ࡱ> a pAjbjbtt $|2;0 ^^^ h fffl!!!8!,!lU"""""#F# $UUUUUUU,}WRYDUf$##$$DU&ff""YU:&&&$6f"f"U&z^t^ff$U&&vODff"S" x!E%P&"SU<UPBgZ&gZL"S&fl$t!$lt!Communication Skills Session #5 Cultural/Language Issues in the Medical Interview [Based in part on Cultural Competence module of the SFDC Professionalism in Contemporary Practice course] 10/24 2:15 3:30 or 3:45 5:00 F-labs/Wards & Clinics Erika Schillinger, MD Clarence H. Braddock III, MD, MPH Stanford University Goals: Enhance awareness of your own cultural attitudes Increase skills in exploring patients health beliefs and concerns Develop skill in working with interpreters Objectives: Assess your own cultural adaptability Demonstrate use of the explanatory model to explore patients health beliefs and concerns Demonstrate effective work with interpreters Summary: ActivityTime (min)Overview of session LGO3Debrief cultural adaptability assessment and Doc.com learner reflection questions what did you learn?10 Demo on importance of cultural competence: Preceptor models generic approach to discussion of patients medical problem, giving advice. (see attached role play) Patient has hidden health belief that may or may not come out. 2 Debrief asking the students to comment and then to guess the patients views on their health condition5 Review: Why cultural competency? Kleinmans explanatory model5Each student triad does SP interview, practicing using the explanatory model questions to understand the patients chief concern. 5-7 minutes for each interview, then 3-5 for each debrief. Three cycles so each student gets chance to practice30Review guidelines for working with interpreters5 Role play/demo: preceptor interviews non-English speaking patient with interpreter present, doing poor job. Ask students to comment on effective use of interpreter5Repeat role play/demo with preceptor modeling effective use of interpreter. Ask students to identify what was different, better5Learner reflection and establishment of personal learning goals5 TOTAL TIME =SUM(ABOVE) 75 Student Assignment: Cultural adaptability survey to be completed BEFORE class and submitted on-line (confidential) Complete doc.com assessment questions and one learner reflection question prior to session Post-session personal goals must be posted to personal portfolio for review and comment by preceptor Teaching Preparation Coulehan Ch 10 Doc.com Module #15 https://wrinkle.stanford.edu/SCRIPT/inde201_05/scripts/serve_home Look at the Cultural Adaptability survey (attached) Review Arthur Kleinmans explanatory model Overview of session LGO (3 min) Please give students a road map for todays session. You may want to put some notes up on the white board to remind students what they will be doing, and when. Student Assignment review (10 min) Students will have completed the anonymous (and required) cultural adaptability assessment. This is a 50 item multiple choice questionnaire designed to stimulate self reflection with respect to cultural sensitivity and adaptability. (CB: PLEASE ADD PRN) Students will complete the doc.com learner assessment questions from module #15 and one learner reflection question prior to session (by midnight the day before session). Preceptors will have access to these responses on the day of class. Please review your students responses, highlighting salient issues, questions, and topics for discussion at the beginning of class. Doc.com Learner Reflection Module #15 Questions: What are your cultural origins, or the cultures with which you identify? What values come to mind that you particularly like or dislike, as you reminisce about your cultural heritage? Describe an experience where you have felt different (race, color, ethnicity, etc.). How have you experienced a sense of power, or lack of power, in relation to other groups? What challenges have you noticed in interacting with patients whose backgrounds differ from your own? Preceptor Demo on importance of cultural competence (2 min) In this demonstration, please model a generic approach to the discussion of a patients medical problem, giving advice as part of the interaction. Your patient is a Standardized Patient with a hidden health belief that may or may not come out during the course of the brief interview. (See end of this session handout, role play scenario.) Debrief (5 min) Ask the students to comment on the interview, addressing briefly the domains of opening, relationship skills and gathering information from the Stanford Interview Checklist. Then ask the students to guess the patients views on their health condition. Review: Why Cultural Competency? Kleinmans explanatory model. (5 min) Arthur Kleinman's eight questions for eliciting the patient's explanatory model of his/her illness 1 What do you call the problem? 2 What do you think has caused the problem? 3 Why do you think it started when it did? 4 What do you think the sickness does? How does it work? 5 How severe is the sickness? Will it have a short or long course? 