CHAPTER 14

Culture and Diversity

Mr. Jackson is an African-American man in his 50s, known to the staff in the clinic as a difficult patient, not because he is angry or disrespectful but because his health only worsens and never improves. The clinicians and nurses in the office try to treat him with kindness but never seem to be able to get past what they perceive as his “disengagement.” Dr. Barrett, Mr. Jackson’s primary care clinician, feels resigned and sometimes hopeless. Though Dr. Barrett would never openly criticize him, she privately wonders whether Mr. Jackson just doesn’t care about his diabetes, hypertension, and chronic kidney disease. Whenever Dr. Barrett asks her patient, “Do you have any questions about your health?,” the answer is almost always, “No.”

In my travels as an educator, I (Denise Davis) often survey healthcare professionals about whether they have had training in communicating across racial, ethnic, language, and other differences. During one session at a regional academic conference, the only hand that went up belonged to a medical student from my home institution! When I initiate these conversations, people tell me that when these sensitive topics come up in healthcare, they simply don’t know what to say.

The major risk is that if we don’t address these issues, we miss critical opportunities for building trust and improving quality of care for minority patients. When we make a point to tackle the sensitive issues of race and ethnicity in healthcare, we learn how to improve care for minority patients and provide better care for everyone across another critical cultural divide—healthcare professionals and their patients.

Though I’ve never met a clinician or nurse who voiced an intention to discriminate against patients, reliable research indicates that unconscious bias is both real and very common among physicians and nurses. For example, observational studies show that African-American patients’ visits with clinicians are shorter than white patients’ visits, and they experience less positive emotional connection and less sharing of decision-making with white clinicians than with African-American clinicians.¹

We know from a variety of studies that minority patients (African-American, Latino, Native American, LGBT, and some Asian-American groups) have poorer health outcomes than their majority counterparts.² For example, end-stage kidney disease is twice as common for black patients as compared to white patients; Latino patients develop end-stage kidney disease at approximately three times the rate of white patients.³ Many of these patients require dialysis, a treatment that is often lifesaving but results in severe disruptions in the patient’s physical, social, and economic life, not to mention the lives of the patient’s loved ones. Other examples include women identifying as lesbian who are less likely to undergo recommended screening for breast cancer or cervical cancer,⁴ and Asian-American groups with significantly lower cancer screening rates and high cancer mortality.⁵

What can we do to ensure that all our patients receive equal treatment? By addressing these disparities, we seek to reduce inequity, improve patient experience for minorities, and simultaneously improve the experience of healthcare professionals. Mr. Jackson, the patient mentioned at the beginning of this chapter, triggers negative emotions in his healthcare team because team members feel frustrated and hopeless when they interact with him. Dedicated clinicians want to change a patient’s poor health. When we are unable to do so, it can feel like a personal failing and can impact the level of support we offer. Learning more about how to communicate effectively with minority patients can help clinicians enjoy these relationships and find ways for patients to achieve better health.

Dr. Barrett is having challenges in communicating with Mr. Jackson in part because she is making assumptions and inferences about Mr. Jackson without explicitly bringing up her concerns. This is a common trap that clinicians often fall into. Most clinicians I meet tell me that they treat everyone the same and don’t see color, and many may feel anxious about coming across as anything but supportive. Dr. Barrett does not want to be seen as discriminatory, or worse, a racist. But she is avoiding addressing an elephant in the room: race and its effect on health, healthcare, and the patient-clinician relationship.

I know of a patient with a very different story. Mr. Young is an African-American man in his 50s who has learned to care for his chronic illnesses over time, in partnership with his physician and the healthcare team. He feels comfortable talking about his relationship with his clinician, including the difficulty he feels in discussing sexual concerns with a female clinician. His clinician has also invited conversations about what it was like for him to live in the American South as a young black man, and how his life has changed and has not changed since he moved to a politically liberal, urban, coastal city. How can we achieve this alternative to the typical guilt-ridden interactions that commonly affect clinicians?

Good Communication Takes Practice

Comparing Mr. Jackson and Mr. Young, it’s easy to think that some clinicians naturally have the comfort, confidence, and skills to discuss sensitive topics. But it’s important to recognize that good communicators about sensitive topics are made, not born. I look back on my early years as a physician, and I feel embarrassed about how often I lacked the courage to open a conversation about differences. I thought that being a “good doctor” was enough.

It turns out that the fundamental skills presented earlier (see Chapters 3–5) are powerful resources for improving communication across many differences. In the United States, racial differences, especially differences between white and black patients, have been extensively researched. But these communication techniques can go beyond bridging racial and ethnic divides. Committing ourselves to adopting the fundamental communication skills will help, or even resolve, many of the challenges we face when treating patients across a variety of differences. The following recommendations are evidence-based, in part on medical literature⁶ and in part on a series of focus groups I conducted of African-American patients in the San Francisco Bay Area. I learned to enhance my practice from these groups of men and women who became my teachers, and I have found these principles to be very effective for many, if not most, of my encounters with patients, families, and learners who present differences, obvious or subtle.

