©2003 Community Faculty Development Center Teaching Culture and Community in Primary Care: Teaching Culturally Appropriate Communication Skills

©2003 Community Faculty Development Center OBJECTIVES 1. Understand the middle stages of the cultural sensitivity ladder 2. Explain concept of patient-centered interviewing and the LEARN communication tool 3. Facilitate skill building as students move beyond minimization By the end of this module, trainees will be able to:

©2003 Community Faculty Development Center Where have we been?

©2003 Community Faculty Development Center CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) Cultural Sensitivity Scale

©2003 Community Faculty Development Center Needs Assessment Focus your teaching on learner’s cultural sensitivity level At egocentric stages, attempt to explore values and raise awareness

©2003 Community Faculty Development Center Where do we go from here?

©2003 Community Faculty Development Center CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) MINIMIZATION Cultural Sensitivity Scale

©2003 Community Faculty Development Center MINIMIZATION MINIMIZATION Learner acknowledges that cultural difference exists, but views it as unimportant against a backdrop of basic human similarity. “I don’t see this culture stuff as important. It’s simple, just treat people with respect and there won’t be any problems.”

©2003 Community Faculty Development Center POTENTIAL EGOCENTRIC REACTION “I tried to help these people and they ended up walking out on me.”

©2003 Community Faculty Development Center CULTURALLY EGOCENTRIC CULTURALLY SENSITIVE Minimization

©2003 Community Faculty Development Center Objectives for minimization stage Debunk that “common sense” is common Discuss that “respect” may be different in other cultures Help move them forward and prevent sliding back after “tripping up”.

©2003 Community Faculty Development Center CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY SENSITIVE (Empathy, Integration, Celebration) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) CULTURALLY EGOCENTRIC (Fear, Overgeneralization, Superiority) MINIMIZATION ACCEPTANCE “The learner respects that being attentive to cultural issues is an important component of a satisfactory provider-patient encounter.” Cultural Sensitivity Scale

©2003 Community Faculty Development Center Student needs at acceptance stage Learners can be overwhelmed by the immense scope of information with a variety of cultures “I’m having a difficult enough time learning medicine, how can you expect me to learn this culture stuff too?”

©2003 Community Faculty Development Center Objective to meet this need Attend to the need of feeling overwhelmed with empathy Frame the opportunity to learn about other cultures Teach a framework for obtaining cultural information generically

©2003 Community Faculty Development Center Student needs at acceptance stage WARNING! DANGEROUS STAGE Focus on knowledge can foster stereotyping and assumption of causation “I bet that mother thought her child was suffering from empacho and didn’t bring him in for evaluation because of this.”

©2003 Community Faculty Development Center Objective to meet need Teach the difference between generalizing and stereotyping The patient should be the source for learning about their cultural identities

©2003 Community Faculty Development Center CULTURALLY SENSITIVE CULTURALLY EGOCENTRIC (Fear, Overgeneralizing, Superiority) CULTURALLY EGOCENTRIC (Fear, Overgeneralizing, Superiority) MINIMIZATION ACCEPTANCE EMPATHY How do you spell success?

©2003 Community Faculty Development Center Patient Centered Interviewing Patients as experts about themselves and their own culture Patient as a partner with the caregiver Growing evidence: –Better satisfaction –Better outcomes

©2003 Community Faculty Development Center The LEARN Mnemonic LISTEN actively with respect ELICIT the health beliefs of the patient ASSESS priorities, values and supports RECOMMEND a plan of action with adequate explanation and understanding NEGOTIATE by involving the patient in next steps and decisions

©2003 Community Faculty Development Center LISTENING Appropriate greetings Interpreter? Open ended questions Avoid interruption Could you please tell me your reason for the visit today? How can I help you today?

©2003 Community Faculty Development Center ELICITING Patient’s Perspective What worries you the most? Are you afraid that you might have something serious? What do you think has caused your problem? Why do you think it started when it did? How can I be most helpful to you?

©2003 Community Faculty Development Center ASSESSING: Values, supports, needs and priorities Medicine in the US may be foreign. Decision maker may be family or elder. Deference to the professional I’d like to get to know you more today. Could you tell me about yourself? What brought you here to this country?

©2003 Community Faculty Development Center Ask about: Control over the environment Change in the environment Social stressors and support network Literacy and language Social Context Review of Systems

©2003 Community Faculty Development Center RECOMMEND a plan of action Physicians tend to: –Underestimate the desire for information –Use language that patients do not understand To make sure that we understand one another, can you tell me what it is that I explained to you?

©2003 Community Faculty Development Center NEGOTIATE: Involve your patient in decisions What are your ideas about what should happen next? Involving the patient in care is shown to improve: –Satisfaction –Compliance –Improved clinical outcomes

©2003 Community Faculty Development Center Teaching LEARN: Use all of the teaching styles Assertive: “Have you heard about the LEARN interview? Let me give a 3 minute summary of the technique….” Suggestive: “Would it be helpful to understanding Mr. Saq’s non-adherence to know what he thinks about Western medicine?” Collaborative: “She won’t consent to the lumbar puncture? What do we know about her thinking on that?” Facilitative: “How do you think her culture is playing into her decision to forego further treatment?”

©2003 Community Faculty Development Center Teaching LEARN: Modeling with the POSE Be specific in POSEing the question: “I’m going to try to get at her health beliefs with some questions about her background. Let me know what you think worked in the process”.

©2003 Community Faculty Development Center Teaching LEARN: Acknowledge risk There is a chance of misunderstanding Empathize with the difficulty, highlight the benefit. “I think that this is a very challenging situation. Sometimes, I really feel like I don’t understand what the patients are thinking.”