Striving for Culturally Sensitive Care

The term “cultural competence” has been used in medicine for decades, with physicians aiming to deliver care that addresses a patient’s social, cultural, and language needs.¹ But as the medical community – and society as a whole – grapples with complex issues like how to achieve equity and tackle structural racism, the conversation is turning to different terms, such as cultural sensitivity and cultural humility.

“We are never competent. It’s not like we’re taking a test where there is a right answer,” said Ana Maria López, MD, professor and interim chair of medical oncology at Sidney Kimmel Medical College and associate director of Diversity, Equity, and Inclusion at Sidney Kimmel Cancer Center at Jefferson Health in Philadelphia. “Things work best when we approach the patient with humility and understanding that there may be a lot that we don’t know about the patient’s experience.”

Cultural sensitivity doesn’t aim to achieve competence in patients’ cultures but rather shows respect for them and their cultures throughout the interactions with the physician and staff, in the broader health care policies, and in the physical environment of the clinic or hospital.² Cultural humility is a related concept that encourages clinicians to recognize that they don’t know everything about a patient’s experience and puts patients in a position to lead the way.³

“Doctors are trained to know it all and have all the answers. With humility, we don’t have all the answers and that’s okay. It’s not something to shy away from,” said Laura Anne Lowery, PhD, associate professor of medicine and director of Diversity, Equity, and Inclusion for the Section of Hematology and Medical Oncology at Boston University (BU) and Boston Medical Center. “We need to be comfortable with our lack of understanding and awareness of other people’s experiences. We all have unconscious biases that may impact our thoughts and actions, and the more we’re aware of them, the better clinicians we’ll end up being.”

ASH Clinical News spoke with Drs. López and Lowery and other experts about the evolving language of culturally appropriate care and tips for how to make patients feel welcome and respected when receiving hematology treatment.

Don’t Make Assumptions

The golden rule of providing culturally sensitive care in hematology, and throughout medicine, is “Do not make assumptions,” experts agreed.

“We never know the life experiences and the full complement of someone’s identity when we enter a room with them for the first time. Even after we’ve known them and treated them for a while, we never know a person’s total experience and what they’ve been through,” Dr. Lowery said.

In practice, that could mean not making assumptions about their literacy, religion, gender identity, values related to medical treatment, origin or ancestry, or even their ability to access care, explained Leeann Medina-Martinez, LMSW, an oncology social worker and the disparities program coordinator at CancerCare, a national organization that provides free professional support services and information to people with cancer, their caregivers and loved ones, and the bereaved. Instead, Ms. Medina-Martinez suggested adding some basic assessment questions to the intake paperwork. That allows the practice to gather information that can help a physician start a conversation later, as well as prepare the staff when scheduling future appointments.

Office staff will often suggest a time for a follow-up appointment without first inquiring about the best time of day for the patient, Ms. Medina-Martinez said. A midday appointment, for instance, could be difficult for patients who have to work or do not have childcare, although they may not feel comfortable asking for a more convenient time.

“The patient might not show up for the appointment, and meanwhile in the doctor’s office, no one is aware of the reason why. The patient might be deemed as being noncompliant with their appointment or their treatment, but there’s a reason for the noncompliance,” she said.

The better approach, she added, is to start by asking patients about their preferences up front, signaling the practice’s willingness to work around the patient’s schedule.

Similarly, physicians should not assume that they know a patient’s level of literacy, English proficiency, or how they best receive information, said Dr. López, who is also a past chair of the Health Equity Committee of the American Society of Clinical Oncology.

When reviewing the possible side effects of a prescribed treatment, for instance, Dr. López recommended asking whether there is a specific way the patient would prefer to receive the information.

“Some people like for me to go over it, some people like to read it first, some people would like to see a video about it,” she said. “Everybody has different ways that they accept communication. You might be the most learned person and you might say, ‘I’m really tired and I just want to see a video right now.’”

