How understanding cultural backgrounds can lead to better patient care [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

Joining us today is Raj Sundar, a family physician with expertise in cultural humility and safety.

Raj explains that the traditional approach to such situations tends to ignore the patient’s cultural values and beliefs, with the health care team often focused on achieving their goals. However, cultural humility and safety offer an alternative paradigm. Cultural humility involves self-reflection of one’s own values and beliefs, while cultural safety aims to create an environment free from harm for the patient when receiving care.

By applying these principles, we can gain a better understanding of the patient’s cultural background and how it influences their decision-making.  Through cultural humility and safety, we can create a shared world of care that respects and values diverse communities, providing the best care possible.

Raj Sundar is a family physician and can be reached on Twitter @krajsundar.

He shares his story and discusses his KevinMD article, “It’s time to ditch cultural competence.”

The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.

With a growing physician shortage, increasing burnout, and declining patient satisfaction, a dramatic change is needed to make health care more efficient and effective and bring back the joy of practicing medicine. AI-driven ambient clinical intelligence promises to help by revolutionizing patient and provider experiences with clinical documentation that writes itself.

The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled, ambient clinical intelligence solution that automatically captures patient encounters securely and accurately at the point of care. Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 83 percent of patients say their physician is more personable and conversational.

Rediscover the joy of medicine with clinical documentation that writes itself, all within the EHR.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RATE AND REVIEW → https://kevinmd.com/rate

FOLLOW ON INSTAGRAM → https://www.instagram.com/kevinphomd

FOLLOW ON TIKTOK → https://www.tiktok.com/@kevinphomd

GET CME FOR THIS EPISODE → https://earnc.me/pXZ4Jz

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Raj Sundar. He’s a family physician. His KevinMD article is titled “It’s time to ditch cultural competence.” Raj, welcome to the show.

Raj Sundar: Thanks for having me, Kevin.

Kevin Pho: So we’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.

Raj Sundar: Yeah. I always think about where I should start with my story, but I do want to start in a village in India that I grew up in, in southern India, Tamil Nadu: Thamarankottai. There’s somebody out there listening who knows where that is. It’s a small village, but that’s where my grandparents grew up, and I start there because they grew up in poverty. They really struggled to make ends meet and even went to bed hungry, and they really felt that, you know, the way out of this was to make all my family members doctors. There’s already a feeling out there that there are a lot of Indian doctors, but this is the specific story that I have. I essentially had an arranged marriage with medicine in many ways, to use that metaphor.

After I found myself in medicine, medical school and residency, I’ve been trying to revisit what it means for me to be a doctor, because this story started pretty early for me, that I was going to be a doctor. I wanted to be a doctor, but also a healer, you know? Now I’m a family physician. I call myself a community organizer because I work hard to build relationships with the community to identify where we are falling short as health care systems and how we bridge that gap. That answer is complex and multifaceted, and I think a lot of people are working on it, but that’s what gives me the most passion and drive to keep going in this field and caring for folks.

Kevin Pho: All right. In your mind, what is the difference between a doctor and a healer?

Raj Sundar: Yeah, a good question. I think we were all trained as doctors to isolate organs from the person because of our scientific paradigm, which has helped us a lot, right? We can talk about antibiotics or infection and all the advancements we’ve made. It has helped us get so far, but it’s still limiting, because at the end of the day, a person shows up to you and they want to feel better. They’re suffering, and they want to transcend that suffering somehow, or they feel broken and they want to feel whole again, right? They show up to you and they want to be whole again, spiritually, mentally, and physically. It’s not that they just show up and say, “Hey, fix my liver, and then I’m good,” you know? There’s a specificity of, yes, the liver could affect the whole person, but there’s so much suffering they experience, and I think they want doctors to be more than just the doctors that we were trained to be.

I think there’s a debate on what truly is our role, because our systems want us to be just doctors: 10- to 15-minute visits, deliver the care recommendation, and then somebody else can deal with it. But I think our patients and communities want more out of that relationship.

Kevin Pho: Yeah. So I think what you articulated absolutely is correct. I’m a primary care physician myself, and the system wants us to be one way, but we want to practice perhaps in another way. So how do you reconcile that? You’re a family physician. How do you become more of a healer in our current system of primary care?

