Originally published March 2014
Culture incorporates a mix of beliefs and behaviours that define the values of communities and social groups. All physicians have their own cultural background, and most doctors practising in Canada are accustomed to providing care to patients from different backgrounds. Moreover, physicians are increasingly aware of the way in which culture can shape the practice of healthcare and influence health outcomes.
There are visible and non-visible signs of culture. Visible signs include language, dress, food, and rituals. Non-visible indicators include perceptions of time, notions of modesty, reactions to physical space, and how emotions are managed.
In Canada, patients and physicians come from many different cultures. Consequently, it is possible to unintentionally offend by missing clues or misunderstanding a cultural viewpoint. As well, while a patient may appear to be fluent in the doctor's language, it may be the patient's second or third language and so there may be gaps in understanding. A trusted translator can help when appropriate, but physicians should be cautious in using friends or family members who could influence or inhibit the discussion.
Culture influences health and the management of illness, and issues related to culture can sometimes heighten risk or impact care. Culture may influence, for example, beliefs about what causes disease, whether to engage in certain health promotion activities or seek advice regarding health concerns, as well as whether treatment options are followed.
Culture can also impact a patient's approach to attending medical appointments in a timely manner. Some patients prefer not being informed of a terminal illness or the implications of not following through with a procedure. First Nations patients may consult a doctor and a traditional healer.
Culture can also influence eating and fasting rituals, even when nourishment is vital to recovery and overall function. It can also play a role in the level of family influence in patient care decisions. Gender differences in a given culture may also affect health and patient outcomes.1 As well, there may be differences among men and women seeking treatment for mental health problems.2 These are just some examples of the possible effects of culture on individual healthcare behaviours and choices.
While it is common to speak of cultural awareness and cultural sensitivity, physicians and other providers are increasingly recognizing the importance of cultural competence and providing cultural safety to patients.
Culture and physicians' care
While physicians have a duty of care based on the physician-patient relationship, a physician's culture and beliefs may impact their ability to respond to certain requests for care in elective situations. Physicians must not discriminate against patients on grounds such as gender, race, religion, or sexual orientation (among other factors), however they may refer patients to another doctor if they feel it is in the patients' medical interest.
Doctors who use their knowledge and skills to provide effective healthcare for patients of diverse cultural backgrounds are said to be culturally competent. Competence requires a blend of knowledge, conviction, and a capacity for action. Clinical cultural competence includes being aware of a patient's and one's own socio-cultural background and using skills and strategies that focus on culturally appropriate healthcare interventions. It also includes an understanding of the power differential between patients and physicians and how to enable patients to become more active partners in their healthcare whenever appropriate.3
A lack of cultural competence can affect patient safety and impact overall health outcomes, specifically regarding repeat hospital admissions, misdiagnoses, ordering unnecessary or inappropriate tests, and patient misunderstanding of treatment protocols.4 Physicians can practise in a more culturally competent manner by:
Being aware of how one's own cultural values and potential biases can impact interactions with patients and families from diverse cultures.
Demonstrating understanding and responsiveness to different values and beliefs.
Adapting practice style, when practical, to meet the individualized needs of patients and families.
Working collaboratively with people from diverse populations in a respectful manner.
Continuing to learn about culture and its impact on healthcare providers, patients, and families.
Adopting inclusive medical practices.5
Not only should physicians and other healthcare professionals provide culturally competent care, healthcare facilities are also increasingly expected to do so. This implies that culturally safe knowledge and behaviour should be actively encouraged within institutions. For example, organizations should promote values, principles, and structures to work cross-culturally; recognize and respect the cultural contexts of the communities served; and systematically involve patients, families, and communities in care.6
Given their important position within the healthcare system, physicians can be effective trailblazers for cultural competence among healthcare professionals and within healthcare facilities. Strategies to enhance clinical cultural competence among physicians include discussing these matters during trainee orientation, medical grand rounds, interprofessional departmental rounds, and in dedicated workshops. Information and presentations should be tailored to the culture-related issues pertaining to particular medical specialties such as emergency, pediatrics, palliative care, and so on.
