Cultural Competence in
Medical Practice
Leah Karliner, MD MAS
UCSF
August 2006
Culture
1 a : the integrated pattern of human behavior
that includes thought, speech, action, and
artifacts and depends upon the human
capacity for learning and transmitting
knowledge to succeeding generations
b : the customary beliefs, social forms, and
material traits of a racial, religious, or social
group
Merriam-Webster’s Medical Dictionary
Cross-cultural
“Dealing with or offering comparison between two
or more different cultures or cultural areas”
Merriam-Webster’s Medical Dictionary
►All doctor-patient encounters are cross-cultural
►All doctor-patient encounters are human
encounters
Cultural Competence
Synonyms
Cultural humility
Cultural awareness
Culturally responsive care
JCAHO: “The delivery of health care services in
a manner that is respectful and appropriate
to an individual's language and culture”
CLAS Standards
National Standards for Culturally and
Linguistically Appropriate Services (CLAS)
in Health Care
Issued by the U.S. Department of Health and Human Services’ Office of
Minority Health (2001)
3 types of standards:
1.
2.
3.
Culturally competent care
Language access services
Organizational supports for cultural competence
How are we doing?
Disparities in health and healthcare exist for U.S. ethnic
minorities in almost every area that has been studied:
 Access to care
 Asthma care
 Cancer survival
 Cardiac care
 Diabetes
 Pain management
 Preventive care

Unequal Treatment: Confronting Racial and Ethnic Disparities in
Health Care; 2002. Institute of Medicine.
http://www.iom.edu/?id=16740
Multiple Factors
 Social factors: poverty, education/literacy,
housing, diet
 Health insurance systems
 Healthcare systems (organizational cultural
competence)
 Doctor-patient relationship / communication
Doctor-Patient Communication
 The Cultural Formulation, a useful tool in
clinical practice
 Working with interpreters in clinical practice
The Cultural Formulation
(adapted from DSM-IV, Appendix I: “Outline for Cultural Formulation and Glossary of CultureBound Syndromes”)
I.
Cultural Identity
II.
Explanatory Models of Illness
III.
Cultural Stressors and Supports
IV.
Cultural elements of the Relationship with
clinician(s)
V.
Clinician Self Assessment
When to Use the Cultural Formulation
 Clinician suspects that difficulties in
communication, evaluation or treatment may be
based in cultural differences.
For example, in a cross-cultural encounter,
clinician perplexed by:



Medication non-adherence
Lack of follow-up for diagnostic tests
Refusal to consent to procedures
Cultural Formulation
I.
Cultural Identity
Where are you from?
What language would you like to use during our
visits?
Do you ever have difficulty understanding what I
say in English?
Do you ever have difficulty expressing your
concerns to me in English?
I.
I: Cultural Identity
Individual versus Collective
 The family (video: Annie Hall)
 Confidentiality: unit patient? family?
I.
I: Cultural Identity:
Acculturation
 Degree to which an individual conforms to
majority cultural values and norms
 Helps avoid stereotyping
I.
Cultural Identity
Communication style
 Direct vs. indirect
 Verbal vs. non-verbal emphasis
(taking the history)
video: The Joy Luck Club
Outline: Cultural Formulation
II. Explanatory Models of Illness
What do you think caused or triggered this
problem?
How does your culture (of origin) explain these
symptoms?
II. Explanatory Models of Illness

Idioms of distress;
Somatization: expression of
individual distress in the
metaphor of the body

Culture-bound syndromes
Outline: Cultural Formulation
III. Cultural Stressors and Supports
Who lives at home with you?
When someone is sick in your family, to whom do
you turn for help?
How much do your family or friends know about
this illness?
III. Cultural Stressors and
Supports

Family support/stress

Immigration history (and acculturation)
IV. Cultural elements of the
Relationship with clinician(s)
Outline: Cultural Formulation
IV. Cultural elements of the
Relationship with clinician(s)
What kinds of experiences have you had in
working with doctors? What was helpful?
What was not?
IV. Cultural elements of the
Relationship with clinician(s)

