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Welcome to a special segment on ethics and medicine. You’re listening to ReachMD XM157, The Channel for Medical Professionals. I am your host, Dr. Maurice Pickard, and our guest today is Dr. James Webster. Dr. Webster is professor of medicine at the Northwestern University, Feinberg School of Medicine. He is also the executive director of the Institute of Medicine of Chicago and president of the Chicago Board of health.

DR. MAURICE PICKARD:

Thank you very much Dr. Webster for joining us.

DR. JAMES WEBSTER:

My pleasure, thank you very much for the invitation, glad to be here.

DR. MAURICE PICKARD:

What is cultural proficiency or competency?

DR. JAMES WEBSTER:

It is a relatively new concept, relatively new over the past decade or so. The idea that we should be able to relate to patients from different cultures, do it professionally, and with the appropriate humanistic and medical skills that allow us to be comfortable and to make the patients comfortable, no matter whether they come from a different background than we were originally raised in.

DR. MAURICE PICKARD:

Does this have any effect on medical outcomes?

DR. JAMES WEBSTER:

Oh, absolutely, patients who, for whatever reason do not feel welcome in the setting where they are being treated, when they cannot understand the reasons as well as the language that they are being dealt with, this is a huge problem and adversely affects outcome. Just think of it yourself, I mean if you cannot understand why and how and what you are supposed to do, you are not going to follow the directions and adherence falls to “zippo” and it is just a terrible problem, in many cases injuring the most vulnerable of our patients.

DR. MAURICE PICKARD:

So, you would say that cultural proficiency leads to what we have been talking about so much in the press and in medical schools, the medical disparities that exist in minority groups, in particular?

DR. JAMES WEBSTER:

Absolutely, again, this is a problem because the quality of care given minorities in the country today is significantly worse than that given the general population and if we want to improve quality, this is really low-hanging fruit, if we can improve the kind of care and outcomes that we get in minority and vulnerable populations, it really will make a huge difference in the overall health and productivity and everything else in our country today.

DR. MAURICE PICKARD:

Well, how do you go about dealing with this now that you identified a problem?

DR. JAMES WEBSTER:

It is really an educational problem and it builds on the education that helps professionals. I have already gotten many of the more senior practitioners, both physicians and nurses and others who could care for patients, graduated at a time when this was not even recognized, much less made a priority, but they have the basic skills of communication and trust building that allow them to be successful in their practice. We just have to make sure that they understand how things look from the patient’s perspective if the patient comes from a different culture than the one that the practitioner was raised in.

DR. MAURICE PICKARD:

Well, I know you are teaching in a medical school, a very fine medical school, how are you incorporating this into the curriculum of the medical students, actually before we get to people like you and I who have already been in practice for a while?

DR. JAMES WEBSTER:

They get a large exposure to this in their preclinical years, the first 3 years of medical school. It is really medical sociology if you well and they have as part of their clinical skills development, they have formal direction of education to improve their cultural sensitivity, cultural competency with lots of non-related talking head lectures, but more importantly a lot of role playing and small-group education. I know that, that takes place in all the medical schools in the Chicago region, and the studies nationally suggest that the vast, vast majority of medical schools in the country are doing the same thing, and nursing schools as well I should add. So, I am not concerned about the younger clinicians. I am, however, concerned that you said those of us who are a little older who do not have the appropriate attitudes or skill sets to make this happen.

DR. MAURICE PICKARD:

You know, I have often wondered how and this certainly applies to myself, how can I always be sure that my patients in the minority group understand what I am saying? Very often, they are embarrassed, they cannot read, they nod as if they understand, you ask them do they understand, they say yes, and then you will find out that they not able to read your instructions or may even be taking their medications incorrectly. Is there some tool that I could access that would somehow benefit my being sure that my patients really understand what I am telling them?

DR. JAMES WEBSTER:

Well, you identified a serious problem for all of us, and if you will, not a nightmare, but certainly a concern that we all have with all patients. There are a lot of things that could be done for example, taking the time to have a talk back is a great idea when you are all done and the patient has nodded and smiled and everything, you say now please tell me exactly what you heard me say. What is the problem here, what is the disease or illness or whatever, what are my recommendations for you, why do we want you to follow this diet, take this pill, do whatever, and see if they can repeat to you the information that you just gave them and it is sometimes very embarrassing, at least for me, when I realize that we are 180 degrees out of face, so talk back if a wonderful situation and also open-ended questions, I mean there are a whole lot of mnemonicsand what have you that I won’t go into here, but open-ended questions to find out what the patient’s attitudes are, what they think is going on, etc. are just wonderful ways to undertake this and I think it is important to understand that in this day of 12- or 15-minute visits there is a lot going on and there is good data that particularly from minority populations, a patient-centered medical home with a team approach where the physician provides leadership, but has nurse practitioners, nurses, panel supervisors working with him or her is a great way because they can take the time and sometimes physicians do not have to really drill down and make sure that the patients understand what is going on and why and how and can do the things that sometimes we do not have time for.

