A young couple that just immigrated to your town from Bosnia comes to your clinic because they are expecting their first baby. The wife is a healthy 23-year-old woman and in her first trimester of pregnancy.
Your scheduler knows that many Bosnians are of the Muslim faith and has heard that female Muslims are supposed to refrain from care by male physicians.
Question 29.2.1 When making the appointment for this patient, the scheduler should:
A) Schedule her with the first available OB provider, regardless if it is male or female.
B) Schedule her with the first available female OB provider.
C) Schedule her with your only Bosnian-speaking OB provider who is male (this will cut down on the time needed for an interpreter).
D) Ask if she has a preference from whom she would like to receive care and schedule her within her preferred provider.
E) Schedule her with the OB provider who has the most experience and interest in working with patients from diverse cultures (maybe Dr. Smith since he eats out at a different ethnic restaurant every night).
Answer 29.2.1 The correct answer is "D." Although many Muslim women would find it inappropriate to have a male provider, this is not universally true. Besides, we are not even sure this patient is of Muslim faith (only about 40% of Bosnians are Muslim)! Cultural characteristics and belief systems are generalizations that often accurately describe a population. However, if you extrapolate these generalized beliefs to the individual, you are engaging in stereotyping and may often come to the wrong conclusion.
Use your knowledge of a patient's culture as a starting point. Ask about any assumptions or suspicions in a nonjudgmental way. Make sure you know how the belief applies in the current context.
When she arrives in your clinic, you realize she speaks no English and her husband speaks only a little. Using his limited English and some hand gestures, you feel that you could conduct an interview with them. Because you completed a course entitled "Advanced Life Support for Culturally Responsive Care," you are able to deal with such a situation! Your mind drifts back to that course … ah, CME on the beach!
Question 29.2.2 You recall that "culturally responsive care" is defined as:
A) Learning about multiple cultures.
B) Being able to speak multiple languages.
C) Taking diversity classes.
D) Adopting a set of cultural behaviors and attitudes that enable you to deliver effective medical care to people of different cultures.
E) Hiring staff from a variety of different cultures—preferably all good cooks who will provide some excellent ethnic cuisine.
Answer 29.2.2 The correct answer is "D." While the other answers are laudable goals, they do not define culturally responsive care. Culturally responsive care is a set of behaviors and attitudes that aims to help healthcare providers deliver better care to patients from many different cultures.
You rack your brain trying to remember why culturally responsive care is important to you. You now regret skipping some of the lectures to go snorkeling in those beautiful Hawaiian waters.
Question 29.2.3 Which of the following is NOT a benefit of providing culturally responsive care?
A) It allows efficient use of time and resources.
B) It increases the chance of providing services that are consistent with patient needs.
C) It might improve health outcomes for minority patients.
D) It might improve patient retention.
E) It is less expensive in the long run.
Answer 29.2.3 The correct answer is "E." Culturally responsive care allows you to use your time and resources efficiently to increase the likelihood that you will provide the services your patient actually wants, and needs! This can lead to improved health outcomes for your patients, increased patient satisfaction and retention of your minority patients (and perhaps increase your patient satisfaction scores!). Unfortunately, no studies so far have shown that it can reduce your practice costs.
The National Center for Cultural Competence at Georgetown University has identified six compelling reasons that healthcare providers should incorporate culturally responsive care into their practice. They are as follows:
To respond to current and projected demographic changes in the United States
To eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds
To improve the quality of services and health outcomes
To meet legislative, regulatory, and accreditation mandates
To gain a competitive edge in the marketplace
To decrease the likelihood of liability/malpractice claims
Pondering this, you decide to try and provide culturally responsive care to this Bosnian woman.
Question 29.2.4 Which one of the following is NOT a step in providing culturally responsive care?
A) Understanding your own culture.
B) Understanding others' cultures.
C) Being frustrated with having to work with people different than you.
D) Understanding how your patients' cultural beliefs affect their attitude toward healthcare.
E) Adapting your way of practicing to provide optimal care.
Answer 29.2.4 The correct answer is "C." The goal of culturally responsive care is to provide better healthcare for patients from different cultures. Some of the specific things this goal calls for include:
Being respectful of potential cultural differences
Learning about other cultures
Being aware of the health impact of cultural beliefs and practices
Being sensitive to patients' needs
Using interpreters when necessary
Adapting practices to provide optimal care
An easy way to achieve these goals is by using the Berlin and Fowkes' LEARN model described earlier in the chapter.
While learning and respecting patients' different cultural beliefs is vital, providing good care does not call for accepting practices that are detrimental to your patient's health. But beware … there are many potential ethical dilemmas that can occur when traditional Western medicine intersects with a culture that has radically different health beliefs. Many cross-cultural medical decisions are not as black and white as we would like to think. Western medicine may have to bend a little to accommodate belief systems.
Now that you are ready to proceed with caring for your patient, the question of language comes up. Should you use the husband to interpret (he seems to know a bit more English)?
Question 29.2.5 To help guide you, you call your hospital compliance officer who tells you that:
A) It is Federal Law that you must provide an interpreter for patients who need it, at your own cost if necessary.
B) It is Federal Law that patients must provide their own interpreters at their own expense.
C) Most insurance companies reimburse for interpreter services.
D) Using family and staff to translate rarely reflects current practice standard.
E) There are no privacy concerns when using nonprofessional interpreters.
