Friday, October 17, 2008

Culture Shocked

A New Jersey jury recently awarded $400,000 to a deaf patient because her physician refused to provide a sign language interpreter throughout their visits. The patient ultimately switched physicians since the steroids she was receiving caused facial edema. The new rheumatologist subsequently took her off steroids and was able to explain that the edema was a side effect of the steroids and not from her illness.

This case presents many ethical dilemmas for the practicing clinician. I have seen other blog posts related to this case. The knee-jerk reaction talks about moral obligations and financial implications for the physician to hire an interpreter that would result in a net loss for the visits (the visits were reimbursed at $49 and the interpreter would cost about $150-200/hr).

Those angles miss the point. Where is the culturally competent care? Cultural Competence is defined as: (via wiki)

... an ability to interact effectively with people of different cultures. Cultural competence comprises four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and (d) cross-cultural Skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures.

If providers can't communicate with their patients, what good is that?

The physician's malpractice didn't defend the claim and will not cover the liability because quality of care was not an issue. I say, it wasn't?!? What comprises "quality" if the patient doesn't understand what the treatment plan is? Shame on the insurance company. Do they interpret "quality" as only being able to write prescriptions appropriately and treating lab values?

Maybe I have a different idea of quality or competent care. My view involves communication in addition to the science of rendering care. What good is it to treat symptoms and lab values if you can't communicate about the disease process, side effects, complications, etc?

I don't think providers need to bear the ultimate financial brunt of providing culturally competent care. This is where we need real leadership from our elected officials. It is so easy to think of healthcare in terms of patients, nurse practitioners, physicians, insurance companies and medications. Each patient brings a uniqueness to their condition that is undeniable. We have for too long subscribed to the "one size fits all" approach. We need to shift our focus on individualized, evidenced-based care.

Finally, the patient also needs to participate in this process as well (the article states that she reportedly handed the physician a business card of a sign language interpreter). Was that enough? It amazes me there was no middle ground mentioned.

What could've been done differently to have avoided such a drastic outcome? Perhaps an interpreter could've been hired for a specified number of visits. Why couldn't the patient and physician split the cost of the interpreter? What state/federal programs are in place to help these providers & patients in these situations? Did the patient's own health insurance have any programs in place (a quick google search came up with a list of insurance company programs that assisted with these types of situations).

This case also carries American's with Disabilities Act (ADA) implications. It is largely because of the ADA laws why this money was awarded and the case was won. But what about the conditions that don't fall under this Act? Providers still need to find ways to deliver care that is individualized. Having cultural intelligence doesn't make the provider's job easier however, it does enrich one's practice so that patient's needs are appropriately met.

The great thing is if you can't find a provider that is willing to partner in your care, you have the choice to find one that will.

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