Effective Communication Between Elders and Providers JOYCELYN DORSCHER MD ASSOCIATE DEAN FOR STUDENT AFFAIRS AND ADMISSIONS ASSOCIATE PROFESSOR, DEPARTMENT OF FAMILY MEDICINE UND SCHOOL OF MEDICINE AND HEALTH SCIENCES Build Rapport Accurate Diagnosis Protecting the Patient What is the Purpose of the Patient-Provider Interaction? 4 Compliance and Concordance Health Promotion 2 1
Lack of Time What are the potential causes of miscommunication? 5 Lack of Information Fear of telling the truth Confusion Cultural incongruence 3 Culture A set of beliefs, behaviors (ceremonies, rituals), values and worldview that are learned and shared by members of a group 6 4 2
Which cultures are involved? The Patients Culture The Providers Culture The Culture of Medicine 5 5 Physician Culture 6 Natal Healthcare System Gender Physician Subgroup Adapted from Kagawa-Singer 2003 6 3
Figure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care Clinical Appropriateness and Need Patient Preferences Quality of Health Care Non-Minority Minority Difference The Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases and Prejudice, Stereotyping, and Uncertainty Disparity Populations with Equal Access to Health Care IOM Unequal Treatment 7 7 The Research Question Is there perceived miscommunication between Native American patients and health care providers such that it interferes with the patient/doctor relationship? 3 8 4
Scientific Evaluation of the Impact of Culture on Patient-Physician Relationship 9 Is there perceived miscommunication between Native American patients and health care providers such that it interferes with the patient/doctor relationship? Qualitative Analysis Grounded theory Culturally appropriate Participatory Research Model Oral culture Elder groups 9 Tribal Council Approval University Approval Individual consent Approval Process 10 10 5
Study Design Focus Groups Local facilitator Snow ball recruitment Informed consent 11 Questions Communication Sickness Terminal illness End of life issues Issues for the future Audio recording Transcribed document Analysis of verbal data 11 Participants Elders identified by the community Representative of the community Total number of groups and participants Focus groups- 5 Participants- 34 Male- 6 Female- 28 12 12 6
Findings 13 Community Relationship Learning Family 13 Community There is an expectation by the community and patients that doctors are involved in the community--to learn: About the people as individuals and families How people are related to each other What is important to the people of the community 14 How the people of the community relate to the rest of the world 14 7
Relationship The unique importance of the person to person relationship This relationship is not built solely on the time within the clinic but outside the clinic as well. Time (longitudinal) is important to build this relationship Relationship of equals 15 This relationship is different than that experienced in other such medical settings (bi-directional trust and respect) The relationship itself is important to the ability to treat the patient. 15 Learning 16 There is a process involved in understanding what each person wants from the relationship. This requires: Mutual participation in the learning process from both the doctor and the patient A need to learn about the other in order to improve the relationship Time--the patient should make and keep appointments; the doctor should take the time to explain the issues with regard to the patients health Learning together/ building together 16 8
Family The patient and illness are not distinct from the community and family, therefore community and family need to be involved Western medicine requires strict regulation of information 17 17 Conclusions Is there a perceived miscommunication between Native American patients and health care providers such that it interferes with the patient/doctor relationship? Not just perceived but real Culture plays a major role in this miscommunication Providers can acquire information and skills to address 18 18 9
Recommendations Health care providers should be required to learn the skills and information needed to effectively work with American Indians. Patient Centered Care Treat the patient the way that they want to be treated Collaboration with the patient Importance of Uniqueness of the relationship Personal vs. professional Understanding connectedness Within the family Within the community Within the world Involvement with community 19 19 Cultural Competence Knowledge, attitude & skills about health related beliefs and cultural values, disease incidence and prevalence and treatment efficacy 20 20 10
CULTURAL COMPETENCE 21 KNOWLEDGE 21 Ten Leading Causes of Death in the U.S. in 2004 for AI/AN as Compared to the Nation 22 AI/AN 1. Heart disease 2. Cancer 3. Unintentional injuries 4. Diabetes 5. Stroke 6. Chronic liver disease & Cirrhosis 7. Chronic lower respiratory diseases 8. Suicide 9. Influenza and Pneumonia 10. Nephritis, Nephrotic Syndrome, & Nephrosis US 1. Heart disease 2. Cancer 3. Stroke 4. Chronic lower respiratory diseases 5. Unintentional injuries 6. Diabetes 7. Alzheimer s Disease 8. Influenza and Pneumonia 9. Nephritis, Nephrotic Syndrome, & Nephrosis 10. Septicemia Source: Health, United States, 2005, Table 31. ttp://www.cdc.gov/nchs/data/hus/hus05.pdf#summary 11
Comparisons 23 TIM Holistic approach Tribal beliefs of health and illness along with physical, social, and spiritual data to diagnose Teaches pt à heal self Healing and harmony Honors pt à heal self H&P/family assessment used along with tx plan Herbal meds may be used MWM Reductionist approach Reductionist data MD does healing Teaches patient to depend on system Disease and curing emphasized Honors MD to curing H&P, labs used for tx plan Pharmaceuticals may be used Primary Care of the Native American Patient 23 CULTURAL COMPETENCE 24 ATTITUDE 24 12
Attitude 25 Minimize the influence of stereotypes and beliefs on the recognition of diagnosis and treatment of disease to provide better care Understand the importance of cultural issues in optimal health care delivery Awareness of similar and dissimilar characteristics Increase self-awareness in dealing with situations of cultural competence Developing an ability to acknowledge issues to include stereotypes and bias Avoid the presumption of understanding without asking Satcher et al 2008 25 CULTURAL COMPETENCE 26 SKILLS 26 13
CRAASSH 27 Cultural dynamics and the expression of the many variables that influence culture Demonstrating respect by asking questions, addressing patients appropriately and expressing respect for and seeking to learn about the patients culture Assessing health beliefs, knowledge, literacy Affirming the positive values and characteristics of other culture by recognizing the expertise and experience that the patient offers and reframing cultural differences to address positive characteristics that contribute to practices we may often view as different Offering sensitivity through awareness of the cultural nuances, historical, political, religious and social concerns and differences in models of disease and health Examining ones personal attitudes and biases through identifying personal norms and values (self assessment) Exhibiting a measure of humility in recognizing that cultural competence is not a finite skill set that is acquired but rather a life-long journey and commitment Satcher et al 2006 27 Cultural Strengths Elders and Oral Tradition High context speech Noninterference Misunderstood Spirituality Connectedness Family and kinship Communal ceremonies 28 28 14
Health Care Providers are Problem Solvers 29 Culture puts up barriers to be overcome Culture provides assets to be employed to improve the health of the patient. Collaborator Barb Elliott PhD Funders Acknowledgements Minnesota Medical Foundation President s Faculty Multicultural Research Award 30 30 15