Special guest Stephen Carek, MD, CAQSM, DipABLM, Program Director for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program and Clinical Associate Professor at the University of South Carolina School of Medicine, Greenville, joins us to talk about cultural competency in healthcare.
Listen in as we discuss cultural differences and how biases can lead to disparities in healthcare.
None of the speakers have anything to disclose.
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Transcript:
00:00:07 Stephen Carek
I think part of this too is you have to be comfortable to get into areas of discomfort. We all have our own lived experiences. We all have our own backgrounds. But I think to fully immerse yourself and really understand and hopefully get rid of your own biases.
00:00:20 Stephen Carek
So I think the tool to do that is really kind of push yourself, push yourself in these areas of discomfort and try to seek more understanding and connection.
00:00:29 Stephen Carek
With those that have different backgrounds as you, because I think that is really what builds your ability to both label and acknowledge times when you are being biased as well as to create tools to hopefully mitigate that when you are feeling that.
00:00:42 NARRATOR
Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist Letter, Prescriber Insights, RX Advanced, and the most trusted clinical resources.
00:00:52 NARRATOR
On today’s episode, we’ll listen in as our panelists review cultural differences and how biases can lead to disparities in healthcare.
00:01:00 NARRATOR
Our guest today is Dr. Stephen Carek from the USC School of Medicine Greenville.
00:01:05 NARRATOR
This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.
00:01:19 NARRATOR
The full webinar originally aired on September 19, 2024.
00:01:24 NARRATOR
And now the CE information.
00:01:29 NARRATOR
This podcast offers continuing education credit for pharmacists, physicians and nurses.
00:01:35 NARRATOR
This podcast offers Continuing Education credit for pharmacists, physicians, and nurses. Please log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose.
00:01:47 NARRATOR
Now, let’s join TRC Editor, Dr. Sara Klockars, and start our discussion!
00:01:54 Sara Klockars
According to the US Census Bureau, by the year 2044, the United States is expected to become a majority minority nation, meaning that more than half of the population will consist of racial and ethnic minorities.
00:02:10 Sara Klockars
Unfortunately, we already know that health disparities exist across different groups.
00:02:16 Sara Klockars
Implicit bias can play a significant role in the quality of health care that patients from marginalized communities receive. Since these patients often face more obstacles when seeking care and tend to have worse health outcomes compared to their non-minority counterparts.
00:02:32 Sara Klockars
So to truly address these disparities.
00:02:35 Sara Klockars
We need to actively expand our understanding of the differences between ourselves and our patients.
00:02:41 Sara Klockars
Cultural competence involves developing the ability to respect and respond to the cultural needs of our patients and by enhancing our cultural competence, we can create a more inclusive and supportive environment for our patients but strengthens the trust and relationships we build with patients.
00:02:59 Sara Klockars
So Stephen, are there any specific strategies you’ve found useful in your practice or with your team to help increase cultural competence?
00:03:11 Stephen Carek
Yes, talking about implicit bias training simulation, I mean I think simulation and practicing this with your team is really important. If we don’t work on this in a safe environment, I think that it helps us create our own tools, helps us prepare, helps us understand. I mean it’s the right words to use right terminology to use and.
00:03:32 Stephen Carek
How to also use the non-verbal skills so that we can make sure that we are approaching our patients again in that unbiased and hopefully patient centered way that we can be advocates for them and meet their.
00:03:42 Stephen Carek
And the other two is also a lot of reflection and they mentioned we’ll still probably still make mistakes, but learning from those mistakes being open minded, reflecting on those opportunities, talking with someone about them is also a great. And so having resources, individuals within your team who are champions for this like in our program we have champions on DEI.
00:04:01 Stephen Carek
And being able to talk through these scenarios with them and understand what we can do better, maintaining that growth mindset is really been helpful for our team and trying to help move everyone forward and provide equitable high-level care.
00:04:16 Sara Klockars
Great. Thank you.
00:04:22 Sara Klockars
As we know, patients come from a variety of cultural backgrounds, each with its own set of beliefs, values, and practices, and just taking the time to learn about cultural norms and health related beliefs of the communities we serve can really enhance the care we provide, and this can be done through direct interaction education.
