Marisol Lizardo is a 62-year-old patient from the Dominican Republic, who presents as a new patient to the primary care office. Your attending informs you that she has been bouncing between a variety of providers (including two of his practice partners) and is known to be noncompliant with her anti-hypertensive regimen. The patient, whose primary language is Spanish, has limited English skills but refuses a language interpreter (similar to past clinic appointments). Her chief complaints today include stress, dizziness, and headaches.
She shows you two partially filled prescription bottles (filled 3 months ago, #30): Hydrochlorothiazide 12.5mg daily, Metoprolol 25mg twice daily, and Lisinopril 10mg daily.
Case adapted from The Doctors Company – Challenges of Cultural Diversity in Healthcare: Protect Your Patients and Yourself.
Using a language line interpreter, you decide to first proceed with the physical examination – and will ask her more history questions afterwards.
Her vital signs are: BP 162/105 HR 85 RR 16 T 37C (98.6F) 100% RA.
She appears anxious but is otherwise in no acute distress. Her physical exam is normal.
- What other specific questions are important to ask Ms. Lizardo?
First, you attempt to explain to her why a language interpreter is needed. You tell her that you are very concerned she won't receive the best care and that you will make mistakes without a trained interpreter (focusing on her “care” and her “safety”). She agrees to using a phone interpreter for the encounter.
Through the interpreter, you gauge her understanding of hypertension and her opinions about the antihypertensive medications. She tells you that her blood pressure is only elevated when she is stressed out, and it doesn't make sense to take the medication if she doesn't feel any stress. She says that the real problem is that she worries all the time, that she has no way to relax. She also worries about money and doesn't want to spend it on a bunch of medications that she only needs during stressful times.
She denies chest pain, shortness of breath, or leg swelling.
- How might you address her health literacy needs?
In order to address her health literacy needs in a culturally competent manner, you might use a LEARN approach.
Listen to the patient’s perception of the problem.
- She believes that her hypertension is only due to stress.
- Since it is episodic, she does not believe there is a need to take the medication every day.
Explain your perception of the problem.
- You mention your concerns based on her markedly elevated blood pressure from the visit today.
- You explain that her arteries are under high pressure, even if she has no symptoms.
- You discuss the long-term risks of uncontrolled high blood pressure, such as heart attacks and strokes.
Acknowledge and discuss differences and similarities.
- You agree that her blood pressure likely does go up during stressful times.
- You also agree that managing her stress is an important part of her treatment.
- However, you point out that her arteries are under tension/pressure all the time, even when she doesn’t feel stressed. Hypertension is often “silent” and generally symptom-free.
- Based on your assessment, you reinforce the need to treat her hypertension with medications in addition to stress reduction and other lifestyle modifications.
- You verify whether she has an active prescription and then proceed to discuss the cost for her medications. If she has Medicaid and is unable to afford the copay, the pharmacy will waive the cost of the medication.
- She does not have an active RX plan, so you review the cost of each of her medications, ensuring that she is able to obtain a generic version that is the least costly. In fact, all the prescribed medications are on the Walmart $4 formulary for a 30-day supply, or the $10 formulary for a 90-day supply.
- You ask her to keep a diary of her blood pressure values as well as side effects (if any) from the prescribed medications. You promise to review these with her at the next clinic visit. You are able to negotiate with the patient to add relaxation techniques to her daily routine. You explain that if the dietary changes, exercise, and stress reduction exercises lead to further lowering of her blood pressure, you may eventually be able to reduce her medications.
Key points regarding cultural competence in healthcare:
- Cultural competence in healthcare refers to the “ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including the tailoring of healthcare delivery to meet patients’ social, cultural, and linguistic needs.” ("Becoming a Culturally Competent Health Care Organization"; Accessed March 31, 2022)
- Patient safety events that can result from the failure to address culture, language, and health literacy include diagnostics errors, missed screenings, unexpected negative responses to medication, harmful treatment interactions from simultaneous use of traditional medicines, healthcare-associated infections, adverse birth outcomes, inappropriate care transitions, and inadequate patient adherence to provider recommendations and follow-up visits
- Approaches to improve your cultural competence (adapted from: "Cultural Competence and Patient Safety"; Accessed April 16, 2022):
- Language assistance – Use the interpreter line, bilingual clinicians/staff (who are certified), and other qualified foreign language and American Sign Language interpreters. Don’t try to “get by” with the limited English skills of patients. Examples of documented patient safety events due to a lack of timely language assistance include performing an x-ray on the wrong part of the body, falls due to the patient not knowing to ask for assistance, and inability to treat emergency room patients due to failure to obtain medical history or medication list. Use approaches such as the teach-back method to ensure patient comprehension.
- Cultural brokers – Interpreters, community health workers, and patient navigators can play the role of a cultural broker by providing context and by serving as a partner for both the patient and provider. This person must be a trusted and respected member of the community. It is an acknowledgement that providers can’t have a sufficient understanding of of all the different cultures present in the patient population they serve.
- Cultural competency training – Sessions are known to increase cultural awareness, knowledge, and skills – which can lead to behavior change.
Medical interpreters – Additional reading and references:
- "Best Practices for Communicating Through an Interpreter"
- Juckett G, Unger K. "Appropriate Use of Medical Interpreters"; Am Fam Physician. 2014;90(7):476-480.
Cultural competence – Additional reading and references:
- "Becoming a Culturally Competent Health Care Organization" (AHA).
- "Cultural Competence and Patient Safety" (AHRQ).
- Brach C, Fraser I., "Reducing disparities through culturally competent health care: An analysis of the business case." Qual Manag Health Care. 2002;10(4):15-28.
- Ladha T, Zubairi M, Hunter A, Audcent T, Johnstone J., "Cross-cultural communication: Tools for working with families and children." Paediatrics Child Health. 2018;23(1):66-69. doi:10.1093/pch/pxx126.
- "Improving Patient Safety Systems for Patients With Limited English Proficiency" (AHRQ).
- "Understanding cultural diversity in healthcare – Case Studies"