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April 18, 2013

Creating culturally competent health care

healthcareDelivering culturally competent health care begins with being culturally aware, contends Candi Castleberry-Singleton, chief inclusion and diversity officer at UPMC. She delivered a lecture April 3 as part of the Center on Race and Social Problems’ Reed Smith spring 2013 speaker series.

“We want to get to a place where you have no excuses,” she said. “Ultimately, we want to end with culturally appropriate interactions. None of this stuff is hard.”

Nor is it necessarily obvious. Most people think they act, or try to act, appropriately at all times but few think they are treated properly in every instance. Castleberry-Singleton received a sea of positive responses when she said, “Raise your hand if you believe you deserve dignity and respect?” and “Raise your hand if you believe you treat everyone with dignity and respect.” But no one responded when she told the audience, “Raise your hand if you think in every experience you’ve been treated with dignity and respect.”

Fostering diversity in the health-care workplace is everyone’s job, she stressed.

“The first position I eliminated when I started at UPMC … was the diversity recruiter,” she said. “If I take that diversity recruiter and have her train all the other recruiters, that’s more effective.”

The movement toward more diversity in the workplace — or simply the acknowledgment that diversity already is there — has been building for many years; women, people of color and those with disabilities began to benefit in previous decades.

“After 9/11, religion entered the workplace,” Castleberry-Singleton noted. In health care, that is particularly significant, she said, since faith often is a greater guide for patients’ decision-making than any other demographic factor.

Most recently, gays and lesbians, as well as veterans, increasingly have been acknowledged in the work environment.

But she said miscues still are cropping up during cultural interactions, and physicians and patients sometimes seem to represent two different cultures in themselves. She recalled flying to the bedside of her sister, who is a teacher, after the sister was involved in a car accident and lay in a brace from her ears to her waist. The attending physician dealt well with Castleberry-Singleton until her other sister, who is a physician, arrived.

“And suddenly no one else mattered,” she recalled. “Someone came in and outranked me.”

Even her sister the doctor, she added, too often “still spoke to me in a foreign ‘physician language.’”

Delivering culturally competent health care begins with being culturally aware, contends Candi Castleberry-Singleton, chief inclusion and diversity officer at UPMC. She delivered a lecture April 3 as part of the Center on Race and Social Problems’ Reed Smith spring 2013 speaker series.

Delivering culturally competent health care begins with being culturally aware, contends Candi Castleberry-Singleton, chief inclusion and diversity officer at UPMC. She delivered a lecture April 3 as part of the Center on Race and Social Problems’ Reed Smith spring 2013 speaker series.

Castleberry-Singleton prefers to see female doctors — not out of prejudice, but because she says they speak in a different manner about women’s bodies. If one group feels misunderstood or disrespected and feels they must remain silent about their differences in a health-care setting, she said, they may not feel confident that they are going to get the proper level of care.

“When you come to see us, it’s because you are here for a reason. We must make sure our interactions are right. If you had a good experience, you tell a few people. If you had a bad experience, you tell lots of people. And if you have Facebook, you tell millions of people.

“Patient satisfaction will eventually impact the reimbursement rate for organizations like hospitals,” she added. “I would suggest to you that [patients] are most unforgiving if it is something they have felt disrespected about.”

UPMC has been instituting new high-tech tools in its hospitals and offices to help employees deal with cultures, ethnicities, faiths and other groups with which they may not be familiar.

CultureVision, for instance, is software that allows health-care professionals to have access to culturally appropriate background information from within a patient’s record. If a patient mentions that she is Amish (one of the largest religious groups seen at UPMC hospitals) or he is Somali (the fastest-growing immigrant group in Pittsburgh), background information on these factors is available with a click. The information is geared toward medical situations. A physician might learn, for instance, that Somali men sometimes think it is inappropriate to be present at a birth, thereby avoiding a misunderstanding at that important moment in the life of the patient and her family.

CyraCom, a Skype-like tool, allows a health-care worker to connect with a live medical translator on screen. Users can choose among more than 150 languages.

“The next big disparity is going to have to do with technology,” Castleberry-Singleton warned. Different generations’ ease with technology use already is making certain people feel excluded from today’s physicians’ offices. She recently visited her doctor at UPMC Montefiore and was handed an iPad-like tablet instead of a clipboard to provide the usual information.

“I think nothing of it,” she said. “How I see the world is: technology is just what it is.”

But behind her came the voice of another, much older woman, with a message loud and clear for the health-care staff: “‘I told you last time I didn’t want to use this thing.’

“Self serve is here,” Castleberry-Singleton said. “The good news is, there’s still a full-service lane. But there won’t be a notice” when it goes away for good. In the future, patients are likely to be seen more often remotely. Health-care systems are promoting apps in their current television commercials because “they’re teaching you to get ready for the full-service lane to disappear. Except they’re not telling you the full-service lane is going away.

“The self-service lane is going to exacerbate everything we already know about health care [disparities]. When you’re talking and trying to get a second opinion from a person you’ve never seen before but you’ve uploaded your information through an app … think about who is not going to have access to this: the very people who already have limited access” — older patients, the poor and those with disabilities.

The new self-serve lanes will be for one demographic, she said: “They will be for that 20-year-old who goes to the doctor for the first time” without his parents.

“Sometimes when you hear the stories that don’t go right, often you go back to the cultural awareness,” she said. The easiest cure is to think always of the central principle: “I just wanted to be treated with dignity and respect.”

—Marty Levine


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