How to approach Patient Diversity in the Medical Environment

FLASCO Rapid Integration Program, September 29, 2019
How to Approach Patient Diversity in
the Medical Environment
Jose D. Sandoval-Sus, MD
Assistant member, Department of Malignant hematology & Cellular Therapy
Moffitt Cancer Center at Memorial Healthcare System
Pembroke Pines, FL

Objectives
• Differences between Race and Ethnicity.
• Describe what is culture and race.
• Describe the differences between health disparities and healthcare disparities.
• Understand what is “Cultural Competence” and how it can improve the
oncology patient experience through all the stages of his/her care.
• Identify barriers within the system related to aspects of cultural competency (i.e.
race, gender, religion, language, culture, etc).
• Apply knowledge of personal barriers to improve the care of diverse patient
populations with a cancer diagnosis.

Bucaramanga,
Colombia.

Race and Ethnicity
Race
• A biological category: a way to label different groups of people
according to a set of common inborn biological markers.
• A social defined concept based on physical criteria.
There is overwhelming evidence that grater genetic variation can occur within a
racial group than across racial groups.

Ethnicity
• A common heritage shared by a particular group.
• Heritage: similar history, language, rituals and social
costumes such as music, food, healthcare conceptions,
gender roles, etc.
Race and Ethnicity

Health Disparities vs. Healthcare Disparities
Health disparities (HD)
• HD are defined by:
– Incidence & prevalence of a
disease.
– Mortality.
– Burned of disease (morbidity).
Within a specific population.
Healthcare disparities (HCD)
• HCD are the differences in the
presence of:
– Illnesses
– Health outcomes.
– Access to care
Within a population.

What is Culture?
• A common heritage or set of beliefs, norms and values.
• The shared, and largely learned, attributes of a group of
people.

10%
90%
Hall ET. Beyond the culture 1976

Diversity
• Different
• Individuals
• Valuing
• Each other
• Regardless of
• Skin
• Intellect
• Talent or
• Years
Inclusion
Getting patients/families
fully engaged.

Healthcare Disparities and Culture
Healthcare/cancer disparities among racial/ethnic groups
do exists:
• Genetics.
• Environment.
• Lifestyles choices.
• Differences in cultures beliefs.
• Linguistics Barriers.
• Trust in Healthcare providers.

Cancer Disparities by Racial/Ethnic Groups
African Americans
 For all cancers combined, cancer incidence rates between 2007 through 2011 were the highest
overall in black men (587.7 per 100,000 men) compared to any other racial or ethnic group.
 African American women with cancer have higher death rates despite them having a lower risk
of cancer overall (compared to white women). Also, African American men have lower 5-year
cancer survival rates for lung, colon, and pancreatic cancers compared to non-Hispanic white
men.
Hispanics
 Hispanics and Latinos have the highest rates for cancers associated with infection, such as
liver, stomach, and cervical cancers. Higher prevalence of infection with human
papillomavirus (cervical cancer), hepatitis B virus (liver cancer), and the bacterium H. pylori
(stomach cancer) in immigrant countries of origin contributes to these disparities.
 Although Hispanics and Latinos have lower incidence and death rates for the most common
cancers than non-Hispanic whites, they are more likely to be diagnosed with advanced stages
of disease.

Cancer Disparities by Diagnosis
Breast Cancer
 African American/black women are more likely to die from breast cancer despite white women having
higher incidence rates for the disease and are less likely than white women to survive five years after
diagnosis.
 Aggressive breast tumors are more common in younger African American/black and Hispanic/Latino
women living in low SES areas.
Cervical Cancer
 Hispanic and Non-Hispanic black women are almost twice as likely to have cervical cancer and 1.4
times more likely to die from cervical cancer as compared to non-Hispanic white women.
 Among Asian Americans, incidence rates for cervical cancer are almost three times higher in
Vietnamese women than in Chinese and Japanese women.
Prostate Cancer
 African American men have the highest incidence of prostate cancer in the U.S. and are more than
twice as likely as white men to die of the disease. Prostate cancer is the second leading cause of
cancer-related deaths among African American men.

