cross cultural care and education in geriatrics jerry johnson, m.d. professor of medicine university...
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Cross Cultural Care and Education in Geriatrics
Jerry Johnson, M.D.Jerry Johnson, M.D.
Professor of MedicineProfessor of Medicine
University of PennsylvaniaUniversity of Pennsylvania
Objectives
Overall Goal: Preparation to Teach Cross Cultural Overall Goal: Preparation to Teach Cross Cultural Aspects of GeriatricsAspects of Geriatrics Anticipate predictable challengesAnticipate predictable challenges Relate your teaching content to the domains of cross Relate your teaching content to the domains of cross
cultural interactionscultural interactions Apply mnemonics for interactions with patients and Apply mnemonics for interactions with patients and
caregiverscaregivers Use diverse approaches to teaching Use diverse approaches to teaching Identify resources for education and learning Identify resources for education and learning
Crossing the Quality Chasm
““The system by which health care is delivered The system by which health care is delivered and financed must be designed to ensure that care and financed must be designed to ensure that care is safe, effective, efficient, equitable, timely, and is safe, effective, efficient, equitable, timely, and tailored to each individual’s specific needs and tailored to each individual’s specific needs and circumstances.”circumstances.”
- Institute of Medicine Report, 2001- Institute of Medicine Report, 2001
Cultural diversitytraining
programs forproviders
Increase providersensitivity to attitudes
and beliefs whichmarginalize ethnic
groups
Analytic Framework: Cultural Diversity Training for Providers
Increase provider knowledge of
culturally-based beliefs and behaviors
Decrease differentialtreatment due to
unconsciousdiscrimination
Increase use ofculturally appropriate
health care interventions
Improvedhealth status
outcomes
Greatersatisfaction
with care
Decrease ethic differentialsin utilization
and treatment
Increase provider abilities and strategies
for cross-culturalinteractions
Greater client adherence to
care and treatmentrecommendations
Challenges of Cross-cultural Care
Defining the concept of cultureDefining the concept of culture Concern about stereotyping, relevance and legitimacyConcern about stereotyping, relevance and legitimacy Cross cultural care overlaps with other aspects of clinical Cross cultural care overlaps with other aspects of clinical
care: professionalism, humanismcare: professionalism, humanism Multiple levels of cultural competence Multiple levels of cultural competence
the health professional- patient relationshipthe health professional- patient relationship the health systemthe health system the communitythe community
What is Culture? Acquired attitudes, values and beliefs or “unwritten rules Acquired attitudes, values and beliefs or “unwritten rules
of behavior.”of behavior.” CaveatsCaveats
Culture is not synonymous with race or ethnicity, Culture is not synonymous with race or ethnicity, but...but...
““Culture is not a fixed, knowable entity that guides Culture is not a fixed, knowable entity that guides individuals’ behaviors in linear ways” individuals’ behaviors in linear ways” ((see Gregg J. see Gregg J. Losing Culture on the Way to Competence: the use and misuse Losing Culture on the Way to Competence: the use and misuse
of culture in medical education. Acad Med 2006: 81: 542-547of culture in medical education. Acad Med 2006: 81: 542-547).). Culture is mutable and multiple. Culture is mutable and multiple.
Cross cultural education is relevant because health care is delivered in a cultural context.
Relevant Cultural Constructs
• The culture of the patientThe culture of the patient
• The culture of the practitioner The culture of the practitioner
• The culture of the practitioner’s profession: The culture of the practitioner’s profession: e.g. medicine, nursing, and social work. e.g. medicine, nursing, and social work.
• The culture of the workplace: health The culture of the workplace: health system, institution, or other entity system, institution, or other entity
Relevance of Group Identities
Each individual’s identity is partly determined by Each individual’s identity is partly determined by group affiliation: gender, ethnicity, religion....group affiliation: gender, ethnicity, religion....
Preservation of these group identities for many is Preservation of these group identities for many is a matter of self esteema matter of self esteem
Group identity partly determines how others view Group identity partly determines how others view us and interact with usus and interact with us
Cox, Taylor . Cultural Diversity in Organizations. 1993
Content Areas or Domains of Cross- Cultural Care
Content Areas Relevant to Interactions
Self awarenessSelf awareness World view World view Causation or explanatory models Causation or explanatory models SpiritualitySpirituality Complementary alternative medicine Complementary alternative medicine Help-seeking behavior (community and family)Help-seeking behavior (community and family) Language and health literacyLanguage and health literacy Historical, social and economic factorsHistorical, social and economic factors
CREATE SOME REPRESENTATIVE CASES
Case Example: Explanatory Model and Alternative Healing Depression in a 75 yo man, self explained by the Depression in a 75 yo man, self explained by the
patient, and treated outside the formal health care patient, and treated outside the formal health care system.system.
