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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) Stanford Faculty Development Center 2006 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” Stanford Faculty Development Center 2006 (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) Stanford Faculty Development Center 2006 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 Stanford Faculty Development Center 2006 Schulman, 1999 Patients as portrayed by actors in the video component of the survey A Stanford Faculty Development Center 2006 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 Stanford Faculty Development Center 2006 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? Stanford Faculty Development Center 2006 Role-play How does the patient understand the current illness or episode of care? Stanford Faculty Development Center 2006 Debrief What elements of the Kleinman Explanatory model were present? Were these elements effective? Stanford Faculty Development Center 2006 Brainstorm: What are barriers to communication? How can you overcome these barriers? Stanford Faculty Development Center 2006 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