Recently, I have been discussing various Latino cultural values as they relate to the healthcare setting. However, I feel that before introducing more Latino cultural values it is important to take a moment to consider the other side: the impact of the doctor´s own cultural values on his or her ability to relate to the patient or understand the patient´s views. In this post, I will discuss the importance of cultural self-awareness in offering quality care. Then I will offer suggestions for how instructors can guide medical professionals towards an increased awareness during Spanish for healthcare courses.
When we are blind to our own culture, we are unable to fully comprehend other cultures or understand why others do not simply “act as they should”. Various studies, as well as some of many peoples´ own personal experiences, point to the truth in that statement. When something is believed to be “normal” or “the norm”, divergence from that behavior or idea is viewed as “strange” or “incorrect”. Other times, a certain behavior or belief is assumed to the extent that it is not inquired about nor a command to do such behavior stated outright. This can include ways of greeting people (kisses, hand shakes, a wave), personal space boundaries (normal and expected to touch someone when talking to them or give them more space), appropriate conversation topics (in Germany it is common to ask what salary people earn whereas in other countries it is considered rude to even ask what they do for work), etc.
However, these cultural expectations are not limited to general life situations but also affect how the doctor and patient interact in clinic and the expectations they bring to this context. In clinic, we might not realize that the nursing work-up is not universal and may forget to remind the patient, especially a non-English-speaking one, that the doctor will be in shortly and that the visit has not ended. Nonetheless, various Latino patients at the clinic where I worked would come find me after being seen by the nurses because they thought the visit was over and wanted to understand what the diagnosis was. Other expectations are related to health behaviors, such as when I stopped drinking red wine because I was having stomach troubles and, when I mentioned it to my Spanish doctor, he stated that maybe that was the problem. I had acted on the cultural assumption that red wine could hurt my stomach whereas he was coming from the perspective of red wine being healthy and stress-reducing, which may help with stomach-related issues
Even though the examples I presented are more or less innocuous, failure to understand our own cultural assumption can block us from comprehending where the cultural beliefs of others (in this case the patient) can affect their health, behavior, and the manner in which they interact with the medical professionals in clinic. This is even more important when we consider the significant impact cultural beliefs can have on health outcomes, as I have described in the past posts on Latino cultural values. For this reason, understanding one´s own cultural values is key to providing good care. As Obermeyer and Sanchez state in their course on cultural competency:
“Before entering into a client-caregiver relationship, the individual must become aware of her/his cultural and historical background. By recognizing the different influences from his/her cultural background, the individual will be able to recognize the different influences in the client’s background and will be more likely to engage in a sensitive, therapeutic relationship.”
However, as the common saying regarding cultural self awareness goes: a fish cannot see the water that it´s in. It is not easy to assess our own culture while we are still in it. So, other than putting your students on a plane to another country so they can escape the fish bowl and more easily see their cultural beliefs and tendencies, how can we guide our students to a deeper cultural awareness that will allow them to better understand and be more sensitive to other cultures and their struggles as they integrate into US culture?
One good way to start the discussion and reflection in class is through a quiz or a self-assessment. There are many pre-made assessments online; however, I would warn against choosing just any one and would recommend creating your own instead. One reason for this is that many of these assessments do not force the student to truly seek and reflect on their beliefs or actions but allow them to answer based on current self-perception. For example, a question from one of these questionnaires is: “I do not impose my beliefs and value systems on my clients or their family members”. To this, most people will respond with a high, positive indicator (“this statement describes me perfectly” or “most of the time”) without necessarily reflecting on their own culture and becoming aware of ways they may impose it on others.
Another reason for creating your own assessment is that, given that we have the specific goal of improving the medical professional’s self-awareness as well as his/her sensitivity to the patient´s cultural beliefs, our assessment also needs to be specific. The course material is centered around Spanish in the medical setting as well as cultural beliefs and ideas that arise within that context. Therefore, the students reflections on the topic of culture will be most relevant, and thus most motivating, when they are specific to this setting. Though some questions naturally will be general at the beginning in order to start the reflection process, they will eventually lead to those that are specific to the setting at hand.
