Cultural Competency in Caring for Diverse Populations Fern R. Hauck, MD, MS Department of Family Medicine University of Virginia Health System POM-1, September 21, 2009 Cultural Beliefs and Health Care Cultural beliefs influence how people: • Understand normal bodily functions • React to signs and symptoms • Identify abnormal functions • Classify diseases • Speculate about and determine etiologies • Determine their prognoses • Consult others • Choose healers and treatments • Expect healers to behave • Evaluate results • Make medical decisions Different understandings about these concepts can contribute to disagreement between healthcare professionals and their patients! The Case of MH* • MH was a healthy 70-year-old Hmong, widowed woman with an asymptomatic goiter who suddenly had trouble breathing. • Step-sons brought her to the ER, physicians diagnosed thyroid cyst had ruptured and compressed her trachea. • They intubated her with an endotracheal (ET) tube after quickly getting permission from family without presence of a trained interpreter. • Days 2-3: Surgical team recommended operation to remove the blood, remove the thyroid and place a temporary tracheostomy until the swelling decreased. • Family: refused surgery, preferring to wait and reevaluate *Culhane-Pera KA, Vawter DE. J Clin Ethics 1998;9(2):179-90. The Case of MH (Cont’d) • Day 4: Surgeons asked for assistance from family physician who understands the culture and speaks Hmong, a Hmong patient advocate, and a trained interpreter. • Family continued to refuse surgery. • Patient pleaded to have ET tube removed because of discomfort and being restrained, felt she could breathe without it. • Day 5: Patient and family requested extubation; family felt swelling had decreased and asked for trial period of extubation. Family said it would be ok to re-intubate if needed, patient did not. Would you extubate MH? 1. Yes 2. No 3. Unsure, need more information What would you like to know about the Hmong to help you make a decision? What would you like to know about the Hmong? • Who are the Hmong? Social structure? Religious beliefs? • Beliefs about illness/thyroid disease? Preferred treatments? • Reactions to surgery? Fears? Concerns? • How do people make medical decisions/role of family? Hmong Culture • Who are the Hmong? Social structure? Religious beliefs? – Began coming to U.S. 30 years ago from Laos after Vietnam War—they fought on side of U.S. About 187,000 reside in U.S., mostly in CA, WI, MN. – Previously had been subsistence farmers; exposure to modern U.S. culture has caused in some Hmong debilitating chronic illnesses. – Patriarchal society that values family-based decision making. – Animist religion: spirit world and everyday world live side by side. Hmong Culture • Beliefs about illness? Thyroid disease? Preferred treatments? – Illness results from: • Natural causes (imbalance between yin and yang, buildup of air or wind in body, change in weather, germs) • Social causes (fights between people, curses) • Spiritual causes (loss of soul due to fright, fate) • Supernatural causes (spirits) – Healing and healers: • Coining, herbs, massage • Soul callers and chanting • Shamans who communicate directly with wild and tame spirits – Goiter: caused by build-up of wind in the neck, which if symptomatic could be relieved by coining and poking with a needle to release the wind and decrease the pressure (MH’s family denied that they had done this) Hmong Culture • Reactions to surgery? Fears? Concerns? – Fear of loss of soul, as well as morbidity and mortality – Unable to fulfill social roles – Suspicious of doctor’s motivations – Adverse effects in next life: mutilation, metal in body – Usually not accepted unless tests show that surgery is required for a cure Hmong Culture • How do people make medical decisions/role of family? – Family is responsible for sick people and consequences of treatment – Sons need to be good sons – Frequently, clan leader, male family leader, or other patriarchal figure makes decisions Perspectives of All Parties • Surgeons: – Life-saving treatment, would die without ET tube or tracheostomy – Confused by different approaches of patient and sons – Couldn’t guarantee re-insertion of ET tube – They have the superior biomedical view Perspectives of All Parties Patient: – ET tube miserable, causing suffering – Swelling had decreased, could breathe on own – Up to her to decide, not doctors – Multiple explanations and alternatives available to explain the problem – Considered her needs in this life, next life, and afterlife Perspectives of All Parties • Family: – Condition had improved (they were examining her neck often) – Remove ET tube, but re-insert if needed – Avoid surgery and tracheostomy – They and patient have right to decide – Family responsible for consequences – Underlying spiritual etiology had been taken care of (divination ritual determined that dead father was angry with sons for being disrespectful of their stepmother. Sons made verbal amends.) – Distrust of surgeons – Need to be good sons Now, what would you do regarding the patient’s and family’s request to extubate? 