Emma Groarke, MD, an attending hematologist and physician researcher in the Hematopoiesis and Bone Marrow Failure Laboratory at the National Heart Lung and Blood Institute, treats patients from different countries as part of her clinical trial work. She recently encountered an example in which making assumptions about a patient led to less-than-ideal care. A child enrolled on a clinical trial was not eating, and the dieticians assumed there was a medical cause, she said. However, after speaking with the child, it turned out she simply did not like the processed American food being served. The staff arranged for the child’s mother to prepare food she enjoyed eating at home, and she was soon eating again.

“You need to consider the entire picture,” Dr. Groarke said. “This was something that we should have thought of earlier. If we had spoken to the family and tried to figure out what was going on, rather than just assuming it was a medical issue, then we could have come up with this sooner.”

Mindful Use of Language

Understanding the impact of language is another critical component of culturally sensitive care, said Camille Edwards, MD, an assistant professor of medicine and a hematologist at BU and Boston Medical Center. That means being able to have conversations in the patient’s preferred language with interpreters and providing forms and educational materials in the patient’s preferred language.

Practices can signal that they are welcoming of patients who prefer languages other than English by having a list of languages offered posted by the check-in desk.

How physicians communicate during the visit can also make a difference in whether patients feel respected, Dr. Edwards said. For instance, asking patients where they are from originally, rather than asking about their background, can make patients feel like they don’t belong based on how they look or speak.

Always treat patients with respect, even when they express a belief that may not be supported by evidence, Dr. López advised. Instead of trying to correct patients, ask them to talk more about why they think that way. That approach helps to build trust with patients and creates openness so they might be more willing to hear the physician’s perspective later; it allows the physician to learn as well.

Interconnection of Factors

Being culturally sensitive also means being honest with patients when the evidence behind treatment recommendations is incomplete because representation of racial and ethnic minorities in clinical trials is inadequate, explained Ann-Kathrin Eisfeld, MD, director of the Clara D. Bloomfield Center for Leukemia Outcomes Research at The Ohio State University and assistant professor in the Division of Hematology.

Issues like clinical trial diversity and structural racism are all intertwined, Dr. Eisfeld said, and clinicians need to keep that in mind to provide quality care to their patients.

“You have to consider all the obstacles that a patient encounters until the moment they sit in front of you, whether it’s socioeconomic disparities, comorbidities, or transportation issues,” she said. “It’s all a continuum.”

Don’t Be Afraid to Make Mistakes

One of the barriers to practicing with cultural sensitivity is the physician’s concern about “being right,” Dr. Lowery said. “When I say the wrong thing, and someone points it out, I so desperately want to defend my intention. But intention does not negate impact, and by focusing on the intention instead of the impact, that invalidates the [other] person’s experience,” she said.

A better approach is to apologize and pledge to work to do better, Dr. Lowery said.

“Put yourself out there,” Dr. Eisfeld advised. When it comes to presenting her research, Dr. Eisfeld said she begins with a disclaimer that she may make mistakes and tells her audience that she wants feedback to improve. “Showing this vulnerability and showing that you are thinking about it is something that is appreciated by patients and also by colleagues,” she said.

Making mistakes when trying to understand someone else’s beliefs and culture is inevitable, Dr. López said. She suggested approaching the patient with a “sense of inquiry.” Asking questions from a place of genuine interest in the patient is more likely to lead to a culturally sensitive conversation – or to forgiveness when there is a misstep, she added.

Lifelong Learning

When it comes to practicing cultural sensitivity, lifelong learning is essential since the concepts will continue to evolve, experts said.

Ms. Medina-Martinez said physicians can look at the communities they serve for continuing education. Attending community events can give physicians insight into the issues that matter to patients and what is happening within the community, she said. “Learn about what’s important to them and what are challenges for them,” she advised.

Dr. Eisfeld pointed to the Spotlight Sessions at the American Society of Hematology (ASH) Annual Meeting, which can offer diverse perspectives on research and practice. She also noted that she keeps up with health disparities literature and seeks out educational opportunities outside of medicine that can help her understand other cultural perspectives.