Cultural safety builds on the concepts of cultural awareness, sensitivity, and competence, but goes one step further. Cultural safety is based on actions that enable safe care to be defined by those receiving the care.
Cultural safety is achieved by building relationships that focus on increasing the opportunities and choices of individuals, groups, and communities to access healthcare.7 It involves developing a relationship of trust between the physician and the patient, one that recognizes and respects individual differences. In many cases, both the healthcare provider and the patient need to understand and consider each other's diversity.
A physician who embraces a culturally safe practice keeps different perspectives in mind when providing treatment to patients. This means reflecting on the information obtained about individuals in their care as well as their own cultural background. Translating this knowledge into specific actions and practices will enhance the quality and safety of medical care. Physicians may also need to model and encourage this approach in team-based care settings. As in any evaluation of healthcare quality, the person receiving medical care is the one who decides whether it was, in fact, culturally safe.
"Within primary medicine, the goal for practitioners is to use (…) self-awareness to achieve a patient encounter that the patient perceives as culturally safe 8
Respect for patients is key to minimizing the risk of culture-related disagreements or misunderstandings. Physicians should consider the following practices:
Foster strong doctor-patient relationships by being "intentionally inclusive" in patient care. This decreases the likelihood of unknowingly being "accidentally exclusive."
Treat every patient encounter as potentially cross-cultural.
Watch for potential language barriers, particularly when communicating in a patient's second or third language. A trusted translator can help, when appropriate, however physicians should be cautious when relying on friends or family members who may add their own interpretation into the discussion.
Inquire about the patient's beliefs related to disease, the reasons for illness, and issues about treatment.
Ask patients how they want to be treated and how care can be provided in a culturally sensitive way.
Be aware of how professional boundaries (i.e. limits to the physician-patient relationship) are perceived.
Document any culture-driven patient accommodations in the medical record.
Rely on a third party or "cultural broker" when working in difficult or emotionally-charged situations that may be rooted in cultural differences, such as inter-generational value conflicts.
Finding the right balance
While most physicians want to respect every patient's culture and work with the patient to plan care accordingly, doctors must ensure they provide competent care and meet Canadian practice standards. Making accommodations for cultural diversity is important, as is respecting a patient's healthcare choices. In all cases, doctors must provide advice to patients about treatment and care based on sound medical grounds and principles. The obligation to obtain informed consent always rests with the physician who will carry out the treatment or investigative procedure.
A final thought
Physicians are often known for their understanding and respect of patients, including patients whose cultural background differs from their own. Understanding and respect will serve CMPA members well as they provide culturally competent and culturally safe care. Committing to and encouraging cultural competence and safety in medical practice is a life-long journey, with clear benefits for patients and physicians.
World Health Organization, "Gender, Women and Health." Retrieved on December 20 2013 from: http://www.who.int/gender/genderandhealth/en/index.html
World Health Organization, "Gender and Mental Health." June 2002. Retrieved on December 20 2013 from: http://www.who.int/gender/other_health/en/genderMH.pdf
The Hospital for Sick Children, "Introduction to clinical cultural competence," Cultural competence E-learning modules series, 2013 (slide 10). Retrieved on October 29 2013 from: http://www.sickkids.ca/NISN_ELearning/IntroductionToClinicalCulturalCompetence/player.html
Ibid., slide 12
Ibid., slide 11
Brascoupé, S., Waters, C., "Cultural safety: Exploring the applicability of the concept of cultural safety to Aboriginal health and community wellness," Journal of Aboriginal Health (November 2009) p.18-19
University of Victoria, "Cultural safety: Module 1," 2013. Retrieved on October 29 2013 from: http://web2.uvcs.uvic.ca/courses/csafety/mod1/index.htm
Baker, A.C., Giles, A.R., "Cultural safety: A framework for interactions between Aboriginal patients and Canadian family medicine practitioners," Journal of Aboriginal Health (November 2012) p.1