Relationship to Authority, Conflict avoidance

History of medical treatment: “treatment
pathway”

Experiences of racism/disparities in care

Informed consent (not abdicating
responsibility for outcome)
Cultural Formulation Outline
V. Clinician Self Assessment
For the clinician to ask of him/herself:
Do I have any preconceived ideas about this patient’s
race/ethnicity?
What are my prior experiences with patients from this
culture?
How are these affecting my communication with this
patient? The care I give him/her?
Know your own culture
Putting It All Together
Putting It All Together
 Systematic review of five main topic areas
 Can spend single visit on review, or cover
areas over several visits;
 Use worksheet as you go
Cultural Formulation Worksheet
Patient Name:___________________ Date:_________
CULTURAL FORMULATION SECTION
IDENTITY
Country/Region of Origin
Where are you from?
English proficiency / primary
language
How hard is it to speak in English?
Do you ever have difficulty understanding what I
say?
Level of acculturation
(fully/somewhat/little/none)
EXPLANATION
Symptom/diagnosis
What do you think caused or triggered this problem?
How does your culture (of origin) explain these
symptoms?
STRESSORS &
SUPPORTS
Who lives at home with you?
When someone is sick in your family, who do you
ask for help?
How much do your family or friends know about
this illness?
RELATIONSHIP
What kinds of experiences have you had in working
with doctors? With other healers?
What was helpful? What was not?
Prior Experiences with
Doctors or Healers
Clinician SelfAssessment
What are my preconceived ideas about this patient’s
race/ethnicity or country of origin?
What are my prior experiences with patients from
this culture?
ASSESSMENT
(what I already know)
PLAN
(what I would like to
know/what I learn)
Limited English Proficiency
 Unable to speak, read, write or understand
English at a level to interact effectively with
health care providers
 Different from primary language spoken at home
 U.S. 2000 Census:


47 million non-English primary language at home
Half report speaking English less than very well
Language Barriers & Health Disparities
 Less access to usual source of care
 Fewer physician visits & preventive services
 Poorer adherence to treatment & follow-up for chronic





illnesses (e.g. asthma)
Lower comprehension of dx & treatment after ED visit
Less satisfaction with care
Increased medication complications
Increased admissions from the ED
Increased length of stay in hospital
Language Barriers in Healthcare Settings: An Annotated Bibliography of the
Research Literature; 2003. The California Endowment.
http://www.calendow.org/reference/publications/cultural_competence.stm
Language Concordance
 Patient and physician speak the same language
 Associated with increased:




Patient satisfaction
Patient-reported health status
Adherence with medication
Adherence with follow-up
Language Concordance
Why we cannot rely on language concordance alone
 >100 languages spoken commonly in U.S.
 At UCSF in our survey of primary care clinicians, 20
different languages reported
 Patients maneuver through entire healthcare system






Registration
Lab
Radiology
ED
Hospitalization
Cashier
What does the law say?
 Civil Rights Act of 1964 – Title VI
 If providers receive Federal financial assistance, and
 If language is a ‘threshold’ language (>=5% of patient
population), then
 Must offer linguistic assistance
What actually happens?
 Bilingual clinicians
 Bilingual staff – clinical and non-clinical
 Family & friends
 Telephone – e.g. Language Line
 Video conferencing professional interpreters
 In-person professional interpreters
Definitions
 Interpreter
 3rd party present in clinical interaction whose role is to
facilitate oral language interpretation
 Ad Hoc Interpreter
 Untrained person called upon to interpret
 e.g. family member/friend, bilingual staff pulled away
from other duties, self-declared bilingual who
volunteers (other patients)
 Professional Interpreter
 Person paid & provided by hospital or health system to
interpret
 Training not standardized
Do Interpreters Make a Difference?
 Systematic review of literature 1966-9/2005
 28 published papers comparing at least 2
language groups & reported data about
medical interpreters in following areas:




