Respecting personal backgrounds can make a big difference when delivering health care.
By JUDY SIEGEL-ITZKOVICHhospital bed 88(photo credit: )
Racists hate people who are different from themselves. The culturally competent, however, have respect for everyone. Racism can - and should - get people into trouble. But demonstrating cultural competence when dealing with individuals who look, speak, think, feel, pray, eat and even smell different is a commendable ability - and increasingly required by governments in countries with heterogeneous populations.
There are few countries with such diversified populations as the US and Israel, and hospitals are among the key institutions where cultural competency is required - as patients' understanding of doctors' instructions and staffers' understanding of patients' complaints can be a matter of life and death. After all, when a patient gets a prescription for a skin salve but tries to swallow it because he can't understand the doctor or read the label, a tragedy may ensue. The same risk presents itself if a doctor or nurse is unable to figure out a medical history.
However, while US states increasingly demand that hospital staffers take courses on cultural competency, in Israel - with citizens, new immigrants, foreign workers and tourists coming from over 100 countries and speaking 80 languages - cultural competency is a still a new concept.
JERUSALEM'S ALYN Hospital for the rehabilitation of physically disabled children is voluntarily becoming the country's first medical center to formally launch a program promoting its staff's cultural competency. Director Dr. Shirley Meyer said she was inspired by the conviction that patients and families of different languages, ethnic groups, customs and beliefs must feel welcome and understood. As part of the New York/Jerusalem Dialogue Project of the Jewish Community Relations Council of New York and the Jerusalem Inter-Cultural Center, Alyn organized a pioneering conference on cultural competency last month.
Meyer, who welcomed the guests from New York, said that in this region, cultural gaps are also a political issue, as "the political situation colors our lives. There is suspicion, anger and fear." She added that doctors should be aware of the fact, for example, that having a limb amputated to save one's life is regarded by Muslims as a fate worse than death, and this must be taken into account when dealing with patients. Hospitals that treat Muslims should, for example, always have a Koran within reach; when a patient is dying, relatives will want to read and pray from it.
Some of the speakers from abroad represented the 374-bed Coney Island Hospital in Brooklyn, New York. The city-owned medical center has seen its patient population change constantly. Decades ago, Jews, Italians and blacks were the most frequent patients, but in the 1980s, the influx of Russian Jews who didn't move to Israel made the place look and sound like Moscow. Thus the hospital was recognized for its expertise in treating the large numbers of thyroid cancer patients among the Ukrainian and Russian survivors of the Chernobyl nuclear accident (although Israeli hospitals have much more experience).
Today, Coney Island Hospital (whose executive director is Peter Wolf) treats a growing number of patients who migrated from Croatia, China, Japan, Korea, Mexico and Pakistan, along with US-born Americans, including secular and Orthodox Jews. Half of all its obstetrics patients are Muslims from Pakistan. (I myself grew up on the broad, tree-lined Ocean Parkway less than two kilometers north of the hospital, but never needed its services).
BRIAN PALMER, the hospital's associate executive director, told the audience that it opened in the late 19th century as a first-aid station for prosperous summer beachgoers, as the hospital is a kilometer from the sea.
In non-culturally competent hospitals, where there are no interpreters, English-speaking children are often asked to translate for their parents. But this is often difficult for them because they don't understand medical terms or must explain embarrassing, intimate conditions. Can a child tell a parent he has cancer? Sometimes such hospitals use recently arrived cleaning staff from other countries to translate.
But in Coney Island, said Palmer, there are signs throughout the campus in English, Russian, Spanish, Urdu and Chinese so patients and families can easily find their way. The Patients' Bill of Rights appears in three languages on the wall. It also employs a woman who is apparently the world's only hospital interpreter in Russian sign language. As keeping translators on duty at all times is prohibitively expensive, Coney Island also uses a round-the-clock translation service over phone lines that offers interpreters for doctors and patients in over 100 languages.
It also set aside prayer rooms for Jewish, Muslim, Christian and other religious groups; provides kosher and halal meals for religious Jews and Muslims ("We brought in frozen halal food, but when Muslims didn't eat it because it wasn't spicy enough for them, we replaced it with food that was tasty for them"); makes an effort to supply doctors and nurses of the same gender as patients who ask for it; and gives every staffer ongoing intensive training on being sensitive to the needs and beliefs of patients.
Palmer said his institution has two Torah scrolls and a Jewish chapel where a rabbi lectures. There are Christian and Hindu chapels and a mosque prayer room for Muslims (instituted at the request of staffers who wanted to pray there, especially on Fridays). There are also interfaith gatherings that bring everyone together. Palmer noted that sometimes there are memorial services when a staff member or retiree passes away. "Personnel usually don't have time to go to a funeral, so several times a year we gather staffers together for interfaith memorial meetings."
