Understanding cultural context in healthcare can seem overwhelming, especially when time and resources are limited. Why should clinicians invest energy in learning about different cultures? In this pod, we break down the differences between cultural competence and cultural safety, explaining why the latter is essential for patient care. We share practical examples of how understanding cultural context can improve interactions, strategies for making patients feel seen and heard, and the pitfalls of the term ‘non-compliant’. We also touch on how these practices can make your job more rewarding and prevent burnout.
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Guest Bio: Raj Sundar, MD, is a family physician and community organizer in Washington state. His podcast, Healthcare for Humans, “is dedicated to educating you on how to care for culturally diverse communities so we can be better healers.”
Mentioned in this episode
- Out On Time: Our 10-week course to get you out the door on time and home unencumbered
- Flameproof: The anti-burnout curriculum we all should have learned in training. Next cohort begins Sept 10, 2024
- 4 Free Resources to elevate your career
We Discuss
What does it mean to care for diverse communities effectively?
Avoid burdening patients or communities to educate healthcare providers about their identities, histories, and cultures.
The healthcare experience often undermines patients’ humanity and dignity.
The medical curriculum and healthcare system excessively focus on the scientific aspects of medicine, often neglecting the human elements.
Patients bring their values, beliefs, histories, and cultures to every healthcare encounter.
The job can be fulfilling and rewarding but also frustrating and burnout-inducing due to these human elements.
An argument for why it’s not the patient’s job to teach clinicians about their culture
- Clinicians are experts in medical conditions but may lack knowledge about specific cultural norms.
- Patients experiencing multiple interactions with the healthcare system without their identities being acknowledged can find it a source of significant pain.
- Short clinical encounters do not give patients sufficient time to explain their cultural beliefs or why certain medical advice may not work for them.
- The goal for clinicians is to lead with curiosity and understand the cultures and communities they serve, not necessarily to become experts in every cultural background.
- Recognizing that cultural differences influence patient behavior and responses can transform frustrating encounters into opportunities for meaningful connections and better care.
Understanding the cultural context of frustrating behaviors
- Understanding the underlying reasons for patients’ actions can lessen the frequency and intensity of negative emotions during interactions.
- Knowledge of the community’s beliefs and behaviors can help clinicians navigate conflicts more effectively..
- Clinicians can experience a change in their emotional response to patients’ actions once they grasp the cultural reasons behind those behaviors.
Shifting from ‘why me’ to ‘of course’
- Earlier in their careers, clinicians might feel strong ownership over patient outcomes, leading to frustration when patients do not follow recommendations.
- Presenting medical advice in a culturally sensitive manner is crucial, even if the clinician does not fully understand every cultural background.
- Accepting cultural behaviors and understanding the limits of one’s influence can alleviate the emotional burden on clinicians.
- Recognizing systemic issues and advocating for changes can improve care for culturally diverse communities without burdening individual clinicians.
How to create a framework for cultural knowledge
- Individual Identity: Each person has unique personal experiences and characteristics.
- Community Identity: People belong to various groups or tribes, such as professional communities (e.g., ER tribe) or cultural groups (e.g., South Indian).
- Universal Human Identity: Shared human experiences include joy, suffering, anger, and hope, transcending individual and community identities.
- Avoid Stereotyping: Recognize each person’s multiple layers of identity, avoiding oversimplified assumptions.
- Cultural Skepticism: Some communities, like Native Hawaiians and Pacific Islanders, may exhibit skepticism towards Western medicine and not follow-up.
- Approach with Curiosity: Embrace a mindset of curiosity to understand cultural contexts and patient behaviors better.
- Building Relationships: Develop relationships with communities to learn about their healthcare perspectives and build trust.
- Practical Steps: Engage in activities like podcasting or direct community outreach to gather insights and share knowledge within the healthcare system.
- Empowerment through Action: Taking steps to understand and address cultural issues in healthcare can reduce frustration and improve patient outcomes.
What happened to Raj’s practice when he started interviewing local Pacific Islander community leaders
- Provided insights into culturally sensitive care practices for Native Hawaiians.
- Learning from community leaders highlighted the importance of not making assumptions or casual comments about topics like vacations to Hawaii, which could inadvertently dismiss the patient’s experiences and struggles.
- Shifting the approach from casual connection attempts to intentional, empathetic communication helped foster better patient-clinician relationships.
- Understanding the deep connection Native Hawaiians have with their land and the impact of displacement informed more respectful and meaningful interactions with patients.
- Recognizing and addressing patients’ emotional and cultural context improved trust and adherence to medical advice.
How to have patients feel seen, heard, and known in the point of care
- Ask patients about their cultural background respectfully and caringly to help bridge the gap in understanding.
- Frame questions to show genuine interest in caring for the patient better, avoiding aggressive or dismissive tones.
- Recognize that it might be challenging to connect fully in the moment without knowing the cultural context, but identifying the culture can be a starting point.
- Consider whether a colleague might have a better understanding of the patient’s cultural background and could provide more effective care.
- Advocate for the inclusion of community health navigators in the healthcare team to assist with cultural nuances and improve patient outcomes.
Cultural competence vs cultural safety
- Cultural Competence: Historically emphasized in healthcare, implying that one can become fully knowledgeable about different cultures.