6 What kind of treatment do you think the patient should receive? What are the most important results you hope he/she receives from this treatment? 7 What are the chief problems the sickness has caused? 8 What do you fear most about the sickness? See attachment for further information about Kleinmans model. Student Triads Round Robin, interviewing Standardized Patients (30 min) Each triad (diad or quartet) should team up with a Standardized Patient. There will be 3 or 4 SPs per small group. The triad will then go through the exercise as done in previous sessions, with each of the students taking one of the 3 roles (doctor, consultant, timekeeper). After 5-7 minutes of interviewing, the 3-5 minute debrief commences for each triad with the doctor starting his/her impressions, followed by the Standardized Patient, and then the observers. While each student is interviewing, the other two students should be observing using the Stanford Interview Checklist (SIC copies will be provided at the beginning of the session). You may choose to have one observer focus on rapport, relationship-building behaviors, and information gathering skills, and the other focus on the explanatory model questions. This is critical for a rigorous debrief. This debrief is only conducted within the triad and with the SP for that station, not with the whole group. After the debrief, the triad then rotates to the next Standardized Patient. For this new patient, with a different presentation, the person who was the doctor in the previous encounter takes on a different role. This allows each of the three in the triad to play the role of the doctor as they rotate in round robin fashion from SP to SP, through 3 cycles. Review guidelines for working with interpreters (5 minutes) Role play/ demo (3 min) In this first demonstration of working with interpreters we would like for you, the preceptor, to interview a non-English speaking patient with an interpreter present. You should do a BAD JOB interviewing. Some suggestions: Dont introduce yourself and/or the interpreter Dont explain your and the interpreters role Dont mention confidentiality (your and the interpreters obligations) Intentionally cut the patient out of the loop Dont make eye contact with him/her Make no effort at establishing rapport or checking for understanding Sit in a way that you are not facing the patient Use the third person pronoun (he/she) in talking about the patient Speak quickly, with medical jargon if possible Dont pause for understandingspeak in long paragraphs Try to engage the interpreter in a long discussion that excludes the patient If the patient and interpreter engage in discussion, try to zone out and allow yourself to become disengaged Dont ask for the patients questions No closure or formal goodbye Role Play debrief (2 min) Ask students to comment on effective use of interpreters, drawing on specific, concrete examples from your demonstration. Repeat Role Play and debrief (5 min) This time, the preceptor should please model effective use of an interpreter. Ask students to comment on what was done differently. What was better? Learner goals (5 min) Have each student write down one take home learning point. They should formulate this as a personal learning goal I plan to work on They should write this down in their notes from the session, and be encouraged to keep these notes throughout the quarter. Briefly discuss the goals, asking a few students to share their personal goals. You can then give feedback on the goal, encouraging them to make it more specific, etc. Looking ahead: During the next session, students will go to the hospital for their second Practicum. The focus of the session will be learning about the patients social context, eliciting a social history. Students will take turns interviewing patients on the ward. They will conduct the opening, gather information including the chief concern, PMH, FH and Social History. Cultural/Language Issues in the Medical Interview Role-play: Patient role You are a Mexican-American living in El Paso, Texas. You are a migrant farm worker; 34 years of age. It is your first time visiting this physician. Please review the following to prepare for your role-play interaction: You are convinced that the susto* event you experienced three weeks ago has caused you to be ill, possibly with diabetes. Like many Mexican-Americans, you attempt to connect your condition to your personal history, citing the susto event as cause of the illness. Your susto event occurred when you witnessed a child get hit by a truck; this was very traumatic for you. You experienced a strong fright and goose bumps, like adrenaline, like something strange happening in your body. This fright caused your body to go completely out of order, and from that day on, you were very thirsty. You drink water all the time, and then you urinate frequently. You feel its possible that you had diabetes before the episode, but the fright caused the diabetes to manifest itself. You attended an educational class with your mother, who has type 2 