Speaking the same language

By Emily Margosian, assistant editor

Sometimes a seemingly innocent gesture can have unintended consequences. In 2012, former President Barack Obama sparked a minor diplomatic scuffle after kissing humanitarian Aung San Suu Kyi on the cheek during a visit to Burma, upsetting cultural boundaries on appropriate contact between men and women. More notoriously, pop star Justin Bieber once remarked during a visit to the Anne Frank House that he hoped the Holocaust victim, “Would have been a ‘belieber.’” While pop culture is rife with these occasionally amusing (and often embarrassing) cultural gaffes, for physicians, a lack of cultural competency can have implications that go far beyond simply offending a patient.

While the significant health disparities that exist for underrepresented minorities in the United States have been widely reported on, often unaddressed is the poor quality of physician-patient interactions among these groups that can play a key part in their negative health outcomes. Particularly as the racial and ethnic demographics of the country continue to change, dermatologists’ ability to demonstrate cultural awareness during patient visits will become increasingly crucial, according to Amy McMichael, MD, professor and chair in the department of dermatology at Wake Forest Baptist University Health Sciences. “Cultural competency is important even as we are diverted from the tasks of taking care of patients with paperwork. Taking our eye off the ball of recognizing what patients need from us in a culturally sensitive way can lead to poor care and unsatisfied patients who are not compliant with therapies,” she said.

Abel Torres, MD, JD, MBA, professor and chair in the department of dermatology at the University of Florida College of Medicine, agrees that cultural competence should be a key asset in any physician’s toolbox. “The key to effective leadership and effective patient care is communication, and communication requires cultural competency. While you can meet all the other demands that come with being a physician, at the core of it, if you fail at communication you will fail at accomplishing your goals — whether those be good patient care or leadership in dermatology.”

This month, Dermatology World talks with leaders across the specialty to discuss:

Why cultural competency matters to dermatologists
Common examples of cultural sensitivities in the clinic
Strategies for improving cultural competency

Nuances of the skin: Cultural competency and dermatology

Although demands on physicians are already multifold, “With the increasingly diverse patient population in the United States, there is an ever-growing need for physicians and other health care providers to improve health care delivery beyond having exceptional clinical skills and successfully achieving system-wide quality measures” (J Am Acad Dermatol. 2017;77(6): 1159-1169).

Given these expectations, what does cultural competency for dermatologists look like — and how is the specialty doing so far? Dermatology’s lack of diversity has been well documented, and improving workforce representation has become a priority in recent years, particularly as racial and ethnic disparities within the specialty have been shown to have clinical implications among minority patient populations. “Diversity among the medical workforce has been linked to better patient care,” said Dr. McMichael. “Minority physicians are more likely to care for patients of their own racial or ethnic group, and race-concordant visits often have higher patient satisfaction than non-race-concordant visits.”

While research and papers investigating diseases affecting skin of color populations has picked up over the past decade — “Often by researchers who are also skin of color dermatologists,” notes Dr. McMichael — representation within the specialty still falls short when compared to the general U.S. population, especially in light of a projected majority-minority flip by 2060 as predicted by the U.S. Census (J Am Acad Dermatol. 2017;77(6): 1159-1169).

Until the specialty catches up, dermatologists can help bridge the gap through improved cultural competency and communication when treating patients of a different cultural or ethnic background than their own. “One example that I encounter each week in my practice is many African-American women with seborrheic dermatitis who are told by their primary care physician to use anti-dandruff shampoo daily for weeks or months,” said Dr. McMichael. “This practice can cause significant breakage of hair in African American patients due to innate fragility of the hair shafts, and patients can end up with worse hair issues by seeing someone who is not culturally competent enough to know that most women of African descent wash their hair every 1-2 weeks. In this case, a medicated shampoo can be recommended for weekly use and other treatment options for scalp treatment can be offered.”

Amit Pandya, MD, professor in the department of dermatology at the University of Texas Southwestern Medical Center, agrees that improved cultural competency among dermatology providers will be a key aspect of improved patient satisfaction — and outcomes — going forward. “Despite all the increasing regulatory hurdles that dermatologists face nowadays, the essence of each encounter is still the relationship between the dermatologist and the patient,” he said. “This relationship can be improved if the dermatologist can carefully and respectfully elicit cultural information from the patient that will improve rapport and compliance and management of the patient’s condition.”

