Attitudes: cultural humility and unconscious bias

The geriatric clinician’s journey to becoming culturally competent needs to begin with a broad base of cultural humility. It is impossible to be an expert in the hundreds of cultures and subcultures that might be represented among one’s patients, so it is important to let the patients become the teachers and the clinician the learner in culturally related issues. It is always important to ask older patients their own perspective, even if the provider is “sure” he or she knows. According to Tervalon and Murray-Garcia, cultural humility incorporates a commitment to self-evaluation and self-critique, and to redressing the power imbalances in the patient-physician dynamic.[12] The self-evaluation and self-critique referred to includes reflecting on one’s own background and what conscious or unconscious biases might lead to assumptions about individuals from different cultures that could affect clinical interactions. Shulman and others showed that physicians made different clinical decisions for patients of different races and/or genders even when they presented with the same clinical symptoms. Authors suggest that different decisions might result from unconscious assumptions held by physicians.[13] Unconscious or implicit clinician bias is increasingly being studied in relation to clinical decision making and to patients’ satisfaction and their perceptions of clinicians.[14] For example, Green et al. found clinicians’ implicit bias was related to their decisions about thrombolysis (15); Oliver et al. found that, while physicians had implicit and explicit biases, those biases did not predict decisions about total knee replacements.[16] Blair and colleagues found that clinicians with greater implicit bias were rated lower in patient-centered care by their black patients.[17]

Developing cultural humility and being aware of one’s biases, however, does not relieve the provider of the need to learn as much as possible about the older patient’s native culture to use as background for the encounter without making the assumption that that particular elder adheres to any of that culture’s specific values and health beliefs. This tension between what is traditionally considered “culturally competent” care when the provider makes an effort to recognize the elder’s cultural needs and preferences and what is usually considered patient-centered care when the elder is treated as a unique individual is one of the most difficult challenges in effective ethnogeriatric care. The Ethnogeriatrics Committee of the American Geriatrics Society (AGS) has emphasized the importance of incorporating cultural information in working with diverse elders in their three-volume series, Doorway Thoughts: Cross-cultural Health Care for Older Adults, based on the assumption that clinicians need to be somewhat familiar with the cultural background of elders before they open to door to the encounter.[18–20] This does not preclude individualizing the interaction, however. One the AGS editors of the Doorway Thoughts series teaches clinicians to check out the cultural information with each older patient with questions such as, “Some people have found it helpful to [e.g., balance their diets between foods that are considered cold or yin and those that are considered hot or yang. What beliefs do you have about balancing your diet?]”

Knowledge: cultural health beliefs, cohort experiences, and epidemiology

Cultural health beliefs and values In an early classic description of clinical cultural competence, geriatrician Risa Lavizzo-Mourey and colleague identified knowledge of “population-specific health-related cultural values” as the first component.[21] These cultural values and beliefs include unique definitions of diseases common to some cultures that are not familiar in the biomedical model used by most American clinicians. Examples geriatric providers might encounter would be the concept of “susto,” or fright, among some traditional Mexican-American elders that may be believed to cause a variety of symptoms; “high blood” in some traditional Southern African-American families, referring in most cases to high blood pressure believed to be caused by too much blood; or the traditional experience of depression in many parts of Chinese society as physical rather than emotional, so that depressed elders might report pain, dizziness, or fatigue rather than feeling sad.[22]

Other manifestations of health-related cultural values include attitudes about diagnosis and treatment, such as: the heavy stigma associated with mental illness and dementia among some traditional families from Korean, Vietnamese, and other Asian backgrounds that make it less likely an elder would have cognitive symptoms evaluated; the belief that if an elder is told she has cancer, she will give up, which may lead many adult children from Middle Eastern or Filipino backgrounds to urgently request the physician not to tell their older parent the diagnosis; the reticence of some families from Mexican-American backgrounds to use hospice for elders because of the hope for a miracle cure; and the preference of some Native American elders to have healing ceremonies in their tribal home communities rather than Western pharmaceutical treatment. The belief from classical traditional Chinese medicine that health is a matter of balance of the elements, such as “hot” (yang) or “cold” (yin), has influenced similar beliefs in many other Asian countries so that herbal medicine or food choices to restore balance might be preferred over Western medicine. Background knowledge of health beliefs and values among populations in the community the geriatric clinician sees is a crucial step to cultural competence, but it is imperative that the clinician never assume a particular older patient has those beliefs or values.