Answer 29.2.5 The correct answer is "A." The 2010 census found that more than 60.6 million adults (around 21% of the U.S. population) speak a non-English language at home, while almost 13% of the U.S. population is foreign born. When the healthcare professional does not speak the primary language of the patient, there is potential for loss of important information, misunderstanding of physician instructions, and poor shared decision-making. Title VI of the 1964 Civil Rights Act requires healthcare professionals to provide interpreter services for patients who need them, at the physician's cost if necessary. Failure to do so would qualify as discrimination and could be prosecuted in a court of law. Unfortunately, most insurance companies do not reimburse for these services. Interpreters can be scarce and costly. As a result, many physicians use any help they can get for translation, including staff members and family members who are bilingual; this leaves room for error (so, "D" is a false statement). Using a family member as an interpreter makes it hard for the patient to disclose private information they do not want known by the family. Professional interpreters have been trained and certified, while ad hoc interpreters often have no formal training and can make translation mistakes.
Question 29.2.6 Regarding provision of healthcare, language barriers may result in:
A) Increased risk of intubation for children with asthma.
B) Greater nonadherence to medication regimens.
C) Higher resource use in diagnostic testing.
D) Increased risk of drug complications.
Answer 29.2.6 The correct answer is "E." Language barriers have been associated with worse health outcomes to include lower likelihood of having a usual source of medical care; lower likelihood follow-up after an emergency room visit; greater nonadherence to medication regimens; increased risk of drug complications; impaired understanding of diagnoses, medications, and need for follow-up; lower patient satisfaction; longer medical visits; higher resource utilization; increase risk of intubation for children with asthma; greater risk of being labeled with psychopathology; and increased risk of leaving the hospital against medical advice.
Question 29.2.7 What is the proper method to use an interpreter?
A) Address all questions to the interpreter while facing the interpreter.
B) Address questions to the patient while looking at the interpreter.
C) Address questions to the patient while facing the patient.
D) Address questions to the interpreter while facing the patient.
E) Have the interpreter get you coffee while you muddle through using gestures.
Answer 29.2.7 The correct answer is "C." The physician should speak to and look at the patient; in other words, don't speak about the patient in the third person. Remember that nonverbal communication is important even when common languages are not shared. Be aware that seemingly universal gestures such as the "OK" sign and a thumbs up may have different meanings in other cultures. The physician should speak clearly and give the interpreter time to translate questions and answers. The physician should periodically pause and ensure that the patient understands the questions that are being asked. Failure to look at the patient while asking questions impairs the establishment of the physician–patient relationship and should be avoided.
You remember from medical school that there was disagreement as to the degree that a medical interpreter should function as a cultural advocate.
Question 29.2.8 Which of the following would be the most effective pre-encounter instructions for your interpreter to facilitate the best possible communication between you and your patient?
A) "Translate word-for-word all that the patient and I say. You may repeat phrases, but do not rephrase anything."
B) "When clarifying, explaining or culturally translating concepts, make sure that you are transparent (i.e., let the both parties know what you are saying and why)."
C) "Be sure to culturally translate whenever you think it is appropriate."
D) "If the patient doesn't seem to understand, go ahead and explain whatever you think that I mean."
Answer 29.2.8 The correct answer is "B." Ideally, an interpreter would do an exact translation. However, many concepts do not translate literally or have very different meanings depending on the context that surrounds them. Good interpreters are often aware when the healthcare provider and the patient do not have the same understanding of an event, concept, or plan. In this case, the translator should be sure to let each party know exactly what has been communicated. This feedback to each party is important so that the interpreter's moral values don't get projected onto the patient and unduly influence decisions made by the patient. Transparency is thus critical.
You remember that low literacy is associated with poor outcomes.
Question 29.2.9 Which of the following is NOT true?
A) Patients with low literacy have a 50% increased risk of hospitalization.
B) Only half of all patients take medications as directed.
C) Low literacy is a stronger predictor of a person's health than race.
D) Low literacy is only an issue among minorities and immigrants.
Answer 29.2.9 The correct answer is "D." Poor health literacy skills are a stronger predictor of health status than a person's race, age, income, socioeconomic status, or employment. This relationship holds across different racial and cultural groups. Unfortunately, up to 90 million people in the United States have low literacy skills and many are ashamed to share this with their physicians. This can lead to "noncompliance" because patients cannot read prescriptions and other instructions. It is not surprising, then, that low-literacy patients have an increased risk of hospitalization. To help combat this problem, the National Patient Safety Foundation (NPSF) launched the "Ask Me 3" program (http://www.npsf.org/?page=askme3). "Ask Me 3" urges doctors to make sure their patients ask and understand the answers to three simple questions: What is my main problem? What do I need to do? Why is it important for me to do this? Other suggestions to improve communication include (1) asking the patient to repeat instructions back to the physician (known as the "teach back"); (2) using basic, nonmedical language when talking to patients; and (3) allowing patients to talk uninterrupted at the beginning of the visit.
Between 10% and 40% of low-income children have no books at home. A quarter of college-educated parents do not read to their young children daily. Reach Out and Read is a program designed to increase reading at home. You can employ this program to help with literacy by using the SAFER mnemonic: Show the book early in the visit, Share the book with the child yourself (modeling the reading for the parents), Ask the parents about reading; Assess the child's development and the parent–child relationship; give Feedback about what you've observed the child do and about parents' attitudes and interactions with the child, Encourage the parents to read daily to the child; Explain about literacy development. Refer to the library and literacy programs, and Record in the chart what you did. Other than giving a book and briefly reading to the child, you need not do all the activities at each visit. If your clinic is not involved in the program, you can get started at www.reachoutandread.org.
Objectives: Did you learn to…
Describe ways in which you inquire about a patient's culturally related health beliefs?
Define culturally responsive care and understand its importance?
List some complications that can occur as a result of language barriers?
Use interpreter services effectively and appropriately?
Describe the state of health literacy in the United States and its impact on population health?