Case Example: Spirituality
Woman with multiple admissions for CHF Woman with multiple admissions for CHF accompanied by markedly elevated BP, who accompanied by markedly elevated BP, who believes her faith, not medications, will treat believes her faith, not medications, will treat HTN.HTN.
Woman dying of metastatic breast cancer who Woman dying of metastatic breast cancer who wants chemotherapy as an example of “being wants chemotherapy as an example of “being strong” and maintaining faith.strong” and maintaining faith.
Case Example: Language issues
Russian speaking man admitted with pain and gait Russian speaking man admitted with pain and gait dysfunctiondysfunction
Case Example: social and economic factors Woman with large family, inadequate funds, Woman with large family, inadequate funds,
under significant stressunder significant stress
Negotiating with Patients and Families
Conceptual Framework
Emphasis on the illness and its context:Emphasis on the illness and its context: Kleinman’s questions: Eisenberg et al. Culture, illness, and Kleinman’s questions: Eisenberg et al. Culture, illness, and
care: clinical lessons from anthropologic and cross cultural care: clinical lessons from anthropologic and cross cultural research. 1978research. 1978
Carillo et al. Cross cultural primary care: a patient based approach. Annal Carillo et al. Cross cultural primary care: a patient based approach. Annal Int Med 130:829, 1999Int Med 130:829, 1999
Explore the meaning of illnessExplore the meaning of illness Conduct a social context “review of systems”Conduct a social context “review of systems” Negotiate managementNegotiate management
Kleinman’s Questions
1 What caused it?1 What caused it? 2 Why now?2 Why now? 3 How affects you?3 How affects you? 4 How severe is it?4 How severe is it?
5 What treatment?5 What treatment? 6 What results expected?6 What results expected? 7 What chief problem?7 What chief problem? 8 What do you fear most?8 What do you fear most? 9 What duration?9 What duration?
Mnemonics
Mnemonics for Cultural Interactions
LEARNLEARN BELIEFBELIEF RESPECTRESPECT ETHNIC and ETHNICSETHNIC and ETHNICS BATHEBATHE ADHEREADHERE OthersOthers
LEARN
Listen with sympathy and understanding to the Listen with sympathy and understanding to the patient’s perception of the problempatient’s perception of the problem
Explain your perceptions of the problemExplain your perceptions of the problem Acknowledge and discuss the differences and Acknowledge and discuss the differences and
similaritiessimilarities Recommend treatmentRecommend treatment Negotiate treatmentNegotiate treatment
Berlin E. Western Journal of Med 1983; 139: 934-938
BELIEF
Health Beliefs (What caused your illness ?)Health Beliefs (What caused your illness ?) Explanation (Why did it happen?)Explanation (Why did it happen?) Learn (Help me understand your belief/opinion)Learn (Help me understand your belief/opinion) Impact (How is this illness affecting your life?)Impact (How is this illness affecting your life?) Empathy (This must be very difficult for you)Empathy (This must be very difficult for you) Feelings (How are you feeling?)Feelings (How are you feeling?)