00:04:41 Sara Klockars
Immersion and cultural activities. You know, the more we know about different cultural groups, the better equipped we are to provide care.
00:04:50 Sara Klockars
Culturally competent care is patient centered care, and this means tailoring our approach to meet the individual needs and preferences of each patient.
00:04:59 Sara Klockars
By involving patients in their care decisions and respecting their autonomy, we can offer treatment options that align with their cultural values and result in better health outcomes.
00:05:11 Sara Klockars
And one way to identify cultural considerations is by asking those open-ended questions about their health. And this might just provide valuable insights into their culture or their beliefs. What do you think has caused your problem? This question might help you uncover the patients understanding, or potentially the beliefs about their condition.
00:05:33 Sara Klockars
Why do you think this problem started when it did so just by exploring their thoughts on the timing? That might reveal some personal beliefs.
00:05:43 Sara Klockars
What do you think this illness does to you?
00:05:45 Sara Klockars
How does it work?
00:05:47 Sara Klockars
These questions might provide insight to how the patient perceives the impact of the illness on their body or their overall health. So these are some questions we can ask that may give us some insight into their culture and health leads.
00:06:04 Sara Klockars
So Stephen, can you share some specific questions that you ask patients to really dig in and understand their needs and their care preferences to help tailor care for that patient?
00:06:15 Stephen Carek
Yeah, I think it’s a really a really good question and things that come to mind when I’m having patience with that. I think a lot of it’s like what are what.
00:06:24 Stephen Carek
Are your healthcare?
00:06:25 Stephen Carek
Goals. If you are having to make a difficult decision, who are the people that you lean on? Who are the people that you rely on? A lot of it is. Some of it is built in the past, especially if you have continuity these patients.
00:06:36 Stephen Carek
Understanding what are their beliefs in terms of their faith background, their their support system, their education level, building the relationships over time, these patients really can give you some understanding.
00:06:48 Stephen Carek
But I think at the end of the day, it’s really interesting. What are their goals, what influences that decision for their goals? What support do they have to achieve those goals? And then how is I as a provider help them in that journey and help them meet those goals?
00:07:06 Sara Klockars
Great. Thank you. Finding out patients needs and care preferences can be challenging, but let’s go ahead and shift gears and talk about some specific patient needs that we can help address.
00:07:20 Sara Klockars
Identifying a patient’s preferred language is important for providing culturally competent care.
00:07:27 Sara Klockars
In the US, about one out of five people speaks a language other than English at home.
00:07:32 Sara Klockars
And if we don’t know that a patient prefers a language other than English, then we may not be able to accurately identify the patient’s problem or concern. Make sure the patient understands explanations, or help the patient with basic medication needs.
00:07:49 Sara Klockars
Patients may know several languages, but maybe they prefer and have a higher health literacy in one language over the other when discussing their health care.
00:08:00 Sara Klockars
There’s some very helpful tools out there, such as the language identification flash card from the US Bureau of the Census, and this card allows patients to tick a box next to a statement in one of the 38 languages. And it does say, Mark this box, if you read or speak.
00:08:20 Sara Klockars
Croatian French so it allows you to check the box and then you’re able to tell.
00:08:27 Sara Klockars
What language the patient prefers?
00:08:30 Sara Klockars
And it’s very.
00:08:31 Sara Klockars
Important to document this in the patient profile or the medical record.
00:08:36 Sara Klockars
And as we know, there are many language resources available to support the patients preferred language. We have our organizations interpret our services, our computers.
00:08:48 Sara Klockars
Many have the capability to translate to certain languages.
00:08:52 Sara Klockars
And there are many other resources out there, some of them.
00:08:56 Sara Klockars
Include Medline Plus so this offers a library of health information in various languages so you can access a list of health topics with content and Chinese, Spanish, Vietnamese and many more. We also have the Agency for Healthcare Research and Quality or HRQ.
