December 2004 Bulletin

Getting the message across

Tips to improve communications with diverse cultures

By Mary Ann Porucznik

No one, least of all health care professionals dedicated to delivering the best possible care to their patients, wants to be accused of bias, prejudice or stereotyping. Yet racial, ethnic and gender differences in care may be due, in part, to the way that health care professionals communicate with and respond to patients of different races, nationalities or genders.

Several studies, including the Institute of Medicine (IOM) report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, found that racial and ethnic minorities receive lower quality health care than whites. This is true even when they are insured to the same degree and when other health care access-related factors, such as the ability to pay for care, are the same. According to the IOM report, “there is considerable empirical evidence that even well-intentioned whites who are not overtly biased and who do not believe that they are prejudiced typically demonstrate unconscious implicit negative attitudes and stereotypes.”

Among the factors that can influence the outcome of a clinical encounter are the patient’s and physician’s demographics (age, race, gender), their beliefs and attitudes, the patient’s health status and trust in the physician, and the physician’s stereotypes about a patient.

This can have significant implications for a specialty like orthopaedic surgery.

According to the most recent AAOS member survey, 89 percent of currently working, board-certified orthopaedic surgeons in the United States are Caucasian. The next most represented ethnic group is Asian-American (3.8 percent), followed by Hispanic/Latino (1.5 percent) and African-American (1.3 percent). This is a sharp contrast to the population at large, where the proportion of racial and ethnic minorities is increasing; nearly one in two Americans will be a member of a minority group by the year 2050.

Although considerable research is still needed on both physician and patient communication behaviors that contribute to racial differences, there is also an increasing awareness of the need for more culturally sensitive communication. The Communication Skills Mentoring Program sponsored by the AAOS is one way surgeons can improve their cultural sensitivity.

“Surgeons are very good at explaining medical facts, but not so good at checking to see if the patient understood the explanation or at eliciting patient preferences,” says Wendy Levinson, MD, vice-chair of medicine at the University of Toronto, who has studied surgeon-patient communication. In her study on informed decision making between orthopaedic surgeons and older patients, surgeons covered the nature of the decision—the medical facts—84 percent of the time. However, verifying that the patient understood the decision occurred only 7 percent of the time.

A patient’s understanding and acceptance of a treatment decision is vital to the final outcome. Studies indicate that patient satisfaction, adherence to a treatment regimen, and even the likelihood of a medical liability lawsuit in the event of an unsatisfactory outcome may be affected by the quality of communication during the clinical encounter.

What is said, however, is only part of the communication. Tone of voice, time spent with the patient, the sharing of common life experiences, even the composition of your office staff can also affect the clinical encounter.

Here are five ways that orthopaedic surgeons can help reduce disparities in care resulting from communication difficulties.

Don’t make assumptions

Because people of the same ethnicity can have very different beliefs and practices, making assumptions about lifestyles and behaviors could undermine communication and produce “self-fulfilling prophecies.” Make no assumptions about education levels or professionalism. Ask rather than assume.

If many of your patients come from a different background or are of a different race or ethnicity than you, consider expanding your understanding of their situation through cross-cultural education. For example, first-generation immigrants may have had very different experiences with medical providers in their native countries or may rely more heavily on alternative therapies such as acupuncture or herbal medicines.

Reflect diversity in your office

If you serve a culturally diverse population, try to reflect that mix in your office. Display pictures and use printed materials that reflect the different ethnic backgrounds of your patients. Hire staff members of different ethnic backgrounds. You may find that patients are more willing to express concerns to a staff member than to you. If so, encourage your staff to share the information with you, and incorporate the relationship between the staff person and the patient in your dealings with the patient.

Use an interpreter

According to a 2002 report by the Office of Management and Budget, an estimated 66 million patient encounters occur across language barriers each year. As many as one in five Spanish-speaking Latinos report not seeking medical care because of language barriers.

If a significant portion of your patient base speaks a language other than English, a skilled interpreter can make a difference. Remember to speak directly to the patient—not the interpreter—and to give the interpreter time to translate your directions. Not all words and thoughts exist in other languages, and the interpreter may need to ask you to explain or clarify certain terms.

When using an interpreter, don’t forget to check the patient’s understanding. Ask the patient to repeat your instructions, and have the interpreter translate back to you. If possible, reinforce verbal instructions with materials written in the patient’s language. But don’t use computer software translations; they’re very unreliable.

Encourage minority students

Increasing the diversity of the physician work force is key to increasing access to care and improving the quality of care for minorities. According to one study, minority physicians see substantially more minority, uninsured and Medicaid patients than other physicians. Although the number of minority students applying to medical schools is increasing, the number who complete the programs is actually decreasing. The AAOS Diversity Committee has brochures and videos that you can use to help attract minority students to the orthopaedic profession.

Know yourself

Surveys have shown that more than half of all Americans believe that relative to whites, minorities—particularly African Americans—are less intelligent, more prone to violence and prefer to live off welfare. Yet most of these people do not recognize their attitudes as prejudice. Recognizing your own biases and working to overcome them can be the most significant step you take to help eliminate disparities in care.


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