Beyond Cultural Competence:The Family Medicine Educator

as “Cultural Broker”

Elizabeth Lee-Rey, MDElizabeth Lee-Rey, MDNereida Correa, MDNereida Correa, MDHispanic Center of ExcellenceHispanic Center of ExcellenceAlbert Einstein College of MedicineAlbert Einstein College of Medicine

Margi Gold, MDMargi Gold, MDDepartment of Family Medicine andDepartment of Family Medicine andCommunity Health, Montefiore Medical CenterCommunity Health, Montefiore Medical CenterBronx, New YorkBronx, New York

Objectives

To discuss the competencies that are needed To discuss the competencies that are needed to be an effective “cultural broker”to be an effective “cultural broker”

To highlight the role for physician To highlight the role for physician advocacy in navigating various social and advocacy in navigating various social and health care systems that impact on patient health care systems that impact on patient health and well being.health and well being.

Cultural Competence

At the level of individual provider-At the level of individual provider-

Defined as “ a set of academic and Defined as “ a set of academic and interpersonal skills that allow individuals to interpersonal skills that allow individuals to increase their understanding and increase their understanding and appreciation of cultural differences and appreciation of cultural differences and similarities within, among, and between similarities within, among, and between groups.”groups.”

What is Cultural Competence to a successful cross-cultural encounter?

Awareness of diversityAwareness of diversity Respect for these differencesRespect for these differences EmpathyEmpathy CuriosityCuriosity

Does Cultural Competence go far enough?

What is Cultural Brokering to a successful cross-cultural encounter?

Understanding and incorporating the needs Understanding and incorporating the needs and perspective of cultural diversity while and perspective of cultural diversity while understanding forces that impact health-understanding forces that impact health-their linkages and their interactions.their linkages and their interactions.

What does it mean to be a cultural broker? Go beyond Cultural Competency 101Go beyond Cultural Competency 101 Accept often other needs feel more immediate Accept often other needs feel more immediate

then health carethen health care Acknowledge need for navigating various social Acknowledge need for navigating various social

and health care systemsand health care systems Acknowledge systems are seen as difficult and Acknowledge systems are seen as difficult and

adversarialadversarial Advocate for patients when systems are unfriendly Advocate for patients when systems are unfriendly

or complicatedor complicated

Questions to consider

Does cultural competence limit us to a Does cultural competence limit us to a paternalistic view of non-dominant cultures?paternalistic view of non-dominant cultures?

Is cultural competence enough to bridge the gap Is cultural competence enough to bridge the gap between physician-patient and health-wellness in between physician-patient and health-wellness in individual and community?individual and community?

Is there a role for the family physician in helping Is there a role for the family physician in helping patients to define and develop skills to navigate patients to define and develop skills to navigate systems?systems?

Case 1

GW brings in 6 year old nephew whom she GW brings in 6 year old nephew whom she has legal guardianship for prescription for has legal guardianship for prescription for Ritalin. School has advised that child can Ritalin. School has advised that child can not return unless he is on medication. GW not return unless he is on medication. GW who is a recent immigrant wants nephew in who is a recent immigrant wants nephew in school. At home GW also has terminally ill school. At home GW also has terminally ill mother.mother.

How would you deal with situation?

Cultural Competence 101 would consider:

From another country From another country No control over situationNo control over situation Education is importantEducation is important Stressful living conditionsStressful living conditions No social supportNo social support Literacy/Language BarriersLiteracy/Language Barriers

A Cultural Broker could ask:

Do you know your options? Do you know your options? Do you understand what is being requested?Do you understand what is being requested? Do you know how to make an appointment Do you know how to make an appointment

to see you nephew’s teacher?to see you nephew’s teacher? Can you help him with his homework?Can you help him with his homework?

Case 2

AB is pregnant and wants a medical AB is pregnant and wants a medical abortion. AB has sent her own paperwork abortion. AB has sent her own paperwork home for fear of INS but submits relative’s home for fear of INS but submits relative’s documentation. AB is currently employed documentation. AB is currently employed under this assumed identity. under this assumed identity.

Cultural Competence 101 would go as far as…

Immigrant fearsImmigrant fears Access to free clinicAccess to free clinic Nonjudgmental careNonjudgmental care

A Cultural Broker could ask:

Do you know that identity fraud can put Do you know that identity fraud can put you and friend in jail?you and friend in jail?

Are you aware that no documentation can Are you aware that no documentation can get you deported?get you deported?

How do you plan on getting health care?How do you plan on getting health care?

Case 3

RP presents to a community health center RP presents to a community health center with c/o of vaginal bleeding. She is with c/o of vaginal bleeding. She is undocumented and evaluation and workup undocumented and evaluation and workup determine that she will need aggressive determine that she will need aggressive management and therapy for uterine cancer management and therapy for uterine cancer with metastatic spread. Access to outpatient with metastatic spread. Access to outpatient pain medication is proven difficult.pain medication is proven difficult.

Cultural competency 101 would go as far as: EmpathyEmpathy Foreign bornForeign born Identify social supportsIdentify social supports Referral for concrete social servicesReferral for concrete social services

A Cultural Broker could ask:

Do you know how to obtain your green Do you know how to obtain your green card?card?

Do you want the embassy to intervene on Do you want the embassy to intervene on your behalf?your behalf?

What will you need to get through?What will you need to get through? Do you have enough food and clothing?Do you have enough food and clothing?

Questions to consider

Can we be cultural brokers within the scope Can we be cultural brokers within the scope of our practice?of our practice?

Can we be competent physicians without Can we be competent physicians without being cultural brokers?being cultural brokers?

How does this impact on individual and on How does this impact on individual and on community health and wellness?community health and wellness?

Conclusions

Accept responsibility – we make a Accept responsibility – we make a difference not only in patient lives, but also difference not only in patient lives, but also in the health and well being of our in the health and well being of our communitycommunity

““It is much more important to know It is much more important to know what sort of a patient has a disease, what sort of a patient has a disease, than what sort of disease a patient than what sort of disease a patient has.” -William Oslerhas.” -William Osler