Patient-Centered Care:
Cultural Competence
Stanford Faculty Development Center
Professionalism in
Contemporary Practice
Stanford Faculty Development Center 2006
Professionalism in Contemporary Practice
Defining and
Teaching
Professionalis
m
Patient
Safety
Reflective
Practice
Quality
Improvement
Cultural
Competence
Stanford Faculty Development Center 2006
Shared
Decision Making
EvidenceBased
Care
Working Effectively
In Teams
Goals for the module
At the end of this module, you will be able to:
• Define cultural competence
• Describe how communication is related to health
disparities
• Assess personal cultural attitudes
• Apply tools to improve cross-cultural communication
• Reflect on specific ways you can use what you’ve
learned in this module to improve
– your teaching
– your clinical practice
– your institution
Stanford Faculty Development Center 2006
Module overview
In this module, we will cover…
• Definitions and our own perceptions of culture
• Evidence for health disparities in the United States
and potential explanations
• Exploring the patient’s perspective
• Working effectively with interpreters
Stanford Faculty Development Center 2006
Dimensions of cultural
competence
• Cultural Awareness
– Cultural sensitivity, cultural biases
• Cultural Knowledge
– Cultural world views, theoretical and conceptual framework
• Cultural Skills
– Cultural assessment tools
• Cultural Encounter
– Cultural exposure, cultural practice
Stanford Faculty Development Center 2006
Campinha-Bacote, 2002
A few definitions
• What is race?
– Subpopulation of human beings with observed or
imagined physical characteristics associated with a
geographical territory of origin (Stevens, 2003)
• What is ethnicity?
– An intergenerational group that exists by reference to
a past, present, or future political society that is often
in a location other than where putative members of
the group currently reside (Stevens, 2003)
• What is culture?
– The individual’s character and belief system, as
influenced by race, ethnicity, religion, gender, social
status, and environment. (Rosen, 2004)
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How do you perceive and respond to
people who are different from you?
Stanford Faculty Development Center 2006
Assessing cultural attitudes:
Health Beliefs Attitude Survey
• 15-item tool for evaluation:
– attitudes on patient health beliefs
– other cultural competence components
• Used to assess effect of cultural competence
curriculum on medical students’ attitudes
towards their patients in following domains
critical to quality health care: opinion, belief,
context, quality
Stanford Faculty Development Center 2006
Crosson, 2004
How do we compare to our colleagues?
• 1st year medical students
– HBAS pre- & post-intervention showed improvement in:
• Importance of assessing patients’ perspectives and opinions
(p=0.012)
• Importance of determining patients’ beliefs for history taking and
treatment (p<0.0001)
(Crosson, 2004)
• Physicians
– National Survey of Physicians was based on a nationally representative
random sample of 2,608 physicians
– Majority of physicians say the healthcare system “rarely” or “never”
treats people unfairly based on racial or ethnic background
• 55% “rarely”
• 14% “never”
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(Kaiser, 2002)
What do patients perceive?
Patient-physician communication
• National Healthcare Disparities Report (2004):
AA
WA
“Provider did not listen”
23%
17%
“Less than desired involvement”
27%
22%
“Race affects my health care”
17%
3%
Stanford Faculty Development Center 2006
National Healthcare Services AHRQ, 2005
Patient survey
Examples from the NHDR include:
• Many racial/ethnic groups as well as poor and
less educated patients report:
– poor communication with their physicians
– more problems with some aspects of the patientprovider relationships
• Asians, Hispanics, and those of lower
socioeconomic status report greater difficulty
accessing healthcare information, including
information on prescription drugs.
Stanford Faculty Development Center 2006
National Healthcare Services AHRQ, 2004
Module overview
In this module, we will cover…
• Definitions and our own perceptions of culture
• Evidence for health disparities in the United States
and potential explanations
• Exploring the patient’s perspective
• Working effectively with interpreters
Stanford Faculty Development Center 2006
Evidence of health disparities
How extensive are healthcare
disparities?
Why do health disparities exist?
What is the link between physicianpatient communication and health
disparities?
Stanford Faculty Development Center 2006
IOM Report:
Unequal Treatment
• Disparities exist over a wide range of diseases:
–
–
–
–
Cardiovascular disease (e.g., thrombolytics in AMI)
Asthma (e.g., hospitalization and treatment types)
Cancer (e.g., breast cancer screening)
Psychiatric disorders (e.g., use of restraints)
• Research shows disparities are not solely due to:
–
–
–
–
Clinical factors
Access
Patient preferences and refusal rates
Socio-economic status
Stanford Faculty Development Center 2006
IOM, 2003
Why do health disparities exist?
Potential explanations
-
Actual clinical differences (e.g., disease
presentation, pharmaco-genomics)
-
Access to healthcare (e.g., insurance and ability to
pay)
-
Patient-physician interaction
-
Differences in patients’ preferences for healthcare
Differences in patient-physician communication
Discrimination, bias, stereotyping
Stanford Faculty Development Center 2006
Adapted from Oddone, 2002
Evidence of provider bias
• Physician survey to determine provider bias in racial
and SES stereotypes
• Patient characteristics
–
–
–
–
Personality
Affect
Friendliness
Intelligence
• Blacks half as likely as whites to be rated as:
• “no risk” for substance abuse (OR=0.58)
• “desiring an active lifestyle” (OR=0.47)
• “very intelligent” (OR=0.51)
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Van Ryn, 2000
Evidence of provider bias
• Actors portray patients with same clinical
characteristics but different gender and
race
• Physicians viewed videotapes; made
recommendations for managing chest pain
Stanford Faculty Development Center 2006
Schulman, 1999
Is there bias in medical practice?