RESPECT
Respect: a demonstrable attitude Respect: a demonstrable attitude Explanatory model: patient explanation of causeExplanatory model: patient explanation of cause Social cultural context: gender, migration status, Social cultural context: gender, migration status,
sexual orientation, economic group, historysexual orientation, economic group, history Power differential: acknowledge itPower differential: acknowledge it Empathy: put into wordsEmpathy: put into words Concerns and fears: eliciting themConcerns and fears: eliciting them Therapeutic alliance and trustTherapeutic alliance and trust
ETHNIC and ETHNIC(S) Explanation : What do you think is the reason for your sx?Explanation : What do you think is the reason for your sx? Treatment: What kinds of treatment have you tried, what kinds Treatment: What kinds of treatment have you tried, what kinds
of treatment do you want?of treatment do you want? Healers: Advice from alternative healers?Healers: Advice from alternative healers? Negotiate: discuss options and expected resultsNegotiate: discuss options and expected results Intervention. Determine an interventionIntervention. Determine an intervention CollaborationCollaboration Spirituality or SeniorsSpirituality or Seniors
Levin, S. Ethnic. Patient Care 2000; 34 (9): 188-189
BATHE
Background (what is going on in your lifeBackground (what is going on in your life?)?) Affect (How do you feel?)Affect (How do you feel?) Trouble (What troubles you most?)Trouble (What troubles you most?) Handling (coping)Handling (coping) Empathy (That must be very difficult)Empathy (That must be very difficult)
ADHERE
Acknowledge (need for treatment and joint goals)Acknowledge (need for treatment and joint goals) Discuss (potential treatments and alternatives)Discuss (potential treatments and alternatives) Handle (questions)Handle (questions) Evaluate (health literacy and barriers to Evaluate (health literacy and barriers to
adherence)adherence) Recommend (treatment)Recommend (treatment) Empower (the patient by listening)Empower (the patient by listening)
General Tips in Cross Cultural Care
Avoid idiomsAvoid idioms Use titles such as Mr. and MissUse titles such as Mr. and Miss Yes does not always mean yesYes does not always mean yes Be cautious of touching Be cautious of touching Use trained interpreters when availableUse trained interpreters when available
TRAINING TOOLS AND APPROACHES
Large Group Exercises
Aging Panel: Who are the elderly Aging Panel: Who are the elderly Working with interpreters-filmWorking with interpreters-film Spirituality panel and case discussionsSpirituality panel and case discussions CAM presentation with practitionersCAM presentation with practitioners
Small Group Activities
Discussion sessions following large groups, often Discussion sessions following large groups, often with guests (seniors, chaplains)with guests (seniors, chaplains)
Self awareness exercisesSelf awareness exercises Introduction to the Physical Community Introduction to the Physical Community
part of a home visitation coursepart of a home visitation course Narrated van tour of West Philadelphia Narrated van tour of West Philadelphia Resident and fellow presentations in community sites Resident and fellow presentations in community sites
Faculty and Preceptor Education
One or two orientation sessions per yearOne or two orientation sessions per year Materials prepared with key readings and Materials prepared with key readings and
discussion questions for small groupsdiscussion questions for small groups Debriefings after small group sessionsDebriefings after small group sessions
Evaluation
Students: one or two page description of an Students: one or two page description of an experience with presentation to peers in a small experience with presentation to peers in a small groupgroup
Focus groups of traineesFocus groups of trainees Critique of presentations and sessions: value, Critique of presentations and sessions: value,
lessons learnedlessons learned
References and Materials
Full CurriculaFull Curricula UCSF: Culture and communication in health care, a UCSF: Culture and communication in health care, a
curriculumcurriculum TACCT: Tool for assessing cultural competence TACCT: Tool for assessing cultural competence
training : a project initially privately funded, now training : a project initially privately funded, now adopted by the AAMCadopted by the AAMC
References and Materials
Monographs and articlesMonographs and articles Doorway Thoughts-American Geriatrics SocietyDoorway Thoughts-American Geriatrics Society Ham and Sloan: Cased Based Primary Care Geriatrics, Ham and Sloan: Cased Based Primary Care Geriatrics,
chapters on Ethnic and Cultural Aspects of Geriatrics chapters on Ethnic and Cultural Aspects of Geriatrics (4(4thth and 5 and 5thth editions). Jerry Johnson editions). Jerry Johnson
Other Resources for Teaching
Stanford: Stanford: stanford.edu/group/ethnoger HRSA website: cultural and linguistic competence HRSA website: cultural and linguistic competence
education: education: www.hrsa.gov/culturalcompetence/curriculumguidewww.hrsa.gov/culturalcompetence/curriculumguide
The California Endowment websiteThe California Endowment website Kaiser Foundation websiteKaiser Foundation website Manager’s electronic resource center (ERC) Manager’s electronic resource center (ERC) a cultural a cultural
competence quizcompetence quiz produced by Management Sciences for produced by Management Sciences for HealthHealth
Summary Cultural differences are common and germane.Cultural differences are common and germane. The process of inquiry, rather than knowing a set of facts The process of inquiry, rather than knowing a set of facts
about a group, is fundamental. about a group, is fundamental. Knowledge of critical domains can direct the interaction. Knowledge of critical domains can direct the interaction. Several mnemonics are available.Several mnemonics are available. Discussions and interactive exercises work.Discussions and interactive exercises work. Extensive resources on cross cultural care are available.Extensive resources on cross cultural care are available. Culture mattersCulture matters