THE BEGINNING OF THE ENCOUNTER

Human beings have evolved to judge others as friend or foe very quickly. Our species has survived in part because of our ability to make snap judgments about whether another person will harm us or help us. These judgments are unconscious, and they happen in milliseconds. Therefore, the way we initiate a patient encounter is critical (see Chapter 3). To more effectively begin encounters where difference is present, we must prioritize building trust with patients, many of whom may harbor mistrust from personal or vicarious experiences of bias and discrimination. One need only think of the infamous Tuskegee experiments on black men to remember how the healthcare system defied moral standards of practice and undermined trust.⁷ For minority patients who may have low trust, we can win or lose the ballgame in the first few minutes. And the risk is real. Low-income whites, highly educated blacks, and people who experience economic barriers in obtaining healthcare are more likely to perceive discrimination in their clinicians.⁸

Research shows that race-concordant patient-clinician visits (where the race of the patient and clinician are the same) show improved patient experience. Instead of attributing this improvement to some amorphous halo effect in which black patients always magically feel more comfortable with black physicians, careful observations of interactions were revealing: smiles and laughter were prominent.⁹ Trust underlies this level of comfort. We can create a strong foundation of trust at the beginning of an interview with a warm greeting, a well-paced and generous introduction to the patient and everyone else in the room, and a clear explanation of our role.

Dr. Meredith: Mr. Thomas, I’m Dr. Meredith. It’s a pleasure to meet you, though I’m sorry I’m meeting you on a day that you don’t feel well. I’m a family practitioner, which means I take care of adults and children, men and women of all ages for their general health. I’ve worked here at the Wright Clinic for ten years and I love what I do. May I get you a cup of water and hang up your coat?

If this does not ring true to the reader, I agree. It’s not typical. Yet, when I have used exactly these skills with patients billed as “difficult,” their responses have usually been very warm and positive. After an elaborate introduction, similar to the one just described, that included years in practice with an explanation of my specialty, one patient said, with a smile on his face, “No one has ever done that before.” These may seem like trivial interventions, but they are not easy changes to make when we are rushed, burdened by productivity metrics, and annoyed by the electronic health record. In addition, data suggest that only 40 percent of interns at a major East Coast research hospital actually introduced themselves to patients in the hospital. Only 37 percent of interns explained their role, and, sadly, a mere 9 percent sat down and looked the patient in the eye.¹⁰

Beginning encounters in this way is certainly different than many of the rushed introductions I’ve witnessed during my observations of clinicians and nurses. An effective opening like this may require an additional 15 to 20 seconds, but the return on investment is almost always well worth the additional time up front. Higher levels of trust are associated with improved health outcomes, including diabetes management, hypertension,¹¹ and improvement in cardiovascular disease risk factors (see Chapter 1), conditions that disproportionately affect African Americans, Latinos, and Native Americans.

ADDRESSING BARRIERS

The hierarchy that separates physicians and patients is exaggerated for patients from the black community. How better to address this social phenomenon than to practice relationship-centered skills at the beginning of an encounter? The story of one of my family members illustrates this.

Dr. Fannie Fiddmont went to see a new primary care clinician near her home in Littleton, Colorado. Into the exam room walked a friendly, young white male physician. “Hi, Fannie,” he said. That was Dr. Fiddmont’s first and last visit to see that physician. My beloved Aunt Fannie is an African-American educator who experienced the injustice of segregation while growing up in Texas before the US Supreme Court’s Brown v. Board of Education decision. Using titles shows respect and is an important part of setting the stage for a successful visit.

One additional important barrier is language. Many researchers have found that patients with limited English proficiency report more problems with clinical interactions than patients proficient in English. Even when translation services are high quality and readily available, clinicians may intentionally choose not to use the services because of time constraints.¹² Patients with language barriers have lower patient satisfaction, longer hospital stays, and an increased risk of misdiagnosis.¹³

From a workshop in St. Paul, Minnesota, I learned, from a group of very caring surgeons who treat many Somali patients, to say to the patient via the translator: “I wish that I spoke your language.”

WHEN IN DOUBT, LISTEN TO THE PATIENT: THE PATIENT’S PERSPECTIVE

Think about the hierarchy in our lives as healthcare professionals. With equals, we share important details about our work, our qualifications, and our lives. We don’t think of our patients the same way we think about our colleagues, but it is critical that we treat them as equals. A framing statement, related to the ideas and expectations questions discussed in Chapter 4, can help mitigate the social stratification that interferes with partnership: “You know your body. I am interested in what you know to be good for your health and what you have found to be negative.”

Another potential way to deepen understanding of the patient’s perspective is to acknowledge the past and present in order to make the future better. The 1999 Institute of Medicine report Unequal Treatment analyzed health disparities in the United States, revealing that minority patients often receive lower quality medical treatment.¹⁴ Complex reasons cause these disparities. The document takes aim at how social factors, including unconscious bias and stereotyping, influence the patient-clinician encounter. We must also remember the effects of trauma, internalized oppression (internalized negative stereotypes and beliefs that become part of the self-image of individuals belonging to marginalized groups), and learned helplessness on the thoughts, feelings, and behaviors of minority patients.

