Physicians are increasingly faced with providing care to a multicultural society complicated by literacy issues. Ensuring safe and quality healthcare for all patients requires physicians to understand how each patient’s sociocultural background affects his or her health beliefs and behavior.
Consider the following scenarios: A married 32-year-old Middle Eastern female with uterine fibroids presented at the office of a gynecologist. After years of infertility and pain, a hysterectomy was recommended. She spoke English moderately well but with a heavy accent. Offers of an interpreter were declined, including translation of the surgical consent form. Eight weeks posthysterectomy, the patient asked the physician how soon she could expect to become pregnant.
An elderly female Asian patient was noncommunicative with the physicians and staff during the first three days of her hospitalization. She would not maintain eye contact or talk, even when an interpreter was provided. Communication regarding the patient’s care or concerns would occur only when a male family member was present. The staff and physicians—concerned with privacy issues—generally spoke with the patient when family members were not present. After several days of delayed treatment because consent for a necessary but nonemergent surgery could not be obtained from the patient, a visiting chaplain of the same nationality explained the cultural requirement that a male be present for a female’s care.
The Doctors Company’s closed claims studies have shown that inadequate provider-patient communication is a frequent contributing factor to patient noncompliance, poor patient outcomes, and litigation. Effective provider-patient communication leads to an increase in patient satisfaction, better compliance, and improved outcomes. In multicultural and minority populations, the issue of communication may play an even larger role because of behavioral, cognitive, linguistic, contextual, and cultural barriers that preclude effective patient-provider communication. Research has shown that services for minorities can be improved by removing language and cultural barriers.
When cultures and languages clash, physicians are unable to deliver the care they have been trained to provide. Culturally competent care depends on resolving systemic and individual cultural differences that can create conflicts and misunderstandings. If the provider is unable to elicit patient information and negotiate appropriate care, negative health consequences may occur.
How can physicians easily acquire and maintain the skills to provide culturally responsive and appropriate care to the increasingly diverse population of patients in the United States? Traditionally, training in cross-cultural medicine has focused on providing a list of common health beliefs, behaviors, and key “dos and don’ts.” This approach does not take into account acculturation and socioeconomic status and can lead to stereotyping.
An alternative approach, proposed by Drs. Carrillo, Green, and Betancourt, helps physicians elicit a patient’s beliefs and preferences in order to identify and deal with the patient’s concepts, concerns, and expectations. This communication model is called ESFT (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, and Therapeutic contracting).
Consider this scenario with an example of the ESFT approach: A 62-year-old Dominican patient presented with hypertension. In the past two years, she had been seen by several physicians, had multiple tests to rule out any underlying etiology, and tried a variety of medications to control her blood pressure. Despite these efforts, her blood pressure remained poorly controlled. The patient, whose primary language was Spanish, had limited English skills but refused an interpreter at all clinic appointments. It appeared that the patient was nonadherent with taking the antihypertension medicine, taking it only periodically when she felt tense or stressed. Further inquiry by the physician revealed that the patient was illiterate and did not understand the complex medication regimen she had been given.
The physician was able to explore the patient’s explanatory model for hypertension using the ESFT approach. The patient strongly believed that her hypertension was episodic and related to stress. She didn’t take her daily antihypertension medication because it didn’t fit her explanatory model. The physician was able to reach a compromise by explaining that, although her blood pressure goes up during stressful times, her arteries are under stress all the time, even though she didn’t feel it. Taking medications daily would relieve the arterial stress but would not help with her emotionally stressful episodes. The physician was able to negotiate with the patient to add relaxation techniques to her daily routine.
The Doctors Company supports the Agency for Healthcare Research and Quality (AHRQ) interventions to reduce the complexity of healthcare, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Studies have shown that people from all age, race, income, and education levels are challenged by an inability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and to follow instructions for treatment. AHRQ has found that only 12 percent of the adult population has the skills to navigate and understand our complex health systems—skills reduced by stress and illness. We encourage you to explore the AHRQ Health Literacy Universal Precautions Toolkit.
Consider taking the following steps:
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.