Culturally Competent Care
Harry R Gibbs, M.D.
Chief Diversity Officer, HR Administration
The University of Texas MD Anderson Cancer Center
Read the following content and view the videos below in order.
Introduction: Introduction to Culturally Competent Care (1:40)
by Harry Gibbs, M.D.
Chief Diversity Officer, HR Administration
UT MD Anderson Cancer Center
Cancer disproportionately affects minority communities in the United States:
- African Americans have the highest death rate and shortest survival of any racial and ethnic group in the U.S. for most cancers.
- In 2009, it was reported that African American patients are more likely to distrust both physicians and medical researchers than White patients.
- African Americans’ distrust of medical research has been suggested to be an important reason for their lack of participation in clinical trials.
- This distrust may be attributed both to a cultural memory of victimization and exploitation during clinical experiments, such as those which occurred during the Tuskegee Syphilis Study.
Culture: The integration of patterns of human behavior that includes language, thoughts, communications, behaviors, customs, mores, beliefs, values, and institutions of different racial, ethnic, religious and/or social groups.
Cultural Competence: Acquiring and integrating knowledge with awareness, attitude, and skills about culture and cultural differences that enables Health Care Professionals to provide optimal and expert care to patients from different racial, ethnic, socio-economic, and cultural backgrounds.
Credibility: Physicians must be sensitive not just to others’ personal cultural beliefs, practices and values, but also to their own belief systems. This self-assessment is critical to successfully Building Trust Across Cultures and providing culturally competent care.
Tips To Achieve Cultural Competence
- Practice self-awareness
- Obtain cultural knowledge
- Develop cross cultural communication skills
- Learn techniques to develop dialogue and build trust
- Exhibit cultural humility
- Recognize attitudes
Building Trust – Increasing Awareness Among Minorities
According to the Office of Minority Health:
- African-American women had the highest levels of distrust.
- 15 percent of Hispanic women and 9 percent of Arab women did not trust health care organizations to keep their information private.
- This study shows that mistrust is more systemic than previously suggested.
- The findings in Arab and Latina women point out the flaw in blaming all mistrust on the infamous Tuskegee Study.
NOTE: Although the following videos address African American and mistrust of the healthcare system, here are some tips regarding addressing culture differences across all demographics:
- Sensitivity to cultural issues enhances trust between patients and doctors.
- Initial time investment avoids later misunderstandings and/or bedside ethical conflicts.
- Personalized cancer care incorporates patients’ and families’ culture and draws on community resources.
A patient who distrusts the medical system
This video is about trust, the culture of medicine, and its impact in cross-cultural communication in the provider and patient relationship. As you watch the videos, consider the following question: What is your current stage of cultural competence? At the conclusion of the videos we will explore strategies for overcoming distrust in relationships with patients and families in medicine and research with minorities in general, specifically African-Americans.
John Washington, a patient who was screened a year ago was told by his provider to return due to a concern of blood in his stool, suspicious of a malignancy. Mr. Washington waited too long to return to the clinic, especially due to his distrust of the medical system. He trusted that his neighborhood doctor would take care of him and is angry because his doctor said it might be something simple like hemorrhoids.
The physician notifies the patient regarding his test results. The patient is annoyed and defensive. As an African American, he distrusts the healthcare system because of the Tuskegee Experiment and its link to a close family member. Some of you may have heard about the Tuskegee syphilis experiment. In 1932, nearly 400 poor black men with syphilis from Macon County, Alabama, were enrolled in an experimental study. They were never told they had syphilis, nor were they ever treated for it. According to the Centers for Disease Control, the men were told they were being treated for "bad blood," a local term used to describe several illnesses, including syphilis, anemia and fatigue. For participating in the study, the men were given free medical exams, free meals and free burial insurance. At the start of the study, there was no proven treatment for syphilis. But even after penicillin became a standard cure for the disease in 1947, the medicine was withheld from the men. The Tuskegee scientists wanted to continue to study how the disease spreads and kills. The experiment lasted four decades, until public health workers leaked the story to the media. By then, dozens of the men had died, and many wives and children had been infected.
The patient’s reaction makes the disclosure of the news more complicated because he is upset that his PSA was okay and he feels okay. Dealing with anger and distrust are bound to be part of this discussion, therefore techniques to deal with emotion are necessary. Concerns about mistrust need to be taken seriously and explored since they may also lead to non-compliance in treatment. A statement of fact in response to a patient’s emotion ignores the main issue which is the patient’s anger and mistrust of the medical system.