00:09:17 Sara Klockars
Has a list of standard and simple medication instructions that might be helpful in your practice, and this is simply how to say take 2 tablets twice a day in different languages, so it’s a great resource. It’s available in Chinese, Korean, Russian, Spanish, and Vietnamese.
00:09:35 Sara Klockars
And then there’s also the USP pictogram library, which offers a simple way to use standardized images to communicate medication instructions, precautions or warnings to patients. And they’re free for healthcare professionals to use and make it easier to reinforce important information.
00:09:54 Sara Klockars
And it is also very helpful to understand a patients cultural beliefs and as we touched on earlier, these may be shaped by and intertwined with many factors, religion, race, ethnicity, age, gender. All of these factors can impact.
00:10:08 Sara Klockars
Care. So, for example, a person’s culture may affect how a patient feels about western medicine or traditional remedies.
00:10:16 Sara Klockars
Or their comfort level of having and speaking openly with the healthcare provider of the opposite gender. So it’s important to consider that unintentional disrespect or an unwillingness to acknowledge and appreciate cultural differences may hinder communication with patients of very diverse backgrounds.
00:10:34 Sara Klockars
It’s easy for misunderstandings to unintentionally come up if a patient has a different culture or language from you. So just accepting these differences without being judgmental is super helpful.
00:10:47 Sara Klockars
So we’re going to cover a few common differences that we can consider in our practices.
00:10:52 Sara Klockars
Gender roles may be defined by a patient’s culture, so consider whether you are the opposite gender of the patient and how that might affect their interactions with you. So in some cultures, care is only provided by healthcare professionals of the same gender.
00:11:08 Sara Klockars
Certain topics, such as those related to sex or bodily functions, might even be taboo when discussed with patients of the opposite gender.
00:11:17 Sara Klockars
Physical contact between genders may also need to be avoided. In some cases, patients may be less trusting if health information is provided by someone of the opposite gender. So these are just considerations to keep in mind.
00:11:31 Sara Klockars
Providing gender diverse care is also important, since more than 1.6 million people in the US identify as transgender or gender diverse. And that means having a gender identity or expression that is different from the sex assigned to them at birth. And we just want to avoid making assumptions and also consider each patient’s unique needs.
00:11:50 Sara Klockars
For example, a transgender male, a person assigned female at birth who identifies as a male, may still have a uterus and require contraception.
00:12:01 Sara Klockars
A transgender female likely has a prostate and could develop prostatitis.
00:12:08 Sara Klockars
We can also ask patients about the pronouns they prefer and document preferences and their profile.
00:12:15 Sara Klockars
Or perhaps it’s better to use the patients name instead of assuming pronouns and some circumstances.
00:12:22 Sara Klockars
And also it’s super important if you make a mistake. Apologize. We all mess up and it’s important for us to be open and honest with patients.
00:12:33 Sara Klockars
Many spiritual or religious practices and beliefs can impact a patient’s health as well. So, for example, due to their religious beliefs, some patients may oppose the use of vaccinations or contraception, animal derived products or blood or blood products.
00:12:47 Sara Klockars
Some cultures may believe that discussing an illness can cause it, while others may believe that an equilibrium between the person’s body and the environment is responsible for their health. So these are just some examples of the wide range of beliefs patients may have about their health.
00:13:08 Sara Klockars
If you have a significant number of patients in your practice with a culture or religion different from your own, maybe consider researching and exploring it.
00:13:16 Sara Klockars
Reach out to a local community leader and find out how their beliefs may impact their health care, and then share what you find with your coworkers to help increase everyone’s awareness.
00:13:26 Sara Klockars
Stephen, did you want to share one of your experiences and how it impacted you?
00:13:34 Stephen Carek
Yeah. I mean, there’s so many that it’s hard for me to just pick one. I think. I think the ones that are most rememberable for me are the ones that I sort of entered an area that I was most uncomfortable with.
00:13:44 Stephen Carek
But then had the experience with the patient and just emerged with just a completely different understanding, I think some of these examples are like in hospitals.