Cancer Mortality by Race/Ethnicity from 1990 to 2015
for Breast Cancer and Prostate Cancer
Siegel RL et al. CA CANCER J CLIN 2018

Disparities in Malignant Hematology
Acute myeloid leukemia (AML)
 SEER analysis from 1999-2008 and found that African American and Hispanic patients with
AML had increased risk of death by 12% and 6%, respectively compared to non-Hispanic
whites.1
Acute lymphoblastic leukemia (ALL)
 ALL is one of the most common cancers diagnosed in children (25% of childhood cancers),
and the incidence also appears to be highest in Hispanic children (43 per 1 million).15.
 SEER analysis showed that the probability of death for black and Hispanic patients with
ALL was about 45% and 46% higher, respectively, than for Caucasian patients. APIs had
similar probability of death compared to white pts. No differences in survival were observed
in patients with ALL >40 years of age.
Multiple myeloma
 Incidence of MM between 2008 -2012:
• NH Black men: 16.1; NH Black women: 11.5.
• NH White men: 7.2; NH B White women: 4.2.
• Hispanic men: 6.4; Hispanic woman: 4.3. 1. Patel M et al. Cancer Causes Control. 2012;23(11):1831-37.
2. Kirtane K and Lee SJ. Blood 2017 2017 Oct 12;130(15):1699-05
3. Costa L et al. 2017 Jan 4;1(4):282-87

Disparities in Malignant Hematology
Multiple myeloma
• In an analysis of > 37,000 MM patients 23, Hispanics had a significantly worse median OS
compared to Caucasians in a multivariate analysis (2.4 vs 2.6 years; p =0.006). Asians and African
Americans did not have significantly different median OS compared to Caucasians. For patients ≥
75 years of age, Hispanics had the worst median OS at 1.3 years.
1. Ailawadhi S, et al. BJH 2012 158(1):91-98.
2. Costa L et al. BBMT 2015 Apr;21(4):701-6

Cultural Competence
“ To be culturally competent doesn’t mean you are an
authority in the values and beliefs of every culture. What it
means is that you hold a deep respect for the cultural
differences and are eager to learn, and willing to accept,
that there are many ways of viewing the world”
http://www.newahec.org/Cultural_Competency.html
Okokon O. Udo, PhD

What is Cultural Competence?
• A group of skills, attitudes and knowledge that allows a
person, organizations and systems to work effectively
with diverse racial, ethnic and social groups.
• Emphasizes the idea of effectively operating in different
cultural contexts.
Cross TL et al. Towards a Culturally Competent System of Care 1989

Cultural
Sensitivity
• Knowing that cultural differences as well
as similarities exists, without assigning
values.
Cultural
Specificity
• Understanding that ethnic and racial
groups will have values that may be
specific to their culture.
Cultural
Humility
• Giving careful consideration to one’s own
assumptions and believes that are
embedded in one’s own understanding
and goals of ones encounter with a patient.

• Lack of knowledge: inability to recognize the differences between cultures.
• Self-protection/denial: leads to believes or attitudes that these differences
are not important or significant.
• Fear of the unknown or the new: its challenging to understand and accept
something that does not fit in our “world view.”
• Feeling of pressure due to time constrains: feeling rush and unable to look
in depth at an individual’s needs.
Why is Cultural Competency important ?
• Patient-provider relationships are affected
when expectations are not “ in-sync”.
• Miscommunications arise.
• Non-verbal cues do not fit the expectations.

What patients and families may experience
Feelings of
being insulted
and
discriminated
Their health is
not as important
as the health of
other pts.
Poor
understanding of
information
regarding
treatment and
follow up.
Discomfort asking
for information,
advice, follow
ups, etc.
COMBINED WITH THE
NATURAL FEAR OF
CANCER

Strategies to Create Cultural Competent Healthcare
• Involve patients, families and community members.
• Identify community needs, assets, and barriers in creating
appropriate program response.
• Make necessary enhancements in provider’s procedures to address
the needs of culturally diverse patients:
– Adequately document cultural and linguistic background of the
patient.
– Partner with other agencies to combine and expand culturally
competent services (i.e. FLASCO, ASCO, etc).

Examples of Cultural differences in the health care context.
• “Thumbs up”
– “O.k.”: Western countries
– “One”: France
– Rude sexual sign: Some Islamic countries.
• Eye contact
– Related to evil spirits (“mal de ojo”): some Latin American countries.
– Avoid eye contact as a sign of respect: China.
– Potentially inappropriate in some context: Some Western countries.
• Blood transfusions
– Accepted as almost a “certainty” in patients diagnosed with acute
leukemias, expect in Jehovah's witness.