What to Watch For:
The first scenes show an ineffective approach to building trust with the patient. Notice the doctor avoids acknowledging and validating the patient’s concerns and scolds him. Some of the doctor’s responses heighten the patient’s distress. He then proceeds to pass the patient off to his nurse without providing the nurse with any background on the patient on why he didn’t come in sooner.
What Could Help this Doctor-Patient Relationship:
- Addressing the patient’s fear of the healthcare system and cultural basis of concern
- Seeing the patient’s concerns through the patient’s lens rather than the provider’s lens
- Including the medical team in the patient’s medical care decision-making and spending the time to explain the proposed treatment
- Explaining to the patient the treatment plan along with receiving input from the patient and acknowledging the patient’s input
Video #1: A patient who distrusts the medical system (3:01)
A Patient Who Distrusts the Medical System: How to enhance communication
You have just observed how a lack of awareness of cultural beliefs can lead to miscommunication and unfavorable patient care outcomes. In these next scenes you will observe how the same interaction could have been done better.
Distrust is a major communication issue for minorities. Acknowledging and validating the patient’s concerns is a technique that diffuses these strong emotions. Confirming the patient’s understanding of his medical condition is critical. There are times when a patient does not want to receive information so a good rule is to ask the patient if he wants to hear it. Communicating with the nurse and other members of the medical team is extremely important to ensure that others are aware of the concerns of the patient.
What to Watch for:
You will see the doctor acknowledge that the patient is upset and validate his concerns. He explains to the patient that the medical profession is bound by laws and ethics. The doctor then listens to the patient and acknowledges that he has had a lot to cope with and allows the patient to tell him more. Asking the patient (before you tell) if he can discuss the possibility of a clinical trial is a strategy used to bridge the gap between the patient’s attitude toward the medical profession and his treatment options. Note how the doctor informs the nurse of the situation.
Key Points to watch for:
- Use of open ended questions when talking to patients
- Allowing the patient the opportunity to express concerns
- Acknowledging and validating the patient’s concerns
- Confirming the patient’s true understanding of the information presented
- Involving and communicating patient’s fears and concerns to the medical team
Hostility towards enrollment in a clinical trial
The nurse is attempting to explain and enroll the patient in a clinical trial. The words “clinical trial” evokes memories of his spouse’s family member who participated in the Tuskegee study, hence the reason for his distrust in the healthcare system.
The patient continues to react with fear and distrust because of his knowledge of the Tuskegee study. Failure to address and acknowledge the patient’s emotions and continuing to dismiss his concerns is a major communication issue especially when the patient continues to refer to his past experience with a relative who was involved in the Tuskegee Study.
What to Watch For:
This video demonstrates the wrong approach. The nurse and doctor both have difficulty understanding the patient’s concerns and try to reassure the patient with defensive statements that are not meaningful to the patient when he is in distress.
Video #3: Hostility toward enrollment in a clinical Trial (2:09)
Hostility Towards Enrollment in a Clinical Trial: A Way to Enhance Communication
In the previous scenes, you have just observed how the doctor failed to communicate the patient’s concerns to the nurse and this made the nurse’s job very difficult. In this next scene you will observe how differently the conversation goes because the nurse now has some insight into why the patient is distrustful and fearful of participating in the clinical trial. The doctor also does a much better job addressing the patients concerns because he was able to understand them.
Clinicians are often faced with emotional responses from patients. Moving past the emotion involves active listening, acknowledging and validating patient concerns, and responding with empathy. This allows you to align with the patient. Then, asking permission to give the information, explaining what is involved, and stating that you will continue to be available to the patient will reassure the patient and allow you to work together as you move forward.
What to Watch for:
You will see the doctor acknowledge that the patient is upset and validate his concerns. He explains to the patient that the medical profession is bound by laws and ethics. The doctor then listens to the patient and acknowledges that he has had a lot to cope with and allows the patient to tell him more. Asking the patient (before you tell) if he can discuss the possibility of a clinical trial is a strategy to use to bridge the gap between the patient’s attitude toward the medical profession and his treatment options. Acknowledging that the information is confusing and that he and the nurse will be available to answer questions puts the patient at ease. The doctor lets the patient know he will receive the best care even if he chooses not to participate in the trial. The nurse’s approach in this scenario is much more inviting to the patient.