The Workplace: Bridging the Culture Gap

There you are, high in the Himalayas, trekking through the ancient temples of Bhutan, when a nagging pain in your lower abdomen that popped up a few days earlier suddenly becomes acute. A trip to the local hospital does little to reassure you. You can’t communicate with the physicians trying to treat you. You’re sick, you’re scared, and you’re more than a little skeptical of the remedies your caretakers may prescribe.

Welcome to the world of some 18 million American immigrants with poor English proficiency who experience their own brand of culture shock each time they require medical attention. “When you walk into a physician’s office, if you can’t speak to anyone there, it’s daunting,” says Alex Green, a physician at Massachusetts General Hospital and a senior faculty member with the Disparities Solutions Center. “All you need is one person who speaks your language to make you feel more comfortable - someone you can talk with who understands your background.”

Indeed, culturally competent patient care - and a healthcare work force that reflects the diversity of the population it serves - is more important than ever as the number of foreign-born residents in the United States continues to expand. The Department of Health and Human Services (HHS) estimates that by 2050 no racial or ethnic group in this country will comprise a majority. “The need for cultural competency has reached a tipping point, and it will continue to grow in importance as the population becomes more diverse,” says Robert Like, director of the Center for Healthy Families and Cultural Diversity at the Robert Wood Johnson Medical School in New Jersey. “As a physician, my own belief is that every encounter is a cross-cultural experience.”

Of course, one’s “culture” encompasses much more than race or ethnicity. It’s an integrated pattern of human behavior stemming from where one is born that includes language, emotional responses, methods of communication, customs, beliefs, religion, and values. Each of these elements can influence an individual’s perception of and approach toward health and healing. Both patient and physician bring their respective cultural assumptions about healthcare into the exam room - the place where effective communication is essential to the restoration of health.

Developing a system whereby physicians can work productively with staff members, patients, and fellow providers from backgrounds that may be far different from their own is no small challenge. But learning to adapt to the culturally prescribed perceptions of different people also creates an opportunity, says David Hunt, president and chief executive of Critical Measures in Minneapolis, a healthcare consulting group specializing in cultural competency.

“When we talk about cross-cultural medicine, we’re not talking about a social program,” says Hunt. “We’re talking about good medicine.” Patients who are treated with respect, he says, are more likely to come back, follow their physicians’ advice, and refer friends and family to their physicians. That in turn helps doctors provide better quality care while also building their businesses. Hunt says that such respect for patient differences is not optional: “Practices need to become racially and linguistically competent in the future, or they won’t have a practice at all.”

Building an integrated office

By all accounts, the first step toward offering improved cross-cultural care is to create an office environment that makes all patients feel welcome. That means hiring employees who reflect local demographics. “Physicians, nurses, and staff from different backgrounds can help make that bridge between patients and the provider,” says Green, adding that ongoing research associates racial and ethnic diversity in the healthcare work force with improved patient outcomes for minorities. Patients who see their culture reflected in the staff and physicians who treat them, explains Green, are more likely to seek treatment to begin with - and share relevant information during patient interviews.

Beyond putting patients at ease, employees from different cultures bring diverse language and communication skills as well as unique socioeconomic perspectives to the office. Such diversity can help physicians develop better systems of care tailored to their entire patient base. “A diverse staff that understands the various populations being served can actively participate in quality improvement teams to help develop services that are tailored to the needs of individual patients, families, and communities,” says Like.

But cultivating a mixed work force can be a challenge all its own. For starters, a shortage of minorities trained for healthcare jobs - particularly higher-paying positions - makes it tough to recruit for diversity in certain markets. Although racial and ethnic minorities represent 26 percent of the country’s total population, just 6 percent of practicing physicians are Latino, African-American, or Native American, says the Association of American Medical Colleges.

At the same time, state or local “reverse discrimination” laws often prevent employers from overtly seeking out minority workers. “You don’t want to focus on any one group at the exclusion of others,” says Mark Tatum, an employment law specialist for Shook, Hardy & Bacon in Kansas City, Mo. “You want to be fair, but you can also set up a process to ensure that your applicant pool is diverse.” Minority job fairs, says Tatum, are a good place to begin your search for diversity. Practices can also require specific language skills from qualified applicants, which can help focus their recruiting efforts.

For her part, Mona Walden-Frey, manager of the HealthEast Roselawn Clinic in St. Paul, Minn., says she considers all applicants for new positions, but she boosts her odds of securing a more diverse selection of qualified candidates through strategic advertising. “I place ads in newspapers that target different cultural groups, along with the mainstream newspapers,” she explains.

HealthEast Roselawn Clinic, which treats a large percentage of Hmong and Somali patients, was literally built with cross-cultural medicine in mind. During the clinic’s construction, the practice’s leadership worked with a designer to select culturally appropriate paint colors and art. The practice installed privacy curtains in exam rooms for patients who prefer to have family members present during the physician-patient interview. Staff members have posted welcome signs in several languages; they play an international mix of music; and they supply waiting rooms with reading material from all over the globe.

“We’ve learned from our focus groups that these are the visual cues that right away make patients feel more comfortable,” says Walden-Frey. “We’ve had very positive response from our patients, which is ultimately good for business. Word of mouth is important.”