00:13:52 Stephen Carek
I think taking care of patients who are at least one specific patient in their family, who were of a different faith belief than I was, they were Islamic. I come from a Christian background and so working with the family during an end-of-life period with a patient and them including us and some prayer and in some celebration for this family was.
00:14:12 Stephen Carek
For me a new experience, you know, you kind of enter that feeling a little uncomfortable, not knowing what to expect, but then you kind of emerge from and after participating and being part of such a.
00:14:21 Stephen Carek
I think a very important and a very sacred event with them was really, really meaningful to me, something that was really powerful and I think part of this too is you have to be comfortable to get into areas of discomfort. We all have our own lived experiences. We all have our own backgrounds. But I think to fully immerse yourself and really understand and hopefully.
00:14:44 Stephen Carek
Get rid of your own biases. So I think the tool to do that is really kind of push yourself. Push yourself in these areas of discomfort and try to seek more understanding and connection with those that have different backgrounds as you. Because I think that is really what builds your ability to.
00:14:59 Stephen Carek
Both label and acknowledge times when you are being biased, but as well as create tools to hopefully mitigate that when you are feeling that.
00:15:07 Sara Klockars
Thank you.
00:15:09 Sara Klockars
By listening carefully to patients, you may discover that some patients prefer to use an alternative or herbal product.
00:15:16 Sara Klockars
We want to be sure to ask patients for all prescription meds, Otcs, vitamins and supplements they’re taking when we’re updating patient profiles or Med lists, and this may help identify patients who prefer natural medicines.
00:15:29 Sara Klockars
We can also acknowledge that these alternative therapies and, if appropriate, help patients understand how they fit into their overall therapy.
00:15:37 Sara Klockars
So for example, some alternative or natural medicines may interact with the patient’s prescription drugs or with their diseases. Others may not have much evidence to support their use, but may not be harmful.
00:15:50 Sara Klockars
So Steven, I want to pause here. Can you share an example of a discussion you’ve had with a patient who preferred natural medicines over other recommended therapies and how that discussion went?
00:16:03 Stephen Carek
That’s a very good question and we see this a lot. You see this a whole lot, especially with the prevalence of social media and people out there telling people to do all sorts of things. And I think there’s kind of two trains of thought, right. There’s gonna be thoughts of I think people will attempt to do their research and understand what is going to be a safe alternative for me. That’s not part of maybe the traditional pharmaceutical route in terms of management.
00:16:25 Stephen Carek
And there’s be those that may have sort of this outlandish idea of what may be beneficial for them. And you worry that could potentially cause harm.
00:16:32 Stephen Carek
For them. So I think part of us is be curious, why do they want to use that? I think the other thing sometimes I do a lot is just awesome. I don’t know a whole lot about this. I really don’t. But I want to do some research with you right now so I can understand what this may, how this may impact your health. And I typically also add what you want to use is not well studied, is not FDA approved.
00:16:52 Stephen Carek
There’s certain agencies that really, really take a lot of time to understand if this is something can be safely used for patients.
00:16:59 Stephen Carek
This is not part of that and so I just want you to know I can’t anticipate every outcome that may come with this but my goal with you is to make sure that you’re being prescribed medications or products that are safe for you that I hope will help you kind of achieve your health goals, whatever the purpose of this medicine may be.
00:17:18 Stephen Carek
Sometimes there’s instances where there may be a disagreement, and that’s OK, you know, you just acknowledge, you know, I may not agree with this. And again, sort of same thing. You know, I care about the patient, I care what’s you. I would not recommend this for you.
00:17:30 Stephen Carek
I would sort of give them what my sort of understanding what may be a better alternative for them, present that to them and allow them to make the decision, but if they make a decision that’s I don’t necessarily agree with that I can accept that. And then again, my goal is to make sure they’re doing so safely. So if there’s any additional follow up labs or additional conversations that we have, we can go support from there, but always letting patient to know that I.
00:17:50 Stephen Carek
You know, I want to help them. I want to support them. And again, if we disagree, that’s OK. That’s OK. My goal is always to make sure that the patient is safe. I don’t want to prescribe or utilize any therapies that I think going to be harmful for the patient. And so I just have to be very honest with them in that.