DR. MAURICE PICKARD:

If you are just joining us, you are listening to a special segment, ethics and medicine on ReachMD XM 157, and I am your host, Dr. Maurice Pickard, and my guest is Dr. James Webster, Professor of Medicine at Northwestern Feinberg School of Medicine, and we are taking about cultural competency and how it leads to disparities in healthcare, especially to minority groups.

DR. MAURICE PICKARD:

I know we have been taking about minority groups when I thought about how often this happens in people with early dementia or another group of people who try to lead you astray, smile, nod, and act as if they are understanding your instructions and probably some of the same tools that you might use with the minority group, you have to be very careful with demented patients’ early dementia and make sure that they talk back to you and give you an idea that they really do understand your instructions. I am struck too, although this isn’t really what we are talking about, about Ron Davis, president of the AMA who is fighting cancer of the pancreas and he, as a patient has started a program called “Ask me free”, and these are questions that patients should ask, what is my main medical problem, what I need to do to improve my medical condition, and why particular treatment is important. Now, in a group of minority groups and people, who may or may not understand what you are saying, do not you think it is going to be hard for these patients to come back to you and ask the same 3 questions that Ron Davis is encouraging the medical community to hear in their office.

DR. JAMES WEBSTER:

I certainly agree and there was a wonderful story about Dr. Davis with New York Times, Einstein Section. In any case, it is very difficult and it is hard for people, who come from a different culture and a different tradition to be willing to, if you will, confront the physician. So, again, it is important to make sure that they feel welcomed in the environment that they are being seen and they have be encouraged with as I said earlier, open-ended questions are a great way to start, but you have to ask those 3 questions of the patient. If they do not volunteer, this would be a wonderful way to start as I said earlier what is wrong, whatever you are trying to do about it and why, and see what they can get back to you, but sometimes you have to make sure that they are empowered if you will to ask those questions and to make sure that you get the answers that are right now as a geriatrician certainly are the same things I talked about team care are very important for the elderly, and it sort of also goes to the idea of a third person in the room, who may be a family member with the elderly, who act as an advocate. In the case of the minority populations, particularly if English is not their first language or if they do not speak English at all, you are going to end up using a translator, which adds another dimension, but it is important, for example, when you are using a translator or an advocate for an older person that you speak to the patient, you do not talk to the daughter, who is in the room for the elderly patient or the translator who is really a third party. You talk directly to the patient and you of course get a lot of cues from them as well apart from a nonverbal communication that you see them give even if you are language skills are not very good.

DR. MAURICE PICKARD:

You know, you bring up an interesting point about translators. So often you have to, however, rely on a child, that could even be a 10-year old or a 12-year old, whose first language is becoming English to help you. This really puts you in a difficult situation because there are certain subjects that might embarrass the parent and yet here you have to rely on a child to get adequate medical history.

DR. JAMES WEBSTER:

Well, you are absolutely right and we try for example in our clinic where we see a number of Latino uninsured patients and what have you, we try never to use a child or a family member because trying to take a sexual history from a 10-year-old child and you are not going to get very far or if you are going to ask about abuse or whatever other sensitive questions come up, so it is absolutely essential if you can possibly avoid it, not to use the family member, but to get a real translator, who again you have to explain or have the translator explain to the patient why they are there and who they are and that it is <_____> etc., etc. There is good data that it changes the interaction, the clinical interaction, of a third person in the room, but unless you are terribly fluent and most of us, I know I do, overestimate our language skills, so that I think I am a lot more competent in Spanish than I really am, so I never try to do anything that is really important for a small talk, for taking the history, and may be doing the physical, may be I can get by alright, but when we get down to the nitty-gritty, the 3 questions and other things you were taking about a moment ago, it really is important that you have someone who is really good at the language that the patient uses.

DR. MAURICE PICKARD:

I want to thank Dr. James Webster, who has been our guest today and we have been taking about this increasing problem of disparities among minority groups, in particular.

I am your host, Dr. Maurice Pickard, and you have been listening to ReachMD XM157, The Channel for Medical Professionals.

To listen to our on-demand library, visit us at www.reachmd.com. If you have comments or suggestions, call us at 888-MDXM157.

Thank you for listening.

Hi this is Dr. Raymond Scalettar at Washington DC, I am the medical advisor to the Distilled Spirits Council of the United States and it is a pleasure to be part of ReachMD XM 157, The Channel for Medical Professionals.