Walden-Frey adds that the clinic’s highly diverse staff has also created countless opportunities to enhance patient care - plus one small challenge. “The only issue I would say we’ve experienced is that communication styles are sometimes different for employees of different cultures,” says Walden-Frey. “As a manager or administrator, it’s very important that you be the one to set the tone for a respectful work force.”

Making patients comfortable

Learning how to be sensitive to a diverse patient population whose culture may be unfamiliar to you is no small task for physicians.

Hunt, who created an e-learning program on cross-cultural medicine, says many foreign-born residents need time to acquaint themselves with Western medicine. “When you think about such concepts as ‘informed consent’ for treatment and surgery, for example, there are some huge cultural presumptions made there,” Hunt explains. “It presumes the patient will be the decision-maker on their own behalf, and in some cultures it’s the elders who make those decisions. It also presumes the patient actually wants to know about all those terrible things that could happen.” Some ethnic groups, says Hunt, believe that just hearing about potential complications can lead to a self-fulfilling prophecy.

Culturally specific beliefs about different illnesses can be as diverse as the world we live in. Some cultures believe that epileptic patients commune with the spirit world when they are in the throes of a seizure, so they are thus unlikely to follow any treatment protocols their doctors might prescribe - if they seek treatment at all. “Physicians should always ask patients from other backgrounds if there is anything special that worries or concerns them about their diagnosis or disease,” says Like.

Physicians should also keep in mind that patients from cultures different from their own often use what the Western world considers “alternative medicine,” such as herbs, to treat specific illnesses. Patients dubious of Western medications may replace them with homespun remedies without their physicians’ knowledge. How can you possibly detect such things?

“You have to talk openly with patients without being judgmental, always with an eye on making sure you’re working together to achieve the best care possible,” suggests Green. “In many cultures, it’s not appropriate to disagree with an authority figure like a doctor, so physicians have to have a heightened awareness and even a suspicion that patients may not be admitting to any different treatment methods they’re using.”

One strategy Green says works for him when treating patients with cultural backgrounds with which he is unfamiliar is relaying a hypothetical story that takes the pressure off the patient. “Tell them that you know some of your patients don’t like to take medication every day, for example, and ask if that’s their position, too,” he suggests.

Language barriers challenge effective communication between physicians and their patients in the most blatant way. All too often, says Like, physicians rely on their patients’ friends and family to serve as interpreters during office visits. Like says that’s not a wise move. “You can’t just pull someone from the waiting room or rely on a child or family member to translate,” he says. “There are confidentiality issues there and the even bigger issue of health literacy. Most people who are not trained in healthcare don’t understand medical terms and can’t interpret charts and other reference material.”

Green agrees. He says each practice should have in place clear protocols when interpreters are deemed necessary. Interpreters’ skills can be accessed remotely via telephone or through a practice’s affiliated hospital. Many hospitals retain interpreters on staff who can be called into exam rooms on request. “Our practice is very diverse, so we have a policy of marking on the patient’s record what their native language is,” explains Green. “That way, our staff can get that process rolling before I even see them. It throws the whole system off to have them wait.”

For patients with poor English proficiency, Like also recommends the “teach back” method. “People who are under stress, in particular, may not understand what you’ve just told them,” says Like. “It helps to ask them to repeat back to you the treatment method you just recommended.”

Getting there from here

In the quest to improve the quality of care for patients of all cultural backgrounds, the American Medical Student Association (AMSA) suggests students and healthcare providers alike conduct self-assessments to detect any prejudices or biases they may possess that could influence their performance as healthcare providers.

Physicians who take stock of their own individual cultural beliefs can better relate to patients. “Consider topics like your family origins; when, how, and why your ancestors arrived; ethic advantages or disadvantages you may have; and any stereotypes you have of other ethnicities,” AMSA writes in “Cultural Competency in Medicine,” an instructional paper for its membership.

Physicians can further cultivate their cultural competence by spending more time in the communities they serve. AMSA suggests visiting neighborhood health centers as well as traditional healers and inquiring about local health beliefs, home remedies, health resources, and rituals surrounding death and dying. A walk through churches, grocery stores, and pharmacies can also yield useful information about a specific population’s everyday cultural environment. According to AMSA, “Community leaders, traditional healers, and patients are the best educators.”

At the very least, says Hunt, physicians should educate themselves about best practices for treating a diverse patient population. The National Standards for Culturally and Linguistically Appropriate Services in Health Care, issued by the HHS Office of Minority Health in 2000, offers providers a list of 14 guidelines for implementing “culturally and linguistically appropriate services [that] should be integrated throughout [a healthcare] organization and undertaken in partnership with the communities being served.”

“People in healthcare are grossly unaware that these guidelines even exist,” laments Hunt. “But every provider should read them because they represent a new community standard for providing care to culturally and linguistically diverse patients.”

As the face of America continues to diversify, physicians will have to work harder to maintain and enhance the quality of care they offer their patients from all walks of life. Many predict that only those practices that learn to adapt will survive. “Cultural competence is really the new challenge in medicine,” says Green, who learned Spanish to better communicate with his Latino patients. “It’s all about being able to reach people where they are. When you make people feel comfortable, they’ll bring a wealth of richness to your practice. ”

Shelly K. Schwartz is a freelance writer in Maplewood, N.J., who has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNN/Money.com and Bankrate.com and in Healthy Family magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the May 2007 issue of Physicians Practice.