Raj Sundar: Yeah, this is an ongoing struggle, right, Kevin? I haven’t solved this, but I like to separate it out into the bigger-level advocacy and change that we need to do, and then my daily work. I do that partly for my survival, but also because it’s the way I can grow without getting burned out. When I say bigger-level advocacy, I mean, yes, I want the system to be different. I want the system to provide us with more time, more time for engagement, and to really be responsive to the patient’s needs from when they make the appointment until we see them. Those are all the things I want to do at a system stage, because I’m also an organizational leader, so I want to work on some of the processes.

But the second part of it is just me going from visit to visit. If I can separate that and say, “OK, I have to accept I only have these 15 minutes. How can I do what I’m doing better?” and if I approach it with that intentionality, there’s always room to grow as a healer and to approach things differently. It could even be a mindset shift, which is not always available, but if you’re able to do it, it’s looking at this moment as just a moment in a longer relationship and asking how you invest in that relationship. I think it’s easy to forget that too, as we’re just trying to solve problems from minute to minute.

Kevin Pho: Now, offline we were talking a little bit about your practice, and I understand you work a lot with immigrant communities. So in a primary care setting, tell us some of the challenges that you face with this demographic.

Raj Sundar: Yeah, there are quite a few with immigrant communities. One is the language, and then the cultural barrier. I think everybody who has interacted with immigrants, or people who just speak different languages, is probably aware of these barriers. But what I was really getting stuck with was these bigger gaps in communication, and they often stem from differences in values and beliefs. It was hard for me to bridge them in the moment because, as we just talked about, they’re coming into this scientific Western paradigm from a whole different reality that they were living in, in a different country, and then immigrating to the U.S., trying to understand this new, foreign place, and then needing some care from a system they’ve never engaged with. That can lead to a lot of complexities, and I’ve been on this journey right now attempting to figure out how I can do that better.

Kevin Pho: So what are some of the conclusions or observations that we can use to help in these situations?

Raj Sundar: Yeah. When I first tried to answer this question, well, people are probably aware of this term, cultural competence. That’s what always comes up. I thought, “OK, let me go look up articles about, let’s say, the Khmer community or the Somali community.” There are so many things limiting about that, because I would read these articles and, one, it was kind of reductive, right? It ends up being stereotypical, because you’re reading articles like, “These are the three values the Somali community holds,” and I’m like, “Well, there’s probably some complexity, but they’re trying to reduce it there.” And it’s strangely othering, where I’m normal and these people are different and strange and exotic, so I’m going to study them, right? I was feeling that while I was reading these articles.

Then there was this idea of, “OK, I read this article, I’m done.” There was this checkbox mentality. I think we like that in medicine, right? “Hey, I met these goals, and then I’m ready to deliver the care.” I found that that didn’t really make me the healer that I wanted to be, right? At the end of the day, I show up and, OK, I know these three values the community holds, but then I’m interacting with this patient and I still didn’t understand where I was not doing well.

And I found that, you know, you do these podcasts, Kevin, and voice and conversation capture the nuances and complexity so much more. I have two kids too, so I listen to podcasts a lot, because I don’t have time for anything else. So I thought, “Hey, what if I reach out directly to community leaders and create a podcast to talk about what it means to care for them?” That was the journey for me to creating the Healthcare for Humans podcast.

Kevin Pho: All right. So you talk a little bit about your journey and this issue in your KevinMD article, “It’s time to ditch cultural competence.” You started off with a little bit of a story about a Somali woman. So tell us that story and how it leads into your article.

Raj Sundar: Yeah. I think we all have these moments too, and probably a common experience people may have had, just to anchor people onto this feeling, is a Jehovah’s Witness denying blood products, right? You’re in there, and it’s like, “You’re dying. I want to give you this blood.” But they feel like that is against their values, and they don’t want to. There are probably similar situations in a lot of communities. But the community that I focus on in that article is the Somali community, because in that community I’m an outsider. It’s a predominantly Muslim population, really wanting female-to-female concordance too, so I’m not directly involved. It was in residency, and I was witnessing it, but I could see the pain, tension, and suffering that everybody on that floor was experiencing because of the situation.