Beyond improvements in patient adherence, satisfaction, and outcomes, studies have also linked cultural competency to more efficient and cost-effective care — a point that Timothy Berger, MD, professor of clinical dermatology at the University of California, San Francisco School of Medicine, said should not go understated. “Cultural competency actually helps the system at large, because it’ll expedite the visit. Communication with patients — which is critical to good patient outcomes — will be enhanced. In the end, patients will do better and there will be fewer return visits for failure of treatment,” he explained. “Right now, in the health care system, we have physicians talking at patients and patients talking at physicians, and the communication link has become poor. As a result, we must have ways to more effectively communicate with patients; that includes being able to reach out when the patient’s background is different than our own.”

In the clinic: Examples of cultural competency

How might cultural competency come into play during a visit with a dermatology patient? One example could involve making additional accommodations during a skin exam for patients’ whose cultures do not allow them to be undressed in front of a member of the opposite sex. “In San Francisco, we have patients from essentially everywhere in the world, and one of the things I try to be aware of is sensitivity among different cultures about women being examined,” said Dr. Berger. “I’m always careful to have a chaperone there, and make sure we’ve talked about what’s going to happen. I think there’s a general awareness we should have when there’s a gender discrepancy between the physician and patient, but there can be a second cultural level there where we want to make sure we’ve done everything necessary to make the patient feel comfortable.”

Communication styles between physicians and their patients can also differ based on cultural norms. “A perfect example is that in Hispanic families there can be an unwillingness to discuss negative issues in terms of poor health or a bad diagnosis. As a result, when questions are asked, the answers that patients give may be very misleading, especially if there’s an elder in the room and the family doesn’t want to say anything to make the elder think they’re sick,” explained Dr. Torres. “I’ve seen it on a personal level coming from a Spanish culture, so understanding that this is a possibility — and perhaps separating the elder when giving medical information — or recognizing that it’s a possibility that the elder’s not being told their true diagnosis would be very important for the care of the patient.”

Translation services can be one way to overcome communication gaps imposed by language barriers. “A key part of cultural competence is to also ensure you have adequate translation support, so you know the information you’re giving to the patient is getting through,” said Dr. Berger. While translating through a patient’s family member can be a last-ditch option, medical information may not be reliably conveyed. Dr. Berger instead recommends that, in a pinch, dermatologists can look into on-demand translation services. “One resource everyone can access is through AT&T or other phone services where you can get a competent medical translator on the phone to translate during the patient visit.”

Read more about language assistance services for non-English-speaking patients at staging.aad.org/dw/monthly/2019/january/language-assistance-services-for-non-english-speaking-patients.

Recognizing the potential social challenges that a patient may be facing due to their skin condition is another aspect of cultural competency, particularly when dermatologists and patients don’t see eye-to-eye on severity or treatment. “If you see someone from the Indian subcontinent who has had a change in pigment — especially a loss in pigment — culturally that’s a major burden for that patient. Understanding what’s important from the patient’s perspective is critical,” said Dr. Berger. “For example, I may have a patient who has a lot of itching and rash and I may think the itching is what’s bothering them the most, but the patient may be more embarrassed by the rash. That would redirect how we might approach that patient.”

WHAT TO SAY, WHAT NOT TO SAY

While few physicians deny the value of cultural competency in theory, actually putting it into practice can pose a much more daunting task. However, the expectation that dermatologists should be able to anticipate the nuances of every patient’s cultural taboos, practices, and beliefs is ultimately an unrealistic one, according to Dr. Berger, who instead suggests physicians approach patients of different backgrounds with a genuine sense of curiosity and acceptance. “I think it’s just a level of alertness — the ability to listen to the patient and find out what their expectations are without making any generalizations,” he said. “Sometimes that means asking, because no one can be culturally competent across all cultures — that’s impossible. The only way to know is to ask. In other words, ‘What about what’s going on with your skin is most important to you?’ Oftentimes, the answer can be quite surprising.”