• Identify and understand the needs and help-seeking behaviors of
individuals and families.
• Design and implement services tailored to the unique needs of
individuals, families and communities served.
• Healthcare practice driven in service delivery systems by patient’s
preferred choices, and not by culturally blind or culturally free
interventions.
Achieving Cultural Competence in Healthcare

• Consider all patients as individuals above all. Then as members of
a minority status and then as members of a specific ethnic group.
• Never assume that a person’s ethnic identity tells you anything about
their cultural values or behaviors.
• Treat all “facts” you have ever heard or read about values or traits of
specific cultures as “hypothesis”, to be tested in with every patient.
Turn facts into questions.
Strategies for Cultural Competence Healthcare

• Identify elements in the patient’s cultural background which can be
built upon.
• Assist the patient in identifying areas that create social or
psychological conflict related to biculturalism and seek to reduce
dissonance in those aspects of his/her care.
• Know your own attitudes about cultural pluralisms, and whether you
tend to favor assimilation into the dominant society values or agree
on maintaining traditional cultural beliefs and practices.
Strategies for Cultural Competence Healthcare

Cancer Care Transitions and Culturally Competency
Case presentation
• 58 yo woman with stage IIIA right breast cancer. She underwent total
mastectomy and ALND, followed by chemotherapy. Following the 3rd
chemotx cycle, she had a major adverse event and her family took her to the
closest ED. She was hospitalized for 10 days.
• The information was not shared with her OP oncology team and she missed
the appointment before the 4th cycle of chemotx. Efforts were made to
contact the patient but her phone was disconnected while being in the
hospital. Three weeks after her scheduled chemotx, she presented to the
infusion center for an unscheduled visit, stating that now she “feels better”
and would like to resume therapy.

Key Findings: Cancer Care for Rural and Southern Patients
The State of Cancer in America 2018 ASCO
• Distance and family caregiving play
a important factors cancer
care.
• Economic resources are limited in
rural areas.
• Communication
– Language.
– Health literacy.
– Limited access to technology.

Cross cultural communication in Oncology Care
• Understanding cross cultural communication may determine how we can
address the patient’s needs (avoid patients “slipping between cracks”).
• Respect among different cultures:
– Cannot question or be in disagreement with the healthcare provider,
even when there is no understanding of the plan.
– Reporting side effects may be considered disrespectful in some cultures.
– Perceived lack of respect from the provider to the patient: may inhibit
questions form the patient/family.
– May find barriers to obtain informed consent.
• Healthcare members need to learn how to ask questions in a non-threating
way and how to create a partnership between the patients and family to
provide appropriate cancer care.

Navigating the Healthcare system for minority patients.
The healthcare system can be another layer of complexity for minority patients
diagnosed with cancer
Patient
Oncology
provider
Emergency
Department
SNF. NH or
Hospice
care
PCP
Miguel:
72 yo Health Colombian man
with newly dx Stage IV NSCLC

Patient Navigators in Oncology
• Excellent strategy to address cultural barriers in oncology care.
• Healthcare workers trained to assist patients through cancer care.
May come from the local community and may be matched by
ethnicity.
• Particularly important in assisting oncology patients coordinate and
“navigate” complex health systems.
• Navigators have shown to improve cancer outcomes in diverse
populations.
• Do not overuse patient navigator or expect from them assistance
outside from their scope of practice.

Cultural Competence: Early Encounter
• It is the first opportunity to gain the patient’s trust and
begin cross-cultural negotiation leading to improved
communication and understanding of cancer and the
healthcare system.

Barriers in the Early Encounter for minority patients
Institutional
• Socioeconomic
• The healthcare system
• Inadequate infrastructure
• Discrimination
• Lack of diversity in the healthcare
system
Community • Mistrust
• Beliefs and healthcare attitudes
• Lack of tangible resources:
transportation, child care, etc)
Providers
• Service delivery
• Provider Attitudes and provider-pts
relationship.
• Inadequate learning and assessment of
knowledge, attitudes and skills.

Language
• Lack of certified medical
interpreters.
• Lack of serving patient in their
primary languages.
Barriers in the Early Encounter for minority patients
Patients with limited
English proficiency
Patients with low
literacy level or
illiterate.
Patients with
disabilities.
Working with certified interpreters

Language Barrier
Problems created by language barriers
• View of health and healing, and wellness belief systems.
• Understanding of disease and how causes are perceived.
• How healthcare treatment is sought and attitudes towards providers,
which can impact cancer treatment.
• Delivery of healthcare services by providers who may compromise
access for patients from other cultures.
• Patient with language discordant MD are more likely to omit
medications, miss appointments and visit ED for care.