The situation was a Somali woman laboring, getting close to delivery but not there yet, and the fetal heart monitoring was showing signs of fetal distress. People in that moment were wanting the baby to be safe, wanting her to be safe, wanting her to get a C-section. She kept saying no, because “I’m going to have this vaginal delivery, because it’s important to me, and this is what God had intended.” That’s the moment. And there was, as I said, so much tension, pain, and suffering, because when people are being stressed, it’s easy to be condescending too. I felt that in that moment, like, “Who is this woman who doesn’t care about the baby?” Even when people weren’t explicitly saying that, that was the sentiment behind all the words that were being expressed. I just felt really uncomfortable if that was how we were going to approach that situation. Even though the situation itself was difficult, it just felt like there was a different way to approach it.

Kevin Pho: So tell us, how did that moment, how did this story change the approach to understanding and reaching across cultures?

Raj Sundar: Yeah. That story had a good ending from a health care perspective, right? We were able to convince her to get a C-section, and then baby and mama were OK. And then we said, “We achieved our goal. Oh, well, she’s still disappointed and angry, but what can we do?” And then we kind of move on, right, because we have other patients, you know? How are we going to address this value that we don’t fully get? But we achieved our goal.

That story stuck with me, and I’ve always thought about whether it could have been different. It was an example of so many other moments that I have in primary care, where it’s so easy to say, “I don’t understand these values or beliefs. I either need to somehow overcome them so I can achieve what I want to, like giving this patient metformin for diabetes, or ignore them and try to get past it with this person, because they’re looking to get better, aren’t they?”

And then, you know, there are all these other paradigms that came about after cultural competence, which I feel like we didn’t learn in medical school, because they’ve evolved in the last few decades as people have thought about it for longer. There’s this idea of cultural humility, where it’s not about the other person but about yourself: What values and beliefs are you holding, and what assumptions are you holding? It’s about being intentional and being aware of that, because a lot of people actually aren’t. And then there’s this different paradigm of cultural safety, which I didn’t learn until later. It was created by Maori nurses, the Maori being the Indigenous population in New Zealand, attempting to figure out how they could receive better care from the health care systems that they were interacting with.

Cultural safety involves focusing on the relationship, not just this other person and yourself, but this relationship between us. How can I make sure it’s trusting and safe? To build that, you as a healer and doctor need to know so much more about the community, because that’s going to lead to a better starting point for empathy and better questions. So understanding the history and culture was such an important part of that, which I feel like I didn’t realize, because in medical school, you know, that wasn’t a core part of what it meant to be a doctor.

As I practiced medicine and learned about the Somali community, reflecting back on this moment made me realize, “Hey, that was a difficult moment.” There are ethical questions there, like what’s our professional duty, and how do we still honor the culture and preferences? But even in that situation, we could show empathy and understand why this patient potentially could want a vaginal delivery so badly, and we did not need to dismiss her as somebody who doesn’t understand her own health or body.

Kevin Pho: Now, you said earlier that you took strides to better understand different communities. You started a podcast. So tell us, what are some of the things that you did to better understand different communities?

Raj Sundar: Yeah. Probably a few examples are going to help people understand. As I said, I do this podcast, and I’m learning things that I haven’t read before. I’ll use two examples. One is from the Ethiopian community. I was talking to the Ethiopian community, and they told me about how their Christmas and New Year’s are different, and their calendar is different. I’m still not an expert in that community, but when I saw a patient right after New Year’s, I asked a different question than others were asking. Everybody, you know, keeps asking, “How was your New Year’s?” for like four weeks after January 1. Nobody knows when to stop asking. So they were asking, and I think they were all nodding along. And then I said, “Hey, how was your Christmas?” And they’re like, “Oh, you know, it’s our Christmas.” I said, “Yeah, I just know it’s different, and I don’t know the exact days. Is that right?” They said, “Yeah,” and then they started sharing all these details with me. It created a moment of connection that wasn’t there before, because I asked the right question, and they knew I was curious enough about their culture that I knew a little bit. I didn’t know everything, but they knew I knew a little bit, and that I would be interested in hearing more, because I asked that question. So we created that space that didn’t exist.

And when I have the conversations with the Ethiopian community, it’s the sense of curiosity that’s built, rather than competence or learning and knowledge acquisition. I think that transferred over to my visits, and that was apparent with my patients.

