Still, taking time to explore a patient’s preferences could also shorten length of stay if, for instance, the patient indicated that prescribed management indicated after an expensive test would not be his choice of care, says Dr. Amin.
Understanding what beliefs and experiences patients bring to the table, as well as their past health behaviors, does involve a time investment, agrees Minn.-based Russell Holman, MD, national medical director for Cogent Healthcare, Inc. and SHM Board member. But that investment “can only help efficiency,” he maintains. “We’ve invested ourselves tremendously in terms of identifying what are best practices for a patient with heart failure, or pneumonia, or heart attack, but the cultural competency dimension of healthcare has been largely overlooked.”
Training in cultural competency is piecemeal at best, notes Dr. Holman, and often acquired on the job. He recalls a situation in which he learned first-hand the profound effect that culture has on health. While working with a Hmong man who was in a coma and on a ventilator, Dr. Holman initially attempted to seek decision-making from the patient’s wife.
“I found out that was not the appropriate decision-making process for their culture,” says Dr. Holman. The discussion was initiated in the patient’s room, and was moved to a lecture-style classroom to accommodate the 37 members of the man’s clan who came to discuss his condition.
“The fascinating thing to me was that the patient’s wife and the other women sat in the back of the classroom and did not speak the entire time,” explains Dr. Holman. “The decisions were largely conducted by the clan elders. I also found out that my patient was the clan leader, and the elders had very clear goals in mind. The goal was to keep this individual alive, because he was so important as a figure in the clan. I learned that their culture had a profound impact on their expectations of me as a physician and a provider—how I conducted myself in terms of family and clan communications, what resources I brought to bear to try and stabilize and improve his health, and how I worked with specialists. I also learned that although some clan and family members were fluent in English, even modest miscommunications, if I were to use them as translators, could result in significant setbacks.”
Prior to his current position with Cogent Healthcare, Dr. Holman managed a group of 30 hospitalists at HealthPartners Medical Group in Minnesota and in partnership with the Center for International Health developed a cultural competency curriculum for their group and for the University of Minnesota residents in training at Regions Hospital in St. Paul.
“When you are busy working in the hospital, you need to be able to quickly access some resources to be able to give you a ‘just in time’ amount of information and awareness” with which to approach your patient, he says.
Agents for Change?
In addition to Title VI compliance, hospitals are now surveyed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are evaluated on their ability to provide language services.
“This is a changing area,” notes Dr. Fernandez, “and I think it is important for hospitalists to be on the forefront of that change, part of the process that says, ‘Yes, we need to be able to provide more efficient, more patient-centered, and safer care.’ Language barriers, as one example, are inefficient, are dangerous, and are clearly associated with increased medical error.”
Dr. Percelay believes that dealing with patients from different backgrounds involves using “common sense, being respectful and legitimately curious, and avoiding shortcuts in terms of translation issues. I think if people have an inherent respect for diversity, and are open to it, it can enrich your practice.”