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Clinical Scenario
You’re seeing a patient who’s new to your practice, a 68-year-old female immigrant from a Middle Eastern country. The patient is dressed in the traditional manner of her native country, and she’s accompanied by her husband, neither of whom speak English. She has been referred to you for an evaluation of a lower neck mass that has been steadily enlarging over the past three months, as well as for progressive hoarseness and a cough.
Owing to the patient’s language, you access a telemonitor-based interpreter before entering the room; you’re accompanied by one of your resident physicians. It has been your custom to greet patients with a handshake, but you’re uncertain whether to do so with this patient. You proceed with the introductions via the interpreter on the video monitor. You note a series of long exchanges between the interpreter and the husband, rather than the patient, and the interpreter’s responses to you in return are rather brief. Obtaining a history turns out to be a drawn-out affair of long exchanges during a three-way dialogue.
When you finally get to the examination portion of the evaluation, the patient seems rather reluctant to be touched by you or your resident. The patient clearly has a weak voice, which you suspect is due to a paralyzed vocal fold, as well as a large, firm unilateral neck mass, likely thyroid in origin. As you request to be allowed to perform a fiberoptic trans-nasal laryngoscopy and explain the procedure, you see that the patient looks to her husband for permission. Describing the procedure and answering questions via the interpreter takes a fair amount of time. You explain your concerns about the neck mass representing a neoplasm of the thyroid gland with an attendant paralyzed vocal fold. You again recommend the fiberoptic laryngoscopy, as well as a fine needle aspiration biopsy, followed by a series of diagnostic scans, and seek the patient’s agreement to proceed with the endoscopy. After considerable information exchange using the interpreter, the husband decides that he will need time to consider the diagnostic plan and requests a return appointment in the future to further discuss the procedures. You agree to this plan, but caution that time is of the essence and excessive delay wouldn’t be in the patient’s interest.
How can you ensure that ethical patient care and communication are maintained while navigating cultural differences? read further for discussion.
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.
It 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.
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Autonomy (self-determination) is a primary ethical principle in the U.S. However, the ability to make decisions regarding one’s own healthcare isn’t always a fundamental principle in other societies and cultures. Some families may choose to make decisions for an elderly family member, while in other cultures, informed consent is expected to be given by the senior male on behalf of an adult female. While some leeway can be taken by otolaryngologists with the former under the special circumstances of an illness, cultural influence on informed consent may fly in the face of medical-legal requirements for patient consent. Such requirements and regulations must be explained to patients and their families so that they will understand what constraints are placed on a U.S. otolaryngologist. Legal and ethical requirements must be followed, even if they are at odds with requests based on cultural or religious precepts held by the patient and/or their family. Understanding and patience will serve the otolaryngologist well in shared decision-making and informed consent processes where cultural dissonance may occur.
Additionally, the patient’s native country and culture may have quite a different type of patient-physician relationship, one that might be paternalistic or not as engaging as is the case in the U.S. For significant barriers to communication or compliance with therapeutic recommendations, the otolaryngologist may wish to seek the assistance of a “cultural broker,” also known as a community health worker, who can act as a liaison among the patient, the family, and the otolaryngologist to maximize the therapeutic plan’s efficacy.
Finally, religion may play a role in the patient’s response to illness, to the recommended plan of care, and to their own personal quality-of-life perspectives. This may be particularly important in end-of-life decision-making, pain and suffering tolerance, and in the dyadic balance of beneficence and maleficence. In American society, the terms “faith,” “religion,” and “spirituality” are used interchangeably, although there are nuanced differences to their meanings. In other cultures, formal religion often carries a great significance for the patient, providing beliefs and practices that can strongly influence their medical decisions. Faith and spirituality tend to be considered more personal and value based in patients’ lives, often offering solace and a perspective for living (and dying). Otolaryngologists should carefully inquire about such issues when they might have an impact on the patient’s care and treatment but are well advised to remain neutral with respect to their own personal religious beliefs so as to avoid introducing a conflict into the patient-physician relationship.
We have an ethical duty to understand our patients in as much totality as possible, which can be a challenge when language, cultural, and religious issues are unknown or not well understood. Improving our care of patients from unfamiliar cultures first involves acceptance of our lack of knowledge of another culture, followed by a desire to become culturally aware through study and inquiry. With experience comes greater understanding, enhancing our ability to provide the same level of care for all patients, regardless of their country of origin.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.