Outcomes
The study examined:
• physician recommendations for referrals
• assessment of personality traits
• predictions of behavior
Multivariate analysis of predictors, adjusted for physician
assessment of probability and severity of symptoms
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Schulman, 1999
Patients as portrayed by actors in the
video component of the survey
A
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B
Schulman, 1999
Evidence of provider bias
• Catheterization referrals differ significantly
– Black patients less likely to be referred than white
patients
• Odds ratio 0.6, p-value 0.02
– Women less likely to be referred than men
• Odds ratio 0.6, p-value 0.02
– In a combined analysis, black women fared the worst as
compared to white males
• Odds ratio 0.4, p-value 0.004
Schulman, 1999
Stanford Faculty Development Center 2006
Evidence of provider bias
Perception of personal characteristics:
• Physicians more likely to attribute negative personality
traits to black patients and women
Individual assessment of predicted behavior:
• Black women more likely to over-report symptoms
• White men more likely to sue
• White women more likely to comply with treatment
Stanford Faculty Development Center 2006
Schulman, 1999
Module overview
In this module, we will cover…
• Definitions and our own perceptions of culture
• Evidence for health disparities in the United States
and potential explanations
• Exploring the patient’s perspective
• Working effectively with interpreters
Stanford Faculty Development Center 2006
“Cultural competence is not a panacea that will
single-handedly improve health outcomes and
eliminate disparities, but a necessary set of
skills for physicians who wish to deliver highquality care to all patients.”
Betancourt, 2004
Stanford Faculty Development Center 2006
Removing cultural blinders:
Systematic review of provider-based interventions
Enhancing cultural competence led to…
• Improvement in patient outcomes
– Increased patient ratings of quality of care
– Increased patient medication adherence
• Reduction in healthcare disparities
– Improved preventative services
• Breast cancer screening
• Cardiovascular disease prevention
• Diabetes education
Stanford Faculty Development Center 2006
Beach, 2005
Critical aspects of contemporary practice:
Exploring the patient’s perspective
Healthcare context
Physician
Patient
Patient’s
perspective
Illness/Wellness
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SFDC, 2002
Tools for exploring the patient’s perspective:
Kleinman Explanatory Model
• Purpose
– Provides valuable insight into the patient’s
perspective and concerns about their illness
– Encourages a more trustworthy environment
– Patient feels acknowledged and respected,
which enhances the physician-patient interaction
Stanford Faculty Development Center 2006
Kleinman, 1981
Kleinman Explanatory Model
What do you call the problem?
What do you think has caused the problem?
Why do you think it started when it did?
What do you think your sickness does? How does it work?
How severe is the sickness? Will it have a short or long course?
What are the chief problems the sickness has caused?
What do you fear most about the sickness?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from treatment?
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Role-play
How does the patient understand
the current illness
or episode of care?
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Debrief
What elements of the Kleinman
Explanatory model were present?
Were these elements effective?
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Brainstorm:
What are barriers to communication?
How can you overcome these barriers?
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Additional challenges in
cross-cultural communication
• Cognitive constraints
– Ways that people think and process new
information
• Behavior constraints
– Rules about behavior which affect how verbal
and nonverbal communication are interpreted
• Emotional constraints
– Type and amount of emotion that people learn
to display
Stanford Faculty Development Center 2006
Ting-toomey, 1999
Module overview
In this module, we will cover…
• Definitions and our own perceptions of culture
• Evidence for health disparities in the United States
and potential explanations
• Exploring the patient’s perspective
• Working effectively with interpreters
Stanford Faculty Development Center 2006
Working with an interpreter
What are some challenges to
working with an interpreter?
Stanford Faculty Development Center 2006
Working with an interpreter
What are some solutions to
working with an interpreter?
Stanford Faculty Development Center 2006
Working with an interpreter
Recommendations
• Physicians should focus on sources of misunderstanding
and difficulties inherent in medical translation
• Provide basic background knowledge of patients’
countries of origin
• Adapt to patients’ communication styles
• Communicate with patient and do not focus on the
interpreter
Stanford Faculty Development Center 2006
Hudelson, 2005
What were our goals and
have we reached them?
Are you able to do the following?
• Define cultural competence
• Describe how communication is related to health
disparities
• Assess personal cultural attitudes
• Apply tools to improve cross-cultural communication
• Reflect on specific ways you can use what you’ve
learned in this module to improve
– your teaching
– your clinical practice
– your institution
Stanford Faculty Development Center 2006
Reflect on specific ways you can use what
you’ve learned in this module to improve
(1) your teaching
(2) your clinical practice
(3) your institution
______________________________
______________________________
______________________________
______________________________
Stanford Faculty Development Center 2006
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