Dr. McMichael agrees. “The best approach is to keep an open mind about cultural practices and ask the patient to help clarify what is likely to fit with their personal care practices, their work schedule, budget, and ability to return to the medical office for follow-up. This is the same that we do for all our patients. It is also a good idea to learn about the patients who are common to your practice at the very least.”

In general, culturally competent care can be characterized by these key aspects:

● A patient-centered approach

● An established rapport

● Shared decision-making

To get there, there are several steps dermatologists can take to assess and improve their overall cultural competency.

Consider your underlying biases.

Physician bias can play a significant role in patient care and outcomes (Read more at Dermatology World’s November 2018 feature story “(Un)Equal care for all?” at staging.aad.org/dw/monthly/2018/november/un-equal-care-for-all). To recognize and ultimately mitigate the effects of bias, dermatologists can identify their own personal biases through a variety of implicit association tests available online, including Project Implicit, offered by Harvard at https://implicit.harvard.edu/implicit/. “I think now we have more awareness of these issues,” said Dr. Torres. “In part because of many different events that have been happening lately in our general culture — for example the #MeToo movement has increased understanding of sexual harassment — and I think within that context people are also recognizing that sensitivity surrounding culture, race, and sexuality is important because it plays such a large part in avoiding misunderstandings and communicating properly with patients.”

Hone your patient interview skills.

Knowing what to ask (and what not to ask) can be a key component to building trust with a patient of a different background while arriving at the best possible treatment plan that’s amenable to both patient and physician. A good starting point for improving patient interview skills is the RISK (Resources, Individual Identity, Skills, Knowledge) Model developed by Kagawa-Singer et al (Acad Med. 2003;78:577-587), which can help physicians build a template of questions phrased to obtain key information during a patient history without potentially causing offense, which includes sample questions such as, “In what language do you feel most comfortable talking?” and “Do you use any complementary or alternative medicine?”

Build a rapport.

Establishing common points of conversation with a member of a culture or group you know nothing about can be hard. Despite the challenge, a good rapport not only breaks down barriers between physician and patient but can also potentially increase a dermatologist’s insight into cultural views on health and healing (J Am Acad Dermatol. 2017;77(6): 1159-1169). Physicians can improve their connection to a particular population by volunteering at diverse clinics or hospitals, attending cultural performances or festivals in their local community, or even potentially learning greetings in different languages that are spoken by a significant portion of their patient population. “It is impossible to learn the nuances of each cultural group, but I recommend dermatologists start with their own community,” suggested Dr. Pandya. “What is the racial and ethnic breakdown of the population you serve? For example, if one practices in a community with many Latino residents, one can read articles and books about the experience of Latinos in the United States, the history of their countries of origin, their traditions, faiths, favorite foods, and family dynamics. One can view movies and attend festivals of Latino music, dance, and theater. This can be quite enjoyable and provide rich conversation starters with Latino patients in the office. It will help the dermatologist understand their Latino patients better, which may then improve rapport, compliance, and treatment results.”

Access online resources.

There are many online resources available to physicians seeking to improve their cultural competency that include online training tools, case studies, small group learning materials for practice staff, information about immigrant and refugee groups, and other various curricula and assessment programs.

Key resources include:

● A Physician's Guide to Culturally Competent Care (Source: Office of Minority Health, Department of Health and Human Services)

● Culture, Language and Health Literacy (Source: HRSA)

● Practical Strategies for Culturally Competent Evaluation (Source: CDC)

Attend in-person education.

Structured live education can help assess dermatologists’ knowledge, cultural sensitivity, and respect for underrepresented groups. “I recommend looking to your local dermatology association,” said Dr. Torres. “The American Academy of Dermatology also has different course offerings and online resources that can be helpful in that regard.” Visit staging.aad.org/meetings for more information on upcoming education opportunities and workshops.

Dr. McMichael also cites the value of hands-on education. “The Skin of Color Society, the American Academy of Dermatology Diversity Task Force, and the National Medical Association Dermatology Section all provide education on this issue," she said.

How cultural competency can improve communication — and care outcomes