1. Would not extubate. 2. Would extubate. 3. Would transfer to a different physician who would extubate her. 4. Extubate, but would reintubate if she has trouble breathing without the ET tube. How the Story Ends • Ethics Committee (Day 6) and Hospital lawyer (Day 7) consulted: – Patient and family have right to refuse therapy as they are competent and understand consequences – Surgeons are not required to act against their moral values – Family is responsible for decisions and subsequent outcomes • Care transferred to another surgeon who removed the ET tube • Patient breathed w/ minimal difficulty and was discharged to home • Patient found to be doing well at follow-up visit No matter which cultures are involved, these areas cause the most difficulty when patient and provider are from different cultures: • Meaning & importance of symptoms • Etiologic understandings • Perceptions of appropriate treatments • Psychosocial contexts for illness • Autonomy, self-efficacy • Prevention orientation and activities • Family involvement & perspectives • Pain expression & management • End of life decisionmaking • Informed consent • Expectations of health professionals • Willingness to participate in groups & classes • Diet and food Source: Kaiser Permanente, 2003. Cultural Issues in the Clinical Setting. The LEARN Model for Effective CrossCultural Communication and Negotiation* • Listen with sympathy and understanding of the patient’s perception of the problem – Listen to the patient’s and family’s concepts of illness, reactions to biomedical approaches, and desires for therapy • Explain your perceptions of the problem – Explain your biomedical assessment, using drawings and other methods that can facilitate understanding *Berlin EA, Fowkes WC. Western J Med 1983; 139:934-8. The LEARN Model for Effective CrossCultural Communication and Negotiation* • Acknowledge and discuss the differences and similarities – Acknowledge differences and similarities between Hmong and biomedical perspectives; emphasize common ground • Recommend treatment and listen to their responses • Negotiate treatment and all areas of care, accommodating the patient’s and family’s beliefs and practices Linguistic Competency • Minority populations currently comprise ~30% of the U.S. population • By 2030, estimated to reach at least 40% • 45 million people in the U.S. speak a language other than English at home • Spanish is the most common language spoken by limited English proficient (LEP) individuals • Therefore, medical interpreting has become a priority for health care in the U.S. Linguistic Competency Legislation • August 2000: Department of Health and Human Services Office of Civil Rights issued “policy guidance on the prohibition against national origin discrimination as it affects persons with limited English proficiency.” – Recommended that entities develop procedures for identifying language needs of patients, provide interpreters, and establish and distribute policies regarding interpreter services Linguistic Competency Legislation • December 2000: Office of Minority Health published Standards on Culturally and Linguistically Appropriate Services (CLAS): – 14 standards directed primarily at health care organizations, but individual providers encouraged to use. – 4 are currently mandated for recipients of federal funds: 1. 2. 3. 4. Offer and provide language assistance services at no cost to LEP patients during all hours of operation Provide patients in their own language notices of their right to receive language assistance services Assure competence of language assistance; family/friends should not be used (unless requested by patient); children should never be used Provide patient-related materials and post signs in commonly encountered languages of that service area - Small practices are not required to provide the same level of language services as bigger offices or hospitals - Certain amount of flexibility permitted Working with Interpreters • UVA has Language Office • When appointments made, system automatically sends request to Language Office • Language Office schedules internal interpreters (Spanish) and requests outside interpreters for other needed languages (included ASL) • Telephone interpreters available 24/7 as backup via CyraCom service (“blue phones”) and you can access also via any phone Working with CyraCom Interpreters Other Resources • Health Sciences Library Website, click on Culture and Communication in Health • Numerous books and articles about specific cultures and practices • Numerous internet resources • NY Times Sept. 20, 2009: A Doctor For Disease, A Shaman For the Soul.