"In Pakistani culture," Palmer continued, "men make the decisions; we have to discuss delivery in the obstetrics department with the husband rather than the wife. Pakistani women usually prefer to have male doctors touch them." The hospital provides an all-woman delivery team when needed. One night, however, a woman needed an emergency Cesarian section when it was impossible to provide 10 females to perform the surgery. Dr. Edwin Bronstein, an Orthodox Jew who was chief of obstetrics, went to the neighborhood mosque to explain the situation to over 1,000 members of the local Muslim community. The ob/gyn clinic has two Pakistani health educators and developed a distinct procedure for Pakistani deliveries such as allowing mothers to remain in their own modest clothing instead of hospital gowns during the early stages of labor. They also play Pakistani music throughout labor when requested.
Offering the community free mammograms, the hospital originally used a poster showing a women wearing a sleeveless dress. "But this didn't attract many religious women, especially the Pakistanis. We made a poster with a modestly dressed woman surrounded by her children instead that was much more effective."
Word of mouth is best way to market the hospital, he insisted. "We do community outreach, working with local groups, and participate in community events, join coalitions and identify community leaders. As soon as we see new faces in the community or new stores and restaurants for the Mexicans who are coming in now, we get prepared for them," Palmer said.
"Do we have a better hospital because we are sensitive to the cultural diversity of our patients and community? Do we have better clinical outcomes and more satisfied patients and staffers? Yes! We celebrate diversity, and have a better hospital because we serve a diverse community."
YOUNG LEE, the hospital's Korean-born director of training and development who arrived in the US at age nine with his parents and served as their interpreter, said giving recognition, rather than extra payment, to employees who excel in cultural competence is an effective incentive to minimize insults, confusion and medical errors.
He recalled that as Japan had occupied Korea for 35 years, he and his family weren't allowed to speak Korean away from home. "My father learned perfect Japanese. We submerged our identities; it was a colonial experience." When he arrived at Coney Island Hospital, he found "3,200 employees from all corners of the earth, including some countries I had never heard of. But I had no problem with that," he said in perfect English. "My mother taught me to respect other people."
Lee noted that cultural competency is increasingly not an option. "Many programs are mandated by regulatory agencies and federal requirements and necessary for accreditation." The hospital management "welcomes these challenges, because it helps us improve. Culturally appropriate care in hospital has a direct impact on quality and safety. It improves clinical performance. But data collection is complicated, so we want to produce a database for cultural competency."
Prof. Leon Epstein, a former dean of the Hebrew University-Hadassah Braun School of Public Health and Community Medicine and a veteran opponent of inequity in health care, said that while there are sporadic programs in various hospitals - for example, to lower the high rate of diabetes in Ethiopian immigrants, which presented itself only after their aliya - these are not enough. There must be a national health policy to educate people of other cultures and eliminate the inequity in life expectancy, infant mortality, accidents, morbidity rates and dangerous health behaviors in groups whose socioeconomic and education levels are low, Epstein said. He noted that new immigrants who barely speak Hebrew are asked to sign hospital consent forms that even veteran Hebrew speakers can't comprehend. Only a handful of Israeli hospitals have medical interpreter services, but a project called Tene Briut, which began as a one-time effort to save an Ethiopian girl whose life was endangered by type I diabetes, is offering paid, well-trained interpreters with medical knowledge.
ALTHOUGH ISRAEL is six decades old, it still has one of the world's widest socioeconomic gaps, Epstein said. "Cultural poverty is growing. It is not only the patient, but also the health professional and increasingly the decision-makers in the health system. We need policy, the defining of standards for cultural appropriateness in health service, and training. I am jealous of what Coney Island Hospital offers. We must realize that people are different, and need the will to act as well as the resources and power to make necessary decisions."
Dr. Amitai Ziv - deputy director-general of Sheba Medical Center at Tel Hashomer and founder and head of the non-profit Israel Center for Medical Simulation (Messer) that screens many candidates for medical schools as well as interns and residents - congratulated Alyn on launching efforts for cultural competency. Ziv said he thought Messer is "a unique platform for teaching cultural competency to doctors from around the country."
As a young doctor who went to study pediatrics in the US, Amitai recalled that he was asked to examine a 14-year-old African-American patient who said she suffered from "crabs." Ziv had no idea what that meant, and - thinking she was allergic to seafood - asked a variety of odd questions. Barely able to control their amusement, his colleagues finally explained to him that "crabs" is the common term for pubic lice.
The Israeli physician was clearly in need of some cultural competency.
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