Language Barrier
Federal Mandates and Regulations
• Title VI of the Civil Rights Act of 1964 considers the denial or delay of
medical care due to language barriers to be discrimination.
• All medical facilities receiving Medicaid or Medicare must provide
language assistance to LEP patients.
• The Joint Commission (JCO) requires that interpretation and
translation services be provided as necessary.

Solutions for language barriers
• Used of trained certified medical interpreters.
• Educational material provided in a language the patient best
understands.
• Serving patients in their primary languages including notices, post-
treatment instructions, etc.
• Develop written language assistance plans.
• Signage and way finding on the patient’s primary language to help
reduce stress and facilitate timely care.

Critical Elements of Culturally Competent Communication
in the Early Counter
1. Communication repertoire.
 Skills to engage in culturally appropriate communication.
 Skills to personalize their communication behavior (i.e. listening to the patient, have
empathy and compassion, negotiate, etc).
2. Situational Awareness.
 Attention to patients cues and expectations and the nuances of interaction.
 Judge the extent to which personally held bias might influence the situation, and attempt to
manage the bias.
3. Adaptability.
 Able to adapt to different patients, individualizing communication to accommodate the
unique needs and characteristics of these individuals
4. Knowledge.
 Identification of cultural groups or social determinants of health and systems put in lace in
different communities to deal with illness.
 Beliefs about gender roles and family roles, believes and practices about death, religious
believes, physician authority, expectations of disease, etc.


The LEARN Model
• Listen with empathy for the patient’s perception
of the problem.
• Explain your perception of the problem.
• Acknowledge and discuss the similarities and
differences.
• Recommend the treatment.
• Negotiate agreement
The Center for Public Health Education

Conclusions
• Cultural competency needs to be on-going. No one ever masters a
culture.
• Cultural appropriate healthcare programs are also community
specific, rather that for a ethnic group in general.
• Integrating and institutionalizing cultural competent policies are
crucial for the effectives and sustainability of a healthcare system.
• Be aware that the success of cultural competency is impacted by
other factors such as health and linguistic literacy.

Conclusions
• Develop a relationship with the communities with whom you work
• Implement patient navigation and EHRs with a web-referral system
(if possible).
• Integrating and institutionalizing cultural competent policies are
crucial for the effectives and sustainability of a healthcare system.
• Be aware that the success of cultural competency is impacted by
other factors such as health and linguistic literacy.

1. Kuwaiti Muslim woman who is covered from head to toe in a burka. She is
accompanied by her oldest brother, her husband, a sister, and one of her
sons. Her brother intercepts the Arabic interpreter in the hallway to ask that
we not disclose the diagnosis of cancer or any other bad news.
2. American Jewish woman who is experiencing rapid respiratory deterioration
from pulmonary involvement. We discuss goals of care, and we recommend
transitioning to palliative care, since additional anticancer therapy is likely to
be risky and ineffective. She and her husband are determined to continue
chemotherapy to ‘keep fighting and go down swinging’. They view death as
failure.
Four 65-year-old patients with stage IV colon cancer
present to the medical oncology clinic to discuss treatment
options.

1. US Viet Nam veteran from Louisiana who wears a camouflage hat, Harley Davidson
T-shirt, and worn military fatigue pants. He has PTSD, smoked heavily until he
became short of breath, and drinks 6–10 beers per day. I ask him: ‘What is your
understanding of your illness?’ He replies in a deep southern drawl: ‘Doc, I know I am
pretty bad. I just don’t want to take stuff that’s going to make me more sick.’
2. African American man who is admitted to the hospital with cancer-related fatigue. He
is confined to bed the majority of the day. He was the sixth of nine children in a family
with limited means, and he was the first to attend college. He served on the law review
of a prestigious east coast law school. Before retirement, he worked as a lawyer in a
large firm specializing in business transactions. He is receptive to the idea of
transitioning to palliative care without anticancer therapy, but his daughter is
adamantly resistant to such a change. She is angry no matter what we say or do. The
patient initially agrees to ‘no code’ status, but she convinces him to remain ‘full code’.
His daughter says ‘I am sure the good Lord will save my father. We have to keep
praying for a miracle.’
Four 65-year-old patients with stage IV colon cancer
present to the medical oncology clinic to discuss
treatment options.

THANK YOU VERY MUCH
Email: jose.sandoval@ moffitt.org; jsandovalsus@mhs.net

How to approach Patient Diversity in the Medical Environment

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