Discussion
As America’s population becomes increasingly diverse, otolaryngologists are caring for patients with a wide range of cultural, language, and religious backgrounds. Some patients are immigrants, migrants, or undocumented residents, and some of these are older and have multiple co-morbidities. In the context of caring for these patients, we’re ethically obligated to better understand how their personal beliefs, developed through their own cultures, may affect their illnesses and interactions with healthcare providers. Although attaining cultural competence is often encouraged, it may be more practical to begin with seeking cultural awareness and appreciation to the extent that a meaningful patient-physician relationship and shared decision-making become possible.
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July 2020It cannot be expected that otolaryngologists will be able to learn all of the nuances and particulars of the various cultures that they might see in an individual practice. It would also be difficult, if not impossible, to fully determine how a patient’s culture might play a role in medical decision-making and the interaction between the patient and physician.
Suffice it to say that it’s incumbent upon a contemporary otolaryngologist to develop a functional knowledge of cultural considerations in patient care, and perhaps a more detailed knowledge base for those cultures most likely to visit his or her practice. There are ethical issues that must be considered when caring for patients who are of a different culture than the otolaryngologist, primarily based on our reliance on the four ethical principles of medical care—autonomy, beneficence, non-maleficence, and social justice.
Navigating Cultural Differences
The foundation for ethical care in Western medicine is the development of a patient-physician relationship that’s built on honesty, concern, and meaningful communication, leading to the capacity for shared decision-making. Honesty and concern are the otolaryngologist’s responsibility, while communication requires a joint capability for information exchange and understanding. Meaningful communication can be challenging with language barriers and diverse cultural experiences; these test a physician’s verbal and nonverbal skills. In order to make the best diagnostic and therapeutic decisions for and with a patient, sufficient information must be exchanged to facilitate the understanding of goals, risks, benefits, and alternatives. When the otolaryngologist doesn’t speak or understand the language of the patient, miscommunication and misinterpretations can occur.
Although attaining cultural competence is often encouraged, it may be more practical to begin with seeking cultural awareness and appreciation to the extent that a meaningful patient-physician relationship and shared
decision-making become possible.
As the clinical scenario indicates, using an interpretation service, even a video one, isn’t a perfect means of communication. Interpretation may prolong the patient interaction time (or may cut it short if visit time is limited), may result in inaccurate or incomplete representation of the otolaryngologist’s or the patient’s meaning, or both, and may be complicated if the patient has difficulty with the translator’s syntax or dialect. But some form of interpretation is necessary.
Co-opting the help of a bilingual family member may be an option to consider, particularly when the patient requests it, but to be HIPAA compliant, that individual must be approved by the patient, and the otolaryngologist must be cautious about asking sensitive personal questions, while understanding the risk that the family member may put their own bias into the interpretation. Certified translators remain the safest option for the patient, but the otolaryngologist must be vigilant about the risks. Interpretation must reflect the exact information to be conveyed, without changes to the meaning; accuracy and completeness are of utmost importance.