Communication (errors and comprehension)
Utilization
Clinical outcomes
Satisfaction
 21 assessed professional interpreters
separately from ad hoc interpreters
Do Interpreters Make a Difference?
 In all four areas

Use of professional interpreters was associated
with improved clinical care approaching or equal to
that of English-speakers

This improvement was more than with use of ad
hoc interpreter
 Karliner, et al. In press. Health Services Research
How to work with a professional
interpreter
 Allow extra time for an interpreted visit;
 Select an interpreter keeping gender and
confidentiality in mind;
 The interpreter is part of your therapeutic team:
hold a brief pre-meeting with the interpreter:


share relevant information about your patient and
this visit;
Ask the interpreter to cover everything that is said,
conveying the tone and meaning of the message,
rather than paraphrasing or rephrasing
How to work with a professional
interpreter
 Introduce yourself directly to the patient;
 Position yourself in a therapeutic triad
Interpreter
Clinician
Patient
 Introduce the interpreter to the patient;
 Address the patient directly;
 Watch the patient during the interpretation
 Body language
 Behavioral clues
 Invite correction: “this is what I understand so far…let me
know if I missed something...”
How to work with a professional
interpreter
 Speak in short units
 Ask short questions
 Explain medical terms in simple language
 Ask the patient to repeat back any
instructions
How to work with an untrained/ad hoc
interpreter:
 Untrained staff

Language abilities may not be equal in both
English and the 2nd language

May not know medical terms in either English or
the 2nd language

Ask if comfortable interpreting with this particular
patient (gender / confidentiality)
How to work with an untrained/ad hoc
interpreter

Be explicit before they come into the room about
what you need / give them guidance




Word for word interpretation (preserving tone &
meaning)
Avoid answering for the patient
Position them in triad (show them where)
Give permission to ask you to slow down or
rephrase something in easier terms
How to work with an untrained/ad hoc
interpreter
 Family and friends

Avoid using minors!!!



May be uncomfortable interpreting
personal/intimate information
May try to ‘protect’ parent from information
Alters relationship between parent and child
How to work with an untrained/ad hoc
interpreter

Same techniques as with staff, but need to
emphasize certain points even more:




Ask them to avoid answering for the patient;
Give them permission to ask you to slow down
or rephrase something in easier terms
Speak directly to the patient
Keep your spoken units and questions short
Steps along the road to cultural
competence
 Like any other skills this takes practice
 Use the cultural formulation when you find
yourself at an impasse with a patient from a
culture different from your own
 Be open to what you might find out –
communication is two-way and so is miscommunication
Steps along the road to cultural
competence
 When you have a language barrier with a
patient, use a professional/trained interpreter
if possible
 If you must use an ad hoc interpreter, give
them guidance
 Avoid using minors to interpret
Selected Online Resources
 CLAS standards:
http://www.omhrc.gov/assets/pdf/checked/Executive%20Summary.pdf
 JCAHO:
http://www.jointcommission.org/HLC/Resources_Standards.htm
 Unequal Treatment:
http://www.iom.edu/?id=16740
 Lewin Report:
http://www.hrsa.gov/culturalcompetence/measures/default.htm
 The Cultural Formulation
http://www.med.uiuc.edu/m34/xcultopps/PDF/clinical%20cultural%20as
sessment.pdf
Selected Online Resources
 U.S. DHHS on-line/DVD CME:
https://cccm.thinkculturalhealth.org/
 The Network for Multicultural Health Resource Page:
http://futurehealth.ucsf.edu/TheNetwork/Default.aspx?tabid=387
 Diversity Rx: Models and Practices (cultural and linguistic
access):
http://www.diversityrx.org/HTML/models.htm
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Cultural Competence: What is it? How do we achieve it?