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Providing Culturally Appropriate Care in the ED

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POSTED IN: EPIC - The Official Newsletter of MOCEP, July/August 2017,

Written by Douglas Char, MD, FACEP

By 2050 Hispanics and Asians will triple, Blacks will double, and Whites will barely hold their own. As the U.S. becomes more ethnically and racially diverse, there is a need for healthcare systems and providers that can reflect and respond to an increasingly heterogeneous patient base.   We serve people with different values, health beliefs and alternative perspectives about health and wellness.

Cultural awareness is the ability of the health care providers to understand and respond to the unique cultural needs brought by patients to the health care encounter.   Physicians should consider the patient’s culture as it relates to the patient’s history and presenting symptoms in recommending a treatment plan that is mutually agreed upon by the patient and physician [taken from the 2014 ACEP policy on Cultural Awareness and Emergency Care].

However, awareness isn’t enough.  Quality health care depends on the scientific competence of physicians as well as their cultural awareness.  Cultural awareness should be an essential element in the training of health care professionals and to the provision of safe, quality care in the emergency department environment.  Health care providers should encourage patients and their representatives to communicate cultural issues that may impact their care.   The federal government has mandated that resources be made available to emergency departments and emergency physicians to assure they are able to respond to the needs of all patients regardless of their respective cultural backgrounds.

We face many challenges in the ED.  Yet the emergency department is an environment where cultural sensitivity is particularly critical. We work in a multi-generational setting where Gen X staff are called upon to care for Millennials and Baby Boomers.   Think about all the languages spoken by our staff and the increasing need for translators. The difference in educational attainment between the unit secretaries /techs and physician is measured in years – decades.  Physicians reap the benefits of a socioeconomic stratum that most of our patients can’t imagine.  It’s all about power and for the most part we (physicians) are at the top.

The National Standard for Culturally and Linguistically Appropriate Services in Health Care (CLAS) report debuted in 2001 and regulatory enforcement went into effect in 2014.  This federal policy covers governance, leadership and workforce disparities.  Physicians are most impacted by the tenets related to communication and language assistance.  Hospitals must offer language assistance at no cost, inform individuals about language services, ensure competence of individuals providing assistance, and provide easy-to-understand print and multimedia material and signage in language commonly used within the health care systems area of service.  Additionally there is a call for ongoing engagement, continuous improvement and accountability by the health system.   Emergency departments like other areas of the hospital must establish culturally and linguistically appropriate goals and policies, and conduct regular assessment of community health assets and needs.  The hospital C-suite is probably aware of this but many emergency physicians and staff are not.   This is a great opportunity to undertake an ED self-assessment to identify needs that you can ask the hospital to help remedy.

On an individual level, one of the biggest eye openers for most physicians is the realization that our patient’s medical belief system might be very different from our own.   Most of us grew up with and trained in a biomedical health model that valued scientific reductionism (grounded in a mechanistic model of the human body).  Traditional (folk) medicine often adheres to a personalistic or naturalistic model predicated on a mind-body-spirit integration.  Harmony with nature is desired, and the spiritual dimension plays an important role. How does one work with multiple, potentially competing, belief systems?

As clinicians we get tripped up in three ways.  First we all possess unconscious biases and stereotypes that impact how we perceive people (patients) and can lead to provider uncertainty.  Secondly we have limited training about how to provide culturally appropriate care (this is especially true of Emergency medicine and surgical specialties).  Third, even if one wanted to work to overcome these barriers we lack sound education opportunities, and to date our professional societies haven’t valued (modeled, reinforced) diversity and inclusion as critical to our professional success.  That is changing.

A generation ago the idea of a Pediatric ED was novel, and a decade ago nobody was thinking about Geriatric EDs.  We now acknowledge that these special populations of patients require not only unique equipment and physical accommodations, but also specially trained staff and providers.  The realization that our youngest and oldest patients deserve extra considerations is now common place.   We must now appreciate a similar analogy when it comes to caring for individuals that speak a different language, adhere to a different religion, embrace a different lifestyle, struggle with daily challenges (financial, housing, food security) we don’t truly understand.

We can start to address some of these discrepancies by increasing cultural awareness and reduce provider biases to interact more effectively with patient populations.  We can strive to accommodate patient preferences and needs through practice adjustments and cultural modifications.   A big part of the solution is to increase provider diversity to raise the level of tolerance, awareness and understanding for other cultures and create more racially and/or ethnically concordant patient-physician relationships.

At a departmental level we can work to involve patients in their own health care.  As a group we can learn more about the cultures we serve. We can speak the language and insist about trained interpreters.  We can remember to ask the RIGHT questions (see below) and pay attention to financial issues that may derail our best medical solutions.

A warenes: Am I aware of my personal biases and prejudices toward cultural groups different than mine?

S kill: Do I have the skill to conduct a cultural assessment and perform a culturally-based physical assessment in a sensitive manner?

K nowledge: Do I have knowledge of the patient’s world view and the field of biocultural ecology?

E ncounters: How many face-to-face encounters have I had with patients from diverse cultural backgrounds?

D esire: What is my genuine desire to “want to be” culturally competent?

We demonstrate our cultural competency through communication (by attitude and behavior, with openness to different cultures), a willingness to adapt clinical practice, acknowledging that patient and family culture is important, and demonstrating a commitment to professional development.   

We must, however, never forget that the variability within cultures may be more pronounced than between cultures. Poor inner-city African Americans and poor White from Appalachia may face more similar socioeconomic barriers and challenges than those faced by wealthy African Americans.  There is also great variability between recent immigrants and those who have been in the United States for one or more generations.

Ask yourself – “is my ED an open and welcoming clinical space?”  What can you change to make it more welcoming for patients and staff? Lots of studies have shown that a space that is open and welcoming to patients will also be open and welcoming to team members, allowing for a more vibrant and inclusive work environment.