Enhancing Cross-Cultural Communication By Telling Patients' Stories

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Patient–physician communication about treatment options can be difficult even under optimal circumstances. But the issues are exacerbated when patients or their family members do not speak English well or have cultural beliefs that clash with modern medicine. A series of films and accompanying facilitator's guide seeks to address these issues by documenting the experiences of four patients as they negotiate the U.S. health care system. These tools are designed to spark discussion among medical students and others about the communications problems illustrated by these case studies and how to resolve them.

Organization: Stanford University Center for Biomedical Ethics
The issue: Cross-cultural patient–provider communication
The intervention: Often, misunderstandings and conflicts arise when patients and health care professionals come together to choose an appropriate treatment plan. Such problems are intensified when patients and their family members struggle to communicate in English or have cultural beliefs that clash with modern medicine. Filmmakers Maren Grainger-Monsen, M.D., and Julia Haslett of the Stanford University Biomedical Center document the experiences of four patients as they negotiate the U.S. health care system. In a series of four films, called Worlds Aparts, they dramatize communication between patients and their doctors, tensions between modern medicine and cultural beliefs, and the ongoing problems of racial and ethnic discrimination. To do so, the filmmakers followed four individuals from their homes, neighborhoods, and places of worship to community clinics and hospitals. The films and an accompanying facilitator's guide, written by Alexander Green, M.D., Joseph Betancourt, M.D., M.P.H., and J. Emilio Carrillo, M.D., M.P.H., are designed to facilitate discussions among health professionals about health care services for culturally and ethnically diverse patients. Educators can choose to use the films and guide in workshops, integrate them into courses, or present them in specific training modules. In one film, Mohammad Kochi, a 63-year-old Afghani man with stomach cancer, refuses chemotherapy in part because of poor communication between his doctors and his daughters, who act as his translators. Kochi had a gastric tumor removed and initially believed that his cancer was cured. A follow-up examination, however, found there was some remaining tumor. These results were not clearly related to him by his younger daughter, who felt that it was important for her father to remain hopeful and strong-willed. In a later visit, his older daughter, who had not been involved in the earlier visit, expressed surprise that Kochi still had cancer and disappointment that he had not chosen to receive chemotherapy. Because Kochi's family makes decisions as a unit, the training guide points out that it is important for health professionals to arrange family meetings and discuss decisions as a group. It also points out the pitfalls of using family members as ad hoc translators. Family members may miss the subtleties or complexities of medical information or—as in the case of Kochi's daughter—bring their own biases to the table. The film underscores the importance of using high-quality, professional interpreters when crucial decisions are being made. Another film introduces Justine Chitsena, a 4-year-old girl who needs surgery for a congenital heart defect. Justine's family are Khmu, indigenous people of Northern Laos. Her grandmother adheres to traditional Laotian and Buddhist beliefs and worries that the scar from the surgery will affect Justine's spirit in her subsequent lives; Justine's mother worries that her family will blame her if something goes wrong. The training guide suggests ways for providers to be flexible, taking into account patients' traditional and religious beliefs and coming up with creative ways to meet patients' needs while aiming for the best possible outcomes. Another film follows Robert Phillips, a 29-year-old African American man with end-stage renal disease. As Phillips has a routine dialysis, he talks about his frustration with the "medical bureaucracy." He has waited nearly three years for a kidney transplant and believes that endocrinologists are hesitant to recommend African American patients for new kidneys because, the doctors believe, "they're just going to ruin it anyway." As Phillips points out, many African Americans do not trust doctors or the health system because of the legacy of racism. In addition, recent studies have found that patients are treated differently by the health care system, based on their race and ethnicity. The training guide suggests ways for physicians to avoid stereotypes and build trust with their patients, while working to address the root causes of health disparities. The last film follows Alicia Mercado, a 60-year-old Puerto Rican woman who lives in New York City. She has several chronic illnesses, including diabetes, hypertension, and asthma, but has not managed them appropriately. The facilitator's guide points out that it is important to explore why patients are not adhering to medical advice. In this case, Mercado has lost her cherished apartment and fears that there may be side effects from the prescribed medications. Exploring these issues with patients can lead to improved compliance and disease management. You can view short clips of the four films or the facilitator's guide by downloading the attachments on the right. Medical schools, hospitals, and other organizations that wish to purchase or rent the films should visit the Fanlight Productions Web site, call 800-937-4113, or send an e-mail to info@fanlight.com.

August 2004