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