Over the last few years I started a family practice serving refugees, and have seen 10,000 refugee patient visits. With regards to culturally competent medicine, medical schools teach about traditional remedies such as coining, and maybe role play with interpreters, but stop short of practice design ideas. The AAFP provides a checklist of qualities, which I feel could be more concrete. So I asked my staff what our diverse patients appreciate about us, and we brainstormed the following tips.

1. Allow walk-ins. Calling for appointments is embarrassing if you can’t speak English, and being on time is tough if you must take care of kids or parents, find a friend to drive or interpret, or take the bus. Many medical issues can’t be planned, and much of the world works on a walk in basis anyway. I have an entirely walk-in practice with no set appointment lengths, but an average patient may wait 10 minutes, and then have a 10 minute appointment. Sicker patients get triaged to the front, impatient ones can return if we are busy, and rarely is the wait more than 15 minutes. No appointments also saves staff time, and eliminates no shows and late shows.

2. Eliminate phone trees, answering services, and centralized scheduling. These are barriers if you don’t speak English, can’t hear, can’t see or read the buttons, live in a loud apartment, have kids, or have poor reception (i.e., if you have Medicaid). My goal is for a human to answer the phone every time, and to return any missed calls and messages immediately. Our staff has a low threshold for passing the phone to a provider, but often the provider answers the phone too. If no one answers by the third ring, then it also rings my cell phone, which I answer, whether I’m in the office or even out of the country.

3. Simplify new patient paperwork. It is rarely filled out correctly, and providers often ignore it, so we skip it, and the provider simply takes the history by asking the patient. We type the demographics and insurance straight from the cards, avoiding embarrassment for patients who can’t write English, and preventing errors in copying foreign names. Our one page of paperwork combines HIPAA, record release and other ignored legalese into one signature. We try to explain what is being signed, but most make it clear that they don’t care.

4. Forget rooming. Some patients may find sitting in a communal waiting room preferable to waiting alone in a patient room.

5. Lose the “no phone” sign. Patients with cultural barriers often have phone calls that they can’t afford to miss, like from their job or social worker. If their phone rings, just let them answer.

6. Make referrals on the spot. In our office, all referrals are done by the provider, who makes a phone call, and/or sends a fax, during the patient visit. The provider then gives a map with appointment time and date, and adds it to our tickler calendar to remind them if we think they will forget. Many practices instead have a “referrals person” who comes in once a week; this creates barriers such as guessing the medical necessity, scheduling an inconvenient time, or trying to contact the patient later with details. We have weeded out specialists with cumbersome referral processes, and are able to schedule most appointments on the spot, eliminating the need for convoluted care coordination systems. Cutting office middlemen helps those with cultural barriers, and also saves overhead.

7. Forget calling, just text. If calling patients, your office phone should not show as unlisted. It should display your office callback number even when you call from your cell — — this technology exists. Also, almost all of my patients (or family members) text, while hardly any email. A language challenged patient can show the text to someone who can read English, can save the specialist appointment address for later (always text a full address so they can tap and get a map), or can text you back to ask for refills much easier than emailing or calling. My next goal is to figure out ways to incorporate WhatsApp, Viber, or Tango, which are increasingly used even more than texting, especially by folks who communicate overseas often.

8. Remember some are illiterate in any language. So printed material may be useless, even if translated. I have seen ERs trying to meet meaningful use criteria, giving patients generic WebMD-type printouts on cough, which the patient never reads, or gets scared because they only half understand it. Cultural sensitivity may conflict with MU or HIPAA paperwork, and smaller practices have more flexibility in striking a useful balance.

9. Don’t e-prescribe all the time. Giving a paper prescription is like giving a ticket that increases the likelihood that the patient will get their medicine. Only folks with better English and knowledge of how a pharmacy works can find the right window and say “my doctor emailed a prescription.” Modern e-prescribing glitches don’t help either. For OTCs, give a written prescription also, adding a note asking the staff to show the patient the product.

10. Use props. Mine include empty pill bottles, inhalers, all manner of OTCs, children Ibuprofen with syringe, an OCP pack, frying pans with too much vs appropriate amounts of oil, a toothbrush, and even an LH surge kit. Patients can snap a pic and show it to the store clerk. When props fail, we use google images: search “herniated disc” and you can show everything from physiology to treatment real quick.

11. Give the patient what they want. This means have a scale set to kilograms, lower your threshold for giving antibiotics (they’re OTC in some countries), give trigger point injections because injections are perceived more powerful, have a lower threshold for x-rays or labs, or give a placebo IV of NS because IVs are considered strong medicine. Of course you should try to educate the patient otherwise, and not always give in. But sometimes if you don’t do these things, the patient may think you are an inferior provider, and then go to the ER, who will do all of the above and more. Cultural competence sometimes conflicts with evidence based medicine. Still, not all visits demand action, and many consider it therapeutic just to have a provider listen to and examine them.

12. Allow family or friends to translate. We find most patients prefer bringing their own helper, because the helper can then take the patient to the pharmacy, can repeat the plan of care that night, or can be contacted later with lab results. When a patient shows up without a helper, we have the next best thing: a cadre of local interpreters who are still better than phone interpreters, because they have local knowledge. Ours are mostly health students, who we sign HIPAA agreements with. We do subscribe to language line for the very rare situations when the issue is personal and we can’t get ahold of one of our students. We try to have a female interpreter (and provider) if the patient is a conservative woman.

13. Wait to get personal. It is respectful to ask a patient’s background, but don’t push it. Some are trying to forget a rough past, some may worry that you support whoever they were fighting, and others may find it racist if they can’t just blend in and be American. Wait a few visits before asking too much.

14. Build a prayer room. If you serve practicing Muslims (e.g., most Somalis), you should have a designated prayer area plus at least a sink.

15. Avoid polyprovider syndrome. Using multiple rotating providers to cut costs in underserved medicine may seem smart, but really just creates a circus of dropped care, results in worse outcomes, and doesn’t actually save money. Continuity of care is even more important when you have cultural barriers to overcome, and making friends with neighboring providers helps too.

This is not an exhaustive discussion, and I welcome other tips. Also, many of these ideas can improve any practice setting. Cultural competence in medicine does not mean forcing patients to learn your culture (e.g., “they should learn to keep appointments”), it means adapting as much as possible to meet theirs.

P.J. Parmar is a family doctor at Ardas Family Medicine and blogs at P.J.! Parmar.

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