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AMBULATORY CAREUnderstanding Cultural Differences Helps Doctors Give Better CareIt started as a textbook doctor–patient interview. The doctor asked if the woman was using birth control. She was not. He then inquired about her sexual activity, to which she replied she had sex on a regular basis. Concerned, the doctor asked the patient if she was afraid of becoming pregnant. The patient said no. When the patient noticed that her responses had stumped the doctor, the interview suddenly changed tacks. The patient took the initiative, suggesting the doctor ask her the following question: "What information am I missing?" The doctor complied, and the patient responded that she was a lesbian. Although the exchange took place a decade ago, Ross Neisuler, HMS instructor in medicine and internist at Harvard Vanguard Medical Associates, vividly recalls the office visit. Neisuler says the lesson he learned that day about perspective and doctor–patient communication was reaffirmed this past spring when he participated in Harvard Pilgrim Health Care's cultural competency course, Foundations in Cross Cultural Health Care. For the past year and a half, Harvard Pilgrim Health Care (HPHC) has offered clinicians formal training in cultural competency. The course was created to help them increase their awareness of how their patients' cultural, racial, sexual, and socioeconomic backgrounds and their care expectations could affect health outcomes. Barbara Stern, vice president of diversity at HPHC, says the course's primary goal is to improve the quality of patient care. This largely can be accomplished through improving clinician–patient interactions, Stern says. "The premise is that enhanced communications will promote treatment compliance, improve patients' health, and increase both clinicians' and patients' satisfaction." The three-day course focuses on identifying culturally based beliefs, attitudes, and practices that influence patients' and clinicians' understanding of health and illness and their treatment expectations. The curriculum is highly interactive and includes case studies, visits to culturally and racially diverse Boston communities, instruction in using interpreters effectively, interview training, role-playing, and discussions on caring for patients who use alternative or culture-based medicine. Michael Nathan, HMS instructor in medicine and internist at the Massachusetts General Hospital HealthCare Center in Revere, attended the course last February. "A lot of my struggle is how do you think of people from other cultures without typecasting them?" Nathan says. "I thought the community tour of Roxbury was incredibly fruitful in terms of opening up dialogue on what it is like to be African American." To enhance communications between clinicians and patients who either do not speak or prefer not to speak in English, the course teaches clinicians how to use interpreters effectively. "I have used translators and interpreters for years, but obviously not well," Neisuler says. In past experiences with interpreters, Neisuler spoke directly with the interpreter. When the patient responded to the interpreter's question, the reply often was lengthy. However, when translated into English, the response became a one- or two-word answer. Something was lost in the process that made the patient the third person, Neisuler says. "I now know to speak directly to the patient, to make eye contact, and to use gestures as if we truly were having a conversation. It is much more effective." For Anita Feins, HMS assistant clinical professor of ambulatory care and prevention and pediatrician at Harvard Vanguard Medical Associates, the course served as a reminder to respect the patient. "The course reinforced the basic elements of respect for the patients and their perspective," says Feins, who attended the course last year. "Respect is an effective tool for enhancing doctor–patient relationships." HPHC is offering the CME-accredited course—which is open to clinicians outside the organization—once more this year, from October 6 to 8. For more information, call 617-730-7710. —Bill Schaller |
