Cultural Competence: Eliminates Non-Compliance

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Interpreter managers are often tasked with teaching cultural competence in their institutions, as a way of checking off the regulatory box that the institution is paying attention to cultural needs of patients. Many healthcare staff, providers, and administrators think of cultural competence as a fluffy extra that would be nice to have but that is certainly not critical to medicine.

But is cultural alignment with patients really fluff, or is it essential to the success of care? Consider the analogy of preparing food: Would it surprise us if we packaged necessary fiber and nutrients in a brown, unpleasant smelling lump, and the hungry person refused to eat it? In the same way, a patient may refuse to commit to health-supporting life-style changes or intervention protocols if these are culturally inappropriate or repugnant to him. Successful cultural competence is about engaging the patient in his own care for good clinical outcomes. More and more, healthcare organizations will need to care about outcomes in order to be reimbursed.

Culture is not about

What kind of clothing a person wears.
What religion is on his birth certificate.
Or what nationality is on his passport.

Outdated cultural competence training claimed to explain what entire communities of people think, based on cues such as their clothing, their amount of eye contact, and their use of herbal tea.

Culture is about a person’s values, goals, fears, needs, and preferences.

The cultural values that we should ask the patient about involve:

What is he asking for our help with? Does he want information in general, information about his own condition, support in his efforts to manage his condition, a cure, relief from pain?

What functionality does he consider so important to his identity that he is asking for our help to achieve it? Does this person want to walk without limping, run a marathon, see better, stop having endless painful periods, have an erection again, control or enhance fertility…

What degree of independence does he consider essential to his dignity: staying at home even with greater fall risk, managing his own meds and food even though family wants to manage these, maintaining his own habits and activities even against medical advice….?
What choices will he make when he cannot have all of the important things? Pain relief or a clear mind to make decisions? Side effects of treatment or progression of disease without treatment?

It is easiest to teach cultural competence to colleagues by presenting real examples of patients. Health care staff and providers are known to relate well to specific cases and stories, rather than to statistics or generalities.

Use the concept of non-compliance as an anchor. Every staff person and provider can think of patients who are labeled as non-compliant by the care team: the patient who no-shows, does not take his meds as prescribed, does not stick to the diet, does not monitor his weight or fluids or salt, does not do his exercises, does not stop smoking, etc. And his condition does not improve.

Each of these patients provides a great lesson on cultural competence. Where did we mistake our care plan for a commitment from the patient to undertake the steps of the plan?

We can align ourselves with the patient’s cultural reality by putting ourselves in his shoes and seeing things through his eyes. If the patient is diabetic and eats a diet prepared for the entire family by his mother-in-law, how could he tell her that the food she prepares is killing him and he cannot eat with the family anymore? If an older patient is brought to the doctor by a well-meaning but overbearing family member who monopolizes every conversation with the doctor, the patient may have no interest at all in following the medication regimen set out for her. One patient may want to extend his life indefinitely in terms of time regardless of whether he is conscious or able to function, while another patient prefers to forego more interventions except for comfort care, knowing that he will not live as long. One person will agree to an amputation to save his life, while another cannot abide the loss of dignity that the loss of a body part entails for him.

If we ask our patients what they want from care, and develop a care plan that fits their needs, it is important to check in with them throughout care to make sure we are still on the track that they want to be on. Wouldn’t it be great if we could ask each patient every year whether the care team was on the right track as far as their attention to what the patient wanted? Our cultural competence would surely grow by leaps and bounds.

For regulatory review visits, it is impressive and authentic to be able to show specific patient examples in which the care team elicited the patient’s goals, values, and concerns, then crafted a care plan to achieve those goals, support those values, and allay the concerns.

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