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Cultural Considerations

From: The Hospitalist, December 2008

Faith, heritage, even sexual orientation can play an important role in hospital care

by Gina Gotsill

Sharnjit Grewal, MD, a hospitalist at Mercy Medical Group in Sacramento, Calif., is familiar with what he calls “the double-take.” A Sikh born and raised in California, Dr. Grewal wears a traditional turban and full beard. When he walks into the room, some patient’s simply don’t know what to make of him, he admits.

“It’s confusing—even to my Hindu and Sikh patients,” Dr. Grewal says. “They sometimes say, ‘You talk like an American, you’re obviously from the West, but you follow a faith from the East. The line between religion and culture is obscured.”

Although the medical community stresses cultural awareness and sensitivity, Dr. Grewal’s experience highlights the fine line between religion and culture, and the barriers standing stand in the way of cultural awareness.

Today, hospitals experience shifting patient demographics and a growing number of languages and dialects observed in the United States today. Between 1990-2000, the foreign-born population in the U.S. increased by 57%, compared with a 9.3% increase for the native population and a 13% increase for the total U.S. population, according to the U.S. Census Bureau.

Differences Come in All Shapes, Sizes, Languages

The healthcare industry is addressing cultural competency and encouraging practices and policies aimed at increasing understanding. Sensitivity regarding patients’ sexual orientation is a component of cultural competency. Often, gay, lesbian, bisexual, and transgender individuals avoid “even routine medical visits after negative healthcare experiences due to providers’ lack of cultural competency,” according to the Gay & Lesbian Medical Association’s 2008 Healthcare Equality Index.

“One of the challenges of promoting cultural competence is that it is often believed to be aimed solely at individuals from minority backgrounds who may have unique beliefs,” says Amy Wilson-Stronks, Project Director for Health Disparities with the Joint Commission and principal investigator of the 2008 Joint Commission report One Size Does Not Fit All: Meeting the Health Care Needs of a Diverse Population. “The point is that we are all unique and cultural competency is important for everyone—not just ‘minority’ populations.”

Language barriers are an everyday occurrence for most hospitalists. The limited English proficient population grew from 14 million to 21.3 million between 1990 and 2000, according to U.S. Census figures.

The healthcare system also is dealing with multilingual populations in cities where language has not been a challenge in the past, according Cynthia Roat, MPH, a consultant and trainer on language access in healthcare. For example, limited English proficient populations in Georgia and North Carolina each grew by more than 240 percent from 1990-2000.

More hospitals are turning to professional healthcare interpreters for assistance with medical interviews and communications, Roat says. The most widely interpreted language is Spanish, she says, but more than 300 languages are spoken in the United States. Interpreters in Cantonese, Mandarin, Vietnamese, Korean, and many other languages, are in high demand, she says.

Location makes a difference: Hmong is a high-demand language in Minneapolis and California’s Central Valley, while Haitian Creole is in demand in Florida and Boston, she says. As new refugee groups enter the country, new languages are added to the list.—GG

Break Down Walls

When hospitalists and patients share a culture or language, the result can be extremely positive. In fact, the Joint Commission report states some hospitals in the United States are working to increase racial and ethnic similarities between staff and patient populations.

Joseph Li, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston, frequently works with Cantonese-speaking patients referred to the hospital by the healthcare clinic in Boston’s Chinatown section. When he greets patients in their native tongue, Dr. Li says he can feel their comfort level rise; even though he speaks what he calls “5-year-old Cantonese.”

“There is an improved therapeutic relationship when doctors and patients share a language, culture, or belief,” Dr. Li says. “There’s a level of comfort that you are going to be understood and nothing will be lost in translation.”

A patient’s culture may drive decisions contradictory to traditional Western medicine, and hospitalists need to make the time to listen and respond. Recently, Dr. Grewal treated a dying, elderly Asian patient whose family insisted on administering an unknown, water-like fluid to cure the loved one. First, the family requested giving the fluid to the patient by mouth. Dr. Grewal denied the request, and told them the water would end up in the patient’s lungs because he was comatose and could not swallow. Then, the family asked if they could add it to the intravenous line. Again, Dr. Grewal denied the request, and told them water in an un-buffered solution could be harmful to red blood cells.

“It was frustrating for them,” Dr. Grewal says. “I told them, ‘It’s not that I don’t believe the water will cure him. Maybe it will or maybe it won’t. But from a medical standpoint, I know there will be complications and I just cannot do this.’ ”

Eventually, the family asked if a tube could be inserted into the patient’s stomach. When the request was denied, the family decided on comfort care for their loved one. Eventually, he passed away. The family, Dr. Grewal says, was grateful for the hospital staff’s care and effort, even though their requests to administer the fluid were denied.

Difficult Cases

Firm cultural beliefs may lead patients to resist treatment. Manish Patel, MD, a hospitalist and assistant professor with the division of General Internal Medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in New Brunswick, N.J., recalls working with an elderly member of the Indian community who refused to be transferred to a rehabilitation facility. Dr. Patel took time to speak to the patient and learned she came from a tradition that encouraged younger generations to care for the elderly. The patient interpreted her transfer to a rehabilitation facility as a sign her family was abandoning her, Dr. Patel says.

“Sometimes you have to probe to learn more,” Dr. Patel says. “Once we understood her fears, we were able to convey to her that this was a temporary situation and that her family could not provide her with the services that she needed at that point in time.”

Dr. Patel also interacts with Hispanic and Indian patients—many of whom revere doctors and defer to them for treatment decisions. In these situations, he uses the same approach as he does with patients who question his treatment recommendations.

“The patient may defer to you, but it’s important to empower the patient and give them all the information they need to make major choices in their healthcare.”

Information Pipeline

Hospitalists may prefer to be upfront about a patient’s condition and treatment, however, cultural norms sometimes dictate who receives information—and how much. For example, Scott Enderby, DO, a hospitalist at Alta Bates Summit Medical Center in Berkeley, Calif., says some Asian families prefer medical staff deliver bad news about the patient to them first. The family then decides what they will tell the patient, he says.

These situations create challenges and opportunities, Enderby says. Medical staff tries to establish a patient-centric care system, so it is important to continue appropriate communication with the patient. It also is important for healthcare providers to avoid putting the family in the middle and marginalizing the patient, he says. Healthcare teams can become frustrated when family members are at odds about decisions and options, and the patient is not involved at the family’s request, he says. In these cases, Dr. Enderby sees an opportunity to further engage the family, and, therefore, the patient.

“Often, when there are cultural and language barriers, a disengaged family can make caring for the patient very challenging,” Dr. Enderby says. “Having the family involved can help everyone feel more aligned with a treatment plan or strategy.”

For Alpesh Amin, MD, associate professor of medicine and vice chair for Clinical Affairs and Quality in the Department of Medicine at the University of California Irvine School of Medicine, being aware of a patient’s cultural values is critical to quality care. As executive director of the hospitalist program at the UCI Medical Center in Orange, Calif., Dr. Amin helped develop curriculum to train students on how to collect “values history” from patients, which includes asking questions about religion and culture. Students document their own values history, and then ask the same questions of a patient. Students discuss patient care and the importance of these histories during small group sessions.

“Knowing a patient's cultural information is just as important as knowing their sexual history or drug history,” Dr. Amin says. “It’s another piece of information that helps you get to know them as a whole. Their overall care is more comprehensive, if you have this knowledge.” TH

Gina Gotsill is a journalist based in California.


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