The second is with the Native Hawaiian community, and there are a lot of them in the Pacific Northwest. One thing the community told me, or the community leader that I interviewed, Dr. Maile Taualii, was telling me, was, “Hey, you know, when we go to receive care, there’s one thing that people always do. They see us, and they want to talk about their last vacation.” Because they walk in the room and they’re like, “How am I going to build rapport? I’m going to say, ‘Hey, I was just on vacation in Hawaii, in this place,'” and try to connect that way. And you feel like that could be the exact wrong thing to say, because you need to understand the history and context. They left their land because of tourism, and it became unaffordable. Now they’re in this new place, and they can’t even visit their family, because they can’t afford anything there. And here you are, talking about taking a vacation in the place they’ve never been to, right?

So if you understand history and culture and the context, you may approach that differently. The takeaway message is not that I’m never telling a single soul that I went to Hawaii. It’s that you have to ask questions and be curious, and now you know that that could exist. So you say, “Hey, where do you call home? Have you been back recently?” And they could say, “Yeah, I was just there last week. I go there every few months.” Or they could say, “I haven’t been back in a long time.” And then your response is different in those situations. That links back to safety, because if you start out talking about a vacation in Hawaii, then they have to share their vulnerabilities and then listen to your recommendations, thinking, “Wow, this person has no idea,” right? That’s how they’re starting the conversation.

Kevin Pho: Sure. Now, for those physicians who may not have a podcast and may not have access to various community leaders, how does one go about learning, immersing oneself, and educating oneself about different cultures?

Raj Sundar: Yeah, I’d say take it one step at a time. I’m doing something bigger because I want to help other people in my shoes and help different community leaders amplify their voices so they’re heard. But I would want people to think about what communities they are taking care of and what they are seeing a lot of. Let’s say I’m seeing a lot of the Ukrainian community recently, right? “Hey, I kind of hear something about it in the news, but I also hear there’s this community organization that’s really supporting them, and maybe I could reach out to them and have a conversation with them in my free time,” right? Just once. And now you’ve established that relationship, and you’ve probably learned a lot about that community. Then you’re going to build relationships through that, just for that community, because you’re going to keep seeing them. It’s not that you’re going to show up one day and be an expert in caring for this community, but over time, not only are you seeing patients in these 15-minute increments, but you also have relationships with these community organizations that you’ve built that can help you care for this population and understand them better, right?

And some people are, you know, taking care of multiple communities and refugees, and obviously you need a lot of support to make sure that you have the awareness and knowledge to take care of them. But oftentimes it’s a few communities that are really close to you because of some migration pattern, and then families started coming there, right? And the question is, what does it take to build a relationship with that community so you understand how to take care of the individual people that come to you for care?

Kevin Pho: When you’re talking to a specific community leader, what kind of questions do you ask them to get a better sense of their culture and just learn more?

Raj Sundar: Yeah. I approach it in a way that makes sense to them, which is, “Hey, I know that we’re letting you down, right?” I’m going to say that up front. “And I want to know how we can do better. So tell me what’s happened to you in your previous interactions and what would be more helpful for you in the future.” I’ve found just through this journey that those open-ended questions are a lot more helpful than saying, “Hey, you know, the Somali women are always refusing C-sections. Can you tell me what to do?” Right? That’s not exactly the right question. I feel like people are really appreciative, because they need to get care, and they want to get care that feels helpful and productive and acknowledges their humanity. I think health care systems just seem so big and corporate these days that it feels inaccessible.

Kevin Pho: We’re talking to Raj Sundar. He’s a family physician. His KevinMD article is titled “It’s time to ditch cultural competence.” Raj, what are some of your take-home messages that you want to leave with the KevinMD audience?

Raj Sundar: Just some questions, right? What does it take to build a healing relationship? What all do you need to know about the person to care for them? And what does it mean for you to learn about them and their community? And take a listen to the Healthcare for Humans podcast if you get a chance. If you like it, maybe that can help you think of ideas to connect with the community as well.

Kevin Pho: Raj, thank you so much for sharing your time and insight, and thanks again for being on the show.

Raj Sundar: Thank you, Kevin.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes