Clinician Goals For Cultural Competence

■ Self-awareness. Learn about your own biases .. . we all have them.

■ Enhanced communication. Work to eliminate assumptions about what is "normal." Learn directly from your patients—they are the experts on their culture and illness.

■ Collaborative partnerships. Build your relationships with patients on respect and mutually acceptable plans.

Self-awareness. Start by exploring your own cultural identity. How do you describe yourself in terms of ethnicity, class, region or country of origin, religion, and political affiliation? Don't forget the characteristics that we often take for granted—gender, life roles, sexual orientation, physical ability, and race—especially if you are from majority groups in these areas. What aspects of your family of origin do you identify with and how are you different from your family of origin? How do these identities influence your beliefs and behaviors?

Another more challenging aspect of learning about ourselves is the task of bringing our own values and biases to a conscious level. Values are the standards we use to measure our own and others' beliefs and behaviors. These may {appear to be absolutes. Biases are the attitudes or feelings that we attach to perceived differences. Being attuned to difference is normal; in fact, in the distant past, detecting differences may have preserved life. Intuitively knowing members of one's own group is a survival skill that we have outgrown as a society but it is still actively at work. We often feel so guilty about our biases that it is hard to recognize and acknowledge them. Start with less threatening con-cts, such as the way an individual relates to time, which can be a culturally etermined phenomenon. Are you always on time—a positive value in the xminant Western culture? Or do you tend to run a little late? How do you eel about people whose habits are opposite to yours? Next time you attend a meeting or class, notice who is early, on time, or late. Is it predictable? Think about the role of physical appearance. Do you consider yourself thin, mid size, or heavy? How do you feel about your weight? What does prevailing U.S. culture teach us to value in physique? How do you feel about people who have different weights?

Enhanced Communication and Learning from the Patient. Given the complexity of culture, no one can possibly know the health beliefs and practices of every culture and subculture. Therefore, remember that your patients are the experts on their own unique cultural perspectives. Patients may not be able to identify or define their values or beliefs in the abstract but should be able to respond to specific questions. Find out about the patient's cultural background. Use some of the same questions discussed in "Expanding and Clarifying the Health History" (see p._). Maintain an open, respectful, and inquiring attitude. "What did you hope to get from this visit?" If you have established rapport and trust, patients will be willing to teach you. Be ready to acknowledge your ignorance or bias. "I know very little about Ghana. What would have happened at a clinic there if you had these concerns?" Or, with the second patient and with much more difficulty, "I mistakenly made assumptions about you that are not right. I apologize. Would you be willing to tell me more about yourself and your future goals?"

Learning about specific cultures is still valuable because it broadens what you, as a clinician, identify as areas you need to explore. Do some reading about the life experiences of individuals in ethnic or racial groups in your region. Go to movies that are made in different countries or explicitly present the perspective of different groups. Learn about the concerns of different consumer groups with visible health agendas. Seek out and establish collegial relationships with healers of different disciplines. Most importantly, be open to learning from your patients.

Collaborative Partnerships. Through continual work on self-awareness and seeing through the "lens" of others, the clinician lays the foundation for the collaborative relationship that best supports the patient's health. Communication based on trust, respect, and a willingness to reexamine assumptions helps allow patients to express concerns that may run counter to the dominant culture. These concerns may be associated with strong feelings such as anger or shame. You, the clinician, must be willing to listen to and to validate these feelings, and not let your own feelings prevent you from exploring painful areas. You must also be willing to reexamine your beliefs about what is the "right approach" to clinical care in a given situation. Make every effort to be flexible and creative in your plans, respectful of patients' knowledge about their own best interests, and consciously committed to clarifying the truly acute or life-threatening risks to the patient's health. Remember that if the patient stops listening, fails to follow your advice, or does not return, your health care has not been successful.

The Alcohol and Drug History. One difficult area for many clinicians is asking patients about their use of alcohol and drugs, either illegal or prescribed. Use of alcohol and drugs often directly contributes to symptoms and the need for care and treatment. Despite their high lifetime prevalence (in the United

States, more than 13% for alcohol and 4% for illegal drugs), substance abuse disorders are under diagnosed.

Do not let personal feelings interfere with your role as a clinician. It is your job to gather data, assess the impact on the patient's health, and plan a therapeutic response. Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history.

Questions about alcohol and other drugs follow naturally after questions about caffeine and cigarettes. "What do you like to drink?" or "Tell me about your use of alcohol" are good opening questions that avoid the easy yes or no response. Remember to ask what patients mean by alcohol, since for some patients the term does not include wine or beer. Asking about alcohol use may not be that helpful for detecting problem drinking, but you can make use of several well-validated short screening tools that do not take much time. Try two additional questions: "Have you ever had a drinking problem?" and "When was your last drink?" An affirmative answer to the first question, along with a drink within 24 hours, has been shown to suggest problem drinking. The most widely used screening questions are the CAGE questions about Cutting down, Annoyance if criticized, Guilty feelings, and Eye-openers.

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