00:18:06 Sara Klockars
Thanks for sharing. And yes, safety is key as more and more patients are using natural medicines.
00:18:14 Sara Klockars
Another consideration that may impact a patient’s Healthcare is family involvement.
00:18:19 Sara Klockars
Have the patient identify whether any family member should be involved in the discussions. For example, some cultures put an emphasis on the importance of family, including extended family like friends or neighbors.
00:18:32 Sara Klockars
And the extended family may play a role in the patients, healthcare and decision making, so it may be just as important to work with the family member to get their buy in for health care decisions.
00:18:43 Sara Klockars
Also, some cultures prefer health information to be shared with the family rather than the patient.
00:18:50 Sara Klockars
So for example, it may be expected that news of a terminal illness will be told to the family, not to the patient in certain cultures.
00:18:59 Sara Klockars
So be sure to ask about the patients preferences when it comes to involving family members in the decision making process.
00:19:08 Sara Klockars
Cultural or personal beliefs can also impact the dietary needs of patients, which can affect their medication use.
00:19:16 Sara Klockars
One example is patients who fast for common religious observances, and this can be very important to consider in patients with diabetes.
00:19:25 Sara Klockars
Patients with diabetes who choose to fast must know how to adjust their medications to avoid their blood sugars from going too high or too low.
00:19:34 Sara Klockars
The care team should work together with patients to determine how to best adjust medicines if necessary during fasting.
00:19:43 Sara Klockars
Vegetarians, vegans and individuals who follow certain religious beliefs may also have specific dietary restrictions that avoid animal sourced ingredients. So, for example, some people avoid pork due to religious or personal beliefs.
00:19:59 Sara Klockars
Gelatin, which is often used to make capsules, some tablets and even vaccines can be a concern for those with these dietary preferences or restrictions. Since gelatin can come from pigs or cows.
00:20:14 Sara Klockars
So we must be mindful that some prescription in OTC meds as well as supplements may contain animal derived ingredients, which could be problematic for some patients.
00:20:28 Sara Klockars
So for instance, calcium can come from oyster shells. Chondroitin from bovine cartilage, and glucosamine from shellfish. A few other examples include Armor Thyroid, which comes from desiccated pig thyroid, or anoxic pyrin, which comes from pig intestine.
00:20:47 Sara Klockars
We also have Premarin from pregnant mares urine and then some flu vaccines are grown in chicken eggs.
00:20:55 Sara Klockars
So just be sure to document details about patient preferences and their profiles, so products with ingredients from animals can be avoided if needed.
00:21:06 Sara Klockars
We can also help patients identify the source of the ingredients.
00:21:11 Sara Klockars
We can definitely reach out to the manufacturer to help patients if information isn’t available in the labeling, we might even be able to work with prescribers to change medicines. For example, sometimes a gelatin capsule can be switched to a tablet, or the patient may be OK with emptying the contents from a capsule.
00:21:32 Sara Klockars
Or possibly switching to a liquid formulation. And then there’s always the option of just switching to other medications altogether that are in a different dosage form.
00:21:43 Sara Klockars
We reviewed so much we can do to provide culturally competent care, and there are many helpful tools out there to help us.
00:21:50 Sara Klockars
And we all know that cultural competency isn’t a box we check off, it’s a skill we continuously develop throughout our careers.
00:22:00 Sara Klockars
Cultural competency is an ongoing, lifelong process and is not something you either do or don’t have. So as healthcare professionals, we need to stay open to learning, adopting, and improving our understanding of the diverse cultures we encounter daily in our practices.
00:22:17 Sara Klockars
By committing to this process, we can provide more inclusive and effective care for all of our patients.
00:22:26 NARRATOR
We hope you enjoyed and gained practical insights from listening into this discussion.
00:22:30 NARRATOR
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00:22:43 NARRATOR
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00:22:50 NARRATOR
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00:23:02 NARRATOR
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00:23:08 NARRATOR
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00:23:15 NARRATOR
Thanks for listening to Medication Talk.