Belinda Avalos, MD, senior advisor to the president of Atrium Health Levine Cancer Institute and a clinical professor of medicine at Wake Forest University in North Carolina, noted many health care systems have incorporated implicit bias training into their educational programs.

“I definitely see an improvement in terms of what’s being offered,” said Dr. Avalos, who is the 2023 vice president of ASH and a past chair of the ASH Committee on Diversity, Equity, and Inclusion (formerly the Committee on Promoting Diversity). She said she hopes this leads to improvements in patients’ experiences.

Aside from lectures, physicians can benefit from hands-on practice in “being uncomfortable,” Dr. Lowery said. Health system leaders at BU receive training on cultural sensitivity using vignettes of difficult situations in which a microaggression is committed or a physician misspeaks in a culturally inappropriate way. The workshop allows physicians to practice responding in a safe and supportive learning environment.

“It’s shining a light on how people’s words can be interpreted differently and how we can be okay with receiving feedback,” Dr. Lowery said.

Why Sensitivity Matters

When physicians – and the wider health care system – fail to provide culturally sensitive care, it can have real implications, Dr. Edwards explained. Imagine a patient who is experiencing progressive fatigue and intermittent gum bleeding but cannot get a convenient appointment to see a physician or who calls the clinic but no one speaks the patient’s primary language. That same patient may present to the emergency room months later with life-threatening bleeding from disseminated intravascular coagulation and a 70% blast count.

“By the time it gets to that emergency situation, it’s already very late,” Dr. Edwards said. “This person presented late because the system just didn’t work.”

Emerging research supports the idea that providing culturally sensitive care can affect patient satisfaction and adherence to treatment. In one study, which analyzed patient perceptions of their provider interactions and treatment adherence in English-preferred and Spanish-preferred Latino patients, researchers found that using a preferred language had “moderating effects” on the relationships between patient-perceived provider cultural sensitivity and general treatment adherence. Overall, the results suggested that interventions to improve treatment adherence should include provider training on cultural sensitivity.⁴

In another study, researchers performed a mediational analysis on a sample of 1,191 patients from U.S. health care sites to assess the role of patient-perceived cultural sensitivity of front desk office staff. The researchers found that as patient ratings of cultural sensitivity of front office staff increased – including showing professionalism and responsiveness – there were associated increases in patient satisfaction. Patient satisfaction ratings were in turn linked with increased reports of treatment adherence.⁵

Dr. Edwards said she cannot imagine being able to treat patients effectively without forming the type of connection that culturally sensitive care provides.

“Personally, that connection with your patient is really rewarding,” she said. “It’s great to grow with your patients, know their families, understand who they are. The other half of it is being able to effectively treat them.”

References

1. Beach MC, Saha S, Cooper LA. The role and relationship of cultural competence and patient-centeredness in health care quality. The Commonwealth Fund. October 1, 2006. Accessed November 8, 2022. https://www.commonwealthfund.org/publications/fund-reports/2006/oct/role-and-relationship-cultural-competence-and-patient.
2. Tucker CM, Marsiske M, Rice KG, Nielson JJ, Herman K. Patient-centered culturally sensitive health care: model testing and refinement. Health Psychol. 2011;30(3):342-350.
3. Penn Medicine Center for Health Equity Advancement. Cultural humility. Accessed November 8, 2022. https://www.chea.upenn.edu/cultural-humility/.
4. Nielsen JD, Wall W, Tucker CM. Testing of a model with Latino patients that explains the links among patient-perceived provider cultural sensitivity, language preference, and patient treatment adherence. J Racial Ethn Health Disparities. 2016;3(1):63-73.
5. Wall W, Tucker CM, Roncoroni J, Allan BA, Nguyen P. Patients’ perceived cultural sensitivity of health care office staff and its association with patients’ health care satisfaction and treatment adherence. J Health Care Poor Underserved. 2013;24(4):1586-1598.