previous Question, I think the best way to teach cultural competency may be as follows: 1) put the students in real-life situations (such as out in preceptorship, cross-cultural medical mission trips) where they must try to understand a patient's perception of why they are ill before they can treat assess and treat the patient appropriately 2) Allow for time to debrief in a group setting so that the students can analyze what they thought/did and whether it was appropriate. By debriefing, the students are educated and may better remember for next time. Any thoughts?

I actually have something somewhat embarrassing to share. While on this rotation in Midlothian, one of my patients who has hyperlipidemia and hypercholesterolemia kept talking about how he could not live without his "fatback" and "fried cabbage." Being from San Francisco, I had no idea what fatback was, except that it was made of fat. I had to ask him to describe to me what fatback and fried cabbage was. While describing the two items, the patient kept going on about how the 2 things taste so good and he just had to eat it. The point of my story is that if I hadn’t asked him what fatback was, I would have just been advising him to eat less fat. Once I realized that fat back is something people eat and use for flavoring, I could advise him to eat less of it and not to soak his other foods with it. This patient helped me realize that cultural disconnects occur between people from different heritages AND between people born and raised in different areas.

I agree with the previous statement about cultural competency promoting stereotyping. The subject of cultural competency is very tough to teach. I think creating an environment in which these issues can be discussed is the 1st step. Taking these matters seriously shows us as students that the faculty does care. Also, by seeing what other students write, it reaffirms how similar we are in our approach to daily life. We share this common bond, which is awesome! These discussions need to occur more often; not just on an e-board but in the classroom, clinic and at home. Furthermore, we have to connect with the common man we see on the street: people are good, more similar then different. Stereotypes may be created but hopefully through learned experience we will effectively combat this behavior and view each patient as an individual. I have faith, just through reading the responses, that everyone who has posted will be effective leaders in this regard

I agree with a lot with what's been said about cultural competency. It's not an algorithm or endpoint in any means. You can't really open up a textbook and say let's learn about it and be a master at this subject. From hearing people's different personal experiences with this issue and also from my experience, I feel that there's a need for me to look closer at how I interact with patients. I've certainly been guilty of making assumptions about someone I haven't met. A lot of times it's a subconscious process. It is difficult because there is such a diverse array of cultures present in America and it's impossible to know all the little nuances of them. I think it's in human nature to see someone from one culture and to presume something about the entire culture. That will get better as we interact more and more with other cultures in our lives and in our careers. We'll learn that not everyone from the same culture is the same.

For now, like many have expressed before, we should try to be open-minded and be genuine and sincere. I think all of us are already doing quite well in that department.

I had a question in regards to learning cultural competency and empathy: As a students, cultural competency and empathy have been drilled into our heads through FCM clinical skills test, and written exam questions. Do you guys think cultural competency and empathy is emphasized as much to physicians? If so, How? If not, how can we ensure that the soft skills (empathy, compassion, cultural awareness) we learn as students are carried over as we become physicians?

I'm not sure how much didactic exposure physicians get with regard to cultural competency and empathy. However, I feel that the physician who wants to do good, connect well with his or her patient, and resolve the suffering of the patient will seek the measures necessary whether they be internal or external to be the "good" doctor. I feel that if someone wants be good, do good and help those in need, he or she will have no problems with empathy, compassion and cultural awareness. He or she may make mistakes along the way but will also have the capacity to learn along the way.

I think that's a great point. Because I do think that this is something that is RIDICULOUSLY lagging amongst established physicians. I think the problem is that in private offices, there are enough patients out there that a doctor can get by without cultural competency just because by word of mouth, patients can choose not to go to them.

I think IN-Hospital the difficulty comes with hospitals that may not have the same cultural exposure as others.

I don't know the solution, because I think it tires in with being able to fight off the cynicism that can creep in regarding all aspects of health care. That's what I think is kind of funny about Project HEART. I think maybe Project HEART is most important for residents and current physicians... more so than medical students.

Yeah... despite all my verbiage, my answer is I don't know....

I agree that communication skills and empathy atrophy with medical training and that Project HEART would be even more useful at higher levels of education. Many residencies are attempting to address some of these concerns with Balint groups and other support/debriefing measures. The internal medicine residency at MCVH is even partnering with the drama department to teach communication skills. There are voluntary CME courses available (some led by Rachel Remen--the author of the Kitchen Table Wisdom book given to your class at matriculation) for those who realize they need a refresher in what brings meaning to their work. Certainly doctors with their humanity in tact are much more satisfied with their careers and work life.

Recommended Resources

 * http://www.diversityrx.org/HTML/ESGLOS.htm
 * http://www.epa.gov/evaluate/glossary/c-esd.htm
 * http://gsbs.utmb.edu/policy/Distributive%20Justice%20in%20American%20Healthcare.pdf

Links to Cases
Back to Miguel or Case studies.

For more information on Project HEART.