To achieve this goal, I propose designing three main groups of questions which are discussed one by one in small groups when presented in class. The small group environment gives the students the security to share their ideas (as opposed to sharing with the whole class), but also the feedback they need to develop a deeper understanding of their own cultural beliefs, which are most likely shared by at least a few of their fellow classmates. The groups of questions I propose would fall into three categories: (1) assessing culture through past experiences, (2) assessing world views, (3) assessing the culture of healthcare. I know this sounds vague, so next week I will post an example of a self-awareness assessment that can be used in Spanish for medical professionals courses.
American Speech-Language-Hearing Association (2010). Cultural Competence Checklist: Personal Reflection. URL: http://www.asha.org/uploadedFiles/Cultural-Competence-Checklist-Personal-Reflection.pdf
Central Vancouver Island Multicultural Society (–). Cultural Competence Self-assessment Checklist. URL: http://static.diversityteam.org/files/414/cultural-competence-self-assessment-checklist.pdf?1342126927
Comas- Díaz, Lillian (2012): “Multicultural care: A clinician´s guide to cultural competence. Psychologists in independent practice”. American Psychological Association 42:13-42.
Livermore, David (2013): “ Self-Assessment of Your CQ”. Cultural Intelligence Center. URL: http://www.culturalq.com/selfassessgo.html
Obermeyer, Marlene & Martha Sanchez (2006): Cultural Advantage: Cultural Competency in Practice. URL: http://www.culture-advantage.com/
Washington Workforce Training and Education Board (2002): “Assess Yourself 2: Cultural Awareness Self-Assessment Form”. URL: http://highered.mcgraw-hill.com/sites/dl/free/0072563974/87090/ch02.html
In the first section, students would answer questions related to life growing up which will slowly reveal parts of their culture. Questions of this type include: where where you born, where did you grow up, what was your family like, what is your favorite family memory did you travel as a child or have you traveled as an adult, what was your earliest recollection as a group member, what is your favorite memory as part of a group, what events or holidays do you celebrate, what do you value in yourself and in others. These questions seems to be simply “getting to know you” style, but they target our basic assumptions of normality. What does it mean to be a family? What does it mean to be apart of a group?
In the second section, we start to get deeper and assess worldviews. As a Western culture, we tend to have a world view molded by an independent spirit, capitalism and, for some, religious ties to protestantism. However, it is important to not tell the students what Western world views tend to be but instead to encourage them to reflect on their own personal wordview. How do they view money? Time? How much space do they need physically, emotionally, or in terms of pauses between speakers in a conversation to feel comfortable? How do they view honesty? Then, challenge them to discuss how they think others world views could differ from theirs. Do they think all cultures view time as they do? For example, if they state that they view time as money, do they believe that is common across all cultures? What is good about both beliefs?
In the third section, the students would start to reflect specifically on their beliefs as they relate to the medical field. “I believe the US health system is easy to navigate”, “I believe that it is easy to access information on health programs that are offered”, “I am aware that family members in other cultures may play a larger role in treatment desicions”. Questions need to be asked as to whether or not a patient from a different cultural would tend to eat or drink the same in response to the same illness, etc.
Before continuing, I would like to give an example of how this played out in one scenario while I was working in-clinic. A diabetic Latina patient came to clinic with unusually high blood sugar. After discussing her diet and lifestyle, it was found that nothing had changed. The doctor increased her medication dose. At the follow up appointment, her blood sugar had continued to increase, again without a dietary explanation. Finally, a case manager was called in and the patient was asked about home remedies. The patient responded she was drinking large amounts of potato milk (milk, potato, sugar) to counteract the heart burn the medicine was giving her. She had not mentioned it to the doctor since he asked her about food and medicine, but what she was drinking was simply a natural remedy and did not fall into either category.