diabetes. It was in this class that you learned how diet regulation is important in the treatment of diabetes. However, you feel that if you have diabetes, diet regulation would interfere with your love of traditional Mexican food, which tends to be high in fat and carbohydrates. You currently use an herbal tea from Mexico to cure whatever illness you have. This was given to you by a friend of your mother. You are afraid to tell the doctor you are using this tea because you dont want the doctor to scold you; youve heard rumors that American doctors do not approve of such things. You see your mothers condition as poor, and you are worried about your health. You feel that you are open to the use of western medicine, but it will take some convincing. You want to keep using your traditional remedy. * Susto definition: fright or scare; unexpected fright from an astounding event in one's life or environment (Finkler, K. 1984, The nonsharing of medical knowledge among spiritualist healers and their patients: A contribution in the study of intracultural diversity and practitioner-patient relationship: Medical Anthropology. 3 195209.) Cultural/Language Issues in the Medical Interview Role-play: Physician role This is the first time you are meeting Mr. Lopez, a 34 yr old migrant farm worker, living in El Paso, TX. After reviewing his chart and blood work results, you see that the patient exhibits classic symptoms of type 2 diabetes (increased urination, excessive thirst, high blood sugar). Objective: (1) Assess the reason for his visit using the Kleinman model. Depending on time, discuss diagnosis and treatment options. What do you call the problem?What do you think has caused the problem?Why do you think it started when it did?What do you think your sickness does? How does it work?How severe is the sickness? Will it have a short or long course?What are the chief problems the sickness has caused?What do you fear most about the sickness?What kind of treatment do you think you should receive?What are the most important results you hope to receive from this treatment? Most things that don't make sense from the outside DO make sense if understood from the inside... Have you ever had this experience - you are talking with a patient about some care option and you just cannot come to an agreement. It seems so obvious to you what needs to be done; how come he/she can't see it? It just doesn't make sense. Yet, perhaps it does. People, especially those from different cultural backgrounds, often have very different ways of understanding illness, its consequences, and how best to treat it - a different explanatory model. Anthropologist Arthur Kleinman suggested that by exploring the explanatory model of illness we can better understand our patients and families, in effect making sense, out of nonsense. To understand others, ask What, Why, How, and Who questions: What do you call the problem, What do you think the illness does, What do you think the natural course of the illness is, What do you fear? Why do you think this illness or problem has occurred? How do you think the sickness should be treated, How do want us to help you? Who do you turn to for help, Who should be involved in decision making? Inquiring about a patient's or family's explanatory model works best in the context of a meaningful relationship. The inquiry is best initiated with a statement of respect such as, "I know different people have very different ways of understanding illness... Please help me understand how you see things." The explanatory model can also be useful in interpreting the culture of Western medicine to others who find our explanatory model peculiar. The Western medical model is mechanistic in nature; the body is a machine, prone to malfunctions, requiring tune-ups or occasional part replacement. The patient's obligation is to present this 'machine' to the 'mechanic' (physician) who will make repairs. This explanatory model differs greatly from other models that view illness more as an imbalance of forces (ex: Chinese - yin-yang, Hispanic- hot-cold) or as being influenced by unseen forces such as spirits, demons or curses. Gaining a better understanding of another's explanatory model will not in and of itself resolve conflicts in end-of-life care. However, a foundation can be established for negotiating a course of care that is acceptable within both the Western medical model and the model of the patient and family. Negotiation and compromise are critical; trying to convince the other that your explanatory model is correct, and theirs is wrong, will not work and will only worsen your relationship. References: Hallenbeck J, Goldstein MK, Mebane EW. Cultural considerations of death and dying in the United States. Clinics in Geriatrics. 12(2); 1996:393-406. Kleinman A. Culture, illness and cure: Clinical lesions from anthropologic and cross-cultural research. Annals Int Med. 1978; 88:251-258.  James Hallenbeck, MD; David E. 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