Cultural competence
The term cultural competence has a variety of definitions but perhaps the most relevant for physician assistants (PAs) is Betancourt‘s 2002 definition:
Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.
This definition refers to a system, recognizing that no one individual can achieve the level of care needed without the integrated support of an organization in which diversity is understood and valued. Each of us can strive through our own actions and reactions to improve both our individual encounters and, to the extent we are able, the system in which we practice. This chapter focuses primarily on the individual with the understanding that we must also work with our clinical and ancillary teams to create a context that is welcoming to all.
Introduction to culturally competent practice
The single overarching goal of culturally competent practice is to reduce medical errors by improving patient–provider communication. Communication, of course, is a two-way process, and errors can occur in either direction. For example, a provider may encounter a patient who uses a wheelchair and has slow speech, and the clinician may assume that he or she is intellectually challenged. Similarly, a financially stressed patient may encounter a clinician who appears to be of a higher social and economic stratum and assume the clinician has no understanding of the challenges of poverty. Either of these assumptions may be made fairly automatically and with little or no conscious thought, and either can lead to significant barriers in communication, regardless of the accuracy or inaccuracy of the assumption.
Assumptions about others are often based in stereotypes , categories of traits that are connected in our understanding. Stereotypes range from the fairly innocuous, such as the assumption that a blue collar worker is more likely to bowl than to play golf, to the detrimental, such as the idea that a black man is more violent than a white man. In either case, the stereotype is based on an unsubstantiated association of unrelated traits. Stereotypes are universal and normal but can lead to bias , a consistent shift (positive or negative) in thoughts and behavior that is not substantiated by facts.
In the clinical setting, PAs and other clinicians must often make rapid judgments with regard to diagnostic and treatment decisions. Such decisions may be colored by incomplete or inaccurate assumptions based on stereotypes. Because these rapid thought processes are subconscious, their occurrence cannot usually be consciously controlled, but this does not mean we are powerless.
If the clinician is aware of the effect of personal bias on decision making, he or she can check any assumptions by eliciting further information from the patient. We can reduce errors in patient understanding of their prescribed management plan by first eliciting the patient’s conception of the illness and expectations of care during the encounter. In addition, the clinician can reduce his or her own inaccurate assumptions about social or cultural factors that may potentially influence patients’ decision making during an encounter. Checking assumptions during the patient encounter helps the clinician to remove stereotypes, allowing the patient to be seen more as an individual than a member of a group (with all its attendant associations). A framework for eliciting the patient’s understanding and cultural context is Kleinman et al.’s explanatory model :
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What do you think has caused your problem?
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Why do you think it started when it did?
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What do you think your sickness does to you? How does it work?
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How severe is your sickness? Will it have a short or long course?
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What kind of treatment do you think you should receive?
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What are the most important results you hope to receive from this treatment?
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What are the chief problems your sickness has caused for you?
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What do you fear most about your sickness?
The busy practitioner may not have time to get all this information in a single visit but incorporating just a few of these questions into your standard clinical history can help resolve errors in communication. The following three questions will usually allow the clinician to evaluate whether or not further discussion of the interaction between personal and cultural beliefs and the understanding and management of illness should be explored:
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What do you think your sickness does to you? How does it work?
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What kind of treatment do you think you should receive?
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What are the most important results you hope to receive from this treatment?
Although obtaining a good understanding of the patient’s view of health and disease may be crucial to building rapport and improving communication in a primary care setting or other ongoing patient–provider interaction, it may not be possible in the context of emergent care. The emergency department (ED) is, however, a place where it is critical that subconscious bias and stereotyping be avoided so that it does not influence clinical decision making. , The most rapid way to circumvent bias and improve patient–provider interactions is through perspective taking. , Perspective taking is instantaneous; the clinician merely takes a moment to picture himself or herself in the patient’s shoes, seeing the situation through the patient’s eyes. The patient can no longer be seen as “other,” and stereotypes fall away. The effect of perspective taking is not equal across clinicians or situations, but with practice, it can become a tool that is both quick and easy. Of course, you can never fully see through your patient’s eyes and must still check your assumptions, but this process can remove some of the barriers.
The basics of culturally competent practice are summarized in Box 17.1 . To clarify the processes involved in improving the interaction between patient and provider, we will delve further into the rationale behind the need to reduce communication barriers and some background into the psychology behind their operation.
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Check assumptions.
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Understand bias.
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Be aware of assumptions.
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Explanatory model
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Check patient understanding.
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Check patient expectations.
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Perspective taking
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Put yourself in your patient’s shoes and see the world through his or her eyes.
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Check your assumptions.
Rationale
To fully understand the importance of culturally competent practice and the steps previously outlined, we must explore how perceived differences between individuals affect clinical decision making and, ultimately, contribute to health care disparities. Disparities in health and in health care are related to a complex web of factors. The landmark Institute of Medicine report in 2003, “Unequal Treatment,” determined that although disparities in health care are influenced by many elements outside of the clinician’s direct control, including the operation of health systems and legal and regulatory factors, they are also attributable to discrimination, bias, and stereotypes on the part of health care practitioners. Bias and stereotypes are largely subconscious and can lead to errors in clinical decision making. Outward discrimination is less common but can occur without intent. For example, choosing to locate a clinic far from a bus route may discriminate against those without cars even though no discrimination was intended.