One of the most challenging communication tools required of healthcare clinicians is acknowledging the realities of injustice and unequal treatment. Sometimes you must name the elephant in the room. One example follows:

“Historically, African Americans, patients without insurance, and other minority groups have received treatment that was not equal to the care given other, more privileged groups. I wish I didn’t have to ask, but I will because I’m an advocate for you. Do you ever feel you have been treated differently?”

I have found this question to be extraordinarily powerful.

EMPATHY AND RESPECT

The PEARLS statements introduced in Chapter 4 work with almost any person. In particular, addressing emotional cues and respect are probably the two highest-yield items. Empathy may well be the universal solvent for bias and disparities in healthcare and could be lifesaving in preventive health: “For Latino women, perceptions of higher professional empathy and less negative emotions were associated with better continuity of cancer screening.”¹⁵ Because every human, regardless of demographic differences, experiences emotion, the impact of empathic statements that recognize emotional cues cannot be overemphasized.

Respect is “fundamental to understanding and thinking about how patients should be treated.”¹⁶ Respect is more than just thinking that we are being respectful—it requires specific words, accompanied by authentic nonverbals. We can demonstrate respect in the way we talk with our patients, deepening their trust and strengthening our relationships with them.

For example, a clinician seeing a patient with diabetes might use brief statements to demonstrate respect, such as:

“I have a great deal of respect for you, Ms. Minaya. You have put together a detailed account of your blood sugars since our last visit. You have done a lot to try to keep up with your medicines.”

MORE ABOUT TRUST

In the 1970s the financial services firm Smith Barney featured the phrase, “They make money the old-fashioned way … they earn it.” The same can be said about trust in relationships with patients. Simply stating, “I want to earn your trust” can be extremely effective.

Rarely is there a good time to address racial, ethnic, or other differences on a first visit, when building a foundation of rapport is paramount. But as we get to know our patients, we may find that inviting conversations about differences is beneficial. Going back to the example of Mr. Jackson, we may recall that Dr. Barrett has been repeating the same conversations without success, spending a great deal of time spinning his wheels and going nowhere. If Dr. Barrett summons the courage to broach a conversation about their differences, she may learn about the experiences that have caused Mr. Jackson to mistrust healthcare professionals. In reality, Mr. Jackson grew up in circumstances in which racial segregation and poverty ruled. As clinicians, we may fear that starting conversations about race and ethnicity is like opening Pandora’s box. Instead, these conversations often help us to connect more deeply with our patients so we can get off the hamster wheel of repeating the same defeating conversations over and over again. To gain a better understanding of Mr. Jackson’s life and perspective, Dr. Barrett could start out by saying, “I would like to get to know you better as a person, including good and bad experiences you’ve had with clinicians.”

Several years ago, one of the trainees I supervised was seeing an African-American man with a serious health problem who had lost faith in his previous healthcare team. He sought out a second opinion at a Veterans Administration hospital associated with a prestigious academic institution. The trainee practiced some of the skills offered in this chapter. Despite the patient’s mistrust, after the trainee said, “I know trust takes time, and I want to earn your trust,” the patient left the visit saying to her, “I want you to be my clinician forever.” Coincidence? I think not.

DELIVERING DIAGNOSES AND TREATMENT PLANS

Focus group participants identified educational disparities as a source of difficulty in relationships with healthcare professionals. Historically, African Americans and Latinos have been forced into segregated low-resource public schools, resulting in generations of black and brown people having less opportunity to receive a high-quality education, the foundation of health literacy.¹⁷ One female focus group participant said, “Some people may not know enough to ask the right questions.” This is one of the causes for a condition called “white coat silence.”¹⁸ When a well-meaning clinician or nurse asks a patient with low health literacy, “Do you have any questions?,” the answer is often, “No.”

This same patient may have health concerns that need to be addressed. So what can we do to get a different response? ARTful (Ask, Respond, Tell) communication (see Chapter 5) is an effective alternative that will draw patients out and give clinicians information to better support them. A simple way to start an ARTful conversation is to change the closed-ended “Do you have any questions?” to “What questions or concerns do you have about the diabetes medication?” The answer is almost universally, “Actually, I have some.”

Patients often ask about the following concerns:

•   Side effects of medicines

•   Cost of medicines

•   Duration of treatment: do you have to take it forever?

•   Alternatives to medicine: e.g., what could I do naturally to reduce my blood sugar?

Finally, African-American clinicians are more likely to share medical decision-making with their black patients.¹⁹ This finding can be generalized to help all clinicians succeed in connecting with patients. Some clinicians I have coached become anxious about giving a patient with little training and experience in medicine power to prescribe their own treatment. Hearing and even reflecting back patients’ ideas does not mean that what they request is what we ultimately recommend or prescribe. Partnership with patients is not just a catchphrase; it’s essential in order to decrease disparities at the level of the patient-clinician relationship and to provide safe, high-quality care that promotes adherence.

Conclusion

Intentional and effective practice of the evidence-based fundamental communication skills outlined in previous chapters will also improve communication across racial, ethnic, language, and other differences. Additional higher order skills that identify and address the elephant in the room require courage, practice, compassion, and wisdom.