Cohort experiences Another important component of the knowledge base for culturally competent geriatricians is knowing significant historical experiences that elders from specific ethnic backgrounds are likely to have had. Experiences that influence elders’ trust in American health care, such as the common knowledge among African Americans of the Tuskegee Experiment, in which African-American men in a research study were not treated for syphilis, are extremely important to understand. The discrimination African-American, Native American, Latino, Filipino, Chinese, and Japanese communities experienced may present a barrier to trusting cross-cultural health care relationships. Other examples that may have affected elders’ health or their attitude toward health care are the forced internment of Japanese Americans on the West Coast during World War II, and Native Americans’ forced attendance in boarding schools where they were punished for speaking their native language and forced to cut their hair and dress and behave like mainstream American children. Periods and circumstances of immigration are also important parts of background knowledge about a patient population that can be used in taking the health and social history of an immigrant elder. For example, understanding the chaotic circumstances of the sudden evacuation of the first wave of Vietnamese immigrants at the end of the Vietnam War, or the difficult life in refugee camps and the dangerous voyages encountered by later waves of Vietnamese immigrants, provides the basis for targeted questions that help providers establish rapport and understand health-related experiences of older Vietnamese Americans. A resource for clinicians to learn the cohort experiences of elders in US ethnic populations – Cohort Analysis as a Tool in Ethnogeriatrics: Historical Profiles of Elders from Eight Ethnic Populations in the United States – is available from Stanford Geriatric Education Center.[23]

Epidemiology of disease risks A second component of cultural competence identified by Lavizzo-Mourey and MacKenzie is knowledge of special risks of diseases and conditions populations face. Knowing what conditions are prevalent in older adults from specific backgrounds can make clinicians more aware of needed assessments and preventive health recommendations for particular elders. An important example is the excess risk of type 2 diabetes among elders from Latinos, African Americans, Native Americans, the Chinese, Asian Indians, the Japanese, Koreans, Filipinos, and Native Hawaiians.[24] Given the potentially devastating consequences of uncontrolled diabetes for so many conditions, including dementia, it is critical for providers to be aggressive in case finding and treatment, especially in older patients who are not overweight, as many with diabetes from many Asian backgrounds are not. A list of conditions that have been found to be more prevalent among older Americans from specific backgrounds is found in the article, “How Will the U.S. Healthcare System Meet the Challenge of the Ethnogeriatric Imperative?”[24]

Skills: eliciting explanatory models, showing respect, assessment, and working with interpreters

Eliciting explanatory models Understanding older patients’ perception of their conditions (their explanatory models) can help clinicians make recommendations that are consistent with patients’ views and are more likely to increase their adherence to clinical recommendations. A widely recommended strategy for eliciting the explanatory models is to use questions similar to those developed by Kleinman and colleagues.[25] (See Box 55.4.)

Then the question becomes, what should the provider do with the information that was elicited? Various models to incorporate patients’ perspectives into recommended management of geriatric conditions have been suggested (see the LEARN model [26] in Box 55.5 as an example), but they all have in common the importance of negotiating an agreeable plan that allows clinicians to provide their best evidence-based care while recognizing and incorporating if possible their older patients’ culturally influenced knowledge of their own health – the epitome of patient-centered geriatric care.

Showing culturally appropriate respect One way a geriatric clinician can help to establish an immediate relationship with an older patient from a different cultural background is to greet the elder in a culturally appropriate way. How would one know whether to shake hands, bow, or look the elder in the eye – all of which differ culturally? This is where a cultural guide from the elder’s background can be very helpful to give a short lesson in greeting etiquette. In general, touching, especially across genders, is not considered appropriate in many Middle Eastern and Asian populations, especially among Muslims. In other cultures, such as many Latino cultures, shaking hands and gentle touching are expected and considered reassuring. Sustained eye contact can be interpreted as confrontational or disrespectful among some cultures such as some Native American or some parts of Asia, so providers may find older patients looking down during an encounter. If unsure about appropriate cultural greetings, asking the elder to provide a lesson would be acceptable. Older patients can also be helpful in instructing providers about their desired form of address and the name they prefer. In general it is usually considered most respectful to use “Mr.” or “Mrs.” and the family name until instructed otherwise; in some cases, however, it may not be clear which name is the appropriate family name, so asking the elder is always safest. A particularly important part of showing appropriate respect is always to greet the elder first before other family members even if he or she doesn’t speak English. Because elders are held in much higher esteem in most other cultures than in the United States, both the older patient and other family members will expect deference to the elder.