The reduction of health care disparities is a key goal of incorporating cultural competence into patient care. Obviously, not all disparities in patient care are related to communication, but the improvement of communication, both conscious and subconscious, can go a long way toward resolving at least one cause of disparities. Communication also involves creating a welcoming atmosphere.
Bias and stereotyping
The term stereotype was coined by Walter Lippman, a journalist, in 1922 and refers to a printing plate made to duplicate a particular type of page. He used it to refer to the tendency of people to form mental images based on preconceptions that members of a particular group are alike in certain ways. These mental images make it easier to associate another person with something that conforms to the stereotype than with something discordant. In other words, congruent associations are automatic, and incongruent associations are just a little slower. The entire process is subconscious and based in our culture, the images we see every day, and the world around us, not in our own logical thoughts or beliefs. Over the past few decades, the process of stereotyping has been evaluated through multiple techniques. Since the advent of computers, the easiest method has been to simply measure the time it takes to associate two items, words, or pictures. This process is repeated with random allocation of right and left, positive and negative associations on a wide variety of subjects. You can test your own automatic associations at Harvard University’s Project Implicit: https://implicit.harvard.edu/implicit . Keep in mind that this is not a test of your values but of the way your world pulls you to automatically respond. It should be used to increase your awareness of the potential for stereotyping so that you can focus your efforts on interrupting the process through further assessment both of your patient and of your own thoughts and feelings.
Bias and stereotyping are important in clinical care because they have a demonstrated influence on diagnosis and management in a discriminatory way. The association between a negative automatic association and reduced quality of care has been shown in computer-based patient scenarios and in patient care. Misperceptions can lead to misdiagnoses and inadequate or inappropriate treatment ( Fig. 17.1 ).
Cognitive errors in decision making
Current psychological research considers human thought to be divided into two pathways variously called fast and slow; intuitive and analytical; or, simply, system 1 and system 2. System 1, frequently used in clinical encounters, involves pattern recognition and rapid associations. System 2 thinking is a slower analytic process. Although system 1 thinking is extremely helpful in emergency situations, it must always be moderated, even by experienced clinicians, by a process of forcing oneself into system 2 thinking to avoid medical errors. Many errors in cognitive decision making have been described, but two are closely related to the need for cultural competence in clinical care: ascertainment bias and fundamental attribution error. ,
Ascertainment bias is caused by an automatic association between two or more traits—a stereotype. For example, a man smelling of alcohol is brought to the ED unconscious. The clinician might initially conclude through system 1 thinking that his loss of consciousness was caused by alcohol but must also bring his or her system 2 thinking into action to consider the myriad of other potential causes. The stereotype must be consciously overridden to provide quality patient care. Other stereotypes, whether based on gender, race, ethnicity, or class, must similarly be recognized and consciously overridden. Otherwise they can lead to erroneous assumptions about the patient’s symptoms and to faulty diagnosis and treatment.
Fundamental attribution error is related to ascertainment bias but is caused by the provider having a judgmental approach to the patient at the start. Fundamental attribution error is particularly problematic for PAs working with marginalized populations. It involves blaming the patient for the problem without full consideration of contextual factors. For example, an obese patient might be seen as being at fault for his diabetes because of a poor diet; however, the patient may have a poor diet because he has no transportation to a supermarket and is forced to buy his food at a convenience store, limiting his access to healthy food.
Reducing errors in decision making is an ongoing process of combining appropriate pattern recognition with checking assumptions and carefully considering other possibilities. Cultural competence practice does not require the PA to ignore automatic associations but rather to evaluate them in the care of each patient as an individual.
Knowledge, skills, and attitudes
In addition to managing the automatic processes of our minds, clinicians must build their knowledge of the people and communities with whom they work. Culture may be defined as the beliefs, values, norms, and customs of a particular group. Although knowledge of the culture is a help in working with individual patients, it is important to ascertain how the individual interacts with that culture. Understanding culture is just a starting point. Your patient may ascribe to some, none, or all of the group norms and values. For example, one cannot assume that a patient from a particular religious community follows every tenet of that religion. This is where cultural understanding can lead to stereotyping. There are also important environmental influences on the behavior of both the individual and the group. Cultures shift according to time, place, and circumstance, leading to changes in the behavior of individuals and of the group.
The skills involved in culturally competent practice are those used in all patient-centered care. Creating a partnership between the clinician and the patient improves both patient perceptions and clinician understanding of the patient’s needs. The clinician can make errors in assuming a patient who seems like himself or herself has similar thoughts and values as easily as he or she can assume that one who seems different has differing thoughts and values. Effective communication requires shared language, meaning that the clinician must check the meaning behind a patient’s words even when both are speaking a shared language. The clinician must also evaluate how the patient understands explanations and instructions.
The clinician can use Kleinman et al.’s questions to obtain an understanding of the patient’s view and then build a partnership based on that understanding. Another model for cross-cultural communication is the LEARN model :
L: Listen to the patient’s perspective.
E: Explain and share one’s own perspective.
A: Acknowledge differences between the two perspectives.
R: Recommend a treatment plan.
N: Negotiate a mutually agreed upon treatment plan.
Good communication allows the clinician to focus on the patient as an individual rather than categorizing. In this way, the patient and provider can build a partnership, collaborating as a team with a shared understanding and shared goals. Perspective taking—imagining oneself in the patient’s situation and then checking one’s understanding—can help the clinician to better understand and empathize ( Fig. 17.2 ).