- Competence Misconception: The idea that clinicians can achieve full competence in a culture is misleading and unrealistic, even within their own cultures.
- Othering Issue: Cultural competence can inadvertently create a sense of “othering,” where the dominant culture is seen as the norm and other cultures as abnormal.
- Cultural Safety: Originated by the Maori population in New Zealand, focusing on humility, self-awareness, and recognizing power differentials in healthcare.
- Humility and Self-Awareness: Cultural safety emphasizes understanding one’s own cultural values and biases while being open to learning about others.
- Power Differential: Acknowledges historical and systemic inequalities affecting healthcare delivery and aims to create a safer, more equitable environment for all patients.
What does cultural safety look like?
- Avoiding Casual Disregard: Providing safety means not disregarding a patient’s suffering by casually discussing topics that may be sensitive or painful.
- Acknowledging Cultural Differences: Recognizing and respecting significant cultural events, like understanding that Ethiopian patients celebrate Christmas differently, fosters a sense of safety and understanding.
- Curiosity and Effort: Demonstrating curiosity and effort to learn about a patient’s culture can create a safe environment where they feel comfortable opening up and sharing.
- Reducing Power Differential: Acknowledging the inherent power differential between healthcare providers and patients and trying to diminish this gap by showing empathy and understanding.
- Building Trust: Actions that show cultural awareness and sensitivity help build trust, making patients feel seen, heard, and understood, ultimately leading to better healthcare outcomes.
Why should I spend my energy on learning another’s culture? If they’ve moved here, shouldn’t they be the ones to assimilate into this culture?
- Immigrants spend significant effort trying to fit into the new culture, often succeeding but sometimes struggling.
- Building a connection based on mutual cultural understanding can make individuals feel valued and respected.
- Connecting on cultural aspects, such as discussing something familiar from their culture or country, can create a positive and welcoming interaction.
- Even if it’s not perceived as the clinician’s job, making patients feel good through cultural understanding can enhance the therapeutic relationship.
- Engaging in cultural awareness can make the clinician’s job more rewarding, fostering genuine connections and moments of joy amidst the challenges.
- Finding ways to connect and create positive experiences in a profession prone to burnout can help clinicians stay anchored to their purpose and motivation for entering the field.
The language of noncompliance vs nonadherence vs nonjudgmental
- Noncompliant: Often used in a blaming and shaming context, implying patients are at fault for not following medical advice, which can negatively affect how clinicians view and treat patients.
- Nonadherent: Shifts the focus slightly to explore why a patient was unable to follow medical advice, opening up the possibility of understanding underlying reasons.
- Describe the Actual Reason: Instead of using terms like non-compliant or nonadherent, document the specific reason given by the patient for not following medical advice, such as financial constraints, fear, or skepticism towards healthcare.
- Avoid Blame: Removing blame-oriented language helps maintain curiosity and empathy, ensuring clinicians remain open to understanding and addressing the root causes of patients’ actions.
Why social determinants of health in documentation might be a good thing
- Understanding social determinants of health, such as housing and transportation issues, can identify barriers to patient care and improve health outcomes.
- Avoiding Checklists: The approach should go beyond quickly checking off items; it requires meaningful engagement to understand the patient’s context and needs.
- Continuous Improvement: Regularly assessing whether the documentation process achieves its intended purpose helps refine the approach, ensuring it remains patient-centered and effective.
Rumi’s The Great Wagon – Raj’s favorite poem
- Key Line: “Out beyond ideas of wrongdoing and right doing, there is a field. I will meet you there.”
- Meaningful Connection: The poem speaks to transcending judgment and finding a place of mutual understanding and peace.
- Mindfulness and Presence: Encourages readers to be present and mindful, lying down in the grass where the world becomes too full for words.
- Beyond Language: Highlights the idea that traditional concepts like “each other” lose their meaning in true connection.
- Contemplation: Invites readers to reflect on the deeper meanings of connection beyond superficial judgments and separations.
When I see your face, the stone starts spinning!
You appear; all studying wanders.
I lose my place.
Water turns pearly.
Fire dies down and doesn’t destroy.
In your presence I don’t want what I thought I wanted,
those three little hanging lamps.
Inside your face the ancient manuscripts
seem like rusty mirrors.
You breathe; new shapes appear,
and the music of a desire as widespread as spring
begins to move like a great wagon.
Drive slowly.
Some of us walking alongside are lame!
Today, like every other day, we wake up empty
and frightened. Don’t open the door to the study
and begin reading. Take down a musical instrument.
Let the beauty we love be what we do.
There are hundreds of ways to kneel and kiss the ground.
Out beyond ideas of wrongdoing and rightdoing,
there is a field. I’ll meet you there.
When the soul lies down in that grass,
the world is too full to talk about.
Ideas, language, even the phrase each other
doesn’t make any sense.
The breeze at dawn has secrets to tell you.
Don’t go back to sleep.
You must ask for what you really want.
Don’t go back to sleep.
People are going back and forth across the doorsill
where the two worlds touch.
The door is round and open.
Don’t go back to sleep.
I would love to kiss you.
The price of kissing is your life.
Now my loving is running toward my life shouting,
What a bargain, let’s buy it.
Day and night, music,
a quiet, bright reedsong.
If it fades, we fade.
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