Respect can also be conveyed by being careful not to use disrespectful movements or gestures. Showing the sole of one’s shoe to someone is very insulting in many Middle Eastern cultures, and there are many hand gestures that are offensive in other cultures, such as several used by many Americans to express “OK” or “Come here, please.” Again, being careful to follow cultural guidelines regarding touching is important.

Assessment In addition to language issues, cross-cultural geriatric assessments need to take into consideration other issues such as appropriate respect, relevant health histories in the context of elders’ cohort experience, asking permission to examine parts of the body and being aware of cultural taboos that prohibit touching some areas, and using linguistically and culturally validated formal assessment measures.[27] If cognitive status is assessed, for example, there are many translations of the most common measures [e.g., Montreal Cognitive Assessment (MOCA) has been translated into 36 different languages, 21 of which have been validated],[28] and there are numerous original measures validated to be accurate in specific populations. Similarly, it is important to use culturally appropriate measures to assess depression. Mui and colleagues found that some of the items in the Geriatric Depression Scale (GDS) were not appropriate for the six different ethnic populations of Asian elders they studied and made suggestions for modifications.[29]

Many elders use herbal and other remedies common in their countries of origin, and in most cases they do not volunteer that information to their physicians unless asked. It is important, then, to explore their use, especially in cases where there is a potential interaction with prescribed medications, as in the case of diabetes drugs. (For more information of ethnogeriatric assessment, see http://geriatrics.stanford.edu/culturemed/overview/assessment.)

Working with interpreters As discussed previously, it is vital for clinicians to insist on using trained interpreters with elders who are limited English proficient rather than family members, especially children. Skills in working appropriately with interpreters include having them sit slightly behind patients so the patient faces the clinician, speaking in short phrases using lay terminology, recognizing that interpreters are obligated to interpret everything that is said so that they cannot be engaged in a side conversation, and not asking interpreters to perform tasks outside of their role, such as independently obtaining consent for a procedure. See an excellent example of appropriate clinical skills in using interpreters in the video developed by the Cross Cultural Health Care Program.[30]

Health literacy

Health literacy is defined by the Institute of Medicine as “the degree to which individuals can obtain, process, and understand the basic health information and services necessary to make appropriate health decisions.”[31] A multifaceted concept, health literacy reflects a range of individual skills and abilities needed to navigate a complex and demanding health-care system. Patients with limited health literacy are likely to face considerable difficulty with health-related tasks – for example, describing symptoms to their provider, determining the correct amount of medicine to take, and understanding information provided in patient education materials. Although such tasks are routinely expected, if not required, of patients in order to effectively manage their health, estimates indicate that more than 90 million US adults are likely to struggle with these everyday health-care tasks.[31]

According to the 2003 National Assessment of Adult Literacy (NAAL), more than a third of US adults have basic or below basic health literacy and are unlikely to have the skills necessary to effectively obtain, process, and understand essential health information.[32] Individuals with low educational attainment, members of racial/ethnic minority groups, and those living in poverty are disproportionately affected.[32] Additionally, elderly persons are more likely to have poor health literacy skills than younger adults, with NAAL results indicating that 71% of older adults have difficulty reading and interpreting print materials, 80% have trouble navigating information provided in tables or charts, and 68% have difficulty performing basic arithmetic or interpreting quantitative information.[32, 33] The natural processes of aging and cognitive decline are likely to play a role in age-related literacy disparities.[33] In addition, multiple comorbidities, multiple physicians, multiple treatment plans, and polypharmacy further exacerbate challenges elderly patients are likely to face.

As elders use disproportionately more medical services and are burdened with greater chronic disease than younger adults, it has become increasingly important to determine how best to address the problem of limited health literacy among this population. Current estimates suggest that low health literacy costs the United States from $106 to $238 billion each year; this economic burden is likely to increase as the US population ages.[34] Consequently, Healthy People 2020 identified addressing limited health literacy as a national priority.[35] Gaining an understanding of health literacy, its impact on health outcomes, and how best to address patients’ health literacy limitations is therefore crucial for clinicians seeking to improve care of older patients.[31]